Assessing the Sustainability of Compliance with Surgical Site Infection Prophylaxis After Discontinuation of Mandatory Active Reporting

评估停止强制主动报告后遵守手术部位感染预防措施的可持续性

• 批准号: 10494063
• 负责人: Westyn Branch-Elliman
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-10-01 至 2026-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10494063
• 关键词: Accounting; Acute Renal Failure with Renal Papillary Necrosis; Address; Adopted; Adoption; Adverse event; Algorithms; Ambulatory Surgical Procedures; Antimicrobial Resistance; Area; Assessment tool; Blood Vessels; Bypass; Cardiac; Caring; Cessation of life; Clinical; Clostridium difficile; Colorectal; Data; Doctor of Philosophy; Documentation; Drops; Educational Curriculum; Electronic Health Record; Electronics; Elements; Evidence based practice; Exclusion; Feedback; Frontline worker; Funding; Future; Goals; Guidelines; Gynecology; Health system; Healthcare; Hybrids; Infection; Informatics; Interruption; Intervention; Interview; Learning; Manuals; Maps; Measurement; Measures; Methodology; Methods; Modeling; Morbidity - disease rate; Operative Surgical Procedures; Orthopedics; Outpatients; Patients; Peer Review; Performance; Perioperative; Pharmacy facility; Policies; Postoperative Period; Prevention Measures; Procedures; Process; Program Reviews; Prophylactic treatment; Provider; Recommendation; Replacement Arthroplasty; Reporting; Research; Resources; Retirement; Sampling; Structure; Surgical Specialties; Surgical Wound Infection; Surgical incisions; Technology; Testing; Text; Time; Time Series Analysis; Training; Translational Research; Work; adverse outcome; antimicrobial; clinical care; contextual factors; cost; data mining; design; effectiveness/implementation study; electronic data; evidence base; evidence based guidelines; healthcare-associated infections; high risk; implementation barriers; implementation science; implementation strategy; improved; informatics tool; innovation; medical specialties; mortality; non-compliance; novel; programs; scale up; structured data; surgery outcome; surgical risk; sustainability framework; tool; voltage

Background: SSIs are common and preventable adverse surgical outcomes that account for substantial morbidity and mortality. Pre-operative antimicrobial administration reduces SSI; post-operative antimicrobials do not reduce SSI but do increase other post-operative adverse events. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) to increase compliance with peri-operative quality metrics, including appropriate antimicrobial use. SCIP included a set of publicly reported evidenced-based antimicrobial guideline compliance metrics targeting high-risk surgeries. The metrics required resource-intense manual review as part of the VA’s External Peer Review Program (EPRP). In 2015, SCIP achieved sustained compliance with antimicrobial use metrics exceeding 95% and the program was retired due to the high costs of manual review with minimal expected additional benefit. This IIR proposal is guided by the Dynamic Sustainability Framework and examines whether the antimicrobial practice changes achieved by SCIP were sustained and how they spread to surgeries and practice areas beyond the original scope of the program. This multiple PI submission by Dr. Hillary Mull, PhD and Dr. Westyn Branch-Elliman, MD, MMSc builds and expands upon their prior VA-funded collaborative work applying electronic algorithms to measure antimicrobial use and identify adverse outcomes. Significance/Impact: Improving antimicrobial prescribing and surgical quality are major VA goals. In FY 2018, within the VA, there were 190,000 surgeries among SCIP-targeted specialties (cardiac, orthopedic, general/colorectal, gynecology and vascular). Of these, 64% were outpatient, where the PIs found high rates guideline discordant post-operative antimicrobial use, which contribute to substantial patient harms. Thus, the potential impact of the research on direct clinical care is high. In addition, there are limited studies examining what happens to practice change after discontinuation of active programs designed to support compliance with evidence-based guidelines. The proposed study will close this gap in implementation science research. Innovation: In line with the VA’s Learning Health System directive, this project will use the VA’s electronic health record data to develop algorithms to identify pre-and post-operative antimicrobial use based on the PI’s prior work. These electronic data mining algorithms capture structured and text note data and represent a significant technological advancement over costly manual review. This study also answers important questions about the sustainability of practice change after discontinuation of an active policy with input from frontline staff. Specific Aims: 1) Measure sustainability of antimicrobial prophylaxis guideline compliance after SCIP retirement and assess whether practice changes spread to SCIP-excluded procedures; 2) Assess facilitators and barriers to implementation sustainability through staff interviews, and map results to implementation strategies; 3) Develop an implementation playbook with assessment tools, training curricula and other elements to support scale-up and spread of evidence-based antimicrobial practices in a future HSR&D Hybrid III trial. Methodology: Aim I will adapt existing informatics algorithms to extract pre-and post-operative antimicrobial use from clinical note texts and antimicrobial orders for each of the SCIP surgeries. Previously manually reviewed 2005-2015 EPRP data will be used as the gold-standard for adapting and refining the data mining tools. SCIP sustainability will be measured by applying the validated antimicrobial compliance algorithms to 2005-2020 data and performing interrupted time series analyses. SCIP spread within specialties will be assessed with regression models. Aim II will use qualitative interviews with frontline staff to identify reasons for sustainability of evidence- based practice using constructs in the Dynamic Sustainability Framework and will triangulate qualitative and quantitative data to ascertain the long-term impacts of SCIP. Aim III will develop an implementation playbook with input from our Operational Steering Committee comprised of national and local VA surgical stakeholders. Next Steps/Implementation: Test implementation playbook in a Hybrid Type III study to improve practice.

