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Session 2 – June 30th, 2011

Scott Flanders MD

Christopher Ohl MD

Edina Advic PharmD

Diane Jacobsen, MPH

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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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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 1 –

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

- Review of questions – Chris Ohl MD, Scott Flanders MD, Edina Avdic

PharmD

• The role of Hospitalists – Scott Flanders MD

• “High Leverage Change” Making antibiotics patient is receiving and start

dates visible at point of care

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

• Final Questions & Close

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Medical Staff Leadership & Buy-in

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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Your focus since the June 16th Session

Operational and Team Issues

• Identify a unit-based multidisciplinary team to

actively test changes, identifying key roles in your

organization that may not currently be involved in

the process

• Getting Started

- what unit did you identify to begin your work?

- what roles will make up your unit-based

multidisciplinary team?

(nursing, pharmacy, ID, hospitalist, infection prevention,

others??)

- did you recruit additional roles/individuals not

previously involved in the process?

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Your focus since the June 16th Session

Operational and Team Issues

• Assess current process & Prioritize areas for

improvement/focus – what’s currently in

place in your hospital?

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

─ process for reconciling and adjusting antibiotics

at all care transitions

─ stopping or de-escalating antibiotics

─ monitoring & providing feedback on process

measures

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Follow-up from Session 1

Questions and Discussion

Why engage hospitalists?

• In the U.S., numbers of hospitalists are

growing

─ 30,000 in 2010

• Many hospitals have hospitalist programs

─2/3 of U.S. hospitals

• Increasingly taking the lead on QI work

─They understand systems redesign

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Hospitalists and Antimicrobial

Stewardship

• Antimicrobial resistance and antibiotic

complications (C.difficile) hit home

• Templates 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?!

Hospitalists and Antimicrobial

Stewardship

Disease Specific Targets Ripe for Intervention

• Community Acquired Pneumonia

─ Is it really pneumonia?

─ How long should we treat it?

• Urinary Tract Infections

─ Overdiagnosis and overtreatment commonplace

─ Preventing CAUTI is a major national focus

─ Hospitalists are part of the solution

• Skin and Soft Tissue Infections

─ Guideline based strategies have been successful

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Today’s 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

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Making antibiotics patient is receiving and

start & stop dates visible at point of care

• Specific Change ideas:

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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Making antibiotics patient is receiving and

start & stop dates visible at point of care

Specific Change idea:

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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Making antibiotics patient is receiving and

start & stop dates visible at point of care

Specific Change idea:

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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Making antibiotics patient is receiving and

start & stop dates visible at point of care

Specific Change idea:

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

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What We Expect of You

• “All Teach, All Learn” philosophy

• Join and participate on all calls

• Participate in the listserv discussion

• Test, test, test

• Share what you’ve learned (challenges as

well as successes and insights)

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What You Should Do Over the Next 14 Days

• 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).

Upcoming Sessions 1-2pm ET

• July 14th – Reconciling and adjusting antibiotics –

focusing on care transitions

• 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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