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ImprovingAntibioticPrescribinginNursingHomesthroughWorkSystemRedesign
ChristopherJ.Crnich,MDPhD1,2
1 UniversityofWisconsinSchoolofMedicineandPublicHealth,Madison,WI2 MiddletonVeteransAffairsHospital,Madison,WI
March17-20,2016¥ GaylordPalmsResort&ConventionCenter¥ Orlando,FL
SpeakerDisclosures
• R18HS022465-01A1• R18HS023779-01• HHSA290201000018I
• FCC1043– CivilMonetaryPenaltyFund
LearningObjectives
Bytheendofthesession,participantswillbeableto:• Identifydifferentopportunitiesforaffectingantibioticutilizationinnursinghomes
• Identifyaspectsofthenursinghomeworksystemthatimpactantibioticprescribingdecisions
• Identifystrategiestomodifythenursinghomeworksystemtoalterantibioticutilizationpatterns
AMDALongTermCareMedicine- 2014
AntimicrobialUse:NHs
Abx(-)35%
Abx(+)65%
n=449
Crnichetal.IDWeek 2012,SanDiego,CAPolketal.Clin InfectDis 2007;44(5):664-70
0100200300400500600700800900
DDD DOT
NHs Hospitals
20%ofsubjectsresponsiblefor:§ 48%ofantibioticdays§ 60%ofantibioticstarts
InappropriateAbx UseinNHs
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
1 2 3 4 5
ExplicitCrite
riaM
et(%
)
Facility
“Appropriateness”ofAntibioticUseinFiveWisconsinNursingHomes
MetEitherCriteria McGeer Loeb
k =0.52
k =0.41k =0.18
k =0.19
k =0.24
Crnichetal.SocietyforHealthcareEpidemiologyofAmerica 2015Spring Conference.2015
AntibioticPrescribing–MultipleRatherthanOneDecision
DoITreat? HowDoITreat? CanIRefine?
WhatAntibiotic? HowLong?
Naughton etal.JAGS2001;49(8):1020-24
Loebetal.BMJ 2005;331(7518):669
Schwartzetal.JAGS2007;55(8):1236-42
Monette etal.JAGS2007;55(8):1231-5
Zabarsky etal.AJIC 2008;36(7):476-80
Petterssonetal.JAC 2011;66(11):2659-66
AIR- AHRQReport2012(#290-2006-000-191-8)
Jumpetal.ICHE 2012;48(1):82-8
Zimmermanetal.JAGS2014;62(5):907-12
Fleetetal.JAC2014;69(8):2265-73DenHlth - AHRQRep2012(#290-2006-000-
191-20)
HarmofBroad-SpectrumAbx:Clostridiumdifficile
Wenisch etal.Antimicrob AgChemother 2014;58(9):5079-83
AntibioticSpectruminNHsOftenUnnecessarilyBroad
FQ
B-lac
Sulfa
MaclTet
Other
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ASCrnichetal.IDWeek 2012,SanDiego,CA
Pickeringetal.JAmGeriatr Soc 1994;42(1):28-32• Randomchartreviewofasampleofall
ciprofloxacinorders(100of323)• 72/100ordersdeemedinappropriatebyimplicit
review• 23/72duetoindication• 49/72duetobetteralternative
Rotjanapan etal.ArchInternMed 2011;171(5):438-43• Treatmentinitiationoftendelayeduntil culture
resultsavailable(69/96starts[72%])• 56%ofstartsinvolvedanunnecessarilybroad
antibiotic(e.g.,FQwhenTMP/SMXorNFTactive)• Duration:tooshort[3%]/tooong [67%])
DurationofTherapyinNHs
(n=353) (n=194) (n=12) (n=162)
Crnichetal.APICWisconsin 2015Daneman etal.JAMAInternMed2013; 173(8):673-82
ClinicalSituationAntibioticDecision
BaselineResidentCharacteristics
FamilyKnowledge,Attitudes,&Beliefs
FacilityStructure&CareProcesses
StaffKnowledge,Attitudes,&Beliefs
PracticeCharacteristics
PrescriberCharacteristics
Resident&FamilyFactors
NursingHomeFactors PrescriberFactors
Zimmermanetal.http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-hai/hai-article8.html;2014.
FactorsInfluencingAntibioticDecision
35.2
121.9
0
40
80
120
160
1 2 3 4 5 6
DOTsper1,000
resid
ent-d
ays
Facilities
~4-foldvariation
ContextInfluencesPrescribing
0
10
20
30
0 1 2 3 4 5 6 7 8 9 10 >15
%ofFacilities
AntimicrobialCoursesper1,000Resident-Days(PooledFacilityMean)
DistributionofAntibioticUse:73NHsin4U.S.States(09/2001– 02/2002) • Degreeofvariationnot
explainedbyclinicalfactors– Mylotte,AmJInfectControl
1999;27:10-19
• Inter-facility>Intra-facilitylevelvariation– Mylotte,AmJInfectControl
1999;27:10-19
• ContextualeffectsseenwithotheragentsprescribedinNHs(i.e.,anti-psychotics)– Hughesetal.DrugsAging
2007;24(2):81-93– Tjia etal.AmJGeriatr
Pharmacother 2012;10(1):37-46
Benoitetal.,JAmGeriatr Soc 2008;56(11):2039-4Crnichetal.,IDWeek2012
SystemsEngineeringInitiativeforPatientSafety(SEIPS)
Holdenetal.Ergonomics2013;56(11):1669-86
DesiredProcess&OutcomeChanges
Delaytesting&treatmentofresidents
withlow-riskCIC
Post-prescribingantibioticoptimization(“AntibioticTimeout”)
DESIREDPROCESSES UPSTREAMOUTCOMES
⇓ Abx Starts
⇓ Abx Duration⇓ Abx Spectrum
⇓ C.difficile⇓ Abx Resistance
Requiresintroduction ormodificationof:1) Tasks2) Tools3) Internaladaptive
influences(environment)
STRUCTURE
DOWNSTREAMOUTCOMES
Pre-PrescribingComponent
AbnormalVitalSigns?(Anychecked
InB2)
LocalizingSymptoms?(Anychecked
inB3)
Non-localizingSymptoms?(Anychecked
InB4)
Othersignificantfindings?
