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