Comparative safety and effectiveness of isolation in VHA community living centers

描述（由申请人提供）： 摘要：VHA一直是感染控制的领导者，其MRSA预防倡议旨在预防急性护理和长期护理中的感染。MRSA预防倡议的一个基石是在入院、出院和每半年对所有患者进行MRSA检测。美国没有其他医疗保健系统获得如此数量的MRSA数据。那些被发现患有MRSA的急性护理患者被隔离在一个私人房间，医护人员（HCW）需要使用长袍和手套进行接触。在急性护理中，隔离与更少的HCW就诊和更大的抑郁、焦虑、谵妄、更差的过程测量和更多的不良事件（主要是福尔斯和压疮）相关。目前在长期护理机构（LTCF）的感染预防措施是从那些专为急性护理环境，可能不适合LTCF人群。在社区生活中心（CLC），VHA致力于为退伍军人提供长期的住宿护理，体现了家庭般的环境属性。CLC中隔离的使用因机构而异，从非常积极的（长期隔离那些无法进行个人卫生或活动性感染的人-遵守VA MRSA PI的机构）到保守的（对所有患者使用标准预防措施-主要是手部接触-遵守CDC指南的机构）。这些政策是基于低质量的数据和CLC之间的这种做法差异的影响是未知的;然而，这些问题是至关重要的近45,000退伍军人居住在CLC（根据最近的VHA/CDC出版物高达58%的CLC居民有MRSA）。CLC居民经常需要转移到急性护理设施的感染，并导致爆发急性护理。由于CLC构成了一个家庭般的住所和医疗设施，了解CLC中的MRSA隔离实践需要一种多方法方法，该方法既要考虑国家比较有效性数据，又要考虑遵守感染预防政策的障碍的一线观点。为了进行一项全国性的比较有效性研究，我们将首先对所有CLC进行调查，以评估MRSA隔离实践（作为暴露），并使用独特的VHA二级数据库来评估MRSA获得和感染（IPEC）和非预期后果（MDS 3.0）。将采用直接观察方法来量化这10个CLC中的HCW-居民相互作用。调查结果将为在10个地理上分散的CLC中与CLC HCW进行一对一访谈的招聘提供信息，以了解HCW对遵守感染预防实践的障碍的信念，知识和看法。这些访谈将确定感染预防教育的教育需求。通过这些使用独特VHA数据的综合项目，我们希望确定隔离的哪些方面与1）MRSA预防和2）意外后果有关，以及未来的感染预防工作如何最好地改善整体患者安全性。这些信息将促进长期护理中患者安全的科学，并为VHA CLC感染预防的更合理政策和教育提供信息。

DESCRIPTION (provided by applicant): Abstract: The VHA has been a leader in infection control with the MRSA Prevention Initiative to prevent infections in both acute-care and long-term care. A cornerstone of the MRSA Prevention Initiative is testing all patients for MRSA on admission, discharge and semi-annually. No other healthcare system in the US obtains this amount of MRSA data. Those acute-care patients found to have MRSA are isolated in a private room and healthcare workers (HCW) are required to use of gown and gloves for contact. In acute-care isolation has been associated with fewer HCW visits and greater depression, anxiety, delirium, worse process measure and more adverse events (primarily falls and pressure ulcers). Current infection prevention practices in long-term care facilities (LTCFs) are adopted from those designed for acute-care settings and may not be appropriate for a LTCF population. In Community Living Centers (CLCs), the VHA is committed to providing Veterans with long-term, residential care that embodies the attributes of a home-like environment. The use of isolation in CLCs varies by facility from very aggressive (long-term isolation of those unable to perform personal hygiene or with active infections-facilities adhering to the VA MRSA PI) to conservative (using standard precautions for all patients-primarily hand hygiene-facilities adhering to CDC guidelines). These policies are based on low quality data and the effect of this practice variation between CLCs is unknown; however these issues are of critical significance to the nearly 45,000 Veterans residing in CLCs (according to a recent VHA/CDC publication up to 58% of CLC residents have MRSA). CLC residents often require transfer to acute-care facilities for infections and have led to outbreaks n acute-care. Because CLCs constitute both a home-like residence and a medical facility, understanding MRSA isolation practices in CLCs requires a multi-method approach that accounts for both national comparative effectiveness data and front-line perspectives on the barriers to adhering to infection prevention policies. To pursue a nationwide comparative effectiveness study we will first develop and administer a survey to all CLCs to assess MRSA isolation practice (as an exposure) and use unique VHA secondary databases for outcomes MRSA acquisition and infection (IPEC) and unintended consequences (MDS 3.0). Direct observation methods will be employed to quantify HCW-resident interactions at these 10 CLCs. Survey results will inform recruitment for one-on-one interviews with CLC HCWs at 10 geographically dispersed CLCs to understand HCW beliefs, knowledge and perceptions of barriers to adherence with infection prevention practices. These interviews will identify educational needs for infection prevention education. Through these integrated projects that use unique VHA data we expect to determine which aspects of isolation are associated with 1) MRSA prevention and 2) unintended consequences and how future infection prevention efforts can best improve overall patient safety. This information will advance the science of patient safety in long-term care and inform more rational policy and education for infection prevention in VHA CLCs.