AHRQ Safety Program for Improving Antibiotic Use

Slide Title and Commentary Slide Number and SlideAHRQ Safety Program for Improving Antibiotic Use

Identifying Targets for Improving Antibiotic UseAcute Care

SAY:

Welcome to our second CUSP module entitled “Identifying Targets for Improving Antibiotic Use.”

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Presenter—Sara Cosgrove

SAY:

My name is Sara Cosgrove. I am an infectious diseases physician at Johns Hopkins and I direct the hospital’s Department of Antimicrobial Stewardship.

On the screen is contact information for the project. If you have any questions or need to reach me after this Webex, please use this information.

Slide 2

Identifying Targets for Improving Antibiotic UseAcute Care

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Housekeeping

SAY:Let’s take a moment to go over housekeeping rules for this call.

• If you have a question, either speak up or use the ‘chat’ feature to ask a question during the presentation.

SAY:• Question and answer time will be provided at

the end of the presentation for most questions, please make note of them and save them for the end. Please follow this structure unless I ask for any relevant questions during the presentation. In this case, please participate. Participation and active engagement is how you will get the most out of this presentation and out of this whole program.

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Objectives

SAY:

By the end of this module, participants will be able to: Understand how to identify defects related to

antibiotic prescribing Understand how to leverage frontline wisdom

to guide safety improvement efforts around antibiotic prescribing

Understand how to recognize defects using the Four Moments of Antibiotic Prescribing framework

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Recap

SAY:

Let’s begin by reviewing what we learned from our previous module “Improving Antibiotic Use is a Patient Safety Issue.” CUSP improves the culture of safety while providing frontline staff with the tools and support needed to identify and tackle hazards that threaten their patients. CUSP strives to reduce preventable harm.

At this point, you understand that:Systems impact patient safety. Systems that are fragmented can cause patient harm. Also, the 3 methods needed to eliminate unnecessary harm are —

standardizing practices, creating independent checklists, and learning from each new defect

In this WebEx, you will learn how to identify a defect which you will be able to work on with your team.

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What is a Defect?

SAY:

What is a defect? A defect is anything you do not want to have happen again.

A few examples of defects related to antibiotic use include —

Unnecessarily broad spectrum empiric antibiotic therapy

Delayed antibiotic initiation in patients with sepsis

Forgetting to obtain needed cultures before prescribing antibiotic therapy

Forgetting to narrow antibiotic therapy based on clinical data or culture data

Forgetting to discontinue antibiotics when they are not needed

Forgetting to discontinue surgical prophylaxis Forgetting to convert from IV to PO therapy Accidentally miscounting days of therapy during

transitions of care for example from the hospital to the ambulatory setting or from hospitals to nursing homes or even within the hospital from one clinical service or floor to another

Prescribing excess durations of antibiotic therapy

Or development of a C. difficile infection

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How Can you Identify Defects?

SAY:

How can you identify defects? It is important to identify defects associated with antibiotic prescribing by seeking input from a diverse group of healthcare workers. Encourage frontline staff to complete the Staff Safety Assessment in which they answer the following questions—

Describe the next patient scenario for which antibiotics will not be prescribed optimally

Describe what you think can be done to prevent this from happening

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How Can you Identify Defects?

SAY:

The CUSP team on a unit or service generally consists of a physician lead, pharmacist lead, and/or nurse lead. This team should review the defects identified by the frontline staff with the Antibiotic Stewardship team and prioritize the top three defects. The CUSP team and the stewardship team (and a diverse group of frontline staff) should identify all the factors that could lead to this defect.

Both technical and adaptive factors should be considered when thinking about what contributed to this defect. We will learn what these terms mean on the next slides.

Over the next several months, the defect that we will focus on is non-compliance with the 4 moments of Antibiotic Decision-Making. We ask that your team think about prioritizing defects that lead to failures to follow this framework.

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Technical Problems

SAY:

Problems can be either technical or adaptive. Technical problems are problems where the potential solutions are clear. These usually require a checklist or protocol to guide the implementation of the evidence-based best practice.

For example, if the defect is that house staff are unaware that the recommended duration of antibiotic therapy for community-acquired pneumonia is 5 days and instead are prescribing longer courses of therapy, potential solutions include developing pocket-guides for house staff or automatic pop-ups in the electronic health record when a diagnosis of CAP is entered. The ease of use and accessibility of solutions to technical problems should always be considered. Links to guidelines in the EHR should be considered if feasible.

