Understanding and Addressing Variation in Healthcare-Associated Infections After Adult Cardiac Surgery

项目总结/摘要 每年有近250，000例患者接受外科冠状动脉血运重建和/或瓣膜修复或置换术 在美国.尽管手术护理和技术有所改进，但患者仍有很大的风险， 术后并发症对生活质量和生存率产生不利影响。卫生保健获得性感染 “HAIs”（例如，肺部、血流、深部胸骨伤口）发生在约10%的接受这些手术的患者中 操作，并显着增加90天付款10 - 13 K美元。较高与较低HAI的患者 医院有更高的主要发病率和死亡率的风险（18%对9%），p < 0.001。尽管现有的努力 专注于院内HAI预防实践（例如，适当的抗生素使用时间和类型，加强护理 护理单元捆绑依从性），HAI率存在显著的医院间差异。只有2%的医院 HAI比率的变化是由传统因素解释的，突出了确定重要决定因素的必要性。 我们的团队绘制了为心脏手术患者提供服务的提供者护理交付网络， 患者疾病管理和护理优化（例如，信息交流）， 完成协作任务（例如，患者选择，手术时机，重症监护室恢复，术后 出院护理）。我们已经合并了国家行政索赔 在接受持久左心室辅助装置的患者中进行临床登记研究，发现：（1） 服务于种族隔离社区的网络显示出更大的护理碎片化（即，弱连通性 （2）护理服务提供者之间的差异大于那些服务于更综合社区的护理服务提供者;（3）护理服务的分散程度增加， 这些网络在医院一级的运作是显着相关的概率增加90- 日HAI和（3）护理碎片（网络性能的衡量标准）和术后 出院支付显著介导术后HAI。了解障碍和促进因素 加强护理提供网络的各个阶段（入院前，指数入院， 出院）的最常见的心脏外科手术将作为基础， 有针对性的改善策略，以解决医院间HAI的变异性。基于社区的合作伙伴关系，即 帮助患者获得社区和卫生系统资源以及解决医疗保健不公平问题， 作为一个新的重点，制定循证，面向行动的HAI预防建议。的 本提案的目标是确定医疗服务网络中可提高HAI的干预领域 结果。这一大规模的混合方法提案解决了以下目标：（1）评估提供者护理 递送网络是心脏手术后感染的重要决定因素;（2）制定一个 全面了解最佳护理服务的结构性障碍和促进因素;（3）制定 最佳实践工具包，以解决提供者护理提供网络对心脏手术后感染的影响。

Project Summary/Abstract Nearly 250,000 patients annually undergo surgical coronary revascularization and/or valve repair or replacement in the US. Despite improvements in operative care and technology, patients remain at substantial risk of postoperative complications that adversely impact quality of life and survival. Healthcare-acquired infections “HAIs” (e.g., pulmonary, bloodstream, deep-sternal wound) occur in ~10% of patients undergoing these operations and significantly increase 90-day payments by $10-$13K. Patients at higher versus lower HAI tercile hospitals have higher (18% versus 9%) risk of major morbidity and mortality, p < 0.001. Despite existing efforts focused on in-hospital HAI prevention practices (e.g., appropriate timing and type of antibiotics, nursing intensive care unit bundle adherence), substantial interhospital variability persists in HAI rates. Only 2% of hospital variation in HAI rates is explained by traditional factors, highlighting the need to identify significant determinants. Our team has mapped provider care delivery networks serving cardiac surgery patients that reflect coordination of patient disease management and care optimization (e.g., communication and information exchange) to accomplish collaborative tasks (e.g., patient selection, timing of surgery, intensive care unit recovery, post- discharge care) across multiple provider specialties and settings. We have merged national administrative claims with clinical registry data among patients undergoing durable left ventricular assist devices and found: (1) networks serving racially segregated communities display greater care fragmentation (i.e., weaker connectivity among care providers) than those serving more integrated communities; (2) increased care fragmentation of these networks operating at the hospital level is significantly associated with an increase in the probability of 90- day HAIs and (3) the relationship between care fragmentation (a measure of network performance) and post- discharge payments is significantly mediated by postoperative HAIs. Understanding the barriers and facilitators for enhancing care delivery networks across phases of care delivery (pre-admission, index admission, post- discharge) for the most commonly performed cardiac surgical operations would serve as the foundation for targeted improvement strategies to address interhospital HAI variability. Community-based partnerships, that help patients access community and health system resources as well as address healthcare inequities, would serve as a novel focus for developing evidence-based, action-oriented HAI prevention recommendations. The objective of this proposal is to identify areas of intervention within care delivery networks that enhance HAI outcomes. This large-scale mixed methods proposal addresses the following aims: (1) Evaluate provider care delivery networks as significant determinants of postoperative infections after cardiac surgery; (2) Develop a comprehensive understanding of structural barriers and facilitators to optimal care delivery and (3) Develop a best practices toolkit to address the impact of provider care delivery networks on infections after cardiac surgery.