AHRQ Safety Program for Improving Antibiotic Use

Slide Title and Commentary Slide Number and SlideAHRQ Safety Program for Improving Antibiotic Use

SAY:Thank you for your interest in the AHRQ Safety Program for Improving Antibiotic Use. Johns Hopkins University and NORC at The University of Chicago, are excited to be partnering with the Agency for Healthcare Research and Quality on this important program. ]

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Presenter — Pranita Tamma

SAY:My name is Pranita Tamma. I am an Assistant Professor of Pediatrics, in the Division of Infectious Diseases and the Director of the Pediatric Antimicrobial Stewardship at Johns Hopkins Hospital.…On the screen is contact information for the project. If you have any questions or need to reach me after this webex, please use this information.

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Housekeeping

SAY:Let’s take a moment to go over housekeeping rules for this call.• Please mute your phone lines to avoid any distracting background noise.

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ACUTE CARE: ONBOARDING CALL 2

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• If you have a question, either ‘raise your hand’ in webex or use the ‘chat’ feature to ask a question during the presentation. Both of these items are located within the Webex on the screen.ASK:• If anyone has any questions about where to find or how to use these features, please unmute your phone now and ask...SAY:• Question and answer time will be provided at the end of the presentation so if you have any questions, please make note of them and save them for the end. Please follow this structure unless I ask for any relevant questions during the presentation. In this case, please participate. Participation and active engagement is how you will get the most out of this presentation and out of this whole program.

Objectives of Onboarding Call #2

SAY:By the end of this module participants will be able to apply the four moments of antibiotic decision-making; understand how the CUSP approach can improve safety culture; understand how to use the team antibiotic review form to review antibiotic use with front line staff; and understand data requirements for the project and upload data on the AHRQ safety program website.

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The Four Moments of Antibiotic Stewardship

SAY:

First we will review the Four Moments of Antibiotic Stewardship. This is a conceptual framework that prescribers can use when making decisions about antibiotic prescribing. The AHRQ Safety Program for Improving Antibiotic Use will use this framework to encourage prescribers to think about their prescribing practices.

The first moment occurs at the time the prescriber is

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considering starting antibiotics. The prescriber should pause and consider whether his or her patient has an infection that requires antibiotics. In some cases, the patient may have an infection but does not immediately need antibiotics. For example, it may be reasonable to delay initiation of antibiotics in cases of osteomyelitis when the patient is clinically stable so that appropriate cultures of the bone can be obtained.

The second moment of antibiotic prescribing occurs immediately after the decision is made to prescribe antibiotics. There are two issues to consider at this point. First, the patient should have appropriate cultures ordered and obtained before starting antibiotics. Second, the prescriber should choose an empiric regimen that covers the most likely pathogens causing infection and that is consistent with local antibiotic guideline recommendations.

The third moment of antibiotic prescribing should occur on a daily basis during which the prescriber should consider whether the patient still needs antibiotic therapy and if so whether that therapy can be modified to include an antibiotic with a narrower spectrum of activity or fewer side effects and also whether the patient can be switched to oral therapy.

The fourth moment of antibiotic prescribing should occur when the infectious diagnosis is determined and the patient has improved. At this point, a duration of therapy that is consistent with local and national guidelines should be determined and recorded in the medical record.

This figure depicts the four moments of antibiotics stewardship and will appear on materials associated with the project.

An Overview of the Comprehensive Unit Based Safety Program (CUSP)

SAY:Next, we will discuss the main components of the Comprehensive Unit Based Safety Program, known by the acronym CUSP. For this project we have modified this

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program to assist antibiotic stewardship leaders and frontline providers with improving the safe delivery of care to patients. It addresses behavior, communication and teamwork issues that impact antibiotic prescribing. This webinar provides an overview of CUSP. You will be receiving more detailed training about CUSP as part of this project.

ASP Leaders Must Tackle both Technical & Adaptive Challenges

SAY:Stewardship leaders must tackle different challenges when working with prescribers to improve antibiotic use. These can be grouped into technical problems and adaptive problems.

Technical problems have a clear technical solution which can usually be addressed by providing resources to facilitate the solution. For example, prescribers may not be aware of new local guidelines that can inform their practice. The solution to this problem is to develop an approach to make the guidelines available at the point of care. This might include developing a pocket card, guideline book, or modifying the electronic health record to provide access to such information.

