March 20, 2014 These presenters have nothing to disclose IHI Expedition Antibiotic Stewardship Session 1 Diane Jacobsen, MPH Scott Flanders, MD Arjun Srinivasan, MD Expedition Coordinator 2 Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the Summer Immersion Program, and IHI s efforts for Medicare-Medicaid enrollees. Kayla leads IHI s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the organization s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration. 1
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Expedition Director 11 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 Agenda 12 Ground Rules & Introductions Pre-program Survey Results Making the Case for Antibiotic Stewardship Engaging Front Line Providers IHI s Model for Improvement Action Period Assignment 6
Ground Rules 13 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! Overall Program Aim 14 The Expedition will provide insights from the hospitalist-led antibiotic stewardship initiative in partnership with the Centers for Disease Control and Prevention (CDC) that incorporated specific interventions to improve antibiotic use into the process of patient care, such as an "antibiotic timeout" to facilitate/prompt de-escalation or discontinuation of antibiotics through review of AB, dose, indication and expected duration. 7
Expedition Objectives 15 At the end of this Expedition, participants will be able to: Describe the impact of overuse and misuse of antibiotics on costs 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. Schedule of Calls 16 Session 1 Making the Case for Antibiotic Stewardship Date: Thursday, March 20 th 2:30 PM 4:00 PM ET Session 2 Promoting a Culture for Optimal Antibiotic Use Date: Thursday, April 3, 3:00 4:00 PM ET Session 3 Our Learning Journey: IHI & CDC Partnership Date: Thursday, April 17, 3:00 4:00 PM ET Session 4 Embedding Stewardship Processes into Care Delivery Date: 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 8
Pre-Program Survey Results Diane Jacobsen, MPH, CPHQ 18 Survey Results: What roles will be represented on your team participating in the Expedition? 9
Survey Results: Barriers to a successful Antibiotic Stewardship Program 19 Lack of a Physician Champion C suite not recognizing the impact of ASP, MDRO s CDI Lack of ID physicians; lack of expertise on site Limited access to pharmacy in some clinical areas Limited forum to communicate useful data to physicians Staffing: Cuts, shortages, perceived time constraints IT support; Ability to access/report useful data Culture: We ll need to change a lot of mindsets Survey Results: What we re most proud of in improving Antibiotic Stewardship 20 Developing interest [in ABS] at the management level Creation of a multidisciplinary team through the physician & chief Agreed upon formulary limiting choice of appropriate AB Review of unit based prescribing data at monthly team meetings Active role of pharmacy in monitoring & making recommendations w/input from ID specialist pharmacist Broader representation on ASP committee, including hospitalists Audited transparency of AB use at the point of care & reviewed current status to improve processes, rather than focusing on individual treatment decisions 10
Survey Results: What we re hoping to learn about AB Stewardship 21 About 72 hour AB time out How to start a stewardship program - first thing a facility should do Ideas for eliminating barriers and engaging C suite Better ways to engage/support front-level providers How others have successfully overcome barriers Everything I need to know to pull this together successfully Survey Results: Degree to which each core element is currently in place/practice 22 Do not know the current status of this element in our hospital Do no have this element in current practice at our hospital Have a current process that supports this element in our hospital This element is reliably applied in all relevant situations in our hospital Need further clarification on this element Leadership 15% 17% 56% 9% 3% Accountability 18 38 32 6 6 Drug Expertise 18 26 35 21 0 Prescribing Improvement 15 32 38 15 0 Track AB Use 18 26 38 15 3 Report Rx and Resistance 27 35 29 6 3 Educate 18 23 50 9 0 11
