ICAP Project: Introduction to Quality Improvement, Change Package, & Antibiotic Stewardship

Transcription

1 ICAP Project: Introduction to Quality Improvement, Change Package, & Antibiotic Stewardship AUGUST 28, 2014

2 Agenda Agenda Item Speaker Time Welcome and Introductions Faiza Khan 5 min Orientation to Quality Improvement Brief Introduction to ICAP Change Package Antibiotic Stewardship Programs Mark Shen, MD Joanne Nazif, MD Mary Ann Queen, MD 20 min 5 min 20 min Questions and Answers All 10 min

3 Introduction to QI Methods MARK SHEN, MD

4 Objectives Define important QI steps before P-D-S-A Engage the team Define the objectives Understand the process DON T RUSH TO A SOLUTION!

5 Build the Right Team

6 Reducing Excessive Use of Continuous Clinical Safety & Effectiveness Session # 12 Pulse Oximetry May 21, 2010

7 Engage the Team Team Members Mark Shen, MD Becky Toth, RN-BC, MSN, CNS Patty Cervenka, RN, BSN, CPN Adam Carey, RRT They educated the nurses (not me) 7

8 AIM Statement (Immature Versions) Why do the nurses always continue the pulse oximeter? Is there a Pulse Ox Fairy that comes turns it back on every evening? Let s stop the use of continuous pulse oximetry If you don t know where you re going, you ll end up someplace else. Yogi Berra

9 AIM Statement -Smarter The aim of this project is to decrease the use of continuous pulse oximetryin normoxicpatients with respiratory diseases (asthma, bronchiolitis, pneumonia) by 50% during the period, January 1, 2010 to June 30, The process begins when a patient is admitted to the 4C unit and ends 4 hours after the patient has been on room air with normal oxygen saturations.

10 SMART AIM Specific Measurable Achievable Realistic Time-defined

11 The Model for Improvement

12 Not SMART We keep giving difficult learners poor final evaluations without any documented mid-rotation concerns. Let s create a new form. (talked about every 3 years) Sign-out takes forever. Let s all agree to just discuss the basics. (talked about every 6 months) Let s discharge 50% of patients before noon. (talked about every month)

13 AIM SMART In Amsterdam, the tile under Schiphol s urinals would pass inspection in an operating room. But nobody notices. What everybody does notice is that each urinal has a fly in it. Look harder, and the fly turns into the black outline of a fly etched into the porcelain. It improves the aim. If a man sees a fly, he aims at it. Fly-in-urinal research found that etchings reduce spillage by 80%. It gives a guy something to think about. That s the perfect example of process control.

14 Understand the Process: Pareto Chart Reasons for Continuous Pulse Oximetry Nurse comfort It's "standard" for Not 4 hrs yet Not 8 hrs yet MD directive

15 Measurement is a Tool (Begin Early) Continuous Pulse Oximetry Use in Patients on Room Air > 4 Hours 100% 80% 60% 40% 20% 0% (refined sampling method) Education initiated Week

16 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Understand the Process: Control Chart 0% 11/15/ /22/ /29/ /6/ /13/ /20/ /27/2009 1/3/2010 1/10/2010 1/17/2010 1/24/2010 1/31/2010 2/7/2010 2/14/2010 2/21/2010 2/28/2010 3/7/2010 3/14/2010 3/21/2010 3/28/2010 4/4/2010 -Measured discharge communication within two days - Unstable weeks were due to attendings that never got the memo

17 Revision Date: KEY DRIVER DIAGRAM KEY DRIVERS INTERVENTIONS AIM Copyright 2008 Cincinnati Children s Hospital Medical Center; all rights reserved. Key Dotted box = Placeholder for future additions Green shaded = what we re working on right now

18 Key Driver Diagram AIM KEY DRIVERS INTERVENTIONS All discharges should be dictated as letters with the 50 code. Educate 2 nd and 3 rd year residents Attending makes it clear that s/he is part of the dictation team 90% of hospitalist discharges will have a discharge letter dictated within 2 calendar days of discharge Dictations must be done by day of discharge or at most, by the next day Dictations are reconciled daily Dictations are assigned to a team (attending included) member before the patient is discharged Dictations are a daily topic on rounds A Dictation Done column is added to sharepoint; pts not removed until done Complex/Long/ICU Stays done prior to discharge when possible, with brief addendum on actual d/c Attendings look at sharepoint list daily (or personal COMPASS list) See if pre-service change (off-service, weekend, etc.) notes can be dictated under a 40 or other code Someone remembers to bring this up prior to changes in service

19 Resident & Attending Have Conversation re: Discharge Current Process Maybe Decision to discharge Yes Dictation Assignment is made No No dictation assignment is made Yes Dictation Occurs Yes Dictation assignment is made Dictation occurs No Current Process Three Scenarios Pt stays overnight Resident discharges w/out talking to attending Resident talks with attending Resident dictates discharge Resident/ attending does not discharge Yes Dictation complete Yes Dictation Occurs Assignment is made No Attending sees no dictation on list next day No Dictation did not occur before discharge No Too many options dependent on too many what ifs Resident remembers to dictation next day No HIM contacts PCRS for dicataion

