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

无症状患者尿培养的取消检测和治疗

• 批准号: 10651593
• 负责人: Marin Leigh Schweizer
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-12-01 至 2023-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10651593
• 关键词: Address; Adopted; Adverse effects; Adverse event; Advisory Committees; American; Antibiotic Resistance; Antibiotic Therapy; Antibiotics; Area; Bacterial Antibiotic Resistance; Bacteriuria; Caring; Centers for Disease Control and Prevention (U.S.); Cessation of life; Clinical Practice Guideline; Clostridium difficile; Collaborations; Communicable Diseases; Data; Data Analyses; Databases; Deimplementation; Evidence based practice; Fright; Future; Goals; Guidelines; Harm Reduction; Health Status; Healthcare; Healthcare Systems; Homogeneously Staining Region; Hospitals; Infection; Infection prevention; Intervention; Interview; Knowledge; Letters; Life; Link; Methods; Modeling; Operative Surgical Procedures; Organizational Culture; Outcome; Patients; Perioperative Care; Population; Positioning Attribute; Postoperative Period; Prevention; Prevention Research; Process; Provider; Psyche structure; Publications; Random Allocation; Recommendation; Research; Resources; Site; Societies; Stimulus; Surgeon; Surgical Wound Infection; Symptoms; Testing; Time; Time Series Analysis; Translating; Update; Urinary tract infection; Urine; Variant; Veterans; Visit; Work; acute care; antimicrobial; clinical practice; community living; data warehouse; evidence base; implementation framework; implementation measures; implementation science; implementation strategy; implementation tool; improved; improved outcome; innovation; insight; pharmacy benefit; pilot test; programs; provider behavior; screening; social; success; theories; time use; tool

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.

背景：成功部署减少不必要测试和治疗的策略是关键 改善护理和最小化危害的组成部分。选择明智的倡议强调了 安全有效地进行不必要的测试和治疗实践的重要性。尿液阳性 培养物是不适当使用抗菌剂的主要驱动力。不对称患者经常进行筛查，并且 接受治疗的阳性尿文化，目的地来自国家社会的新准则，没有症状的患者 尿路感染（UTI）不应进行尿培养，不应用抗生素治疗 即使文化是积极的。这种不当使用抗生素可能会导致可预防的患者危害（例如， 艰难梭菌感染，抗生素耐药性）没有任何益处。该建议将制定并测试 在不对称外科手术中减少筛查和治疗尿液培养的实施策略 患者。 具体目的：目标1：开发15个效率CDC创建网络的实时数据库，以识别和到 跟踪与术前尿液测试和ASB相关的组织，提供者和患者水平因素 治疗。目标2：确定术前尿液测试和治疗以及障碍以及 在我们的CDC-Create网络中的5个设施中进行了深入的访谈，以促进者进行促进。目标3： 开发一个实施工具，然后随机选择5个干预站点进行试验测试并比较速率 使用时间序列分析在5个随机选择的控制位点进行尿液测试。 意义：该建议符合HSR＆D实施科学优先领域，该领域针对提供商 行为和秘书长的优先级3：更有效地集中资源。它还解决了感染力 美国疾病协会＃1选择明智的推荐，其中说：“不要对待无症状 带有抗生素的细菌。”对退伍军人医疗保健的影响将是将资源集中在证据上 与福利相关的基于基于的实践（手术预防清单），远离潜在的实践 有害实践（不对称患者的尿液测试和治疗）。这种创新的方法将 使用基于理论的多种干预措施将新指南（以少做）转化为行动。 方法：我们将与Demplationation质量增强研究计划（QUERI）和 调整其概念框架以实现提案目标。此外，我们将利用我们的现有 与CDC创建网站网络的合作伙伴关系，以评估环境，促进者和障碍 尿液培养在不对称手术患者中进行，并试点测试一种消除策略。我们将 使用混合方法方法，包括来自国家VA数据库的数据分析（例如，公司 数据仓库），定性访谈和驾驶DEMPLENTATION策略的试验，其目标是 将来的工作中传播。我们预计本研究中创建和测试的实施策略 将减少不对称手术患者的尿液检查和治疗。 含义和下一步：我们的研究将为患者，提供者和医院提供重要的见解 级别因素以及组织文化和更广泛的外部环境（例如，专业，社会） 与手术患者的不必要的尿液检查和抗生素治疗相关。我们的研究将发展 向提供商提供可靠的相关数据的策略，以便他们可以对证据进行批判性评估 反对尿液测试（学习），并采用替代过程来优化我们的成功 实施目标。我们的下一步将是测试更广泛设施的干预措施并与之合作 抗菌管理工作组，将我们的发现传播给VA抗菌管理团队 全国。我们未来的目标是在全国范围内传播该战略，并将其扩展到其他患者 设置，例如急诊和社区生活中心。