components of an antibiotic stewardship program: a case study€¦ · components of an antibiotic...
TRANSCRIPT
12/18/2018
1
11
Components of an Antibiotic Stewardship Program: A Case Study
Joe Boero, MD
December 10, 2018
Oregon HAI Prevention Network Webinar Series
Components of an Antibiotic Stewardship Program in LTC:
A QAPI Case Study Illustrating How Process Improvement Projects Can Decrease Antibiotic
Use in Viral Upper Respiratory Infection
Joe Boero MD
December 10, 2018
Oregon Patient Safety Commission
2
1
2
12/18/2018
2
There is no facet of medical care delivery that so elegantly lends itself to QAPI and PIP as Antibiotic Stewardship in long term care
This Case Study attempts to illustrate how our facility in northern Wisconsin attempted to decrease the frequency of inappropriate antibiotic use in our residents. We accomplished this goal without realizing we were muddling through QAPI fundamentals to do so by implementing a PIP project.
I bring this story here to encourage you to be not afraid or intimidated to create your own story in your own facility.
3
Process Improvement Project: the Engine of QAPI
• Count and analyze(Audit) an outcome (Performance Indicator)
• Identify components of workflow which lead to outcome(Process Mapping)
• Define your facility professional expectation(Benchmark)
• Educate to improve key systems process components(Intervention With Feedback) and implement interventions
• Re‐audit and re‐analyze• Revise
• Intervene
• Audit, revise, intervene, audit, ………………
4
3
4
12/18/2018
3
5
Park Manor Nursing Home Private for Profit Employee Owned90 licensed skilled bedsCNA school two cohorts/yr
Flambeau Hospital (Critical Access)Marshfield Clinic Primary Care Tertiary Care 90 miles away
6
5
6
12/18/2018
4
7
8
7
8
12/18/2018
5
MRSA associated Staff skin infection
9
Lifeline
The Audience always knows
the correct answer.
“We have a lot of antibiotic resistance”
“It’s those damn doctors, they treat everything”
“You’re the medical director, tell them to stop!”
10
9
10
12/18/2018
6
11
“Get Me the Data !”
“START COUNTING STUFF”
January‐December 2006
12
11
12
12/18/2018
7
13
She counted, she counts, we’re still counting...
14
13
14
12/18/2018
8
Two main core Stewardship strategies
• 1. prospective audit of antibiotic use with direct interaction and feedback to the prescribing physician
• 2. formulary restriction and prior authorization requirements.
ISDA 2007
(2). Using the right drug for the right diagnosis in the right dose for the right length of time.
Crnich 2013
15
Antibiotic Stewardship = Audit + FeedbackAntibiotic Reduction Program
16
15
16
12/18/2018
9
Year urinalysis Repeat Ua Ua total Ua/Kdays Ua/U Res
2006200720082009201020112012*2013201420152016
202148145145175150157111844143
8744594223151051‐‐
291192196187198165167116854143
6.805.135.505.055.604.554.403.102.421.491.61
2.161.481.211.211.661.160.980.700.630.250.27
Annual Urinalyses PMNH
17
Year Antibiotic Abx/Kdays Abx/patient
2006200720082009201020112012*2013
503400343360351295315352
11.7510.689.689.729.938.148.139.41
2.57 2.231.631.811.871.521.23 1.39
Annual Antibiotic Utilization PMNH
18
17
18
12/18/2018
10
Year urinalysis Repeat Ua Ua total Ua/Kdays Ua/U Res
2006200720082009201020112012*2013201420152016
202148145145175150157111844143
8744594223151051‐‐
291192196187198165167116854143
6.805.135.505.055.604.554.403.102.421.491.61
2.161.481.211.211.661.160.980.700.630.250.27
Annual Urinalyses PMNH
19
20
19
20
12/18/2018
11
2013 Antibiotics at PMNH
UTI
RESP
OTHER151
52
147
21
Finding Pneumo 2014: Improving Antibiotic Use in Respiratory Tract Infection
22
21
22
12/18/2018
12
This basic ASP PIP project is…
Predicated on the concept that most new antibiotic orders in our nursing home do not get written until a Nurse contacts the provider and delivers a change in resident condition report.
