Infection Management and Antibiotic Stewardship in Nursing Homes

描述(由申请人提供)：抗生素管理(即推广适当的抗生素以改善结果，减少抗生素耐药性，并减少耐多药微生物的传播)是一项日益被视为疗养院(NH)居民护理迫切需要的创新。NHS呼吁对抗生素进行管理的潜在原因包括与医疗保健相关的多重耐药生物体感染的日益流行，高使用率，以及估计可能不需要25%-75%的处方。然而，减少“潜在的不适当”抗生素使用的挑战很多，而且与NH结构、处方流程和患者特征有关。拟议的实施和传播项目建立在已发表的证据和我们的研究团队成功实施的随机对照试验的基础上，在该试验中，我们将试验性NHS的抗生素处方减少了21.3%，而对照NHS的抗生素处方减少了6.7%(p=0.031)。在证明了有效性之后，我们的下一步是更广泛地实施和传播，但这样做需要注意几个问题。一方面，NH链及其相关的医疗实践是分开管理的，如果组织的切入点主要是通过NH组织或通过医疗提供者实践，目前尚不清楚创新实施是否会更有效。此外，有理由理解与两个入口点的实施和结果相关的因素，因为一些NHS没有适当的质量改进流程(这意味着通过医疗服务提供者的做法进入可能更有效)，而另一些可能有不同的医生照顾他们的住院医生(这意味着通过NH组织进入可能更有效)。另一个问题涉及保健机构组织和/或其医疗实践中的哪些因素与实施效果(保真度)和创新效果(结果)相关，以及这些因素是否因切入点而异。拟议的项目将解决这些问题，方法是根据不同的切入点，对两个分支机构进行执行试验：NH链或医疗服务提供者做法。根据这一努力的结果，我们将与质量改进组织(QIO)和其他利益攸关方合作，促进区域和国家的传播。因此，我们的具体目标是：(1)在34个NHS中进行为期24个月的抗生素管理比较(非随机)实施研究，包括两个实施分支(NH链重点；医疗实践重点)，以确定与(A)实施有效性(即吸收和保真度)和(B)创新有效性(即处方和健康结果)相关的实施方法和组织氛围的要素；以及(2)在区域和全国范围内传播该计划。拟议的项目由一个在这一领域拥有丰富经验的团队与强有力的合作伙伴合作开展，有可能对这一关键而复杂的问题产生国家影响。

DESCRIPTION (provided by applicant): Antibiotic stewardship (i.e., promotion of appropriate antibiotics to improve outcomes, reduce antibiotic resistance, and decrease the spread of multidrug-resistant organisms) is an innovation increasingly viewed as urgent for the care of nursing home (NH) residents. Reasons underlying the call for antibiotic stewardship in NHs include an increasing prevalence of healthcare-associated infections with multidrug resistant organisms, high rates of use, and estimates suggesting 25%-75% of prescriptions may not be needed. Challenges to reducing "potentially inappropriate" antibiotic use are many, however, and relate to the NH structure, prescribing processes, and patient characteristics. The proposed implementation and dissemination project builds on published evidence and our research team's success implementing a randomized controlled trial in which we reduced antibiotic prescribing by 21.3% in experimental NHs compared to 6.7% in control NHs (p=0.031). Having demonstrated efficacy, our next step is broader implementation and dissemination, but doing so requires attention to several issues. For one thing, NH chains and their associated medical practices are administered separately, and it is unclear whether innovation implementation will be more effective if the organizational point of entry is primarily through the NH organization or through medical provider practices. Further, there is reason to understand the factors associated with implementation and outcomes for both points of entry, as some NHs do not have processes in place for quality improvement (meaning that entry through medical provider practices may be more effective), and others may have diverse physicians caring for their residents (meaning that entry though the NH organization may be more effective). Another issue involves which factors within the organization of a NH and/or its medical practices are associated with implementation effectiveness (fidelity) and innovation effectiveness (outcomes), and whether these vary depending on point of entry. The proposed project will address these issues by conducting an implementation trial with two arms based on different points of entry: NH chains or medical provider practices. Based on the results of this effort, we will promote regional and national dissemination, in collaboration with a Quality Improvement Organization (QIO) and other stakeholders. Therefore, our specific aims are: (1) In a 24-month antibiotic stewardship comparative (non-randomized) implementation study in 34 NHs, with two implementation arms (NH chain focus; medical practice focus), to identify elements of the implementation approach and organizational climate that are associated with (a) implementation effectiveness (i.e., uptake and fidelity) and (b) innovation effectiveness (i.e., prescribing and health outcomes); and (2) To disseminate the program regionally and nationally. The proposed project, conducted by a team with extensive experience in this field, in collaboration with strong partners, has the potential to have national impact on this critical and complex issue.