Survey Results: Degree to which specific interventions are currently in place/practice 23 Antibiotic Timeout MDRs include AB Do not know the current status of this intervention in our hospital Do not currently have this intervention in place at our hospital Have a current process that supports this intervention in our hospital This intervention is reliably applied in our hospital Need further clarification on this intervention 9% 70% 21% 0% 0% 6 62 23 9 0 Faculty 24 Arjun Srinivasan, MD, Associate Director for Healthcare Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC), is responsible for oversight and coordination of efforts to eliminate health careassociated infections. He led the CDC health care outbreak investigations team and served as Medical Director for the Get Smart for Healthcare campaign, an effort to improve the use of antimicrobials in in-patient health care facilities. Previously, he was an Assistant Professor of Medicine in the Infection Diseases Division at the John Hopkins School of Medicine, where he was Associate Hospital Epidemiologist and Founding Director of the Johns Hopkins Antibiotic Management Program. Dr. Srinivasan s research focuses on outbreak investigations, infection control, multidrug-resistant gram-negative pathogens, and antimicrobial use. He has published more than 70 articles in peerreviewed journals and is a member of the Association for Professionals in Infection Control and Epidemiology, the Infectious Diseases Society of America, and the Society for Healthcare Epidemiology of America. 12
Faculty 25 Scott A. Flanders, MD, MHM, is a Professor in the Division of General Internal Medicine at the University of Michigan, where he serves as Associate Division Chief of General Medicine for Inpatient Programs and Associate Director of Inpatient Programs for the Department of Internal Medicine. Dr. Flanders was a founding member of the Board of Directors of the Society of Hospital Medicine (SHM) and is a Past-President of SHM. In addition to these activities, Dr. Flanders has been active in quality improvement and patient safety at the University of Michigan. His research interests include hospitalists, hospital-acquired conditions and their prevention, dissemination of patient safety and quality improvement practices, and the diagnosis and treatment of lower respiratory infections. Faculty 26 Lori A. Loria Pollack, MD is a U.S. Public Health Service Medical Officer in the Division of Healthcare Quality Promotion (DHQP) at Centers for Disease Control and Prevention (CDC) in Atlanta, GA. Dr. Pollack received degrees in medicine and public health (MD, MPH) from UMDNJ-Robert Wood Johnson Medical School in 1999 and completed an internal medicine residency at Columbia University s primary care program in Cooperstown, NY. She joined CDC in 2002 as an Epidemic Intelligence Service Officer. Dr. Pollack was an epidemiologist in the Division of Cancer Prevention and Control where she led national efforts related to cancer survivorship. After 8 years at the federal level, she transitioned to work with the medical director of the local public health department in Atlanta, Georgia where she completed a second residency in Preventive Medicine. In July 2012, Dr. Pollack returned to CDC to focus on preventing healthcare-associated illness and addressing antibiotic resistance through antimicrobial stewardship. Dr. Pollack is board-certified in Internal Medicine and Preventive Medicine. She is the author or coauthor on more than 35 papers in epidemiology and health service research. A driving theme in Dr. Pollack s diverse public health career is the translation and dissemination of research into practical guidance and tools improve health and health care. 13
Antimicrobial Stewardship- Why We Must How We Can CAPT Arjun Srinivasan, MD Associate Director for Healthcare Associated Infection Prevention Programs Division of Healthcare Quality Promotion Why the Imperative for Stewardship? Antibiotic overuse and misuse is fueling major threats to patient safety: Antibiotic resistance Clostridium difficile Adverse drug reactions When patients get antibiotics they don t need they are exposed to totally preventable risks for bad outcomes. 14
Why the Imperative for Stewardship? There is huge room for improvement in the way we use antibiotics. Recent CDC Vital Signs report showed that nearly 40% of hospital prescriptions for UTI and vancomycin were potentially inappropriate (no cultures done, given too long). That number is very consistent with many other studies over many years. Why the Imperative for Stewardship? There is huge room for improvement in the way we use antibiotics. Vital Signs report also found that overall antibiotic use on medical-surgical wards at different hospitals varied by 300%. Even more variation in the use of some agents. 15
