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Addressing Antimicrobial Resistance through the CARRIAGE QUERI Program

Annually, approximately two million illnesses and 23,000 deaths are caused by antibiotic-resistant bacteria in the US alone, with an impact of $20-35 billion in excess healthcare costs. Antibiotic resistance increases the difficulty in providing effective treatment. Judicious use of antibiotics is essential to containing the spread of resistance and increasing antibiotic effectiveness, but prevention also requires efforts to control pathogen transmission across healthcare settings. VA faces this rising threat to patient safety and offers unique opportunities to act as a national leader to rapidly transform care through evidence-based practices that address the spread of antimicrobial resistance.

The Combating Antimicrobial Resistance through Rapid Implementation of Available Guidelines and Evidence (CARRIAGE) QUERI program is a direct counterattack to the growing crisis of antimicrobial resistance. The overall goal is to address the growing public health crisis of antimicrobial 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 (HAIs) across VA patient care settings. This goal will be accomplished through complementary implementation strategies and aims to:

• Foster improved hand-washing practice by repairing the broken audit-and-feedback mechanism in VA acute-care hospitals via a VISN-wide quality improvement project;
• Support and enhance the implementation of national VA guidelines to detect and prevent the spread of carbapenem-resistant Enterobacteriaceae (includes Salmonella and E-coli) in VA hospitals; and
• Promote judicious inpatient antibiotic prescribing through a novel antibiotic self-stewardship "timeout" project that prompts VA providers to evaluate the continued need for empiric (typically broad-spectrum) antibiotics.

CARRIAGE projects will target the behaviors and processes at the critical points in the chain of infection that facilitate the development and spread of antibiotic-resistant pathogens, thereby breaking the cycle of transmission and improving healthcare delivery. CARRIAGE will have substantial and long-lasting impacts in improving VA quality of care and patient safety by promoting national initiatives and guidelines and by informing future prevention and patient safety efforts, including the implementation of VA-wide practice guidelines or bundles.

Because antimicrobial resistance lies at the intersection of infectious diseases, infection control and prevention, public health, healthcare quality, and patient safety, addressing this problem within the VA healthcare system requires a network of clinical partnerships. Thus, CARRIAGE has partnered with multiple VA Operations program offices, including the National Infectious Diseases Service (a VA Specialty Care Services program), the Multidrug-Resistant Organism Program, the Antimicrobial Stewardship Task Force, and the National Center for Patient Safety (NCPS). At the same time, it is an important priority for other governmental agencies such as the Centers for Disease Control and Prevention (CDC), and is a critical target for urgent action by the U.S. as described in the National Action Plan for Combating Antibiotic-resistant Bacteria put forth by the White House in March 2015. CARRIAGE is also aligned with VA national priority goals by increasing the impact of VA research findings through bi-directional partnerships and rigorous evaluation, and by making VA a national leader in promoting a learning healthcare organization through innovative implementation science.

For more information about CARRIAGE QUERI, please contact Michael Rubin, MD, PhD at Michael.Rubin2@va.gov .