ICAP Project: Introduction to Quality Improvement, …...Introduction to QI Methods MARK SHEN, MD SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION

ICAP Project: Introduction to ICAP Project: Introduction to ICAP Project: Introduction to ICAP Project: Introduction to Quality Improvement, Change Quality Improvement, Change Quality Improvement, Change Quality Improvement, Change

Package, & Antibiotic StewardshipPackage, & Antibiotic StewardshipPackage, & Antibiotic StewardshipPackage, & Antibiotic Stewardship

AUGUST 28, 2014AUGUST 28, 2014AUGUST 28, 2014AUGUST 28, 2014

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

Agenda Item Speaker Time

Welcome and Introductions Faiza Khan 5 min

Orientation to Quality

Improvement

Mark Shen, MD 20 min

Brief Introduction to ICAP

Change Package

Joanne Nazif, MD 5 min

Antibiotic Stewardship

Programs

Mary Ann Queen, MD 20 min

Questions and Answers All 10 min

AgendaAgendaAgendaAgenda



Introduction to QI Introduction to QI Introduction to QI Introduction to QI MethodsMethodsMethodsMethodsMARK SHEN, MD



ObjectivesObjectivesObjectivesObjectivesDefine important QI steps before P-D-S-A

DON’T RUSH TO A SOLUTION!DON’T RUSH TO A SOLUTION!DON’T RUSH TO A SOLUTION!DON’T RUSH TO A SOLUTION!

Engage the team

Define the objectives

Understand the process



Build the Right Team



Clinical Safety & EffectivenessSession # 12

Reducing Excessive Use of Continuous Reducing Excessive Use of Continuous Reducing Excessive Use of Continuous Reducing Excessive Use of Continuous

Pulse Pulse Pulse Pulse OximetryOximetryOximetryOximetry

May 21, 2010



7

Engage the TeamEngage the TeamEngage the TeamEngage 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)SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE


AIM Statement AIM Statement AIM Statement AIM Statement ((((Immature Versions)Immature Versions)Immature Versions)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 If you don’t know where you’re going, you’ll end up If you don’t know where you’re going, you’ll end up If you don’t know where you’re going, you’ll end up someplace else.someplace else.someplace else.someplace else. –––– Yogi BerraYogi BerraYogi BerraYogi Berra



AIM AIM AIM AIM Statement Statement Statement Statement ---- SmarterSmarterSmarterSmarterThe aim of this project is to decrease the use of continuous pulse oximetry in normoxic patients with respiratory diseases (asthma, bronchiolitis, pneumonia) by 50% during the period, January 1, 2010 to June 30, 2010.

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.



SMART AIMSMART AIMSMART AIMSMART AIM

SSSSpecific

MMMMeasurable

AAAAchievable

RRRRealistic

TTTTime-defined



The Model for ImprovementThe Model for ImprovementThe Model for ImprovementThe Model for Improvement



Not SMARTNot SMARTNot SMARTNot 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)



AIM SMARTAIM SMARTAIM SMARTAIM 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.



Understand the Process: Pareto ChartUnderstand the Process: Pareto ChartUnderstand the Process: Pareto ChartUnderstand the Process: Pareto Chart

Reasons for Continuous Pulse

Oximetry

0

1

2

3

4

5

6

Nurse

comfort

It's

"standard"

for…

Not 4 hrs

yet

Not 8 hrs

yet

MD

directive



Measurement is a Tool (Begin Early)Measurement is a Tool (Begin Early)Measurement is a Tool (Begin Early)Measurement is a Tool (Begin Early)

Continuous Pulse Oximetry Use in Patients on

Room Air > 4 Hours

0%

20%

40%

60%

80%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Week

(refined sampling

method)

Education initiated



Understand the Process: Control ChartUnderstand the Process: Control ChartUnderstand the Process: Control ChartUnderstand the Process: Control Chart

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

11/1

5/20

0911

/22/

2009

11/2

9/20

0912

/6/2

009

12/1

3/20

0912

/20/

2009

12/2

7/20

091/

3/20

101/

10/2

010

1/17

/201

01/

24/2

010

1/31

/201

02/

7/20

102/

14/2

010

2/21

/201

02/

28/2

010

3/7/

2010

3/14

/201

03/

21/2

010

3/28

/201

04/

4/20

10

-Measured discharge communication within two days

-”Unstable” weeks were due to attendings that never got the memo



KEY DRIVER DIAGRAM

______________________________

AIM

KEY DRIVERS INTERVENTIONS

Key

Dotted box = Placeholder for future additions

Green shaded = what we’re working on right now

Revision Date: 10-28-08

Copyright © 2008 Cincinnati Children’s Hospital Medical Center; all rights reserved.



