Leveraging inpatient antimicrobial stewardship infrastructure to improve antimicrobial-prescribing at hospital discharge

利用住院患者抗菌药物管理基础设施改善出院时的抗菌药物处方

• 批准号: 10620189
• 负责人: Daniel Livorsi
• 金额: --
• 依托单位: IOWA CITY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-07-01 至 2026-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10620189
• 关键词: Address; Admission activity; Adverse drug event; Advisory Committees; Antimicrobial Resistance; Attitude; Case Mixes; Characteristics; Clinical; Clostridium difficile; Communicable Diseases; Communities; Data; Dedications; Development; Dose; Feedback; Fostering; Funding; Future; Goals; Health Priorities; Healthcare; Home; Hospital Administration; Hospitalization; Hospitals; Infection; Infrastructure; Inpatients; Intervention; Interview; Knowledge; Length of Stay; Literature; Manuals; Measurement; Methodology; Modeling; Monitor; Outcome; Paper; Patient Admission; Patient Discharge; Patients; Perception; Performance; Pharmaceutical Preparations; Process; Promoting Action on Research Implementation in Health Services framework; Public Health; Qualitative Methods; Resources; Risk Adjustment; Risk Factors; Safety; Services; Site; Site Visit; Standardization; Structure; Surveys; Targeted Research; Time; Variant; Veterans; Veterans Health Administration; Visit; Work; acute care; antimicrobial; dashboard; design; emerging antimicrobial resistance; evidence base; hospital care; improved; innovation; patient oriented; patient safety; patient subsets; pilot test; programs; tool

Background: Antimicrobial overuse is one of the strongest risk factors for the emergence of antimicrobial resistance, an urgent public health problem. Antimicrobial stewardship programs (ASPs) are hospital-based programs that can reduce unnecessary inpatient antimicrobial use and are therefore an essential tool for addressing the crisis of antimicrobial resistance. ASPs are mandated in VHA. Significance: VHA hospitals are only required to monitor their inpatient antimicrobial use. However, at least 40% of antimicrobial exposure associated with a VHA hospital stay is prescribed at hospital discharge and is taken by the patient after discharge (i.e. post-discharge). These post-discharge antimicrobial prescriptions are frequently unnecessary or sub-optimal. Reducing post-discharge antimicrobial overuse will minimize patient harm, such as Clostridioides difficile infections, antimicrobial resistance, and adverse drug events. Innovation and Impact: This proposal will address two critical gaps in the literature. First, standard ASP metrics do not capture post-discharge antimicrobial use and therefore miss a substantial amount of hospital- related antimicrobial exposure. This proposal will evaluate factors that contribute to variation in post-discharge antimicrobial use across patients and hospitals in order to inform both metric development and the design of future stewardship interventions. Second, while there are evidence-based strategies for safely reducing inpatient antimicrobial use, it is unclear how current inpatient ASP activities can decrease post-discharge antimicrobial overuse. This proposal will explore how inpatient ASP infrastructure, which all VHA hospitals are expected to have, can be leveraged to reduce unnecessary post-discharge antimicrobial-prescribing. Specific Aims: Aim 1: Identify factors that contribute to variation in post-discharge antimicrobial use in VHA acute-care admissions across all facilities by evaluating potential patient-level, hospital-level, and environmental effects. Identify hospitals that have low observed-to-expected post-discharge antimicrobial use, low risk-adjusted inpatient antimicrobial use, and perform well on clinical outcomes in antimicrobial-treated patients. Aim 2: Determine whether being admitted to a hospital with a discharge-focused stewardship process is associated with less post-discharge antimicrobial exposure, after adjusting for differences in case-mix, ID expertise, inpatient antimicrobial exposure, and the intensity of inpatient ASP activities. Aim 3: Using qualitative methods, evaluate attitudes and processes that impede or foster reductions in unnecessary post-discharge antimicrobial use. We will perform site visits at 6 high- and 4 low-performing sites, as identified in Aim 1. Methodology: Aim 1 will use VINCI data and linear mixed models to identify factors that influence post- discharge antimicrobial use. Aim 1 will also rank hospitals on their performance on inpatient and post- discharge antimicrobial use plus associated clinical outcomes. In Aim 2, we will leverage VINCI data and findings from a mandatory hospital-level stewardship survey conducted in VHA during November 2020. We will evaluate the effect of a discharge-specific stewardship process on post-discharge antimicrobial use. In Aim 3, we will conduct semi-structured interviews with key stakeholders at 10 hospitals to explore determinants of post-discharge antimicrobial overuse and perceptions of the post-discharge antimicrobial use metric that we developed in Aim 1. Our approach will be based in the i-PARIHS framework. Next Steps/Implementation: The standardized hospital-level metrics we develop in Aim 1 could be incorporated into an interactive ASP dashboard our Patient Safety Center of Inquiry has already built and is pilot-testing in VISN 23. Our findings from Aims 2 and 3 could be incorporated into future stewardship surveys within VHA while informing the processes local ASPs choose to implement to reduce post-discharge antimicrobial overuse. Our findings could serve as the basis for a multicenter, audit-and-feedback trial focused on stewardship at hospital discharge and future work around re-designing ASP processes at discharge.

