Systems analysis of guideline adherence in neonatal intensive care

 描述（由申请人提供）：尽管美国在降低中心静脉导管相关血流感染（CLABSI）率方面取得了重大进展，但CLABSI仍然是美国新生儿重症监护病房（NICU）中可预防的医疗保健相关伤害的主要原因。大多数CLABSI发生在维持期中心静脉导管插入后，此时护士经常使用中心静脉导管进行静脉给药（IVMA）。当护士可靠地遵守标准化护理流程（如中心线维护指南）时，CLABSI大多是可以预防的，但NICU报告难以维持指南的遵守。目前增加依从性的方法集中在改善个体临床医生的表现，尽管这种方法对于随着时间的推移维持指南依从性是无效的。有必要采取另一种方法来维持通过质量改进努力减少的CLABSI。我们建议严格识别危害，并评估与NICU护士遵守CLABSI和IVMA指南相关的风险。我们将采取人为因素工程方法，并使用工作系统和患者安全的系统工程倡议（SEIPS）模型，对指南遵守情况进行前瞻性风险评估。本研究的具体目的是：1）识别NICU工作系统中威胁护士遵守CLABSI和IVMA指南的危害; 2）评估与遵守指南相关的潜在失效模式风险。我们将采用定性和定量的数据收集方法，以实现目标，包括直接观察，访谈，医疗保健失败模式和影响分析，以及与在NICU提供直接患者护理的护士进行的焦点小组。这项研究与公众的健康有关，因为它将增加我们对NICU工作系统（技术，任务，环境）中的因素如何影响护士遵守（和不遵守）旨在预防医院获得性感染和IVMA相关错误的指南的理解。该项目的结果将直接为干预措施提供信息，以提高NICU的指南依从性并提高新生儿患者的安全性。

 DESCRIPTION (provided by applicant): Despite significant national progress in reducing central line-associated blood stream infection (CLABSI) rates, CLABSI remains a leading cause of preventable healthcare-associated harm in American neonatal intensive care units (NICUs). Most CLABSIs occur after central line insertion during the maintenance phase when central lines are frequently accessed by nurses for intravenous medication administration (IVMA). CLABSIs are mostly preventable when nurses reliably adhere to standardized care processes such as central line maintenance guidelines, yet NICUs report difficulty sustaining guideline adherence. Current approaches to increasing adherence focus on improving individual clinician performance, although such approaches are not effective for sustaining guideline adherence over time. An alternative approach is necessary to sustain CLABSI reductions made through quality improvement efforts. We propose to rigorously identify hazards and assess risks associated with NICU nurses' adherence to CLABSI and IVMA guidelines. We will take a human factors engineering approach and use the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety to conduct a prospective risk assessment of guideline adherence. The specific aims of the study are to 1) Identify hazards in the NICU work system that threaten nurses' adherence to CLABSI and IVMA guidelines and 2) Assess risk of potential failure modes associated with guideline adherence. We will employ both qualitative and quantitative data collection methods to achieve the aims including direct observations, interviews, Healthcare Failures Modes and Effects Analysis, and focus groups conducted with nurses who provide direct patient care in the NICU. This study is relevant to the public's health because it will increase our understanding of how factors in the NICU work system (technologies, tasks, the environment) influence nurses' adherence (and non-adherence) to guidelines intended to prevent hospital-acquired infections and IVMA-related errors. The results of this project will directly inform interventions to improve guideline adherence in the NICU and enhance neonatal patient safety.