AIM KEY DRIVERS INTERVENTIONS

90% of hospitalist

discharges will

have a discharge

letter dictated

within 2 calendar

days of discharge

Key Driver DiagramKey Driver DiagramKey Driver DiagramKey Driver Diagram

All discharges should be

dictated as letters with

the “50” code.

Dictations must be done

by day of discharge or at

most, by the next day

Dictations are

reconciled daily

Complex/Long/ICU Stays

done prior to discharge

when possible, with

brief addendum on

actual d/c

Educate 2nd and 3rd year residents

Attending makes it clear that s/he is part

of the dictation team

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

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



Resident &

Attending Have

Conversation re:

Discharge

No dictation

assignment is

made

Dictation

assignment is

made

Maybe

Yes

Dictation

occurs

Resident dictates

discharge

Resident/

attending does

not dictate @

discharge

YesNo

Pt stays

overnight

Resident

discharges w/out

talking to

attending

Resident talks

with attending

Assignment is

made

Three Scenarios

Dictation

Occurs

Dictation

complete

Attending sees

no dictation on

list next day

Yes

Resident

remembers to

dictation next day

HIM contacts

PCRS for

dicataion

No

No

No

Decision to

discharge

Dictation

Assignment is

made

Dictation Occurs

No Yes

Yes

Dictation did not

occur before

discharge

No

Current Process

Too many options

dependent on

too many “what

ifs”

Current Process



Summary: Before You PDSA…Summary: Before You PDSA…Summary: Before You PDSA…Summary: Before You PDSA…

ENGAGE ENGAGE ENGAGE ENGAGE the team

DEFINEDEFINEDEFINEDEFINE the objectives

Begin to measure and UNDERSTAND UNDERSTAND UNDERSTAND UNDERSTAND the

process



Introduction to the Change Introduction to the Change Introduction to the Change Introduction to the Change PackagePackagePackagePackage

JOANNE NAZIF, JOANNE NAZIF, JOANNE NAZIF, JOANNE NAZIF, MDMDMDMD



ICAP Change PackageICAP Change PackageICAP Change PackageICAP Change Package

What it is What it is NOT

• Samples of CAP clinical

pathways and order sets

• Resources for starting an

Antibiotic Stewardship

Program

• Intended to be used as a

guide only

• Mandatory interventions

for every site



Why these interventions?Why these interventions?Why these interventions?Why these interventions?



Pathways and Order SetsPathways and Order SetsPathways and Order SetsPathways 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



Antimicrobial Stewardship Antimicrobial Stewardship Antimicrobial Stewardship Antimicrobial Stewardship Program (ASP) Program (ASP) Program (ASP) Program (ASP) for Hospitalistsfor Hospitalistsfor Hospitalistsfor Hospitalists

MARY ANN Q UEEN, MDMARY ANN Q UEEN, MDMARY ANN Q UEEN, MDMARY ANN Q UEEN, MD



Antimicrobial StewardshipAntimicrobial StewardshipAntimicrobial StewardshipAntimicrobial 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.



Inappropriate Use of

Antibiotics

Antibiotic ResistanceAntibiotic ResistanceAntibiotic ResistanceAntibiotic Resistance

Healthcare Associated

Infections

Costs Patient Safety

DecreasesIncreases

Increases

Associated with

DecreasesIncreases

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

StakeholdersStakeholdersStakeholdersStakeholders�Patients

�Families

�Pediatricians

�Pharmacists

�Administrators

�Communities



Clin Infect Dis 2007; 44:159



Why ASP & ICAP?Why ASP & ICAP?Why ASP & ICAP?Why ASP & ICAP?

