Implementation and Effectiveness of a S. aureus Surgical Site Infection Preventio

约30-50%的手术部位感染是由金黄色葡萄球菌引起的。我们之前回顾了发表的文章 研究和目前的做法，以确定降低金黄色葡萄球菌SSI率的方法。根据我们的检讨，我们 开发了一套基于证据的捆绑方案：1)金黄色葡萄球菌的筛查，2)携带者的非殖民化，3) 头孢唑林和万古霉素预防甲氧西林耐药金黄色葡萄球菌携带者。捆绑药效为 在AHRQ资助的STOP SSI研究中对心脏手术(CO)患者进行测试，总计 20家美国医院公司(HCA)医院的髋关节(THA)或全膝关节(TKA)关节成形术。然而， 没有人将整个捆绑包或捆绑包元素的有效性与不捆绑包的有效性进行比较。此外， Stop SSI研究没有评估该捆绑包的促进者和执行障碍。这些差距存在于 我们的知识可能会阻止外科医生或医院实施该捆绑包。我们的目标是减少 金黄色葡萄球菌(S.aureus SSis)因此，我们建议在20间医管局医院扩展现时的综合社会保障指数研究，并 将研究扩展到更多的医院和外科手术人群，以便我们能够实现4个目标：1)评估 实施完整捆绑包、实施捆绑包的部分和非捆绑包的相对有效性(CE) 在接受CO、THA、TKA、脊柱手术的患者中实施预防金黄色葡萄球菌感染的捆绑包 手术(SO)或开颅/开颅(CRANI)；2)确定捆绑的促进者和障碍 在医院、外科服务和患者层面实施；3)创建可供医院使用的工具包 促进捆绑实施；4)确定捆绑是否增加了对莫匹罗星耐药的数量 或耐CHG的金黄色葡萄球菌分离株。目标1包括3个任务：1)继续准实验(QE)停止 在20家HCA医院进行SSI研究；2)增加医院和手术人群：爱荷华市退伍军人事务部 医学中心(ICVAMC；THA，TKA)，爱荷华大学医院和诊所(UIHC；CO，THA，TKA，SO， CRANI)和圣约人医院(CH；SO，CRANI)；3)重复QE研究的时间序列分析 扩展后的数据集，并进行CE研究，评估“全包”、“元素”的有效性 捆绑、“仅非殖民化”和“不捆绑元素”。HCA、UIHC、ICVAMC、9个额外的VAM和CH 将成为行政长官干预组；不使用捆绑包的8家杜克附属医院将被评为 组。AIM 2包括2个任务(用户界面、ICVAMC、CH、约翰霍普金斯医院、约翰霍普金斯附属医院 医院)来帮助我们确定促进或阻碍医护人员捆绑实施的因素，以及 病人：1)采访医护人员；2)调查病人。为Aim 3创建的工具包将提供 帮助其他医院的工作人员尽可能轻松地实施捆绑包的实用工具。因为莫匹罗星或 ChG耐药性可能会限制这些药物的未来使用，Aim 4将帮助我们确保该捆绑包不会 增加金黄色葡萄球菌对这些药物的抗药性。

Staphylococcus aureus causes ~30-50% of surgical site infections (SSIs). We previously reviewed published studies and current practices to identify ways to decrease S. aureus SSI rates. On the basis of our review, we developed an evidence-based bundle: 1) screening for S. aureus, 2) decolonization of carriers, and 3) prophylaxis with cefazolin and vancomycin for methicillin-resistant S. aureus carriers. The bundle efficacy is being tested in the AHRQ-funded STOP SSI Study among patients undergoing cardiac operations (CO), total hip (THA), or total knee (TKA) arthroplasties at 20 Hospital Corporation of America (HCA) hospitals. However, no one has compared the effectiveness of the whole bundle or of bundle elements with no bundle. Moreover, the STOP SSI Study did not evaluate facilitators and barriers to implementation of the bundle. These gaps in our knowledge may discourage surgeons or hospitals from implementing the bundle. Our goal is to decrease S. aureus SSIs. Thus, we propose to extend the current STOP SSI Study at the 20 HCA hospitals and to expand the study to additional hospitals and surgical populations so that we can accomplish 4 aims: 1) Assess the comparative effectiveness (CE) of implementing the full bundle, implementing parts of the bundle, and not implementing the bundle for preventing S. aureus SSIs among patients undergoing CO, THA, TKA, spine operations (SO), or craniotomy/craniectomy (CRANI); 2) Identify facilitators and barriers to bundle implementation at the hospital, surgical service, and patient level; 3) Create a toolkit that hospitals can use to facilitate bundle implementation; 4) Determine whether the bundle increases the number of mupirocin-resistant or CHG-resistant S. aureus isolates. Aim 1 involves 3 tasks: 1) Continue the quasi-experimental (QE) STOP SSI Study at 20 HCA hospitals; 2) Add hospitals and surgical populations: the Iowa City Veterans Affairs Medical Center (ICVAMC; THA, TKA), the University of Iowa Hospitals and Clinics (UIHC; CO, THA, TKA, SO, CRANI), and Covenant Hospital (CH; SO, CRANI); 3) Repeat the time series analysis from the QE study on the expanded dataset and conduct a CE study assessing the effectiveness of the "full bundle," "elements of the bundle," "decolonization only," and "no bundle elements." HCA, UIHC, ICVAMC, 9 additional VAMCs, and CH will be the CE intervention group; 8 Duke-affiliated hospitals, which do not use the bundle, will be the "no bundle" group. Aim 2 includes 2 tasks (UI, ICVAMC, CH, Johns Hopkins Hospital, Johns Hopkins-affiliated hospitals) to help us identify factors that facilitate or inhibit bundle implementation by healthcare workers and by patients: 1) Interview healthcare workers; 2) Survey patients. The toolkit created for Aim 3 will provide practical tools to help staff at other hospitals implement the bundle as easily as possible. Because mupirocin or CHG resistance could limit future use of these agents, Aim 4 will help us ensure that the bundle does not increase the number of S. aureus resistant to these agents.