De-Implementing Testing and Treating of Urine Cultures in Asymptomatic Patients

背景：成功部署战略以减少不必要的检测和治疗至关重要 这是改善护理和将危害降至最低的组成部分。选择明智的倡议突出了 安全和有效地取消实施不必要的测试和治疗做法的重要性。阳性尿液 文化是不适当使用抗菌药的主要驱动力。无症状的患者通常会接受筛查和 尿培养阳性的患者接受了治疗，尽管国家协会的新指南显示，没有症状的患者 尿路感染(UTI)不应进行尿液培养，也不应使用抗生素治疗 即使文化是积极的。这种不适当的抗生素使用可能导致可预防的患者伤害(例如， 艰难梭菌感染、抗生素耐药性)，却没有任何益处。这项提案将开发和测试一种 减少无症状外科手术中尿培养筛查和治疗的实施策略 病人。 具体目标：目标1：开发一个有15个设施的疾控中心实时数据库--CREATE网络，以确定和 跟踪与术前尿检和ASB相关的组织、提供者和患者水平的因素 治疗。目标2：确定当前手术前尿液检测和治疗的背景，以及障碍和 通过对CDC-CREATE网络中的5个设施进行深入访谈，让促进者取消实施。目标3： 开发取消实施工具，并随机选择5个干预地点进行试点测试和比较比率 采用时间序列分析方法，对随机选择的5个控制点进行尿液检测。 意义：该提案符合针对供应商的高铁与研发实施科学优先领域 行为和部长舒尔金的优先事项3：更有效地集中资源。它还解决了传染病 美国疾病协会排名第一的明智建议是：“不要治疗无症状的 抗生素导致的菌尿。“对退伍军人医疗保健的影响将是将资源集中在证据上 基于与益处相关的实践(手术预防检查清单)，而不是潜在的 有害做法(无症状患者的尿液检测和治疗)。这一创新方法将 使用基于理论的多管齐下的干预措施，将新的指导方针--少做一些--转化为行动。 方法：我们将与非实施质量增强研究倡议(QUERI)合作，并 调整他们的概念框架以实现提案目标。此外，我们将利用我们现有的 与疾病预防控制中心建立伙伴关系-创建网站网络，以评估停止的背景、促进者和障碍 对无症状外科患者的尿液培养做法，并对非实施策略进行试点测试。我们会 使用混合方法，包括分析来自国家退伍军人数据库的数据(例如，公司 数据仓库)、定性访谈和试点取消实施战略，目标是更广泛地 在今后的工作中传播。我们预计，在这项研究中创建和测试的取消实施战略 将减少无症状外科患者的尿检和治疗。 影响和下一步：我们的研究将为患者、提供者和医院提供重要的见解 水平因素，以及组织文化和更广泛的外部环境(例如，专业、社会) 与外科病人不必要的尿检和抗生素治疗有关。我们的研究将发展出一种 向提供商提供可靠、相关数据的策略，以便他们可以对证据进行关键评估 反对尿检(遗忘)，并采用替代流程，以优化我们的脱贫成功 实施目标。我们下一步将在更广泛的设施中测试干预措施，并与 抗菌管理特别工作组将我们的调查结果传播给退伍军人管理局抗菌管理团队 全国范围内。我们未来的目标是在全国范围内传播该策略，并将其推广到其他患者 环境，如急性护理和社区生活中心。

Background: Successful deployment of strategies to reduce unnecessary testing and treatment is a critical component of improving care and minimizing harms. The Choosing Wisely Initiative has highlighted the importance of safely and effectively de-implementing unnecessary testing and treating practices. Positive urine cultures are a major driver of inappropriate antimicrobial use. Asymptomatic patients are often screened and positive urine cultures treated, despite new guidelines from national societies that patients without symptoms of urinary tract infection (UTI) should not have a urine culture performed and should not be treated with antibiotics even if the culture is positive. This inappropriate use of antibiotics can lead to preventable patient harms (e.g., C. difficile infection, antibiotic resistance) without any benefit. This proposal will develop and test a de- implementation strategy for reducing screening and treatment of urine cultures in asymptomatic surgical patients. Specific Aims: Aim 1: Develop a live database of the 15-facility CDC-CREATE Network to identify and to track organizational, provider, and patient level factors associated with preoperative urine testing and ASB treatment. Aim 2: Determine the current context of pre-operative urine testing and treating, and barriers and facilitators to de-implementation, using in-depth interviews at 5 facilities in our CDC-CREATE network. Aim 3: Develop a de-implementation tool and randomly select 5 intervention sites for pilot testing and compare rates of urine testing in 5 randomly selected control sites using time series analysis. Significance: This proposal meets the HSR&D Implementation Science priority area that addresses provider behavior and Secretary Shulkin's Priority 3: Focus Resources More Efficiently. It also addresses the Infectious Diseases Society of America #1 Choosing Wisely recommendation which says, “Don't treat asymptomatic bacteriuria with antibiotics.” The impact on Veteran's healthcare will be to focus resources towards evidence based practices that are associated with benefits (surgical prevention checklist) and away from potentially harmful practices (urine testing and treatment in asymptomatic patients). This innovative approach will translate new guidelines - to do less - into action using a theory based multi-pronged intervention. Methods: We will partner with the De-implementation Quality Enhancement Research Initiative (QUERI) and adapt their conceptual framework to achieve the proposal objectives. In addition, we will utilize our existing partnership with the CDC-CREATE network of sites to evaluate the context, facilitators and barriers to stopping urine culture practices in asymptomatic surgical patients and to pilot test a de-implementation strategy. We will use a mixed-methods approach, including analyses of data from the national VA databases (e.g. Corporate Data Warehouse), qualitative interviews, and piloting of a de-implementation strategy with a goal of wider dissemination in future work. We anticipate that the de-implementation strategy created and tested in this study will reduce urine testing and treatment in asymptomatic surgical patients. Implications and Next Steps: Our study will provide important insights into patient, provider, and hospital level factors, as well as organizational culture and broader external context (e.g., professional, social) associated with unnecessary urine testing and antibiotic treatment of surgical patients. Our study will develop a strategy to provide reliable, relevant data to the providers so they can do a critical assessment of the evidence against urine testing (unlearning) and adopt a substitute process to optimize the success of our de- implementation goal. Our next steps will be to test the intervention in a wider array of facilities and to work with the Antimicrobial Stewardship Task Force to disseminate our findings to VA antimicrobial stewardship teams nationwide. Our future goals are to disseminate the strategy nationally and to expand it to other patient settings, such as acute care and community living centers.