Non-LowRiskCIC(R1)
LowRiskCIC(R2)
No
Yes
Yes
No No
YesSuggestedScriptforLow-RiskChange-In-Condition
“Accordingtomyassessment,thisresidentisexperiencingalow-riskchange-in-condition.Iwouldlikeyourpermissiontoinitiateouractivemonitoringcareplan.Iwouldnot recommendtestingtheurineorstartingantibioticsatthistime
Yes
Post-PrescribingComponent
AntibioticStartedbyPCP?
Schedule Post-PrescribingReview
NotifyPCPofAntibioticStart
Yes No
Assemble PertinentDataforReview
Nurse/PCPPost-PrescribingReview
ResidentconditionMicrobiology resultsOtherlaboratorytestresultsImagingtestresults
① Canantibioticsbestopped?
② Canantibioticspectrumbenarrowed?
③ Canantibioticdurationbeshortened?
48-72Hours
Decision-SupportTool
Audit&FeedbackComponents
ClinicalStand-Up(Meso-Level)• PERSONS:RNLead,NCMorDON• TASKS:
– Assesscompletionoffrontlinetasks
– Near-timefeedbacktofrontlinestaff
– Aggregateperformance forreviewatQAPI
• TOOLS:– Checklistintegratedinto24-hour
report– Spreadsheetmapping to24-hour
reportdataelements
QAPI(Macro-Level)• PERSONS:MDir,DON,ICP,Admin• TASKS:
– Reviewprocessandoutcomemeasures
– Identifybarrierstochangeatfrontline
– Provide resourcesandstrategiesforovercomingbarriers
• TOOLS:– Trendedoutcomeandprocess
reports– Coaching– Collaborativelearning
OptimizingAntibioticStewardshipinSkilledNursingFacilities(OASIS)Study
• Pre-interventionfacilityworkflowanalyses
• Kickoffmeetings
• Educationalmaterials
• Collaborativemeetings
• Coaching&mentorship
Facilitated
Implem
entatio
n
Post-PrescribingTasks• [Nurse] Communicate
antibioticstarttoPCP• [Nurse] Reassessresident• [Nurse] Assess eligibility for
antibioticchange• [Nurse] Communicatefindings• [Prescriber] Change
(discontinue, narrow,shorten)antibioticifappropriate
Pre-PrescribingTasks• [Nurse] Standardized
assessment ofresidentCIC• [Nurse] AssignCICrisk-level
(lowvs.high)• [Nurse] Communicatefindings
andCICrisk-level• [Prescriber] Avoidtestingand
antibiotics forlow-risk CIC
• Dailyassessment ofpre- andpost-prescribing toolutilization• Reinforcementoftoolutilizationwithfrontlinestaff• Preparationofprocessreportsfortop-levelmanagement
Mid-LevelManagement
• Monthly reviewofprocessandoutcomedata• Identificationofbarrierstochange• Provisionofresourcesandsupport forchange
Top-LevelManagement
FrontlineStaff
OASISStudyOverview
• Pre-interventionfacilityworkflowanalyses
• Kickoffmeetings
• Educationalmaterials
• Collaborativemeetings
• Coaching&mentorship
Facilita
tedIm
plem
entatio
n
Wisconsin
Pennsylvania
Wisconsin
Pennsylvania
Interventionhomes
Controlhomes
BASELINEWORK
STATEASSESSM
ENT
OUTCOMESI. Clinical
A. (1’)DOTsper1,000resident-days
B. (1’)%ofASmeetingLoeb
C. (2’)ASper1,000resident-days
D. (2’)FQDper1,000resident-days
E. (2’)CDIper1,000resident-days
II. SafetyA. (2’)Unplanned
transfersper1,000resident-days
B. (2’)Deathsper1,000resident-days
III. ExploratoryA. %ofFQRurinary
isolatesB. %ofenterococcal
urinaryisolatesC. %ofCandida
urinaryisolates
DOT=daysofantibiotictherapyAS=antibioticstartsFQD=fluoroquinolonedaysoftherapyCDI=laboratoryconfirmedClostridiumdifficileinfections
FQR=fluoroquinolone-resistantbacteria
I. Assessmentofintervention fidelityA. Quantitative
• Tooluse• Collaborativeparticipation
A. Qualitative• Walkthroughs• Interviews
II. Assessmentofinterventionsustainability
FOLLOW-UPWORK
STATEASSESSM
ENT
Implementation(3m) Sustainment(9m)Pre-Intervention(12m)
Special ThanksCo-Investigators:
Jay FordDavid NaceMeghan BrennanDavid ZimmermanTosha WetterneckBarbara Bowers
Research Staff:Edmond RamlyMozhdeh BahranianGrace WelhamTim HessHelena Tsotsis
A Huge Thanks to Our Nursing Home Partners in Wisconsin and Pennsylvania:Facility leadershipFrontline staff
Funding Support:Agency for Healthcare Research
and Quality
Wisconsin Department of Health Services