Promoting De-Implementation of Inappropriate Antimicrobial Use in Cardiac Device Procedures By Expanding Audit and Feedback

通过扩大审计和反馈，促进消除心脏装置手术中不当使用抗菌药物的情况

• 批准号: 10404914
• 负责人: Westyn Branch-Elliman
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-05-01 至 2025-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10404914
• 关键词: Accounting; Acute Renal Failure with Renal Papillary Necrosis; Address; Adoption; Adverse event; Age; Algorithms; Antimicrobial Resistance; Area; Cardiovascular system; Caring; Centers for Disease Control and Prevention (U.S.); Cessation of life; Clinical; Clinical Informatics; Clinical effectiveness; Clostridium difficile; Communicable Diseases; Computerized Medical Record; Data; Defibrillators; Deimplementation; Devices; Diffusion; Documentation; Education; Effectiveness; Electronic Health Record; Electronics; Electrophysiology (science); Evidence based intervention; Feedback; Goals; Guidelines; Health; Hour; Hybrids; Infection; Infection Control; Infection prevention; Informatics; Information Systems; Injury to Kidney; Interruption; Interview; Learning; Life; Longevity; Manuals; Measurement; Measures; Medical Records; Methodology; Methods; Morbidity - disease rate; Outcome; Outcome Measure; Outpatients; Pacemakers; Partner in relationship; Population; Procedures; Process; Prophylactic treatment; Provider; Quality of Care; Recommendation; Reporting; Research; Research Personnel; Research Priority; Resistance to infection; Resources; Savings; Site; Skin; Son; Surgical incisions; System; Testing; Time; Time Series Analysis; Translating; Veterans; Work; adverse outcome; antimicrobial; base; cardiac device; clinical care; clinical practice; design; disorder control; disorder prevention; electronic data; evidence base; formative assessment; healthcare-associated infections; implementation outcomes; implementation science; implementation strategy; implementation study; improved; improved outcome; informatics tool; innovation; insight; member; mortality; novel; prevent; primary outcome; programs; tool; uptake

Background: Cardiac device procedures, such as pacemaker and defibrillator placements, are common and increasing as the population ages. These devices are life-saving for the Veterans who need them, but the pro- cedures can be complicated by highly morbid infections and other adverse events, resulting in poor outcomes. Clinical guidelines recommend administration of pre-procedural antimicrobials to prevent cardiac device infec- tions and early discontinuation of antimicrobials after the procedure to prevent harms caused by unnecessary antimicrobial use, such as kidney injury, C. difficile infections, and antimicrobial resistance. However, these guidelines are rarely applied, resulting in preventable morbidity and mortality, and creating a critical need for research investigating strategies to promote adoption of best practices (e.g., learning) and de-adoption of inef- fective and harmful practices (e.g., unlearning). Significance/Impact: The research in this study closes an important gap in the care of cardiac device recipients and advances several VA HSR&D research priorities, including implementation, informatics, and quality of care. It leverages the strength of the VA electronic health record (EHR) and will provide important insights into clinical informatics methodologies for expanding surveillance of healthcare-associated infections and antimicrobial use to include outpatient and procedural areas. Investigators will also promote understanding about how learning and unlearning processes can be leveraged to enhance adoption of clinical guidelines and de-implementation of ineffective and harmful practices. Innovation: The highly innovative, informatics-based audit and feedback system will advance the field of imple- mentation science by yielding a new strategy for promoting de-implementation of inappropriate practices. Les- sons learned about how to implement novel, real-time informatics tools and adapt and scale them will also be generalizable to procedural areas with limited resources to support surveillance. Aim I: Tests the hypothesis that a multi-faceted implementation strategy including automated audit and feed- back, education of electrophysiology team members, local adaptation, and blended facilitation with engagement of local champions, will improve adoption of antimicrobial prophylaxis guidelines for electrophysiology proce- dures at three VA facilities, using a stepped-wedge, Hybrid III design. Primary outcome is adoption of guideline- recommended antimicrobial use. Clinical effectiveness will be assessed through measurement of clinical out- comes (CIED infections, AKI, and C. difficile). Aim II: Measures the feasibility of using an informatics-based algorithm to measure outcomes and guideline- concordance following cardiac device procedures at 78 facilities and tests the passive diffusion of reports. Methodology: There is a major gap in studies evaluating de-implementation of ineffective practices. This study has two complimentary aims and will address this gap by testing the utility of a highly innovative clinical infor- matics tool developed using the robust VA EHR. The informatics tool combines feedback about best practices and positive clinical outcomes (learning) with feedback about ineffective and harmful practices and adverse clin- ical outcomes (unlearning) as part of a multi-faceted implementation strategy. Aim I will test the multi-faceted implementation strategy at three VAs using a Hybrid III design. Aim II will test the tool’s scalability and dissemi- nation throughout the VA and will identify barriers to expansion and potential solutions. Implementation/Next Steps: The central aim of this study is to implement ways to promote best practices. Tools developed during the course of the study will be widely disseminated throughout the VA to enhance the quality of care and will be provided to key operational partners, who can adapt the clinical informatics tools to promote best practices in other clinical cares with limited infection prevention and stewardship resources.

