influence of telephone communication on antibiotic prescribing in nursing homes
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The 2011 Wisconsin Health Improvement and Research Partnership Forum Fluno Center, Madison, WI September, 15 2011. Influence of Telephone Communication on Antibiotic Prescribing in Nursing Homes. Christopher J. Crnich, MD MS 1, 2. - PowerPoint PPT PresentationTRANSCRIPT
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Influence of Telephone Communication on
Antibiotic Prescribing in Nursing Homes
The 2011 Wisconsin Health Improvement and Research Partnership Forum
Fluno Center, Madison, WI September, 15 2011
Christopher J. Crnich, MD MS1, 2
1 University of Wisconsin School of Medicine and Public Health, Madison, WI2 William S. Middleton Veterans Affairs Hospital, Madison, WI
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“We can look forward with confidence to a considerable degree of freedom from infectious diseases at a time not too far in the future. Indeed … it seems reasonable to anticipate that within some measurable time… all the major infections will have disappeared.”
T. Aidan Cockburn, 1963
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“Antibiotic therapy, if indiscriminately used, may turn out to be a medicinal flood that temporarily cleans and heals, but ultimately destroys life itself.”
Felix Marti-Ibanez, 1955
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“At the beginning of the 21st century, antimicrobial resistance is common, has developed against every class of antimicrobial drug, and appears to be spreading into new clinical niches.”
Stephan Harbarth & Matthew Samore, 2005
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Global Resistance
Ryback et al. Pharmacotherapy 2005; 24(12 part 2): 203S - 15S
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The Antibiotic Pipeline
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Improving Antibiotic Use
McCaig et al. Emerg Infect Dis 2003; 9(4): 432-7
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Abx Stewardship: Reduces Rates of MDROs
Valiquette, et al. Clin Infect Dis 2007; 45:S112.
Tertiary care hospital; Quebec, 2003-2006
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Abx Stewardship: Improves Clinical Outcomes
Appropriate Cure Failure0
102030405060708090
100
AMPUP
RR 2.8 (2.1-3.8) RR 1.7 (1.3-2.1) RR 0.2 (0.1-0.4)
Perc
en
t
AMP = Antibiotic Management ProgramUP = Usual Practice
Fishman N. Am J Med. 2006;119:S53.
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Abx Stewardship: Reduces Costs
• Team consists of a clinical pharmacist, an an ID physician and Clinical Laboratories• Methods
– Development of evidence-based guidelines– Antibiotic utilization software to identify targeted interventions– Daily interdisciplinary rounds– Education of staff
• Antimicrobial portion of inpatient drug budget: 22.9% (FY05), 20.5% (FY08) • Cost-avoidance in 2009 Budget = $600,000
12.9%
Slide courtesy of Barry Fox, Director of UWHC Antibiotic Stewardship Program
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Resistance in Nursing Homes
Jarvis WR. Emerg Infect Dis 2001; 7(2): 170-3
????
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MDRO in NHs: MRSA
A B C D E F Overall0
0.1
0.2
0.3
0.4
Prevalent Incident
Prop
ortio
n Co
loni
zed
(%)
Crnich et al. IDSA 2010
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MDRO in NHs: FQRB
A B C D E F Overall0
0.1
0.2
0.3
0.4
Prevalent Incident
Prop
ortio
n Co
loni
zed
(%)
Crnich et al. IDSA 2010
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Antimicrobial Use in LTCFs
• Accounts for 40% of the medications used in LTCF residents in older studies
• 3-13% of residents are receiving antimicrobials at any time
• 50-70% of residents will receive at least one antibiotic during the year
• 25-75% of antibiotics given for inappropriate indications
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Antibiotic Use in WI NHs
β-lactams32%
MACL10%
FQ37%
Tetra4%
Sulfa13%
Other5%
Antibiotic Courses
β-lactams23%
MACL5%
FQ25%
Tetra12%
Sulfa25%
Other10%
Antibiotic Days
1 2 3 4 5 60
1
2
3
4
5
6
7
0
20
40
60
80
100
120
Total Antibiotic Courses Total Antibiotc Days
Facility
Anti
bioti
c Co
urse
s pe
r 100
0 Re
side
nt D
ays
Anti
bioti
c D
ays
per 1
000
Resi
dent
Day
s
Crnich et al. J Am Med Dir Assoc 2011, submitted
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Antibiotic Use in WI NHs
10
102030405060708090
100
Cumulative Proportion of Antibiotic CoursesCumulative Proportion of Antibiotic Days
Total Number of Antibiotic Courses Recieved
Perc
ent o
f Res
iden
t Pop
ulati
on (%
)
No. Subjects = 449No. Abx(+) = 293 (65%)
N = 92 (21%)
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Why?