23
McGeer’s Criteria for Respiratory illness
A. Common Cold or pharyngitis (at least 2)
runny nose or sneezing
nasal congestion
sore throat or hoarseness
dry cough
swollen or tender glands in neck
24
23
24
12/18/2018
13
McGeer’s Criteria Respiratory illness, cont
B. Influenza like illness(both 1 & 2)
1. fever
2. at least three of ILI criteria
chills
new headache or eye pain
body aches
malaise or loss of appetite
new or increased dry cough
Fever = >100F or 2F over baseline
25
C. Pneumonia (all 3)1. X‐ray with pneumonia or infiltrate
2. Clinical criteria (at least 1)
new or increased cough
new or increased sputum
O2 Sat <94% RA or >3% below baseline
new or changed lung exam*
pleuritic pain
3. Constitutional criteria (at least 1 of 4)
fever
leukocytosis
change in MS‐acute, fluctuation, inattention, and disorganized thinking
3 point increase in ADL score‐ bed mobility, transfer, locomotion, dressing, toileting, hygiene, eating
Fever = >100F or 2F over baselineLeukocytosis = WBC >14K or >6% bands26
25
26
12/18/2018
14
D. Lower Respiratory Infection (all 3)
1. Negative CXR or no CXR
2. Clinical criteria (at least 1)
new or increased cough
new or increased sputum
O2 Sat <94% RA or >3% below baseline
new or changed lung exam*
pleuritic pain
3. Constitutional criteria (at least 1 of 4)
fever
leukocytosis
change in MS‐acute, fluctuation, inattention, and disorganized thinking
3 point increase in ADL score‐ bed mobility, transfer, locomotion, dressing, toileting, hygiene, eating
McGeer (2012 Revised)27
*”…Mehr et. al. demonstrated that a nurse’s assessment for the presence of crackles and the absence of wheezing was highly predictive of identifying radiographic evidence of pneumonia.”
McGeer, 2012
28
27
28
12/18/2018
15
1. Facility evidence based RTI best practice criteria
2. Clinical skills
3. Scripting vs hinting and hoping
4. Stewardship principles
5. Empowerment of the nurse role as physician collaborator
6. Validation in nursing knowledge and skill
7. Diplomacy in communication
Staff educational development
Finding Pneumo Jan‐Feb 201429
sample script/URI
Date of onset: 09/16/15
Vitals: Temp 98.9 , Apical Pulse 68, Resp 28, B/P 112/72, O2 sat on RA 91%
Allergies: Sulfa
Change in condition: Cough. Resident is afebrile. No respiratory distress noted. She does have a new dry cough and sore throat. She has no headache, abd pain or general body aches. Lungs clear. Bowel sounds present in all four quads. Urine in unremarkable. Appetite has been 100% over past 24 hours.
Placed in droplet precautions this morning.
This is to inform you of a change in condition. According to our facility best practice, evidence based policy on respiratory tract infection, this resident has symptoms consistent with a viral URI. May we administer cough suppressant according to standing orders and monitor condition for 48 hrs? We will notify you of changing status.
Please Advise .
29
30
12/18/2018
16
Year Antibiotic Abx/Kdays Abx/Ures
2006200720082009201020112012*20132014 2015 2016
503400343360351295315352212209186
11.7510.689.689.729.938.148.309.416.047.626.98
3.73 3.082.122.322.952.081.84 2.131.571.261.18
Annual Antibiotic Utilization PMNH
31
Antibiotic for RTI‐ PMNH
Year Total Abx for RI Abx/Kdays Abx/Ures
201120122013201420152016
10488157726479
2.92.34.22.12.33.0
.73
.51
.95
.53
.39
.52
32
31
32
12/18/2018
17
Year urinalysis Repeat Ua Ua total Ua/Kdays Ua/U Res
2006200720082009201020112012*2013201420152016
202148145145175150157111844143
8744594223151051‐‐
291192196187198165167116854143
6.805.135.505.055.604.554.403.102.421.491.61
2.161.481.211.211.661.160.980.700.630.250.27
Annual Urinalyses PMNH
*Revised McGeer; Stone, et. al.33
Counting stuff‐‐‐‐‐‐Metrics
• Respiratory Tract Infection definition‐McGeer’s (Benchmark)
• Antibiotic Use Event‐Order written with one day of therapy(Outcome)
• Antibiotic Use Indication‐Doctor’s order(Outcome)
• In‐appropriate Antibiotic Use for RTI‐McGeers A or B (Outcome)
• Appropriate Antibiotic Use for RTI‐McGeer C or D (Outcome)
• Frequency of completion on EMR chest evaluation for cough (Process)
• Antibiotic Utilization Rates‐Antibiotic event/Kdays or /Ures (Outcome)
34
33
34
12/18/2018
18
ASP=AUDIT+FEEDBACK
• Audit: Spreadsheet based/resident chart reviewed: IP/DON in context of daily nurse morning report and internal messaging with review of nurse actions in respiratory illness COC flag
• Feedback‐nurse: daily critique of completion of nurse resp EMR chart note, use of appropriate script
• Feedback‐physician: initial letter from med dir, nurse challenge Abxorder, end of year Report Card, outlier letters
35
PMNH Antibiotic Report Cardfor Treatment of Respiratory Infection 2014
*Resident’s clinical symptoms met McGeer’s Surveillance Criteria for diagnosis of Viral Respiratory Infection
Provider Antibiotic Starts
Appropriate Not*Appropriate
Percent notAppropriate
Dan 38 36 2 5.3
Kas 24 23 1 4.2
Cia 8 6 2 25.0
Gu 2 2 0 0.0
Ade 0 0 0 0PMNHCumulative
72 67 5 6.9
36
35
36
12/18/2018
19
“Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement” Crnich, et.all; Drugs Aging (2015) 32:699–716
• “The unique structure of resident evaluation and treatment in nursing homes may represent the most important barrier to improving antibiotic stewardship.”