Why the Imperative for Stewardship? It Works! Published data demonstrate that improving antibiotic use can: Improve infection cure rates Reduce C. difficile rates Reduce antibiotic resistance Improve antibiotic dosing Save money Recommendations for Antibiotic Stewardship Programs CDC recommends that all hospitals implement an antibiotic stewardship program. American Hospital Association also recommends antibiotic stewardship programs as a Top 5 intervention for hospitals. 16
How Do We Make It Happen? Hospitals don t all look the same, and neither do stewardship programs. There must be flexibility in how programs are implemented. But, there are certain key elements that have been strongly associated with success. Core Elements for Antibiotic Stewardship Programs Leadership commitment from administration Single leader responsible for outcomes Single pharmacy leader Specific improvement interventions Antibiotic use tracking Regular reporting on antibiotic use and resistance Educating providers on use and resistance 17
Core Elements for Antibiotic Stewardship Programs CDC has posted details on these core elements, including some specific tips on how to implement them in: Core Elements of Hospital Antibiotic Stewardship Programs http://www.cdc.gov/getsmart/healthcare/imple mentation/core-elements.html Checklist CDC has also developed an assessment tool or checklist that facilities can use to assess implementation of the core elements. Assessment tool can help identify areas for potential improvement. 18
Some is not a number. Soon is not a time. We need to get specific with stewardship. We need all hospitals to implement antibiotic stewardship programs that incorporate the core elements that have proven to be key to success. We know a lot about what needs to be done and how to do it. We need to do it, now. Questions? 38 Raise your hand Use the Chat 19
Engaging Frontline Providers Scott Flanders, MD Why Frontline Providers? 40 Stewardship team often has limited reach Top-down initiatives important, but only step 1 Formulary restriction Data Monitoring Many practices needing change are hard to spot from behind the front Treatment of asymptomatic bacteriuria Prolonged treatment duration Not everyone has a stewardship program 20
Who to Engage? 41 Groups where culture drives practice Surgical ICU Urology Orthopedic surgery, etc. Non-physician team members PAs, NPs, nursing, clerical assistants Patients Infection prevention (hand hygiene, device use) Indication, duration HOSPITALISTS Why Engage Hospitalists? 42 In the U.S., numbers of hospitalists are growing > 35,000 Many hospitals have hospitalist programs 2/3 of U.S. hospitals (over 90% if beds > 500) In 2006 nearly 50% of all U.S. non-surgical Medicare discharges were cared for by hospitalists Increasingly taking the lead on QI work They understand systems redesign 21
Hospitalists and Antimicrobial Stewardship 43 Antimicrobial resistance and antibiotic complications (C.difficile) hit home Templates, guidelines and checklists are commonplace in hospital medicine Hospitalists must tackle issues with signouts, handoffs, and care transitions Dr X comfortable stopping the drug Dr Y started There often isn t anyone else to do this?! What the #! Are Doctors Doing? 44 Antibiotic Use in U.S. Hospitals 56% of hospitalized patients received antibiotics 37% of use for urinary tract infection and Vancomycin use could be improved Three-fold variability in use between similar hospital wards High variability in use for broad spectrum antibiotics Fridkin S, et al. MMWR, 2014 22
Drivers of Escalating Use 45 Hospitalized patients are ill Co-morbid conditions Immunosuppressed The revolving door of the hospital 25% readmitted at 30 days Skilled nursing facilities Home IV antibiotics Healthcare associated infections Drivers of Escalating Use 46 Discontinuities in care Within the hospital (ED-floor, ICU-floor) Within physician groups Admitters / Rounders Night coverage 5 days on, 5 days off Teaching hospitals: 80 hours / week, days off They must have wanted the Meropenem for a good reason 23
Drivers of Escalating Use 47 Performance indicators CAP Antibiotics in 6 hours Value based purchasing (it matters!) Early APPROPRIATE empiric antibiotics Improves mortality Sepsis, VAP, HCAP, etc. Hit it hard, hit it early! Current Challenges 48 What is not happening reliably? Allergy assessment Review of prior culture results / antibiograms Antibiotic restraint Double anaerobic coverage Treatment of asymptomatic bacteriuria Treatment of colonizing organisms Re-consideration of the diagnosis Narrowing coverage at 48-72 hours Treating for an appropriate duration 24