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Antibiotic Start Process: Hospital versus Nursing Home
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Antibiotic Start Process: Hospital versus Nursing Home
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Antibiotic Start Process: Hospital versus Nursing Home
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Antibiotic Start Process: Hospital versus Nursing Home
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Antibiotic Start Process: Hospital versus Nursing Home
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Antibiotic Start Process: Hospital versus Nursing Home
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Antibiotic Start Process: Hospital versus Nursing Home
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Antibiotic Start Process: Hospital versus Nursing Home
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J Am Med Dir Assoc 2005; 6(2): 109-12
• 221 post-acute care residents admitted to 7 Georgia NHs followed for a year
• 105/221 (48%) received at least one course of antibiotics
• 50% were NH-initiated
• 43% of NH-initiated courses had no documentation of infection in medical record
• 67% of NH started antibiotics initiated over the phone
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Antibiotic Start Process: Hospital versus Nursing Home
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Nurse-Physician Communication
• Ineffective communication involved in 60% of medical errors
• Improving N-P communication in LTCFs became a NPSG in 2008
• Quality of interactions viewed as suboptimal by both parties
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Gerontol 1989; 29(4): 502-10
• 40/83 (48.2%) considered avoidable
• 70% due to inadequate diagnostic or treatment facilities
• 15% due to pressure from family/staff
• 15% due to suboptimal communication
– MD not available– Assessment of resident
suboptimal
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• 15 of 21 nurses viewed preparation as critical to effective N-P communication
• Barriers to preparation– Relevant clinical information not all in one place– Assessment incomplete at time of call– Delays in MD returning call
J Patient Saf 2009; 5(3): 145-52
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Research Question:
Does the quality of telephone/fax communication between nursing staff and off-site prescribers influence the appropriateness of antibiotic prescriptions in NHs?
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Research Objectives
• Understand how the communication process influences decisions to start antibiotics in NHs
• Use this information to promote more effective communication between NH staff and off-site prescribers
• Reduce unnecessary and suboptimal antibiotic use in NHs
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Study Aims
• Specific Aim #1: Assess the content of telephone/fax communication between nursing staff and off-site prescribers
• Specific Aim #2: Determine if the absence of specific elements of content are associated with higher rates of inappropriate antibiotic prescribing
• Specific Aim #3: Explore the influence that factors other than communication have on the prescription of antibiotics
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Study Design
• Mixed-methods observational study
• Core data collection methods will be developed and validated in a single pilot facility
• Plan to expand to multiple facilities following the pilot
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Measurement of Communication
• The content of communication events associated with an antibiotic start will obtained:– Telephone conversations between NH staff and
off-site providers will be recorded– Copies of fax communications will be obtained
• The conveyance of specific elements with each communication event will be abstracted onto standard case report forms
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Assessment of Appropriateness of Antibiotic Starts
• Data related to each antibiotic start will be collected and abstracted onto standard CRFs
• Structured implicit review will be used to determine appropriateness– Each member of an expert multidisciplinary panel
will review CRFs independently– Score as appropriate, inappropriate, indeterminate– Consensus on discrepancies between panel
members will be achieved through group consensus
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Assessment of Non-Communication Factors
• Semi-structured interviews with NH staff and off-site prescribers involved with antibiotic start events will be performed.
• Audio tapes of communication events will be used to facilitate memory of prescribing event.
• Transcripts of interviews will be analyzed using a grounded theory approach
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Thank You