Measure #1: Narrow Spectrum Therapy

Measure #2: Macrolide Antibiotic Utilization

Measure #5: Concurrent Asthma Diagnosis and Treatment



Summary: ASP Core ElementsSummary: ASP Core ElementsSummary: ASP Core ElementsSummary: ASP Core ElementsLeadership 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



Components of ASPComponents of ASPComponents of ASPComponents of ASPProspective audit

and feedback

Formulary

restriction

Preauthorization

for specific

antibiotics

Clinician education

Clinical Pathways

Integration of

newer diagnostic

technology



Prospective audit and feedbackProspective audit and feedbackProspective audit and feedbackProspective audit and feedback

Recommendations agreed upon provided in patient chartRecommendations agreed upon provided in patient chartRecommendations agreed upon provided in patient chartRecommendations agreed upon provided in patient chart

Discuss with teams and physicians about recommendations of ASPDiscuss with teams and physicians about recommendations of ASPDiscuss with teams and physicians about recommendations of ASPDiscuss with teams and physicians about recommendations of ASP

Appropriateness and duration determinedAppropriateness and duration determinedAppropriateness and duration determinedAppropriateness and duration determined

Review patients on monitored antibiotic two calendar days after initiationReview patients on monitored antibiotic two calendar days after initiationReview patients on monitored antibiotic two calendar days after initiationReview patients on monitored antibiotic two calendar days after initiation

All inpatients 7 days a weekAll inpatients 7 days a weekAll inpatients 7 days a weekAll inpatients 7 days a week



Antibiotics for monitoringAntibiotics for monitoringAntibiotics for monitoringAntibiotics for monitoringCeftazidime

Cefepime

Ceftriaxone

Cefotaxime

Meropenem

Aztreonam

Vancomycin

Linezolid*

Daptomycin*

Amoxicillin/Clavulanate

Ampicillin/Sulbactam

Piperacillin/Tazobactam

Ticarcillin/Clavulanate

Ciprofloxacin

Moxifloxacin

Levofloxacin*

Amikacin*

Tobramycin

* Require * Require * Require * Require Prior ApprovalPrior ApprovalPrior ApprovalPrior Approval



ASP RecommendationsASP RecommendationsASP RecommendationsASP Recommendations

Narrow antibiotic therapy

Optimize antibiotic choice for

clinical situation

Optimize antibiotic dosing and

monitoring

Set and adjust therapy duration

Discontinue unnecessary

antibiotics



Antibiotic “Time outs”Antibiotic “Time outs”Antibiotic “Time outs”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



Morning HuddleMorning HuddleMorning HuddleMorning HuddleBuild 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



PharmacyPharmacyPharmacyPharmacy----driven Interventionsdriven Interventionsdriven Interventionsdriven Interventions

Automatic changes from

IV to PO

Dose adjustment with organ dysfunction

Dose optimization

Automatic alerts for potential

duplicative therapy

Time-sensitive automatic stop

orders

Detect/prevent antibiotic-

related drug-drug

interactions

Source: CDC Core Elements of ASP



Formulary RestrictionFormulary RestrictionFormulary RestrictionFormulary Restriction

Specific antibiotics not on

hospital formulary

Broad-spectrum High cost Side-effectsReasonable

alternatives exist



What antibiotics should be restricted?What antibiotics should be restricted?What antibiotics should be restricted?What antibiotics should be restricted?

Carbapenems?

Polymyxins?

Linezolid?

Fluoroquinolones?



PreauthorizationPreauthorizationPreauthorizationPreauthorization

Specific antibiotics on hospital

formulary, but require prior approval

Infectious Diseases

PharmacyHospital ASP physician?



EducationEducationEducationEducation



Staffing needs for ASPStaffing needs for ASPStaffing needs for ASPStaffing needs for ASP•Minimum ideally . . .

– Pharmacist

– Physician champion/medical director

•How can community hospitals make ASP work?

– CPGs

– Collaboration with health system partners



Hospitalists as ASP PhysiciansHospitalists as ASP PhysiciansHospitalists as ASP PhysiciansHospitalists as ASP PhysiciansWhy 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



Developing ASP for community IP PediatricsDeveloping ASP for community IP PediatricsDeveloping ASP for community IP PediatricsDeveloping ASP for community IP PediatricsIdentify team members

– Pharmacist

– Hospitalist

– ID specialist (content consultation)

– Microbiology department

– Administrative support, IT, Data analyst

Adult counterparts are better than no collaborators!



Take Away PointsTake Away PointsTake Away PointsTake Away PointsHospital 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.



Important Next Step…Important Next Step…Important Next Step…Important Next Step…

Deadline Extended for Baseline Data:

Due September 15th

Future Data Cycles:

• Cycle 1: Sept-Nov. 2013

• Cycle 2: Dec 2013-Feb 2014

• Cycle 3: March-May 2014



Documents

ICAP Project: Introduction to Quality Improvement, …...Introduction to QI Methods MARK SHEN, MD SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION