7/15/2011

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Session 3 – July 14th, 2011

Scott Flanders MD

Christopher Ohl MD

Edina Advic PharmD

Diane Jacobsen, MPH

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7/15/2011

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Our Expedition Director

Diane Jacobsen, MPH, CPHQ, Director,

Institute for Healthcare Improvement (IHI), is

content director for Project JOINTS, directs

the CDC/IHI Antibiotic Stewardship Initiatives,

Expeditions on Antibiotic Stewardship and

Sepsis, and serves as IHI content lead and

improvement advisor for the California

Healthcare-Associated Infection Prevention

Initiative (CHAIPI). Ms. Jacobsen also

directed Expeditions on Preventing CA-UTIs,

Reducing C. difficile Infections, Improving

Flow in Key Areas and Improving Stoke Care.

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Christopher Ohl, MD

Christopher Ohl, MD, is the Medical

Director for Antimicrobial Utilization

Stewardship and Epidemiology at

Wake Forest University Baptist

Medical Center, and Infectious

Diseases Associate Professor at Wake

Forest University School of Medicine

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Scott Alan Flanders, M.D.

Scott A. Flanders, MD, FACP, is a

hospitalist and clinical professor,

Department of Internal Medicine at

the University of Michigan Health

System. His clinical and research

interests include hospital medicine,

community-acquired and nosocomial

pneumonia, hospitalists, and patient

safety.

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Overall Program Aim

The Aim of this Expedition: To provide

hospitals with the most effective ideas and

practices in improving Antibiotic Stewardship

in their organization.

Objectives

Upon completion of this expedition, participants will be able to:

• Describe the impact of antibiotic overuse on complications, including

Clostridium difficile and adverse drug reactions, length of stay, costs,

and antimicrobial resistance

• Establish or enhance a multidisciplinary focus to heighten awareness

of the challenges of antimicrobial resistance and support antibiotic

stewardship

• Identify and begin improving at least one key process to optimize

antibiotic selection, dose, and duration of antimicrobial agents in their

hospital

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Expedition Focus

The expedition will focus on key “high leverage”

changes to ensure timely and appropriate antibiotic

utilization:

• Making antibiotics patient is receiving and start & stop

dates visible at point of care

• Reconciling and adjusting antibiotics – focused on care

transitions within the hospital

• Stopping or de-escalating therapy appropriately

• Monitoring and providing feedback on process measure to

assess progress over time

Agenda

• Welcome and introductions

• Follow-up from Session 2 – Making antibiotics patient is receiving and

start & stop dates visible at point of care

- Review Assignment: what did you TEST? – Diane Jacobsen MPH

• Session 3 Focus - Reconciling and adjusting antibiotics – focused on care

transitions within the hospital

Scott Flanders MD, Chris Ohl MD

• Testing on a small scale – designing a “test” in your hospital

• Final Questions & Close

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What did you TEST since the June 30th Session?

Design a small test of change to ensure

─ visibility of start & stop dates at the point of care

Ideas to consider………….

1. Define a prominent location in the medical record and at

the bedside for antibiotic therapy to be documented

(e.g., “this is day X of Y”).

2. Develop a system to ensure that antibiotic days are

counted correctly (e.g., does the first day of therapy

count as day zero or day one?).

3. On admission, collect a complete list of the antibiotics a

patient is taking (i.e., what antibiotic the patient is on, at

what dose, when it was started).

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What did you TEST since the June 30th Session?

1. Define a prominent location in the medical record and at

the bedside for antibiotic therapy to be documented

(e.g., “this is day X of Y”).

Things to consider:

- Can be within electronic medical record(EMR),

computerized physician order entry (CPOE) or paper

based

- Group antibiotics together into their own section within

the record

- Add the indication; “day 3 of Ceftriaxone for community

acquired pneumonia (CAP)”

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What did you TEST since the June 30th Session?

2. Develop a system to ensure that antibiotic days are

counted correctly (e.g., does the first day of therapy

count as day zero or day one?).

Things to consider:

- specifically, determine how to handle antibiotics with

multiple doses per day.

- Scenario: A patient with a complicated case of

cholecystitis is admitted at 8 pm on Sunday and started

on q.i.d. piperacillin / tazobactam. The first dose is

given at 10 pm with the next dose scheduled for 6 am

on Monday. Is Sunday or Monday day 1?

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What did you TEST since the June 30th Session?

2. Develop a system to ensure that antibiotic days are

counted correctly (e.g., does the first day of therapy count

as day zero or day one?).

Comments shared on CHAT

- “we use the first dose is day 1”

- “We have an ID attending who uses day one as first day of all

doses are administered or therapeutic levels achieved. Others

vary.”

