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IHI ExpeditionAntibiotic Stewardship Session 4:

Embedding Stewardship Processes into Care Delivery

May 1, 2014

These presenters have

nothing to disclose

Jeff Rohde, MDMegan Mack, MDDiane Jacobsen, MPH

Today’s Host2

Sarah Konstantino, Project Assistant,

Institute for Healthcare Improvement (IHI),

assists in programming activities for

expeditions, as well as maintaining Passport

memberships, mentor hospital relations and

collaboratives. Sarah is currently in the Co-

Operative Education Program at

Northeastern University in Boston, MA, where

she majors in Business Administration with a

concentration in Management and Health

Science. She enjoys cooking, traveling, and

fitness.

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Expedition Director8

Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms. Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions on Antibiotic Stewardship, Preventing CA-UTIs, Reducing C.difficle Infections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI’s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI’s Spread Initiative. She is an epidemiologist with experience in quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master’s degree in Public Health- Epidemiology.

Today’s Agenda9

Introductions

Debrief: Action Period

Assignment – what are you

testing/learning?

Embedding Stewardship

Processes into Care Delivery

Action Period Assignment

Expedition Objectives

At the end of this Expedition, participants will be able to:

Describe the impact of overuse and misuse of antibiotics

on cost of care, antimicrobial resistance and patient

complications, including Clostridium difficile.

Establish a multidisciplinary focus to embed antibiotic

stewardship into the process of care.

Identify and begin improving at least one key

process to optimize antibiotic selection, dose, and

duration of antibiotics in the patient care setting.

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Schedule of Calls

Session 1 – “Making the Case” for Antibiotic StewardshipDate: Thursday, March 20

th2:30 PM – 4:00 PM ET

Session 2 – Promoting a Culture for Optimal Antibiotic UseDate: Thursday, April 3, 3:00 – 4:00 PM ET

Session 3 – Our Learning Journey: IHI & CDC PartnershipDate: Thursday, April 17, 3:00 – 4:00 PM ET

Session 4 – Embedding Stewardship Processes into Care DeliveryDate: Thursday, May 1, 3:00 – 4:00 PM ET

Session 5 – Focus on: 72 Hour Antibiotic “Time-out”Date: Thursday, May 15, 3:00 – 4:00 PM ET

Session 6 – What Are We Testing & Learning?Date: Thursday, May 29, 3:00 – 4:00 PM ET

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Ground Rules12

We learn from one another – “All teach, all learn”

Why reinvent the wheel? – Steal shamelessly

This is a transparent learning environment – Share

Openly

All ideas/feedback are welcome and encouraged!

Debrief: Action Period AssignmentTest one idea related to: Documentation/Visibility at

Point of Care

Univ of Michigan Example:

Assess the current state: Reviewed medical records for all patients on

Hospitalist service on a single day to assess for antibiotic documentation re:

- % pts on AB; indication; start date/day of treatment; expected duration

(% of pts w/ all components documented)

Small test of change: Approached 3 hospitalists during 1 week of service on

non-resident service re: Document in Daily Progress Note and Service Sign-out

– Antibiotic with indication

– Day of therapy

– Expected duration

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Debrief: Action Period Assignment

Test one idea for Promoting a Culture for Optimal

Antibiotic Use with the group of people/providers you

identified to create a partnership with to support

stewardship

Identify the group of people/providers you’re partnering with:

who? what unit? what discipline? (hospitalists, pharmacists,

microbiology, infection prevention, leadership)

AND: what you’re testing to Promote a Culture of Optimal AB

Use

- Use the Chat Box to share

- If you’re connected by phone, raise your hand to discuss

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Questions?15

Raise your hand

Use the Chat

Jeffrey M. Rohde, M.D.

Jeff Rohde, MD, is currently an Assistant

Professor in the Division of General Internal Medicine

at the University of Michigan, where he serves as

Medical Director for the 7A general medicine/telemetry

inpatient unit, General Medicine Quality Committee

Chair and is an active hospitalist. In addition to these

activities, Dr. Rohde has been active in quality

improvement and enhancing transitions of care. His

research interests include transfusion medicine,

hospitalists, health-care associated diseases and their

prevention, and quality improvement practices.

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Megan Mack, M.D. 17


Megan Mack MD

Jeff Rohde MD

Overview

• Hospitalists as patient safety champions

• Barriers to adoption of best practices

• Facilitators to adoption of best practices

• The University of Michigan Experience

• Embedding stewardship practices

• Future directions

Hospitalists as Patient Safety

Champions

Hospitalists as Patient Safety

Champions

• HELPS consortium• Multicenter team designed to identify best

practices for several quality improvement initiatives

• Diverse hospital demographics• Representatives met regularly to

disseminate knowledge• Facilitated institutional implementation

around best practices

Barriers to Adoption of Best Practices

• New process avoidance

• Time constraints

• More work

• Momentum/Inertia• “This is the way we do things here…”

• “Not our problem..,”

• Patient variability• Can we apply “one-size-fits-all”?

• No process owner• Who owns the day to day problems?

