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: 10067042
• 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/10067042
• 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：心脏装置手术，例如起搏器和除颤器放置，是常见且 随着人口老龄化，这些设备可以拯救需要它们的退伍军人的生命，但亲 手术可能会因高发病率感染和其他不良事件而变得复杂，从而导致不良结果。 临床指南建议在手术前使用抗菌药物以预防心脏装置感染 并在手术后尽早停用抗菌药物，以防止不必要的伤害 抗菌药物的使用，例如肾损伤、艰难梭菌感染和抗菌药物耐药性。 指南很少得到应用，导致了可预防的发病率和死亡率，并迫切需要 研究调查促进采用最佳实践（例如学习）和取消采用无效做法的策略 有效和有害的做法（例如忘记学习）。 意义/影响：本研究弥补了心脏装置接受者护理方面的重要空白 并推进了 VA HSR&D 的多项研究重点，包括实施、信息学和护理质量。 它利用了 VA 电子健康记录 (EHR) 的优势，将为临床提供重要见解 扩大医疗保健相关感染和抗菌药物使用监测的信息学方法 包括门诊和程序领域。研究人员还将促进对如何学习的理解。 可以利用遗忘过程来加强临床指南的采用和取消实施 无效和有害的做法。 创新：高度创新、基于信息学的审计和反馈系统将推动实施领域的发展。 通过制定一项新的战略来促进消除不当做法，从而促进心理科学的发展。 儿子们了解了如何实施新颖的实时信息学工具并对其进行调整和扩展 可推广到支持监视资源有限的程序领域。 目标 I：测试多方面实施策略（包​​括自动审核和反馈）的假设 背部、电生理学团队成员的教育、局部适应以及混合促进与参与 当地冠军的支持，将提高电生理学过程抗菌预防指南的采用 在三个 VA 设施中，使用阶梯式楔形混合 III 设计的主要成果是采用了指南 - 推荐的抗菌药物使用的临床效果将通过测量临床结果来评估。 来了（CIED 感染、AKI 和艰难梭菌）。 目标 II：衡量使用基于信息学的算法来衡量结果和指南的可行性 78 个机构的心脏装置手术后的一致性并测试报告的被动传播。 方法论：评估无效实践的取消的研究存在重大差距。 有两个互补的目标，并将通过测试高度创新的临床信息的实用性来解决这一差距 使用强大的 VA EHR 开发的信息学工具结合了有关最佳实践的反馈。 积极的临床结果（学习），并提供有关无效和有害做法以及不良临床的反馈 作为多方面实施策略的一部分，我将测试多方面的成果。 使用 Hybrid III Aim II 设计的三个 VA 的实施策略将测试该工具的可扩展性和传播性。 VA 将在全国范围内确定扩张的障碍和潜在的解决方案。 实施/后续步骤：本研究的中心目标是实施推广最佳实践工具的方法。 研究过程中开发的成果将在整个 VA 广泛传播，以提高质量 护理并将提供给主要业务合作伙伴，他们可以调整临床信息学工具来促进 感染预防和管理资源有限的其他临床护理的最佳实践。