20 Summary: Before You PDSA ENGAGE the team DEFINE the objectives Begin to measure and UNDERSTAND the process

21 Introduction to the Change Package JOANNE NAZIF, MD

22 ICAP Change Package What itis What itis NOT Samples of CAP clinical pathways and order sets Resources for starting an Antibiotic Stewardship Program Intended to be used as a guide only Mandatoryinterventions for every site

23 Why these interventions?

24 Pathways and Order Sets Clinical pathways and order sets should be customized by your interdisciplinary team to reflect: Hospital culture Local antibiotic susceptibility patterns Project metrics

25 Antimicrobial Stewardship Program (ASP) for Hospitalists MARY ANN QUEEN, MD

26 Antimicrobial Stewardship Optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection with minimal toxicity to the patient and minimal impact on subsequent resistance Gerding DN. Joint Commission J Qual Improv 2001;27:403 4.

27 Inappropriate Use of Antibiotics Increases Increases Antibiotic Resistance Decreases Associated with Increases Healthcare Associated Infections Decreases Costs Patient Safety Slide used with permission from M Shen, M Queen, and J Nazif, ICAP Project: introduction to quality improvement, change package, & antibiotic stewardship originally presented 08/28/14 to the VIP Network ICAP QI Project teams

28 Stakeholders Patients Families Pediatricians Pharmacists Administrators Communities

29 Clin Infect Dis 2007; 44:159

30 Why ASP & ICAP? Measure #1: Narrow Spectrum Therapy Measure #2: Macrolide Antibiotic Utilization Measure #5: Concurrent Asthma Diagnosis and Treatment

31 Summary: ASP Core Elements Leadership Commitment Accountability: Single leader responsible for program outcomes Drug Expertise: Single pharmacist leader Action: Implementing at least one recommended action Tracking: Monitoring antibiotic prescribing, resistance Reporting: To doctors, nurses and relevant staff Education: Educating clinicians about resistance and optimal prescribing 2014 CDC recommends all acute care hospitals implement ASP. Source: CDC ASP Web site

32 Components of ASP Prospective audit and feedback Integration of newer diagnostic technology Formulary restriction Clinical Pathways Preauthorization for specific antibiotics Clinician education

33 Prospective audit and feedback All inpatients 7 days a week Review patients on monitored antibiotic two calendar days after initiation Appropriateness and duration determined Discuss with teams and physicians about recommendations of ASP Recommendations agreed upon provided in patient chart

34 Antibiotics for monitoring Ceftazidime Cefepime Ceftriaxone Cefotaxime Meropenem Aztreonam Vancomycin Linezolid* Daptomycin* Amoxicillin/Clavulanate Ampicillin/Sulbactam Piperacillin/Tazobactam Ticarcillin/Clavulanate Ciprofloxacin Moxifloxacin Levofloxacin* Amikacin* Tobramycin * Require Prior Approval

35 ASP Recommendations Narrow antibiotic therapy Optimize antibiotic choice for clinical situation Optimize antibiotic dosing and monitoring Set and adjust therapy duration Discontinue unnecessary antibiotics

36 Antibiotic Time outs Revisit antibiotic selection after more clinical & lab data available Review at 48 hrs Does patient have an infection that will respond to antibiotics? If yes, is patient on right antibiotics(s), dose & route? Can more targeted antibiotics be used? How long should patient receive the antibiotic(s)? Source: CDC Core Elements of ASP

37 Morning Huddle Build in your own accountability system Peer mentoring Start each day assessing new admits in past 24 hours Appropriate therapy Appropriate dose Estimated duration Start each day discussing all new orders for monitored antibiotics

38 Pharmacy-driven Interventions Automatic changes from IV to PO Dose optimization Time-sensitive automatic stop orders Dose adjustment with organ dysfunction Automatic alerts for potential duplicative therapy Detect/prevent antibioticrelated drugdrug interactions Source: CDC Core Elements of ASP

39 Formulary Restriction Specific antibiotics not on hospital formulary Broad-spectrum High cost Side-effects Reasonable alternatives exist

40 What antibiotics should be restricted? Carbapenems? Polymyxins? Linezolid? Fluoroquinolones?

41 Preauthorization Specific antibiotics on hospital formulary, but require prior approval Infectious Diseases Pharmacy Hospital ASP physician?

42 Education

43 Staffing needs for ASP Minimum ideally... Pharmacist Physician champion/medical director How can community hospitals make ASP work? CPGs Collaboration with health system partners

44 Hospitalists as ASP Physicians Why hospitalists? Inpatient providers (bulk of ASP interventions) Specialty based on providing the highest inpatient quality of care possible Provides salary support/security Smaller hospitals=no Peds ID

45 Developing ASP for community IP Pediatrics Identify team members Pharmacist Hospitalist ID specialist (content consultation) Microbiology department Administrative support, IT, Data analyst Adult counterparts are better than no collaborators!

46 Take Away Points Hospital wide incentive needs hospital leadership support. Start somewhere. Don t implement too many things at once. Education alone doesn t work. If lacking hospital support, champion what you can do at division level.

47 Important Next Step Deadline Extended for Baseline Data: Due September 15 th Future Data Cycles: Cycle 1: Sept-Nov Cycle 2: Dec 2013-Feb 2014 Cycle 3: March-May 2014