Misperceptions 49 They don t care about this stuff They already know all this stuff and choose not to do the right thing They are too busy They do not want to be bothered They have more important problems they are working on The Chagrin Factor 50 25
The Chagrin Factor 51 A physician is seeing a patient whose clinical picture and culture results could represent infection. Which outcome would a physician most like to avoid? The Chagrin Factor 52 A) Antibiotics are withheld. The patient develops sepsis, shock, and requires transfer to the ICU B) Antibiotics are given. The patient does well, but develops a rash, and C. difficile requiring metronidazole 26
Where Do We Start? 53 Find a frontline provider champion Try tackling one issue with one provider Focus on common conditions UTI, CAP, Skin / Soft Tissue Infections These 3 drive 50% of all antibiotic use Start with de-escalation opportunities Think about how to build changes into processes of care Then expand Driving Appropriate Use 54 Barriers identified in CDC/IHI Pilot Testing Real-world issues Large / multiple groups make communication difficult Poor continuity / hand-offs Nurses are overwhelmed High patient loads Another!#$#% QI project? IT / CPOE Time / ability to collect data 27
Driving Appropriate Use 55 Navigating Barriers Demonstrate the need to improve Even a sample of 10 charts can tell a story Many providers like the help Order sets / protocols help Start small (sometimes very small) Ask for feedback, de-brief after interventions Share / celebrate successes Bottom Line 56 We have big problems with antibiotic use in U.S. hospitals Drivers of use are complex Stewardship programs are critical.. But frontline providers are key to widespread success Barriers to engagement are surmountable We need to act now 28
Questions? 57 Raise your hand Use the Chat Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Aim of Improvement Measurement of Improvement Developing a Change Act Study Plan Do Testing a Change Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996. 29
59 Act Decide changes to make Arrange next cycle Study Complete data analysis Compare to predictions Summarize learning Plan Compose aim Pose questions/predictions Create action plan to carry out cycle (who, what, when, where) Plan for data collection Do Carry out the test and collect data Document what occurred Begin analysis of data Principles & Guidelines for Testing 60 A test of change should answer a specific question A test of change requires a theory and prediction Test on a small scale Collect data over time Build knowledge sequentially with multiple PDSA cycles for each change idea Include a wide range of conditions in the sequence of tests 30
Repeated Use of the PDSA Cycle 61 Sequential building of knowledge under a wide range of conditions A P S D Changes That Result in Improvement Spread Implementation of Change Hunches Theories Ideas A P S D Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Aim: Implement Rapid Response Team on non-icu unit 62 A P S D A P S D Cycle 2: Repeat cycle 1 for three days Improved Communication Cycle 5: Have Nurse Practitioner respond to calls in addition to RT and RN Cycle 4: Expand coverage of RRT on unit to one unit for one shift for five days Cycle 3: Have Respiratory Therapist attend rapid response calls with ICU Nurse Cycle 1: ICU nurse responds to rapid response team calls on one unit, one shift for one day Cycle 6: Expand rounds to one unit for one shift seven days a week 31
Questions? 63 Raise your hand Use the Chat Action Period Assignment 64 Review the seven core elements and identify areas of strength and areas of opportunity. Identify one specific intervention to focus on during the expedition Identify a group of people/providers that you re not currently engaging with that you will create a partnership with to support stewardship Come prepared to share your plans at the next session 32
Expedition Communications 65 Listserv for session communications: ABSExpedition@ls.ihi.org To add colleagues, email us at info@ihi.org Pose questions, share resources, discuss barriers or successes Next Session 66 Thursday, April 3 rd, 3:00 PM 4:00 PM ET Session 2 Promoting a Culture for Optimal Antibiotic Use Loria Pollack, MD, MPH Centers for Disease Control and Prevention 33