reducing unnecessary use of antibiotics in nursing...
TRANSCRIPT
Problem
Reducing Unnecessary Use of Antibiotics in Nursing Homes with a Complex Multi-Level Intervention: A Study Protocol
Inappropriate antibiotic use, an extraordinarily common and high-variation problem in nursing homes (NH), increases the resident’s risk of adverse drug events, Clostridium difficile infection and acquisition of antibiotic-resistant bacteria.
Our group has developed a novel antibiotic stewardship intervention that targets three loci of control:
a) Change-in-condition: pre-prescribing communication and decision-making about resident changes in condition
b) Antibiotic Timeout: post-prescribing de-escalation of antibiotic therapy focused on stopping unnecessary antibiotics, narrowing from broad to narrow spectrum antibiotics and shortening excessively long treatment courses
c) Quality Improvement Support: regular feedback of various process and outcome measures.
E Ramly2, J Ford2, DA Nace3, M Bahrinian1, C Crnich1
1) University of Wisconsin-Madison (UW) School of Medicine and Public Health, 2) UW Department of Industrial and Systems Engineering, 3) University of Pittsburgh Medical Center
Funding for this project was provided by a grant from the Agency for Healthcare Research and Quality (R18HS022465)
Work System Factors
Intervention: Optimizing Antibiotic Stewardship In Skilled Nursing Facilities (OASIS)
• This intervention will be evaluated in a prospective study in 12 facilities (6 intervention, 6 control).
• We will use human factors analyses to identify barriers and facilitators to implementation of the antibiotic stewardship intervention.
• Components of the intervention will be tailored to overcome these barriers and an implementation package will be developed with structured input from key informants in study NHs.
Study
The impact of and mechanisms by which antibiotic stewardship interventions work in NHs remains poorly studied. There is a need for NH antibiotic stewardship studies that not only identify strategies that work but to also the mechanisms by which they mediate behavioral change in this context.
ComponentsChange in Condition Form
Antibiotic Timeout Form
Quality Improvement Audit & Feedback
0
5
10
15
20
25
30
0 1 2 3 4 5 6 7 8 9 10 >15
%ofFacilities
Antimicrobialcoursesper1,000rdays
AntibioticStartsin73U.S.NHs
0
0.2
0.4
0.6
0.8
1 2 3 4 5ExplicitCrite
riaM
et(%
)
Facility
“Appropriateness”ofAntibioticUseinFiveWisconsinNursingHomes
MetEitherCriteria McGeer Loeb
k =
k =0.41k =0.18
k =0.19
k =0.24
< 60%
• Signs&Symptoms• Communicationcapacity• Clinicalstability
ChangeinCondition(CIC) AntibioticDecision
• Comorbidity/Frailty• Outcomeswithpriorepisodes• Advanceddirectives
Pre-CICHealthStatus• BeliefsaboutcausesofCIC• Knowledge,attitudesandbeliefstowardsantibiotics
FamilyCharacteristics
• Staffmodel&retention• Education&training• Structureandavailabilityofhealthinformation
• Availability&timelinessofdiagnostictestresults
• Qualityofleadership• Monitoring&improvementstructure&process
• Familyeducation/outreach
FacilityStructure&Process
• Training/experience/skills• Familiaritywithresident• Knowledge,attitudes,&beliefstowardsantibiotics
• Perceptionsaboutresident/familyexpectations
NHStaffCharacteristics• Clinicstaffskills/experience• Otherclinicalworkload• CapacitytoaccessNHdataremotely
• Cross-coveragestructure&process
PracticeStructure&Process
• Training/experience/skills• Familiaritywithresident• Knowledge,attitudes,&beliefstowardsantibiotics
• Riskaversion• Perceptionsaboutresident/familyexpectations
PrescriberCharacteristics
Trust&Communication
Resident&FamilyFactors
NursingHomeFactors PrescriberFactors
DoITreat? HowDoITreat? CanIRefine?
WhatAntibiotic? HowLong?
•StandardizeassessmentandcommunicationofCIC
•Differentiatelow- fromhigh-riskCIC
•Promoteactivemonitoringinlow-riskCIC
Pre-PrescribingComponent
•Discontinueunnecessaryantibiotics
•Promoteuseofnon-fluoroquinoloneagents
•Promoteshorterdurationsoftherapy
Post-PrescribingComponent
• Promoteconsistentuseofpre-prescribingtoolsandtasks• Promoteconsistentuseofpost-prescribingtoolsandtasks
Meso-LevelAudit&FeedbackComponent
• Track&trendkeyinterventionprocessandoutcomemeasures• Tailorinterventiontasksandtools
Macro-LevelAudit&FeedbackComponent•Pre-
interventionfacilityworkflowanalyses
•Kickoffmeetings
•Educationalmaterials
•Collaborativemeetings
•Coaching&mentorship
Facilitated
Implem
entatio
n
AntibioticDecision-MakingProcess
(a) (b)
(c)
•Pre-interventionfacilityworkflowanalyses
•Kickoffmeetings
•Educationalmaterials
•Collaborativemeetings•Coaching&mentorship
Facilitated
Implem
entatio
n
Wisc
onsin
Penn
sylvan
iaWisc
onsin
Penn
sylvan
ia
Interventionhomes
Controlhomes BASELINEWORK
STATEASSESSM
ENT
OUTCOMESI.ClinicalA.(1’)DOTsper1,000rdays
B.(1’)%ofASmeetingLoeb
C.(2’)ASper1,000rdaysD.(2’)FQDper1,000rdaysE.(2’)LabID CDIper1,000rdays
II.SafetyA.Unplannedhospitaladmitsper1,000rdays
B.Deathsper1,000rdaysIII.ExploratoryA.%ofFQRurinaryisolates
B.%ofenterococcalurinaryisolates
C.%ofCandidaurinaryisolates
DOT=daysofantibiotictherapyAS=antibioticstartsFQD=fluoroquinolonedaysoftherapyLabID CDI=laboratoryconfirmedClostridiumdifficileinfectionFQR=fluoroquinolone-resistantbacteria
I.AssessmentofinterventionfidelityA.Quantitative
•Tooluse•Collaborativeparticipation
A.Qualitative•Walkthroughs• Interviews
II.Assessmentofinterventionsustainability
FOLLOW-UPWORK
SYSTEM
ASSESSM
ENT
Implementation(3m) Sustainment(9m)Pre-Intervention(10m)
Clinical Stand-Up MeetingsMeso-Level, Daily
• Tools & tasks integrated into existing inter-disciplinary rounding structure
• RN Lead, NCM or DON owns process
• Checklist format• Tool used? • Tasks completed?• Near-time feedback to
frontline staff• Process measures fed up
to QAPI committee
QualityAssuranceandPerformanceImprovementMacro-Level, Monthly
• Processmeasurestrackedandtrended
• Outcomemeasurestrackedandtrended
• Opportunitiesforimprovingexistingprocessidentifiedandimplemented
Contact:[email protected]