QUERI – Quality Enhancement Research Initiative

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Combating Antimicrobial Resistance through Rapid Implementation of Available Guidelines and Evidence (CARRIAGE)

Salt Lake City, UT

Principal Investigators: Michael Rubin, MD, PhD (Corresponding PI, VA Salt Lake City), Charlesnika Evans, MPH, PhD (VA Hines), Eli Perencevich, MD, MS (VA Iowa City)

Principal Operational Partners: National Infectious Diseases Service, Multi-Drug Resistant Organism Program Office, National Center for Patient Safety (NCPS), and the VA Antimicrobial Stewardship Task Force.

Executive Summary:

The goal of the CARRIAGE QUERI program is to address the growing public health crisis of anti-microbial resistance through strategies that support the uptake of new and existing evidence-based practices, policies, and programs targeting the improved use of antibiotics and the prevention of healthcare-associated infections. The CARRIAGE program is a series of related projects unified around the common goal of arresting and potentially reversing the spread of antimicrobial resistance in VA healthcare facilities and beyond. CARRIAGE investigators will accomplish this with rapid, cross-cutting, and interdisciplinary approaches that combine elements of quality improvement and implementation science, and which target the processes that contribute to the development and spread of resistance. Projects will use several broad strategies for:

  • Translating successful HSR&D-funded research into clinical practice,
  • Evaluating and enhancing the implementation of national VA programs,
  • Supporting VA national priority goals, and
  • Leveraging the existing efforts of our VA organizational partners.

By creating an integrated "implementation network" of VA sites around a core team of implementation scientists, CARRIAGE QUERI will establish an infrastructure for rapidly deploying interventions within a broad complex of VA facilities across the nation.

Program Objectives:

The goal of the CARRIAGE QUERI program is to address the growing concern of antimicrobial resistance through strategies targeting improved use of antibiotics and prevention of healthcare-associated infections (HAI) across VA patient care settings. In doing so, investigators will address the priority goals of their VA operational partners, the QUERI Strategic Plans, the 2014 VHA Blueprint for Excellence, and the goals of the National Action Plan for Combating Antibiotic-resistant Bacteria as put forth by President Obama. Specific objectives are to (a) promote judicious inpatient antibiotic use through a novel antibiotic self-stewardship "timeout" project that prompts VA providers to evaluate the continued need for antibiotics; (b) support and enhance the implementation of new VA guidelines to detect and prevent the spread of carbapenem-resistant Enterobacteriaceae in VA hospitals; (c) foster improved handwashing practice by repairing the broken audit-and-feedback mechanism in VA acute-care hospitals via a VISN-wide quality improvement project; and (d) evaluate and enhance the implementation of the national C. difficile bundle at VA acute-care facilities.

Program Methods:

Program projects will vary in study timeframe and start date over the five-year QUERI program timeframe. Research designs utilized across projects will include the experimental stepped-wedge design for implementation of interventions, prospective observational designs of practice implementation of large-scale policy initiatives, and rigorous evaluation of VA national policies. The program will employ complementary implementation strategies and theories guided by an Implementation Core consisting of a team of notable VA implementation scientists with proven track records in designing and executing programs to control antimicrobial resistance and HAIs. Specific implementation strategies will include audit and feedback, clinical decision support, external facilitation, provider education and activation, and adherence engineering. The Promoting Action on Research in Health Services (PARiHS) framework will be used to assess contextual factors influencing implementation within facilities, while work system barriers and facilitators will be assessed using the Consolidated Framework for Implementation Research (CFIR) and the Systems Engineering Initiative for Patient Safety (SEIPS) model. Data collection methods will include the use of national VA datasets, direct observation, and primary data (i.e., surveys, interviews, and focus groups).

Project Summaries:

Project 1 (Quality Improvement): Foster improved hand-washing practice by repairing the broken audit-and-feedback mechanism in VA acute-care hospitals via a VISN-wide QI project.

Project 2: Support and enhance the implementation of new national VA guidelines to detect and prevent the spread of carbapenem-resistant Enterobacteriaceae [gram-negative bacteria resistant to the carbapenem class of antibiotics, considered the drugs of last resort for such infections] in VA hospitals.

Project 3: Promote judicious inpatient antibiotic prescribing through a novel antibiotic self-stewardship "timeout" project that prompts VA providers to evaluate the continued need for empiric antibiotics.