背景：抗菌过度使用是出现抗菌剂的最强风险因素之一 抵抗，紧急的公共卫生问题。抗菌管理计划（ASP）是基于医院的 可以减少不必要的住院抗菌使用的程序，因此是必不可少的工具 解决抗菌抗性的危机。 ASP是在VHA中要求的。 意义：VHA医院只需要监测其住院抗菌剂的使用。但是，至少 与VHA医院住院相关的抗菌暴露的40％是在医院出院处方的，IS 出院后由患者服用（即入院后）。这些释放后的抗菌处方是 经常不必要的或次优。减少病后抗菌过度使用会使患者最大程度地减少 危害，例如梭状芽胞杆菌艰难梭菌感染，抗菌素耐药性和不良药物事件。 创新和影响：该提案将解决文献中的两个关键差距。首先，标准ASP 指标不会捕获抗菌后使用抗菌药物，因此错过了大量医院 相关的抗菌暴露。该提案将评估导致病产后差异的因素 为了通知度量的开发和设计 未来的管理干预措施。第二，尽管有基于证据的策略可以安全减少 住院抗菌使用，目前尚不清楚当前的住院ASP活动如何减少病后 抗菌过度使用。该建议将探讨所有VHA医院的住院ASP基础设施如何 预计可以利用，以减少不必要的释放后抗菌药物。 具体目的：目标1：确定因VHA抗菌后抗菌剂使用而导致差异的因素 通过评估潜在的患者水平，医院级和 环境影响。确定观察到的较低指向预期的抗菌抗菌使用的医院， 低风险调整后的住院抗菌使用，并在抗菌治疗的临床结果上表现良好 患者。 AIM 2：确定是否被送往医院，以出院为中心 与较少的抗菌后抗菌暴露有关，在调整病例混合差异后，ID 专业知识，住院抗菌暴露以及住院ASP活动的强度。目标3：使用定性 方法，评估态度和过程会阻碍或促进不必要的后收费的降低 抗菌使用。我们将在AIM 1中确定的6个高和4低绩效站点的现场访问。 方法：AIM 1将使用VINCI数据和线性混合模型来确定影响后影响的因素。 放电抗菌素。 AIM 1还将对医院进行住院和后的表现进行排名 放电抗菌素使用以及相关的临床结果。在AIM 2中，我们将利用Vinci数据和 2020年11月在VHA进行的强制医院级管理调查的调查结果。我们将 评估特定于排放的管理过程对放电后抗菌剂使用的影响。在AIM 3中， 我们将对10家医院的主要利益相关者进行半结构化访谈，以探索 抗菌后抗菌过度使用和对抗菌后使用度量指标的看法 在AIM 1中开发。我们的方法将基于I-Parihs框架。 下一步/实施：我们在AIM 1中开发的标准化医院级指标可能是 并入互动式ASP仪表板，我们的患者询问中心已经建立，并且是 VISN 23中的飞行员测试。我们来自AIM 2和3的发现可以纳入未来的管理调查中 在VHA内部通知本地ASP的过程中，请选择实施以减少后收费 抗菌过度使用。我们的发现可以作为以多中心，审计反馈试验为中心的基础 在医院出院和将来的工作中，围绕重新设计出院时的ASP流程。