Barriers and Facilitators for Clostridium difficile Bundle Implementation

影响：预防艰难梭菌是VA的优先事项，实施C。艰难 预防包，类似于已经建立的耐甲氧西林金黄色葡萄球菌（MRSA）包， 最近已经在全国范围内推广。然而，我们设计和实施遏制战略的能力 梭由于对影响感染、传播和预防的因素了解有限， 梭很难实现本建议目标的直接好处将是产生重要的 使用系统工程方法收集关于执行障碍和促进因素的数据。我们的研究 将产生具有广泛相关性和可移植性的数据、方法和工具， 减少医疗保健相关感染（HAI），包括但不限于C.艰难感染 背景：C.艰难梭菌是医院感染性腹泻的主要原因， 医院腹泻的病例。C.艰难梭菌感染（CDI）的发病率和严重程度正在增加， 每年有50万美国人死亡，每年造成2万人死亡，并给美国带来巨大的经济负担。 医疗保健机构-美国每年11亿美元预防CDI至关重要;因此，退伍军人事务部 多药耐药微生物（MDRO）计划办公室最近授权了一项国家预防计划 在VA设施的CDI。捆绑包包括适当的诊断测试，手部卫生的优化 通过监测、CDI接触隔离和CDI患者房间的环境清洁实现依从性。 然而，它并没有解决最佳的实施战略，以确保成功地应用这些 干预措施。它也没有规定如何采取这些措施。执行和遵守 这些建议的措施在各机构之间差别很大。 目标：我们假设一些工作系统障碍可能对成功的 接受、采用和实施CDI捆绑包。我们的目标是评估工作系统障碍 和促进者使用混合方法捆绑实现。我们将直接进行 观察与CDI预防相关的做法;开展医疗工作者焦点小组;以及 使用小插图来检查HCW的看法，态度和关于CDI预防的决策。 方法：我们将使用创新的患者安全系统工程倡议（SEIPS）模型， 工作制度和病人安全作为研究框架。该模型以及有关指南的一般文献 实施，将指导焦点小组的问题。将举行三个焦点小组会议。参与者将 包括护士、医生和环境服务。每节课将包括4-5个开放式问题 （覆盖60-90分钟）。我们将设计描述患有CDI或有CDI风险的患者的纸质病例插图，我们将 向医生、护士和环境服务人员询问CDI的相关感染控制实践 预防卫生保健工作者将被问到他们是否会进行CDI的诊断测试， 他们是否会开经验性治疗、隔离或减少伴随的抗生素。Vignette数据将 运用判断分析法进行分析。最后，我们将对HCW进行直接观察 基于SEIPS模型。我们将观察病房，个人，任务和组织，以更好地 了解围绕CDI患者护理过程的整体工作系统。 这是第一批系统地研究实施的障碍和促进因素的研究之一， 为主要的HAI-CDI-提供预防包。我们的项目是创新的，因为它将采用 SEIPS框架，对CDI预防进行完整的工作系统分析;使用一些 数据收集的补充方法;不仅考虑直接参与患者护理的HCW， 也包括对成功预防CDI至关重要的辅助人员。我们的研究方法和途径可能是 不仅广泛用于CDI，还广泛用于其他HAI，并将增加患者安全和感染控制领域。

Impact: Prevention of Clostridium difficile is a priority of the VA, and implementation of a C. difficile prevention bundle, akin to an already established methicillin-resistant Staphylococcus aureus (MRSA) bundle, has recently been rolled out nationally. However, our ability to devise and implement strategies for containment of C. difficile is hampered by a limited understanding of factors influencing acquisition, spread, and prevention of C. difficile. Immediate benefits of achieving the objectives of this proposal will be generation of important data regarding barriers and facilitators of implementation using a systems engineering approach. Our study will produce data, methods, and tools that have widespread relevance and portability, with the potential to reduce healthcare-associated infections (HAIs) including but not limited to C. difficile infection. Background: C. difficile is the major infectious cause of nosocomial diarrhea, causing as many as 25% of cases of nosocomial diarrhea. C. difficile infection (CDI) is increasing in incidence and severity, affects 500,000 Americans each year, causes 20,000 deaths annually, and imposes a significant financial burden on healthcare institutions - $1.1 billion annually in the U.S. Preventing CDI is essential; thus, the Veterans Affairs Multidrug Resistant Organism (MDRO) Program Office has recently mandated a national bundle for prevention of CDI at VA facilities. The bundle includes appropriate diagnostic testing, optimization of hand hygiene compliance by monitoring, contact isolation for CDI, and environmental cleaning of rooms of patients with CDI. However, it does not address optimum implementation strategies to ensure successful application of these interventions. Nor does it prescribe how these measures may be undertaken. Implementing and adhering to these recommended measures varies considerably across institutions. Objectives: We hypothesize that a number of work system barriers may pose challenges to successful acceptance, adoption, and implementation of the CDI bundle. Our objective is to assess work system barriers and facilitators to bundle implementation using a mixed-methods approach. We will undertake direct observations of practices relevant to CDI prevention; conduct focus groups of healthcare workers (HCWs); and use vignettes to examine HCW perceptions, attitudes, & decision-making about CDI prevention. Methods: We will use the innovative Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety as the study framework. This model, as well as general literature on guideline implementation, will guide focus group questions. Three focus groups will be conducted. Participants will include nurses, physicians, and environmental services. Each session will include 4-5 open-ended questions (covering 60-90 min). We will design paper case vignettes depicting patients with or at risk for CDI, and we will ask physicians, nurses, and environmental services staff about relevant infection control practices for CDI prevention. Healthcare workers will be asked whether they would undertake diagnostic testing for CDI and whether they would prescribe empiric treatment, isolation, or reduce concomitant antibiotics. Vignette data will be analyzed using the method of judgment analysis. Finally, we will conduct direct observations of HCWs based on the SEIPS model. We will observe patient rooms, individuals, tasks, and organization to better understand the overall work system that surrounds the process of care for CDI patients. This is among the first research studies to systematically examine barriers and facilitators of implemen- tation of a prevention bundle for CDI, which is a major HAI. Our project is innovative in that it will employ the SEIPS framework to undertake a complete work systems analysis for CDI prevention; use a number of complementary approaches to data collection; and consider not just HCWs involved in direct patient care, but also ancillary staff who are critical to successful CDI prevention. Our study methods and approach may be widely used not just for CDI but also other HAIs, and will add to the fields of patient safety and infection control.