Targeting Surgical Site Infections through a Perioperative Antibiotic Clinical Decision Support Tool

项目摘要/摘要 每年有500,000多名患者感染外科部位感染(SSI)，使其成为主要原因 医院获得性感染。SSI造成了数十亿美元的额外医疗成本，而且 与术后死亡率高达11倍的风险有关。尽管几乎普遍遵守 外科护理改善项目(SCIP)预防性抗生素使用指南，SSI率 仍然停滞不前。与SCIP相比，美国传染病学会(IDSA)提供的 外科抗生素预防综合指南。除了SCIP措施之外，主要关注的是 关于外科手术切口的抗生素时机，IDSA指南还包括：1)更具体 几种外科手术的抗生素选择，2)重量调整的抗生素剂量，3)及时的抗生素 在长时间的手术中重新给药。其中每一个都是抗生素使用的关键方面，而不是 由SCIP指南解决，为大多数围手术期抗生素实践提供信息。在前期工作中 使用国家数据集，我们发现，不遵守IDSA指南的至少一个组成部分 发生在超过三分之一的外科病例中。我们还发现，IDSA的不依从性在 计划外场景，如涉及多个输血产品的手术和紧急手术 这表明这种不遵守可能有情景因素。我们相信，促进遵守 IDSA指导方针可以显著减少SSI，并可以通过针对医疗保健提供者工作流来实现 使用以提供商为中心的临床决策支持(CDS)工具的障碍和知识缺失。我们建议- 目标1：衡量不遵守IDSA指南及其组成部分的关联(抗生素选择， 计时、给药和术中调整)以及SSI的发生 国家注册：国家外科质量改进计划(NSQIP)，它捕获了详细的 术后结果，多中心围手术期结果组(MPOG)记录了详细的 围手术期数据。此外，我们还将检查不依从性(护理方面的差异)的差异 几个AHRQ优先小组，以确定在这些小组内减少SSI的机会。目标2：确定 在实践中与IDSA指南偏差相关的因素通过半结构化访谈 围手术期医疗保健提供者，并将其纳入开发CDS工具，以促进IDSA的遵守 抗生素的做法。目标3：使用以下工具评估CDS工具和提供商反馈的实际性能 RE-AIM(REACH、有效性、采用、实施、维护)实施框架 评估。公共卫生意义：SSIS很常见，成本很高，基本上是可以避免的。建议进行的研究 A)是否有助于确定IDSA指南不遵守与SSI之间的关系，包括AHRQ之间的关系 优先群体；b)确定遵守准则的障碍；c)测试易于使用的干预措施 在未来的大型务实试验中实施，以检测SSI结果的减少。

PROJECT SUMMARY / ABSTRACT More than 500,000 patients acquire Surgical Site Infections (SSIs) each year, making them the leading cause of hospital-acquired infections. SSIs account for billions of dollars in added health care costs and are associated with up to 11 times higher risk of post-surgical mortality. Despite near universal adherence to Surgical Care Improvement Project (SCIP) guidelines for prophylactic antibiotic administration, SSI rates remain stagnant. As compared to SCIP, the Infectious Disease Society of America (IDSA) provides far more comprehensive guidelines for surgical antibiotic prophylaxis. Beyond the SCIP measures, which focus mostly on antibiotic timing with respect to surgical incision, IDSA guidelines additionally include: 1) more specific antibiotic selection for several surgical procedures, 2) weight-adjusted antibiotic dosing, and 3) timely antibiotic re-dosing during prolonged surgeries. Each of these is a crucial aspect of antibiotic administration and is not addressed by SCIP guidelines that inform the majority of perioperative antibiotic practice. In preliminary work using a national dataset, we found that non-adherence to at least one of the components of IDSA guidelines occurred in over one-third of surgical cases. We also found that IDSA non-adherence is markedly higher during unplanned scenarios such as surgeries involving multiple blood product transfusions and emergency surgeries indicating there may be a situational component to the non-adherence. We believe promoting adherence to IDSA guidelines can markedly reduce SSIs and can be achieved by targeting healthcare provider workflow barriers and knowledge deficits using a provider centered clinical decision support (CDS) tool. We propose to - Aim 1: Measure the association of nonadherence to IDSA guidelines and its components (antibiotic choice, timing, dosing, and intraoperative redosing) with SSI occurrence by analyzing merged data from two robust national registries: the National Surgical Quality Improvement Program (NSQIP), which captures detailed postoperative outcomes, with the Multicenter Perioperative Outcomes Group (MPOG) that captures detailed perioperative data. Additionally, we will examine differences in nonadherence (disparities in care) across several AHRQ priority groups to identify opportunities for SSI reduction within these subgroups. Aim 2: Identify factors associated with deviation from IDSA guidelines in practice through semi structured interviews of perioperative healthcare providers and incorporate these to develop a CDS tool that promotes IDSA adherent antibiotic practices. Aim 3: Assess the real-world performance of the CDS tool and provider feedback using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework of implementation evaluation. Public Health Significance: SSIs are common, costly, and largely avoidable. The proposed study will a) help determine relationships between IDSA guideline nonadherence and SSIs including among AHRQ priority groups; b) identify barriers to guideline adherence; and c) test a readily usable intervention for implementation in a future large pragmatic trial powered to detect reduction in SSI outcomes.