背景：心脏设备程序，例如太空人和除颤器位置，很常见，并且 随着人口年龄的增长而增加。这些设备对需要它们的退伍军人来说是挽救生命的，但是 高度病态的感染和其他不良事件会使Cedes变得复杂，从而导致结果不佳。 临床指南建议给予手术前抗菌剂，以防止心脏器械infec- 手术后的抗菌药物的疗效和早期停药，以防止不必要的伤害 抗菌素的使用，例如肾脏损伤，艰难梭菌感染和抗菌素耐药性。但是，这些 很少使用准则，从而导致可预防的发病率和死亡率，并产生了至关重要的需求 研究调查策略，以促进采用最佳实践（例如学习）和逐步采用 种类和有害的做法（例如，学习）。 意义/影响：这项研究的研究缩小了心脏设备接受者护理的重要差距 并提高了几个VA HSR＆D研究的重点，包括实施，信息信息和护理质量。 它利用VA电子健康记录（EHR）的强度，将为临床提供重要的见解 扩大医疗保健相关感染和抗菌使用的监视的信息方法 包括门诊和程序区域。调查人员还将促进对学习的理解 可以利用学习过程来提高临床准则的采用和解除实施 无效和有害的做法。 创新：高度创新的，基于信息的审计和反馈系统将推动IMPLE的领域 提及科学，从而产生一种新的策略来促进不适当实践的实施。 les- 儿子了解了如何实施新颖，实时信息工具并适应和扩展它们也将是 可以推广到资源有限的程序领域，以支持监视。 目标I：检验以下假设：多面实施策略，包括自动审计和馈送 - 返回，电生理团队成员的教育，本地适应和混合设施与参与 在当地冠军的情况下，将改善对电生理程序的抗菌预防指南的采用 - 使用阶梯窗格的混合III设计，在三个VA设施中使用。主要结果是适应准则 - 建议的抗菌使用。临床有效性将通过测量临床范围来评估 来（CIED感染，AKI和艰难梭菌）。 AIM II：衡量使用基于信息的算法来衡量结果和指南的可行性 - 在78个设施的心脏设备程序之后的一致性，并测试报告的被动扩散。 方法论：研究评估无效实践的实现的研究存在一个主要差距。这项研究 具有两个免费目标，将通过测试高度创新性临床信息的实用性来解决这一差距 使用强大的VA EHR开发了模拟工具。信息工具结合了有关最佳实践的反馈 以及积极的临床结果（学习），并提供有关无效和有害实践和不良临床的反馈 作为多方面实施策略的一部分，ICAL成果（不学习）。目的我将测试多方面的 使用混合III设计在三个VAS上实施策略。 AIM II将测试该工具的可伸缩性和分解 整个VA的国家，将确定扩展和潜在解决方案的障碍。 实施/下一步：这项研究的核心目的是实施促进最佳实践的方法。工具 在研究过程中开发的将在整个VA中广泛传播，以提高质量 护理，并将提供给主要的运营伙伴，他们可以适应临床信息工具以促进 其他临床护理有限的预防和管理资源的最佳实践。