• Minimal infection control training, nurse workload, high resident/staff ratio, high staff turnover, use of agency nurses, and sub‐optimal staff assignment consistency combine to compound the problem”
37
• Nursing homes should instead develop and use protocols that restrict all urine testing to residents with a high probability of having a UTI.
• These protocols should be operationalized not only through education of providers but, also through engagement of nursing staff, who should be empowered to discourage providers from ordering diagnostic urine tests in the absence of specific evidence‐based criteria.
• Tracking the frequency of urine cultures and the number of treated UTI events that do not satisfy surveillance definitions provides targets that a facility can follow in order to assess the impact of the intervention.
“Optimizing ABS in NHs…”
These protocols should be operationalized not only through education of providers but, also through engagement of nursing staff, who should be empowered to discourage providers from ordering diagnostic urine tests in the absence of specific evidence‐based criteria.
38
37
38
12/18/2018
20
Nurse as Collaborator
• It’s not the nurse’s role to tell physicians how to practice medicine.
• It’s the nurse’s role to exercise discretionary judgement in the application of knowledge, skills and experience to deliver information that helps the physician practice better medicine.
39
Insights:Success of antibiotic stewardship in LTC depends on…
• Nursing staff education, assessment and communication skills, and empowerment
• Consistent data collection and audit• Nursing staff feed‐back on resident assessment, documentation and physician communication
• Physician feed‐back from medical director, but moreimportantly from the line nurse
40
39
40
12/18/2018
21
“If you really look closely, most overnight successes took a long time.”
• We recognized a bad PERFORMANCE INDICATOR related to improper antibiotic use through AUDIT
• We looked at how physician orders for antibiotic therapy came to our residents: PROCESS MAPPING
• Defined facility best practice professional performance expectation, performed educational intervention through staff in‐service education
• Gave real‐time feedback, and outcome assessment to both our nursing staff and physician providers.
• We leveraged our experience in decreasing inappropriate urine testing to applying similar efforts to decrease the inappropriate use of antibiotic for viral upper respiratory infection.
41
Bibliography
1. QAPI: Five Elements. https://www.cms.gov/Medicare/Provider‐EnrollmentandCertification/SurveyCertificationGenInfo/downloads/fiveelementsqapi.pdf
2. QAPI Description and Background. https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/QAPI/qapidefinition.html
3. Stone et. al. “Surveillance Definitions of Infections in Long‐Term Care Facilities: Revisiting the McGeer Criteria” Infect Control Hosp Epidemiol 2012;33(10):965‐977
4. Wisconsin Healthcare‐Associated Infection in Long Term Care Coalition. Events; UTI 101 Workshops. https://www.dhs.wisconsin.gov/regulations/nh/hai‐events‐index.htm
5. “Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement” Crnich, et.all; Drugs Aging (2015) 32:699–716
42
41
42
12/18/2018
22
43
Thank you!
Today’s Presenter
Joe Boero| MD
Oregon Patient Safety Commission Staff
Suzanne Wood | Patient Safety System Analyst
503.477.8280
VH1
4444
Oregon HAI Prevention Network Webinar Series
Access recorded webinars and register for upcoming webinarshttps://oregonpatientsafety.org/qi‐initiatives/oregon‐hai‐prevention‐network/
43
44
Slide 43
VH1 only provide presenter phone/email if permissionValerie Harmon, 12/7/2018