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Adaptive Problems

SAY:

Adaptive problems are problems where solutions require a change in attitudes, beliefs, and behaviors. For example, physicians may feel uncomfortable discontinuing vancomycin when a colleague decided to start it on the previous day.

The solution to this is more complex than with a technical problem and requires fostering a culture of safety where all clinicians understand that their colleagues may decide to stop or adjust therapy as a patient’s clinical status evolves and it should not be viewed as disrespectful. If a clinician is not confident about the decision to continue or discontinue vancomycin, this is a good time to involve the antibiotic stewardship team or request an infectious diseases consultation, if available.

The CUSP methodology helps teams identify both technical and adaptive issues and technical and adaptive solutions.

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Problem Solving

SAY:

When working as a team to identify solutions to problems, there are first order and second order solutions. First order problem solving involves solving one problem at a time. It’s where you focus on one particular instance and generally does not help prevent future harm from occurring.

This could involve calling a physician who ordered vancomycin and telling him or her that it can be discontinued.

Second order problem solving uses adaptive interventions. It identifies defects in the system and prevents them from occurring again.

For example, implementing an antibiotic time-out tool that should be reviewed on a daily basis during rounds so the team can discuss whether vancomycin and other antibiotics are needed as a team.CUSP helps with finding second order solutions for problems. Second order problem solving or systematic changes are often needed to decrease the harm associated with unnecessary antibiotic use.

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The Four Moments of Antibiotic Stewardship

SAY:

It is important to select specific defects voiced by your frontline staff.Over the course of the next several months, we would like you to consider “failure to follow the four moments in antibiotic prescribing” as your defect.

We will use this framework to review antibiotic prescribing decisions to both identify targets for improving antibiotic use and to determine solutions.After the AHRQ Safety Program for Improving Antibiotic Use is completed, we hope that you will continue to use the Four Moments framework to recognize defects with antibiotic prescribing and to develop, as a team, technical and adaptive solutions.

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Four Moments Review

SAY:

Let’s review the four moments of antibiotic prescribing.1. Does my patient have an infection that requires

antibiotic therapy?2. Have I ordered appropriate cultures before

starting antibiotics? What empiric antibiotic therapy should I initiate?

3. A day or more has passed. Can I stop antibiotics? Can I narrow therapy or change antibiotics from IV to oral therapy?

4. What duration of antibiotic therapy is needed for my patient’s infection?

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Moment 3: De-escalation

SAY:

For now, let’s focus a little more on Moment 3 which includes the decision to de-escalate antibiotic therapy. Antibiotic de-escalation means modifying antibiotic therapy to agents considered to have a narrower spectrum of activity than the initial antibiotic regimen. In the event that a patient is found to have an alternative, non-infectious (or non-bacterial) etiology for his or her symptoms, de-escalation can also include stopping antibiotics altogether.

De-escalation can be guided by microbiology data when an organism is recovered that is susceptible to a narrower-spectrum antibiotic. De-escalation is also acceptable when certain organisms are not detected in specimens, for example stopping vancomycin when MRSA is not present. De-escalation can also be guided by the clinical status of the patient.

The goals of de-escalation are to optimize therapy AND to select agents that minimize side-effects.

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Is Antibiotic De-Escalation Safe?

SAY:

These are the results from a meta-analysis reviewing the results of 13 studies showing that de-escalation of antibiotic therapy is safe. The patients included in these studies were severely ill and did not have worse outcomes after the decision was made to deescalate therapy, and in fact were spared from adverse events associated with broad-spectrum antibiotic use.

This meta-analysis shows that patients who undergo antibiotic de-escalation have a 28% reduced risk of death compared to patients who remain on broad-spectrum antibiotic therapy. Let’s walk through 3 examples of de-escalation.

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Case #1 Example of De-Escalation

SAY:

Your team is taking care of a patient with a past history of mitral valve endocarditis. He is admitted to the hospital with high fevers, hypotension, and diffuse myalgias. He is diagnosed with presumptive endocarditis and started on vancomycin and ceftriaxone.

By day 3 of therapy, blood cultures are growing a viridans group streptococcus which is highly susceptible to penicillin.