Facilitators to Adoption of Best

Practices

• Champion/Process Owner

• Quantify and feed back outcomes

• Create healthy competition

• Celebrate success

• Multidisciplinary team

• Project needs institutional/leadership buy-in

• Use established methodology

• “Plan-Do-Study-Act” cycles

The University of Michigan Experience

UMHS (4 Hospitals) 45,429 discharges in 2013

University Hospital 604 beds

General Medicine Service ~20,000 discharges per year

Medicine Faculty Hospitalist Service

• 60+ hospitalists

• 10 total teams

• Cover wide variety of medical patients; also rotate on consult team,

resident teaching services

Hospitalists’ Antibiotic Stewardship Project

• CDC/IHI multicenter hospitalist kickoff: November 2012

• 3 practices identified to embed into workflow

• Documentation/visibility at the point of care

– Drug and indication

– Day of therapy/Start date


• Appropriate length of treatment

– Easy access to guidelines

– UTI, pneumonia, skin and soft tissue infections

• 72 hour antibiotic time out

– Right diagnosis

– Right drug

– Right dose and duration


Practices

• Champion/process owners:

• 2 hospitalists (JR/MM)

• Hospitalist leadership (SF)

• Regular conference calls with other sites

• How do you make stewardship champions visible?

• Frontline Provider

• Respected by peers

• Walk the walk and talk the talk


Practices

• Quantify/feedback outcomes:

• Hospitalist antibiotic stewardship incentive: May 2013

• 3 domains of stewardship best practices tied to end-of-year

quality improvement incentive

• Random sample of discharge summaries and service sign-out

emails reviewed

• Everyone gets the same incentive!

Embedding Stewardship Practices


Practices

• Multidisciplinary team

• 1 clinical pharmacist: 3-4

hospitalist teams

• M-F face-to-face rounds

• MWF: Antibiotic timeout

• IVPO?

• Discontinue?

• Deescalate?


Practices

• Use established methodology

• Plan: Assess Current State

• Do: Small Test of Change

• Study: What barriers were encountered?

What facilitated the process?

• Act: Address those barriers

Nurture the facilitators

Plan: Assess Current State of Documentation

• Baseline survey of 3 providers:

• “I do it well but others don’t”

• “Guidelines not always easily accessible”

• Baseline review of documentation for all stewardship

components:

• 10% of discharge summaries

• 4% of progress notes

• 18% of service sign-outs

Do: Small Tests of Change For

Documentation at Point of Care

– Approached 3 hospitalists during 1 week of service on non-resident service

– Document in Daily Progress Note and Service Sign-out

– Antibiotic with indication

– Day of therapy


• Educational campaigns

• Regular reminders

• Development of antibiotic pocket card

• Pharmacy partnership

Study: What Worked, What Didn’t?

Barriers to Documentation:

– Difficult to remember to do

– Duration is difficult to determine

– Unclear sign-out

Facilitators to Documentation:

– New way of thinking about antibiotics

– Focused on best care for patient

– Helps your colleagues

– Other services (ID) started documenting in their notes

Act: Address the Barriers to Documentation

Difficult to remember to do

– Educational campaigns

– Regular reminders

– Pharmacy partnership

What’s in it for me?

– Attachment to end of the year quality incentive

– Group based incentive paid out based on performance on

documentation assessment

Act: Address the Barriers to Documentation

Duration is difficult to determine/Guidelines not easily

accessible

• Development of antibiotic pocket card

Embedding stewardship practices

Embedding Stewardship Practices

Barriers/Challenges Potential Solutions

Unawareness of ABS interventions/projects Education: noon conferences, emails, one-on-one

discussion, time outs with pharmacists

Too busy/can’t remember to incorporate into

notes

Timeouts/reminders during pharmacy rounds

Lack of accessibility of appropriate guidelines on

which to base treatment decisions

Development of antibiotic guideline card, to be

distributed both via paper copy and website

Poor handoff from previous physician Encouraged email signout documentation of 3

aspects of ABS (ie, already in place when service

is taken over)

Why is this important/what’s in it for me? Incentivized good documentation with end of the

year bonus money

Future Directions

• Future stewardship metrics:• Decrease in hospital length of stay?

• Decrease in patients discharged with PICCs?

• Decrease in antibiotic resistance?

• Decrease in hospital antibiotic costs?

• Decrease in C. diff infections?

Questions?40

Raise your hand

Use the Chat

Action Period Assignment

Test one idea related to introduce/enhance:


Assess the current state:

MDR’s already in practice?

No formal MDR’s? Opportunity to engage 1 Frontline Provider, 1 RPh, 1 RN

on 1 unit

Small test of change: Discuss/review antibiotics/documentation during

rounds:

- Engage MDR team or “team of the willing” to review documentation of AB in

the record during rounds: AB, indication, day of therapy, duration

- track compliance

- Discuss barriers (difficult to find, takes too much time, etc.)

- Elicit ideas from the team for “next cycle” of test

Share your test/learnings on the listserv AND Come prepared to share your

plans at the next session

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Expedition Communications

Listserv for session communications:

[email protected]

To add colleagues, email us at [email protected]

Pose questions, share resources, discuss barriers or

successes

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mailto:[email protected]

mailto:[email protected]

Next Session

Thursday, May 15th, 3:00 PM – 4:00 PM ET

Session 5 – Focus on: 72 Hour Antibiotic “Time-out”

Jeff Rohde, MDMegan Mack, MD

Matthew Tupps RPhUniversity of Michigan

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