Abstract

Background: SSIs are common and preventable adverse surgical outcomes that account for substantial morbidity and mortality. Pre-operative antimicrobial administration reduces SSI; post-operative antimicrobials do not reduce SSI but do increase other post-operative adverse events. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) to increase compliance with peri-operative quality metrics, including appropriate antimicrobial use. SCIP included a set of publicly reported evidenced-based antimicrobial guideline compliance metrics targeting high-risk surgeries. The metrics required resource-intense manual review as part of the VA’s External Peer Review Program (EPRP). In 2015, SCIP achieved sustained compliance with antimicrobial use metrics exceeding 95% and the program was retired due to the high costs of manual review with minimal expected additional benefit. This IIR proposal is guided by the Dynamic Sustainability Framework and examines whether the antimicrobial practice changes achieved by SCIP were sustained and how they spread to surgeries and practice areas beyond the original scope of the program. This multiple PI submission by Dr. Hillary Mull, PhD and Dr. Westyn Branch-Elliman, MD, MMSc builds and expands upon their prior VA-funded collaborative work applying electronic algorithms to measure antimicrobial use and identify adverse outcomes. Significance/Impact: Improving antimicrobial prescribing and surgical quality are major VA goals. In FY 2018, within the VA, there were 190,000 surgeries among SCIP-targeted specialties (cardiac, orthopedic, general/colorectal, gynecology and vascular). Of these, 64% were outpatient, where the PIs found high rates guideline discordant post-operative antimicrobial use, which contribute to substantial patient harms. Thus, the potential impact of the research on direct clinical care is high. In addition, there are limited studies examining what happens to practice change after discontinuation of active programs designed to support compliance with evidence-based guidelines. The proposed study will close this gap in implementation science research. Innovation: In line with the VA’s Learning Health System directive, this project will use the VA’s electronic health record data to develop algorithms to identify pre-and post-operative antimicrobial use based on the PI’s prior work. These electronic data mining algorithms capture structured and text note data and represent a significant technological advancement over costly manual review. This study also answers important questions about the sustainability of practice change after discontinuation of an active policy with input from frontline staff. Specific Aims: 1) Measure sustainability of antimicrobial prophylaxis guideline compliance after SCIP retirement and assess whether practice changes spread to SCIP-excluded procedures; 2) Assess facilitators and barriers to implementation sustainability through staff interviews, and map results to implementation strategies; 3) Develop an implementation playbook with assessment tools, training curricula and other elements to support scale-up and spread of evidence-based antimicrobial practices in a future HSR&D Hybrid III trial. Methodology: Aim I will adapt existing informatics algorithms to extract pre-and post-operative antimicrobial use from clinical note texts and antimicrobial orders for each of the SCIP surgeries. Previously manually reviewed 2005-2015 EPRP data will be used as the gold-standard for adapting and refining the data mining tools. SCIP sustainability will be measured by applying the validated antimicrobial compliance algorithms to 2005-2020 data and performing interrupted time series analyses. SCIP spread within specialties will be assessed with regression models. Aim II will use qualitative interviews with frontline staff to identify reasons for sustainability of evidence- based practice using constructs in the Dynamic Sustainability Framework and will triangulate qualitative and quantitative data to ascertain the long-term impacts of SCIP. Aim III will develop an implementation playbook with input from our Operational Steering Committee comprised of national and local VA surgical stakeholders. Next Steps/Implementation: Test implementation playbook in a Hybrid Type III study to improve practice.

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DRA: Acute and Combat-Related Injury, Other Conditions, Health Systems

DRE: Prevention, Treatment - Implementation, TRL - Applied/Translational

Keywords: Care Management Tools, Guideline Development and Implementation, Healthcare Algorithms, Knowledge Integration, Sustainability

MeSH Terms: None at this time.