In this case, while vancomycin and ceftriaxone both have activity against the organism, penicillin is the preferred choice given its narrow spectrum, excellent activity against the organism, and low side-effect profile. It would both be appropriate and safer for your patient for vancomycin and ceftriaxone to be de-escalated to penicillin.

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Case #2 Example of De-Escalation

SAY:

Let’s discuss another example of de-escalation. Your team is taking care of a patient hospitalized after undergoing a spinal fusion. He is diagnosed with healthcare-associated pneumonia and sepsis. He requires intubation and is admitted to the ICU and started empirically on vancomycin and piperacillin/tazobactam. Your patient improves over the next few days and is extubated on day 3. Sputum cultures grow a pan-susceptible E. coli.

Although he has improved on vancomycin and piperacillin/tazobactam, it is not necessary to continue broad spectrum therapy when cultures have grown E. coli susceptible to cefazolin and have not grown organisms such as MRSA or Pseudomonas aeruginosa.

These organisms generally grow easily in culture and their absence from culture provides strong evidence that they are not the causative organisms. Cefazolin is preferable to other agents such as ceftriaxone and ciprofloxacin because there is less association with C. difficile infection with cefazolin compared with third-generation cephalosporins like ceftriaxone and fluoroquinolones.

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Case #3 Example of De-Escalation

SAY:

Let’s review one more case. A patient presents to the ED with shortness of breath, increased lower extremity edema, a fever of 100.9°F and a white blood cell count of 13,000. His chest x-ray shows bilateral infiltrates vs. pulmonary edema greater on the right than the left side of the lungs.

He is initiated on ceftriaxone and azithromycin for possible community-acquired pneumonia and furosemide for possible heart failure. The next day, he reports that his shortness of breath has resolved. A sputum culture is pending. In this case, the diagnosis is highly likely to be heart failure, which can be associated with low grade fevers and a mildly elevated WBC.

The patient had a favorable response to diuresis. At this point it is reasonable to stop his antibiotics given his relatively rapid improvement over the past day. There is no reason to wait for the results of a sputum culture when clinical judgment suggests he does not have an infection.

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Your Turn!

SAY:

Now it is your turn. Think about antibiotic usage in your unit… What is a defect related to antibiotic use that you have noticed?It is good to start with a defect that is relatively easy to fix- it builds team momentum. Do not think right now about how you might solve it but instead, think about- ‘how might the next patient be harmed’? Record your defect. You will think more about it in future modules.

Over the next few weeks, you and other staff should use the Staff Safety Assessment form so that a diverse group of healthcare workers can give input into defects related to antibiotic prescribing that they have noticed.

Then your CUSP team in conjunction with your antibiotic stewardship team can review these forms and select the top three issues that should be addressed. Remember, CUSP cannot be successful without a multidisciplinary team. The next module will teach you how to learn from the defects you noticed and how to fix them!

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Summary

SAY:

At this point, you know: That defects are plentiful and it is good to start

with a defect that is easy to fix—it builds team momentum and provides experience.

The Staff Safety Assessment should be completed by all staff on your unit.

That as a team, you should prioritize defects. For the duration of the AHRQ Program for

Improving Antibiotic Use, we ask that you consider defects related to failure to follow the Four Moments of Antibiotic Decision-Making Framework.

Over the next several months, we will use the Four Moments of Antibiotic Prescribing framework to identify defects and use second-order problem solving to determine technical and adaptive solutions.

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Program Website Access

SAY:

You have been sent login credentials to the AHRQ Safety Program for Improving Antibiotic Use website. Please log in to the website to access project resources such as the project schedule, recorded webinars, and slide decks with scripts. The website is updated routinely with new resources. Please note that recorded webinars may take up to 5 days after the presentation date to be posted on this website.

If you have any questions about login credentials or website content please email ANTIBIOTICSAFETY@NORC.ORG

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Questions

SAY:

Thank you all for your attention. At this time, please ask any question you have about identifying targets for improving antibiotic use or any of the other content covered in this webinar. You can type in your questions or speak up on the conference line.

Thanks!

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Next Steps

SAY:

During your next WebEx, we will discuss Improving Antibiotic Use by Learning from Defects.

Contact us at antibioticsafety@norc.org between now and your next call if you have any questions or concerns.

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