Checklist to Prevent MRSA Surgical Site Infections

描述（由申请人提供）： 目标与设计：耐甲氧西林金黄色葡萄球菌（MRSA），占估计94，000侵入性感染和19，000死亡，每年在美国为了防止退伍军人中的MRSA感染，VA成功地实施了VA MRSA预防倡议，减少了MRSA的患者到患者的传播。然而，该倡议并不能预防大多数MRSA手术部位感染（SSI），因为MRSA SSI通常是由MRSA从患者的鼻子转移到他们自己的手术切口部位引起的。心脏手术和全关节置换术（TJA;例如髋关节或膝关节手术）是VA最常见的手术，具有特别高的临床和经济影响。为了消除VA中的MRSA SSI，研究小组基于研究的Meta分析开发了一份清单，该研究评估了预防TJA和心脏手术患者中革兰氏阳性SSI的方法。该SSI检查表包括术前测试手术患者的鼻部是否存在无症状MRSA定植。如果患者为MRSA定植，则将使用莫匹罗星软膏、葡萄糖酸氯己定浴和头孢唑啉和万古霉素预防性抗生素进行预防性治疗。SSI检查表将在10个VA医疗中心（VAMC）实施。将进行一项高质量的准实验研究，并进行定性过程评价，以评估SSI检查表。本项目的目标是：1）评估清单的有效性和成本效益，以防止在接受TJA或心脏手术的退伍军人中发生MRSA SSI; 2）评估清单实施的障碍和促进因素。 方法：本研究包括定量和定性两部分。在定量部分，SSI检查表将在10个VAMC中实施3年，并将在干预组和两个对照组之间比较结局：1）来自相同10个VAMC的5年历史数据，2）来自未实施SSI检查表的其他VAMC的8年（5个历史年份和3个干预年份）同期数据。研究终点将包括：1）CDC定义的MRSA SSI; 2）由其他病原体引起的SSI; 3）预防每个SSI的成本、挽救每个生命的成本、预防每个MRSA SSI的成本以及挽救每个质量调整生命年（QALY）的成本。将使用VA数据库（包括VA国家手术质量改进计划（VASQIP）、VA决策支持系统、VA住院患者评估中心（IPEC）和退伍军人信息学和计算基础设施（芬奇））收集数据。将使用时间序列分析和线性混合效应模型进行统计分析。在定性部分，将在6个不同的VAMC进行过程评估，其中包括在实施之前，期间和之后收集数据，以检查影响SSI清单采用的背景因素和利益相关者观点。 观察和半结构化访谈将在第1年和第3年进行，沿着主题内容分析，以检查不同研究地点实施的促进因素和障碍。实施研究综合框架将用于指导过程评价，并为系统评价影响SSI清单实施的当地背景因素提供基础。本研究的产品包括经过验证的SSI检查表、业务案例分析、实施工具包以及在预防感染的检查表实施方面经验丰富的团队。在本研究期结束时，研究小组将与包括国家传染病计划办公室（NIDS）和MRSA /多重耐药计划办公室（MDRO）以及国家职业健康和感染控制中心（COHIC）在内的运营合作伙伴会面，讨论在全国范围内实施此清单作为VA MRSA预防计划的一部分。这项研究有很大的潜力，以显着减少SSI，并反过来发病率和死亡率由于SSI，在我们国家的退伍军人。

DESCRIPTION (provided by applicant): Aims and Design: Methicillin-resistant Staphylococcus aureus (MRSA), accounts for an estimated 94,000 invasive infections and 19,000 deaths annually in the U.S. In order to prevent MRSA infections among veterans, the VA successfully implemented the VA MRSA Prevention Initiative that has reduced patient-to- patient transmission of MRSA. However, this Initiative does not prevent most MRSA surgical site infections (SSIs) because MRSA SSIs are usually caused by MRSA transferring from a patient's nose to their own surgical incision site. Cardiac surgery and total joint arthroplasty (TJA; e.g. hip or knee surgery) are among the most common operations performed by the VA and are associated with particularly high clinical and economic impact. In order to eliminate MRSA SSIs in the VA, the study group developed a checklist based on a meta- analysis of studies that assessed methods to prevent gram-positive SSIs among TJA and cardiac surgery patients. This SSI Checklist includes preoperatively testing a surgical patient's nose for asymptomatic MRSA colonization. If the patient is MRSA colonized, s/he will be treated with prophylactic nasal mupirocin ointment, chlorhexidine gluconate baths, and antibiotic prophylaxis with both cefazolin and vancomycin. The SSI Checklist will be implemented in 10 VA Medical Centers (VAMCs). A high-quality quasi-experimental study, with a qualitative process evaluation will be performed to assess the SSI Checklist. The goals of this project are 1) to assess the effectiveness and cost-effectiveness of the checklist to prevent MRSA SSIs among veterans undergoing TJA or cardiac surgery, and 2) to assess barriers and facilitators to checklist implementation. Methods: This study includes both quantitative and qualitative components. In the quantitative component, the SSI Checklist will be implemented in 10 VAMCs for 3 years and outcomes will be compared between the intervention group and two control groups: 1) 5 years of historic data from the same 10 VAMCs, 2) 8 years (5 historic year and 3 intervention years) of concurrent data from other VAMCs that did not implement the SSI Checklist. Study endpoints will include: 1) MRSA SSIs as defined by the CDC; 2) SSIs caused by other pathogens; 3) cost per SSI prevented, cost per life-saved, cost per MRSA SSI prevented and cost per quality- adjusted life-year (QALY) saved. VA databases including VA National Surgical Quality Improvement Program (VASQIP), VA Decision Support System, VA Inpatient Evaluation Center (IPEC) and Veterans' Informatics & Computing Infrastructure (VINCI) will be used to collect data. Time series analysis and linear mixed effects models will be used for the statistical analysis. In the qualitative component, a process evaluation will be conducted at 6 different VAMCs, which includes collecting data before, during and after implementation, to examine the contextual factors and stakeholder perspectives that influence adoption of the SSI Checklist. Observations and semi-structured interviews will be conducted in Years 1 and 3, along with thematic content analysis, to examine facilitators and barriers to the implementation at the different study sites. The Consolidated Framework for Implementation Research will be used to guide the process evaluation and provide the foundation for a systematic evaluation of local contextual factors that influence implementation of the SSI Checklist. The products of this study include a validated SSI Checklist, a business-case analysis, an implementation toolkit, and a team experienced in checklist implementation for prevention of infections. At the end of this study period, the study team will meet with operational partners including National Infectious Disease Program Office (NIDS) and the MRSA / Multidrug-resistant Program Office (MDRO), and the National Center for Occupational Health and Infection Control (COHIC) to discuss implementing this checklist nationwide as part of the VA MRSA Prevention Initiative. This study has high potential to significantly decrease SSI, and in turn morbidity and mortality due to SSIs, in our Nation's Veterans.