On the other hand, adaptive problems require changes in people’s priorities, beliefs, habits, loyalties, role, or way of thinking. For example, prescribers may not use local guidelines because they think that they don’t apply to the patients they take care of and thus do not believe the recommendations. The solution to this problem involves having face-to-face discussions, hearing everyone’s opinions, and working collaboratively to obtain a consensus on the content of guidelines. Adaptive problems are harder to solve and require mobilizing people to work together to tackle issues and embrace change.

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ASP Leaders Must Tackle both Technical & Adaptive Challenges

SAY:The distinction between technical and adaptive challenges was first made by Ron Heifetz, who noted,“The most common cause of failure in leadership is produced by treating adaptive challenges as if they were technical problems.”

All stewardship leaders should consider whether problems they face in their programs are technical or adaptive, or a combination of both.

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Why CUSP?

SAY:The Comprehensive Unit Based Safety Program, or CUSP, is a program designed to address adaptive challenges in health care. Its goal is to improve the safety culture of a unit or a team. It involves direct engagement of frontline staff, and empowers them to be actively engaged in safety improvements by learning from mistakes. It helps to reduce barriers between staff and leadership. Use of CUSP has been linked to improvement in clinical outcomes.

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CUSP Steps for Antibiotic Stewardship

SAY:CUSP has five steps—you will receive training in each of these steps as part of the project. We have modified this training to be relevant to antibiotic stewardship practice.

In brief, these steps are:Partner with a senior executiveEducate staff on how improving antibiotic use is a safety issueIdentify defects with current antibiotic useLearn from defects and develop solutionsImprove teamwork and communication

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#1: Partner with a Senior Executive Slide 11

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SAY:The first step of CUSP is partnering with a senior executive. Both the antibiotic stewardship team and the frontline teams should cultivate partnerships with senior executive leadership. Such partnership allows the antibiotic stewardship program to align its goals with the organization’s strategic goals and increase recognition in the organization.

A senior executive can assist with identification of financial resources for the program and its activities (as prescribed by The Joint Commission).

He or she can also help connect the antibiotic stewardship program with stakeholders and reduce barriers to progress including ensuring that the stewardship team is included in relevant high-level meetings. The senior executive can also assist with modifying the behavior of clinicians who are resistant to antibiotic stewardship activities.

#2: Improving Antibiotic Use is a Safety Issue

SAY:The second step of CUSP is understanding the science of safety and for the AHRQ Safety Program for Improving Antibiotic Use, understanding that improving how antibiotics are used in a patient safety issue. Antibiotics have saved countless lives but their use can be associated with adverse consequences such as C. difficile infections, liver and kidney dysfunction, rashes, and emergence of resistance in individual patients as well as across the population.

The CUSP approach assists teams with understanding system factors associated with antibiotic overuse or misuse and encourages the team of individuals involved in prescribing and administering antibiotics to work together to solve these problems. This includes physicians, nurse practitioners, physician assistants, pharmacists, nurses and any other health care workers. It may also include patients and families.

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#3: Identify Defects Slide 13

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SAY:Identifying defects is an important part of the CUSP. There are many possible defects involving antibiotic use that may be present on a unit. Some examples divided by which of the Four Moments they are associated with are noted on the slide. For example, at Moment One, an antibiotic may be started when it was not needed or at Moment Three, broad-spectrum therapy may be continued when a narrow regimen was available.

Frontline providers are encouraged to be proactive in describing how the next patient may be harmed from suboptimal antibiotic use.

#4: Learn from Defects and Develop Solutions

SAY:Once defects are identified, the next step of the CUSP is to determine the reasons they have occurred and how risk can be reduced to prevent the defect from happening again. This may involve both technical and adaptive approaches.

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#5: Improve Teamwork and Communication

SAY:A final essential component of CUSP is improving teamwork and communication. With regard to antibiotic stewardship, this involves developing strategies to improve teamwork around optimizing antibiotic use and learning approaches to effectively communicate among team members and the stewardship team.

For example, participants will learn about teamwork tools that help with monitoring patients on antibiotics and receive tips on how to communicate with a colleague regarding stopping an antibiotic.

