University of Missouri Antimicrobial Stewardship Program : Patient Safety and NPSG CompliancePerformance Improvement Leadership Develop ProgramUniversity of Missouri – ColumbiaFebruary 19, 2010

Team Members•Joe Cameron, Pharm.D., BCPS•Gordon Christensen, MD•Ed Ege, Pharm.D.•Stephanie Lumley-Hemme, RPh•Jennifer Meyer, Pharm.D., BCPS•Stevan Whitt, MD

Focus Area• With the arrival of the Centers for Medicare &

Medicaid's no-pay rules, The Joint Commission's National Patient Safety Goals, and the ever-growing emphasis on quality improvement of patient care, prevention has become the standard of care.

• Participation in multiple quality improvement, automated data surveillance, and antimicrobial stewardship programs have garnered successes for hospitals in terms of improving systems, and in turn care and cost.

AIM Statement• University of Missouri Hospital aims to implement a

process for monitoring and an intervention protocol intended to standardize the use of evidence based antibiotic regimens in the adult surgical intensive care unit.

• The process starts with a list of new antibiotic orders and a daily culture and sensitivity report from the lab.

• The process ends with conclusion of antibiotic therapy

AIM Statement•Our goal is to standardize empiric

antibiotic therapy

•Our secondary outcomes include: improving patient outcomes, decreasing duration of antibiotic therapy, containing antibiotic costs, and decreasing antibiotic resistance and related adverse reactions compared to current practice.

Institutional Strategic Goals• National Patient Safety Goal 7 : Reduce the risk of

health care associated infections• New standards for 2009

▫NPSG.07.03.01: Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals.

▫NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections.

▫NPSG.07.05.01: Implement best practices for preventing surgical site infections.

Institutional Strategic Goals•Diagnosis Driven Therapy

•Uniformity in Prescribing Practices

•Cost Avoidance

•Education

Project TimelineECOMS

Initial Approval

ID Acceptance

Data analysis and

modification

SICU Intial Acceptance

Presentation and

Implementation of Program August

2009

New Process

Development

Lab Report Order Sheet

Creation with ID

Current Process

Evaluation

ECOMS Approval to

move forward

IV to PO Conversion

PolicyPreliminary

Data

Discussion with

PowerChart Documentatio

n

Process Modification and Initiation

Feb 2010

Jan 2010

Dec 2009

Nov 2009

Oct 2009

Sept 2009

Current Process

Continued on Next

Slide

Current Process

Fishbone Diagram

UpstreamStakeholder

s

Point of Change

Stakeholders

DownstreamStakeholder

s• Patients

• Administration

• Pharmacy

• ICU Physicians• Attendings• Residents

• Infectious Disease

• Pathology

• IT Dept.

• Pharmacy

• Infection Control • Units throughout hospital

• Pharmacy

Stakeholders

Interventions ConsideredStrategy 1 Strategy 2 & 3• Active Intervention and

Feedback• Location Based• Patient Based• Organism Based

• Prior-authorization▫ ID Physician or

Pharmacist with authority

• Restricted Formulary▫ Partially implemented, no

authority in Pharmacy

• Education▫ Driven by Attending

Physicians

Suggested Pathway

Continued on Next

Slide

Yes

No

Suggested Pathway

Continued on Next

SlideNo

NoYes

Yes

Suggested PathwayNo

No

Yes

Yes

Key Driver Diagram

Order Sheets

Order Sheet

Microbiology Reports

Microbiology Reports

Measurements•Diagnosis Stated / Use of Preprinted

Order Set>75%

•De-escalation>75%

•IV to PO Conversion>75%

Baseline Data (2 Weeks)• Diagnosis Stated

▫ Zero (0%)

• Patients in SICU▫ 21 Patients

• Antibiotics Prescribed▫ 37 Antibiotics

• One Time Dose (Pre-op)▫ 4 Antibiotics

• De-escalation▫ 2 Accomplished (40%)▫ 3 Missed

• IV to PO Conversion▫ None (0%)

Process and Outcomes Indicators•Outcome Indicators

▫Increased knowledge of appropriate therapy for common infectious diagnoses throughout the institution. Bacteremia, Pneumonia, and Intra-abdominal

Infections▫Compliance with JCAHO NPSG 7

•Process Indicators▫De-escalation of therapy when appropriate▫IV to PO Conversion

Anticipated Return on Investment / Benefits Realized•Increased resident understanding of

appropriate empiric evidence based therapy and de-escalation

•Consistent management of patient specific disease states

•Decreased development of multi-drug resistant organisms

•Decreased medication expenditure

Lessons Learned•Health care team acceptance

•Analysis of current practice

•Prediction of program implementation

•Process improvement application

Next Steps•Encompass all intensive care units•Education of Pharmacists, Nurses, and

Physicians•Increase number of disease state protocols•Increase roll out to all of institution•Successful reduction in multi-drug

resistant organisms•Decreased length of antibiotic therapy and

potentially patient stay

Questions?Joe CameronEd EgeStephanie Lumley-HemmeJennifer Meyer

Thank You!