Guideline Implementation to Decrease Inappropriate Bacteriuria Treatment

对退伍军人医疗保健的预期影响：尿路感染（UTI）是最常见的单一疾病。 常见的医院感染然而，大多数医院导管的病例- 相关性尿路感染（CITTI）实际上是无症状菌尿（ABU）。ABU不是 具有临床意义的疾病，治疗不太可能带来益处。ABU的过度治疗 是一个质量，安全和成本问题，特别是因为不必要的抗生素导致出现 抗性植物群。我们的建议，使临床实践符合出版的指南， 显著降低VA患者抗结核感染和相关抗生素使用不当的潜力 医院的我们的研究还将提供有关如何最大限度地提高审计效率的信息- 反馈，以实现在住院VA设置的指南遵守。 项目背景/理由：循证指南建议提供者既不 在大多数插管患者中筛查ABU，也不治疗ABU。然而，这两者之间的差距很大。 指南和临床实践已经在我们的VA医院和整个 世界由于许多VA患者在急性护理环境和亚急性护理环境中，例如 中期和长期护理，有一个合理的需要导尿管，问题 导管相关ABU的过度治疗是VA的一个活跃问题。 项目目标：我们假设实施现有的循证指南 关于ABU的非治疗将大大减少不必要的抗生素使用， ABU和误诊的AMI的发生率。我们的第一个目标是提高 在特定临床结局方面对ABU的护理（不适当的筛查和 ABU的治疗）通过实施一个反馈策略。我们还假设 成功地执行一项反馈战略将导致在以下方面出现可衡量的变化： 临床医生对ABU实践指南的知识和态度。我们的第二个目标是 通过调查评估实施对临床医生指南意识的影响， 熟悉度、接受度和预期结果。 项目方法：我们的指南实施策略将采用反馈，作为一个 根据既定指南进行处方后抗菌药物审查。的研究人群 临床结局是干预地点（Houston VA）某些病房的所有住院患者， 对照研究中心（圣安东尼奥VA）。我们的研究人群的反馈干预， 是这些病房的卫生保健提供者。我们建议进行为期三年的研究。在第一 我们将观察ABU筛查和治疗不当的基线发生率 在这两个网站。临床结局的盲态监测将在未来2年内继续进行。 study.在第二年，我们将在这两个地点分发准则。的临床医生 干预研究中心将通过电话或亲自收到关于以下内容的个性化反馈 他们的菌尿管理是否符合指南。单位层面的反馈也将 提供了在第三年，个性化的反馈将停止，但单位级的反馈将 继续，因为这是一种可持续的干预。临床医生将完成以下的术前/术后调查： 第2年干预部位的认识、熟悉度、接受度和预期结局， 在第三年的两个地点。第2年个体化干预之间的结果差异 第三年的小组干预将有助于确定 在其他退伍军人管理局设施中传播和实施的干预措施。

Anticipated Impacts on Veterans' Healthcare: Urinary tract infection (UTI) is the single most common hospital-acquired infection. However, the majority of cases of nosocomial catheter- associated urinary tract infection (CAUTI) are really asymptomatic bacteriuria (ABU). ABU is not a clinically significant condition, and treatment is unlikely to confer benefit. Overtreatment of ABU is a quality, safety, and cost issue, particularly as unnecessary antibiotics lead to emergence of resistant flora. Our proposal to bring clinical practice in line with published guidelines has significant potential to decrease CAUTI and associated inappropriate antibiotic use in VA hospitals. Our study will also provide information about how to maximize effectiveness of audit- feedback to achieve guideline adherence in the inpatient VA setting. Project Background/Rationale: Evidence-based guidelines recommend that providers neither screen for nor treat ABU in most catheterized patients. However, a significant gap between these guidelines and clinical practice has been documented at our VA hospital and throughout the world. Since many VA patients in both acute care settings and sub-acute care settings, such as intermediate and long-term care, have a legitimate need for a urinary catheter, the issue of overtreatment of catheter-associated ABU is an active problem for the VA. Project Objectives: We hypothesize that implementing the existing evidence-based guidelines about non-treatment of ABU will dramatically reduce the unnecessary use of antibiotics to treat ABU and the incidence of incorrectly diagnosed CAUTI. Our first objective is to improve quality of care concerning ABU in terms of specific clinical outcomes (inappropriate screening for and treatment of ABU) through implementation of an audit-feedback strategy. We also hypothesize that successful implementation of an audit-feedback strategy will result in measurable changes in clinicians' knowledge and attitudes concerning ABU practice guidelines. Our second objective is to assess through surveys the effect of the implementation on clinicians' guideline awareness, familiarity, acceptance, and outcome expectancy. Project Methods: Our guidelines implementation strategy will employ audit-feedback, applied as a post-prescription antimicrobial review based on established guidelines. The study population for the clinical outcomes is all inpatients on certain wards at the intervention site (Houston VA) and the control site (San Antonio VA). Our study population for the audit-feedback intervention and surveys is the health care providers on these wards. We propose a 3-year study. During the first year we will observe the baseline incidence of inappropriate screening for and treatment of ABU at both sites. Blinded monitoring of clinical outcomes will continue during the next 2 years of the study. During the second year, we will distribute the guidelines at both sites. Clinicians at the intervention site will receive individualized feedback, either by telephone or in person, about whether their management of bacteriuria was guideline-compliant. Unit-level feedback will also be provided. During the third year, individualized feedback will cease, but unit-level feedback will continue as this constitutes a sustainable intervention. Clinicians will complete pre/post surveys of awareness, familiarity, acceptance, and outcome expectancy at the intervention site in year 2 and at both sites in year 3. Differences in outcomes between the individualized intervention in year 2 and the group-level intervention in year 3 will help to determine the necessary intensity of intervention for dissemination and implementation in other VA facilities.