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Using the Team Antibiotic Review Form Slide 16

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SAY:Units will work in collaboration with their Antibiotic Stewardship Programs to complete the Team Antibiotic Review Form.

Team Antibiotic Review Form

SAY:The Team Antibiotic Review Form is a data collection form with an associated completion guide.

This brief form addresses the Four Moments of Antibiotic Stewardship and is designed to be completed for patients receiving antibiotics by the frontline teams in conjunction with the Antibiotic Stewardship Program.

As part of the intervention, teams will be asked to complete ten reviews per month starting in July 2017.

The purpose of this form is to facilitate and guide a collaborative team discussion regarding how antibiotics are being used in their patients.

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Accessing and Uploading Data

SAY:Certain data elements will be collected by participating sites and uploaded to the program website. In the following slides, these data elements will be reviewed and the mechanism to upload them to the program website will be described.

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Data to be Submitted Slide 19

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SAY:Institutions will collect days of antibiotic therapy per 1000 days present by unit and by antibiotic using CDC NHSN AU definitions and methodology (available at the displayed link).

Data to be Submitted

SAY:These data should be submitted monthly and do not have to be reported to the CDC NHSN system.

If the hospital does not have EMAR or barcode data on antibiotic administration, dispensed antibiotic data can be submitted as long as the data extraction approach remains consistent over the baseline and intervention period.

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Data to be Submitted

SAY:We are requesting units to submit C. difficile lab event rates by unit using the CDC NHSN MDRO/CDI module (available at the displayed link).

These data will be submitted quarterly and can be obtained from the hospital’s infection control department.

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Data to be Submitted

SAY:Additional data to be submitted include data from Team

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Antibiotic Review Form, structural assessment survey results (basic information about the institution, unit and current activities in the areas of patient safety and antibiotic stewardship) and patient safety culture survey results using the Hospital Survey on Patient Safety Culture.

Data to be SubmittedSAY:We would like to know how procedures, policies, prescribing practices, and attitudes toward Antibiotic Stewardship and this Safety Program change over the course of the project. We will ask select staff from your site to participate in in-person interviews of no more than one hour each. These will take place early in the project (in May-July 2017) and toward the end (in January-March 2018).The interviews are voluntary and anonymous, and the gathered information will only be reported in the aggregate.

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AHRQ Safety Program for Improving Antibiotic Use— Electronic Data Collection

SAY:Collection of the following data elements will occur electronically through NORC’s Liberty platform:· EHR extracts (antibiotic use data and C. difficile lab event data)· Team Antibiotic Review Form data· Structural assessment· Data from Hospital Survey on Patient Safety Culture

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AHRQ Safety Program for Improving Antibiotic Use— Electronic Data Collection

SAY:

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The three categories of users will have access to the platform to do the following:Participating sites: fill out the surveys, upload clinical data, enter information from the antibiotic review form, and access the educational toolkit.AHRQ: view anonymized and aggregate resultsNORC research team: edit surveys, download data, update dashboard with anonymized and aggregate results.

Data Collected, Analyzed, and Reported

SAY:This slide depicts how data will be collected, analyzed, and reported.

There are 3 types of users who will have access to the website – participating sites, AHRQ staff, and the NORC research team. Users will be able to access the website through a desktop, tablet, or mobile device. Users will have access to different sets of data on the website, depending on their role at their site.

Users from participating sites will be able to access and log into a private portal and complete web-based surveys and assessment tools. They will also be able to access information and toolkits related to antibiotic use.

Once logged in, users from participating sites will be able to access— antibiotic safety resources and information for their specific care setting, data collection tools based on their role in the project, and a dashboard of aggregate findings for data collection tools. Project content and the dashboards will be updated routinely.

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Navigating to Data Collection Tools

SAY:Once the website goes live, you will be given unique credentials to log in. You may also request to register through the website (project registration request information is available on the homepage).

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Once you’ve logged in, navigate to the Data Collection Tooltab on the top banner.

Next Steps

SAY:For your next step, please attend our next webinar on Antibiotic Stewardship Program Development

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Questions

SAY:Thank you for your participation and we look forward to working with you on this very important work.

ASK:At this time, we are happy to take any questions. Either raise your hand in WebEx, Type your question in the chat box or unmute your phone and jump onto the teleconference line!

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