背景：SSI是常见且可预防的不良手术结局， 发病率和死亡率。术前抗菌药物给药可降低SSI;术后抗菌药物可 不会减少SSI，但会增加其他术后不良事件。在2005年，VA实施了外科手术 护理改善项目（SCIP），以提高围手术期质量指标的合规性，包括 适当使用抗菌剂。SCIP包括一套公开报道的循证抗菌指南 针对高风险手术的合规指标。这些指标要求进行资源密集型人工审查， 外部同行评审计划（EPRP）。2015年，SCIP实现了持续遵守 抗菌药物使用指标超过95%，由于人工审查成本高，该计划已退出 而预期的额外益处最小。本IIR提案以动态可持续性框架为指导 并研究了SCIP实现的抗菌实践变化是否持续，以及它们如何 扩展到超出计划最初范围的手术和实践领域。该多次PI提交， 博士希拉里穆尔，博士和博士Westyn分支-Elliman，医学博士，MMSC建立和扩大他们以前的VA资助 应用电子算法来衡量抗菌药物的使用并识别不良结果的协作工作。 意义/影响：提高抗菌药物处方和手术质量是VA的主要目标。财年 2018年，在VA内，SCIP目标专科（心脏，骨科， 一般/结肠直肠、妇科和血管）。其中，64%是门诊病人， 术后抗菌药物使用指南不一致，导致患者严重伤害。因此 研究对直接临床护理的潜在影响很大。此外，也有一些研究探讨 停止旨在支持遵守《公约》的现行方案后， 循证指南。拟议的研究将缩小这一差距，在实施科学研究。 创新：根据VA的学习健康系统指令，该项目将使用VA的电子 健康记录数据开发算法，以根据PI确定术前和术后抗菌药物使用 以前的工作。这些电子数据挖掘算法捕获结构化和文本笔记数据， 相对于昂贵的人工审查而言，这是一项重大的技术进步。这项研究还回答了一些重要的问题 在前线人员提供意见的情况下，就现行政策终止后，有关做法改变的可持续性进行讨论。 具体目的：1）测量SCIP后抗菌预防指南依从性的可持续性 退休并评估实践变化是否扩展到SCIP排除的程序; 2）评估促进者 通过与工作人员的访谈，了解执行可持续性的障碍， 3）制定一个包含评估工具、培训课程和其他要素的执行行动手册 支持在未来的HSR&D Hybrid III试验中扩大和推广循证抗菌实践。 方法学：目的我将调整现有的信息学算法，以提取术前和术后的抗菌药物 从临床笔记文本和抗菌订单中使用每个SCIP手术。以前手动审查 2005-2015年EPRP数据将被用作调整和完善数据挖掘工具的黄金标准。SCIP 可持续性将通过对2005-2020年数据应用经验证的抗菌药物合规性算法来衡量 以及执行中断的时间序列分析。SCIP在专科内的传播将通过回归进行评估 模型目标II将使用与一线工作人员的定性访谈，以确定证据可持续性的原因- 基于实践，使用动态可持续发展框架中的结构，并将定性和 量化数据，以确定SCIP的长期影响。Aim III将制定一个实施行动手册 我们的运营指导委员会由国家和地方VA外科利益相关者组成。 后续步骤/实施：在混合III型研究中测试实施剧本，以改进实践。