- “day one is the day all doses are administered for that drug's

dosing schedule”

- “It is a challenge to consistently define parameters, but prefer 1st

dose as day 1”

- “to some extent it's only of minor significance because at most

you'll be off on your counting by one”

- “Don’t forget to count days of therapy administered in ED,

particularly important for CAP.

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What did you TEST since the June 30th Session?

3. On admission, collect a complete list of the antibiotics a

patient is taking (i.e., what antibiotic the patient is on, at

what dose, when it was started).

Things to consider:

- Ideally, this should happen at every key transition

- In and out of the ICU, and at hospital discharge

Today’s Focus

The expedition will focus on key “high leverage”

changes to ensure timely and appropriate antibiotic

utilization:

• Reconciling and adjusting antibiotics – focused on care

transitions within the hospital

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Reconciling and adjusting antibiotics – focused

on care transitions within the hospital

Key Change Concept:

• Look for all opportunities to stop or change (de-escalate or

broaden) antibiotic therapy when:

- patient condition changes

and/or

- when changing levels of care

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Look for all opportunities to stop or change (de-escalate or

broaden) antibiotic therapy when patient condition changes

and/or when changing levels of care

Specific Change idea:

1. Utilize every Multi-Disciplinary Round (MD) and transition in care to

ensure:

• Antibiotic matched pathogen and sensitivity

• The dose and dose interval are correct given current clinical status (e.g.,

renal function may change);

• Appropriate toxicity monitoring is occurring;

• Duration is clearly specified and there is an end date for the therapy;

• Opportunities for discontinuation or de-escalation in therapy are

considered;

• Whether patient can be converted from intravenous to oral (IV to PO)

antibiotics.

Things to consider:

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Look for all opportunities to stop or change (de-escalate or

broaden) antibiotic therapy when patient condition changes

and/or when changing levels of care

Specific Change idea:

1. Utilize every Multi-Disciplinary Round (MD) and transition in care

Things to consider:

Obvious transitions:

─ ED-floor; floor-ICU-floor; discharge

Less obvious (but common) transitions:

─ Admitting doctor to “managing” doctor

─ Service signout: overnight vs. new doctor

What to address:

─ Clarify the diagnosis (reconsider diagnoses with improvement OR worsening)

─ Establish guidelines for duration

─ Schedule a reassessment after 48-72 hrs of a change in status

─ Vancomycin discontinuation is low-hanging fruit

─ Start with common conditions: CAP, UTI, SSI

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Look for all opportunities to stop or change (de-escalate or

broaden) antibiotic therapy when patient condition changes

and/or when changing levels of care

Specific Change idea:

2. Pay special attention to antibiotic duplication on conversion day.

Things to consider:

─ IV-Oral changes REQUIRE a reassessment of antibiotic spectrum

─ Work to change the culture: “They got better on 3 antibiotics, so they need to

complete courses of all 3”; not necessarily true

─ Streamlining based on micro results: believe your cultures!

─ Double anaerobic coverage

─ Double gram negative coverage

─ Discontinuing antibiotics when an alternative diagnosis is more likely (i.e heart

failure rather than pneumonia)

─ Discontinuing antibiotics when urine cultures are attributed to asymptomatic

bacteriura or candiduria

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Prospective Audit and Feedback

• Antibiotic support teams

─ ID physician/Clinical Pharmacist

• Determine patients given “problem” antimicrobials or targeted “infections”

• Survey hospital culture/antibiotic data

• Make one on one interventions and patient specific education to responsible MD

• Has been shown to impact on antimicrobial use in both university and community hospitals

• Disdvantages: Compliance is voluntary. Resource intense

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What You Should Do Over the Next 14 Days

• Design a small test of change to ensure antibiotics

are reconciled and adjusted on all care transitions

within the hospital

Ideas to consider………….

1. Utilize every Multi-Disciplinary Round (MD) and

transition in care to ensure: • Antibiotic matched pathogen and sensitivity

• The dose and dose interval are correct given current clinical status (e.g.,

renal function may change);

• Appropriate toxicity monitoring is occurring;

• Duration is clearly specified and there is an end date for the therapy;

• Opportunities for discontinuation or de-escalation in therapy are

considered;

• Whether patient can be converted from intravenous to oral (IV to PO)

antibiotics.

2. Pay special attention to antibiotic duplication on

conversion day

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Upcoming Sessions 1-2pm ET

• July 28th – Stopping or de-escalating therapy

appropriately

• Aug 11th – Insights and challenges in community

hospitals

• Aug 25th – Brief report outs from participating hospitals:

progress and challenges

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