Building a Novel Antibiotic Stewardship intervention for nursing homes

描述（由申请人提供）：疗养院中高达75%的抗生素使用是不适当的。不适当的抗生素使用增加了养老院居民发生药物不良事件、艰难梭菌感染和抗生素耐药细菌感染的风险，这些风险可能会传播给他人。养老院抗生素管理干预的结果好坏参半。虽然针对提供者知识和影响处方决策的工作系统方面的多成分干预措施似乎减少了养老院中不适当的抗生素使用，但这些干预措施的工作机制尚不清楚。在缺乏这些知识的情况下，将这些干预措施成功地传播到其他养老院将是不可能的。因此，对养老院抗生素管理研究的迫切需要，不仅要评估干预措施对处方模式的影响，还要评估它们调解变化的机制。我们的长期目标是减少养老院不适当的抗生素使用。因此，我们的团队开发了一种新的抗生素管理干预措施，针对提供者的知识以及影响养老院抗生素决策的重要工作系统因素。这个特殊应用的目标是证明我们在两个州的养老院抗生素管理干预的有效性，并开发一种资源，以促进传播到其他养老院设置。我们将通过三个具体目标实现该项目的目标：1)量身定制抗生素管理干预措施，以实现最佳实施；2)评估其对研究疗养院抗生素使用的影响；3)利用获得的知识开发一个传播工具包。在第一个目标中，我们将使用人为因素分析来确定实施抗生素管理干预的障碍和促进因素。将对干预措施的组成部分进行调整，以克服这些障碍，并将根据研究疗养院的关键信息提供者的结构化输入，制定一套实施方案。在第二个目标中，量身定制的抗生素管理干预措施将在研究疗养院中实施，使用威斯康星大学首创的质量改进协作方法，并将抗生素使用措施与对照设施进行比较。在第三个目标中，通过干预中介研究结果对干预保真度、可持续性和机制进行混合方法评估所产生的知识将用于开发传播工具包。我们将用于定制干预措施并支持其实施（质量改进协作）的方法，以及我们将用于开发传播工具包的严格项目评估，这些都是本提案的创新方面。本研究意义重大；因为预期结果是

DESCRIPTION (provided by applicant): Up to 75% of antibiotic use in nursing homes is inappropriate. Inappropriate antibiotic use increases the nursing home resident's risk of adverse drug events, Clostridium difficile infection and infection with antibiotic- resistant bacteria, whih may then be spread to others. Results of antibiotic stewardship interventions in nursing homes have been mixed. While multi-component interventions targeting provider knowledge and aspects of the work system influencing prescribing decisions appear to reduce inappropriate antibiotic use in nursing homes, the mechanisms by which these interventions work is unclear. In the absence of this knowledge, successful dissemination of these interventions to other nursing home settings will not be possible. Consequently, there is a critical need for nursing home antibiotic stewardship studies that not only evaluate the impact of interventions on prescribing patterns but also evaluate the mechanisms by which they mediate change. Our long-term goal is to reduce inappropriate antibiotic use in nursing homes. Accordingly, our group has developed a novel antibiotic stewardship intervention that targets provider knowledge as well as important work system factors influencing antibiotic decision-making in nursing homes. The objectives of this particular application are to demonstrate the effectiveness of our antibioti stewardship intervention in nursing homes in two states and develop a resource to facilitate dissemination to other nursing home settings. We will achieve the objectives of this project through three specific aims: 1) tailor the antibiotic stewardship intervention for optimal implementation; 2) assess its impact on antibiotic use in study nursing homes; and 3) use knowledge gained to develop a dissemination toolkit. In the first aim, we will use human factors analyses to identify barriers and facilitators to implementation of the antibiotic stewardship intervention. Components of the intervention will be tailored to overcome these barriers and an implementation package will be developed with structured input from key informants in study nursing homes. In the second aim, the tailored antibiotic stewardship intervention will be implemented in study nursing homes using a quality improvement collaborative approach pioneered at the University of Wisconsin and antibiotic utilization measures will be compared with control facilities. In the third aim, knowledge generated from a mixed-methods assessment of intervention fidelity, sustainability and mechanisms by with the intervention mediates study outcomes will be used to develop a dissemination toolkit. The methods we will used to tailor our intervention and support its implementation (quality improvement collaborative) as well as the rigorous program evaluation we will employ to develop a dissemination toolkit are all innovative aspects of this proposal. The proposed research is significant; because it is expected to result in a multi-faceted intervention that can be exported broadly to effectively reduce improve antibiotic use in facilities, which will, in turn, will reduce C. difficile infections and the emergence and spread of antibiotic resistance in nursing homes and the communities they serve.