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

背景：抗菌药物的过度使用是抗菌药物出现的最强烈的危险因素之一 耐药性，一个紧迫的公共卫生问题。抗菌药物管理计划(Asp)是以医院为基础的 可以减少住院患者不必要的抗菌药使用的计划，因此是 解决抗菌素耐药性危机。在VHA中强制规定了ASP。 意义：VHA医院只需监测其住院患者的抗菌药使用情况。然而，至少 与VHA住院相关的40%的抗菌药物暴露是在出院时开出的，并且是 病人在出院后(即出院后)服用。这些出院后的抗菌药处方是 经常是不必要的或次优的。减少出院后抗菌药物的过度使用将使患者最小化 危害，如艰难梭状芽胞杆菌感染、抗菌素耐药性和药物不良事件。 创新和影响：这项建议将解决文献中的两个关键空白。第一，标准的ASP 指标不包括出院后抗菌药物的使用，因此错过了大量医院- 相关的抗菌药物暴露。该提案将评估导致出院后变化的因素。 在患者和医院中使用抗菌药物，以便为衡量标准的制定和设计提供信息 未来的管理干预。第二，虽然有基于证据的战略来安全减少 住院患者使用抗菌药物，目前尚不清楚目前住院患者的ASP活动如何减少出院后 抗菌药物的过度使用。该提案将探讨住院患者的ASP基础设施，即所有VHA医院 预期有，可用于减少出院后不必要的抗菌药物处方。 具体目标：目标1：确定导致VHA出院后抗菌药物使用变化的因素 通过评估潜在的患者级别、医院级别和 对环境的影响。找出出院后抗菌药物使用率较低的医院， 低风险调整的住院患者抗菌药物使用，并在抗菌药物治疗的临床结果中表现良好 病人。目标2：确定是否进入以出院为重点的管理流程的医院 在调整了病例组合的差异后，与出院后较少的抗菌药物暴露有关，ID 专业知识、住院患者的抗菌药物暴露以及住院患者ASP活动的强度。目标3：使用定性方法 方法，评估阻碍或促进减少不必要的出院后的态度和程序 抗菌药物的使用。我们将对目标1中确定的6个高绩效网站和4个低绩效网站进行实地考察。 方法：AIM 1将使用芬奇数据和线性混合模型来识别影响后评估的因素 排出抗菌药物的使用。AIM 1还将根据医院在住院和离职后的表现对其进行排名 出院抗菌药物的使用以及相关的临床结果。在目标2中，我们将利用芬奇数据和 2020年11月在VHA进行的强制性医院级管理调查的结果。我们会 评估特定出院管理流程对出院后抗菌药物使用的影响。在《目标3》中， 我们将与10家医院的主要利益相关者进行半结构化访谈，以探索 出院后抗菌药物过度使用和对出院后抗菌药物使用指标的认知 我们的方法将以I-PARIHS框架为基础。 下一步/实施：我们在目标1中制定的标准化医院级指标可能是 整合到一个交互式的ASP仪表板中，我们的患者安全查询中心已经建立并正在 在VISN 23中试运行。我们在AIMS 2和AIMS 3中的发现可以被纳入未来的管理调查中 在VHA内，同时通知当地ASP选择实施的流程，以减少后排放 抗菌药物的过度使用。我们的发现可以作为以审计和反馈为重点的多中心试验的基础 关于医院出院时的管理和未来关于重新设计出院时三磷酸腺苷流程的工作。

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.