AHRQ Safety Program for Improving Antibiotic Use

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

Improving Antibiotic Use Is a Patient Safety Issue

SAY:

Thank you for joining us. This Webinar is titled “Improving Antibiotic Use is a Patient Safety Issue.”

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Presenter – Pranita Tamma

SAY:

My name is Pranita Tamma. I am a pediatric infectious diseases physician at Johns Hopkins Hospital, and I direct the Pediatric Antimicrobial Stewardship Program.

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 Slide 3

Improving Antibiotic Use is a Patient Safety Issue Acute Care

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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.

• If you have a question, please feel free to speak up 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 ask.

Objectives

SAY:

By the end of this module, participants will be able to— Discuss the potential harm associated with

antibiotic use Understand that patient harm is largely

preventable Understand that change efforts within a unit or

institution often require a focus on systems and not just individuals

Understand the importance of input from a variety of staff to prevent harm

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Clinical Case Slide 5

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SAY:

Let’s start off with a clinical case. This is the case of a 50-year-old man with cerebral palsy and a known seizure disorder who presented to the emergency department with a seizure. In the emergency department, he had a chest x ray that demonstrated bilateral airspace opacities at the base of his lungs. The patient was not producing sputum, so sputum cultures were not obtained. He was initiated on piperacillin-tazobactam for presumed aspiration pneumonia.

The patient was admitted to the intensive care unit and within 24 hours demonstrated clinical improvement. He was then transferred to the medical floor. Piperacillin-tazobactam therapy was continued, and he completed a 7-day course of antibiotics and was discharged home.

Clinical Case, Continued

SAY:

One week later, he re-presented to the hospital with a severe Clostridium difficile infection. Unfortunately, the patient died on day 18 of this hospitalization from complications of severe C. difficile infection.

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Where are the Defects in This Case? Slide 7

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SAY:

Let’s review this case. A number of defects ultimately led to the demise of this patient.

In this slide you will see what we refer to as the Swiss cheese model. Each slice represents a potential safety check. The holes are the errors or defects in your system that occur and risk harming a patient. Notice that there are several slices, which means that there are many chances for a harmful situation to be stopped. But when the holes all line up, as they did in the case you just heard, the likelihood of patient harm increases.

Where are the Defects in This Case?

SAY:

When this patient first presented to the emergency department with his seizure, he was noted to have bilateral lower lung field infiltrates, and there was a concern by the emergency department physicians that he had aspiration pneumonia. However, his lack of purulent sputum and fevers makes pneumonia unlikely.

Aspiration pneumonitis is an acute chemical lung injury caused by inhalation of gastric contents. It has a rapid onset and can progress quickly to respiratory failure followed by rapid improvement within 1-2 days of the initial insult. Supportive care is the mainstay of therapy. A portion of patients with aspiration events (approximately 25%) develop bacterial pneumonia in the ensuring 2 to 7 days, and this becomes apparent because of new fevers and a worsening respiratory status.

Our patient was prematurely started on broad spectrum antibiotics when supportive care without antibiotic therapy would have been sufficient.

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Where are the Defects in This Case? Slide 9

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SAY:

While it is understandable why there might have been concern for an infectious process, as he was unstable upon initial presentation, the decision to continue antibiotics was not revisited at the time of admission to the intensive care unit.

Where are the Defects in This Case?

SAY:

Similarly, the decision to continue antibiotics was not revisited the next day after the patient improved. It is highly unlikely for pneumonia to improve so rapidly, making aspiration pneumonitis much more likely.

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Where are the Defects in This Case?

SAY:

At this time, it would have been very reasonable for the ICU team to discuss stopping antibiotic therapy during clinical rounds.

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Where are the Defects in This Case? Slide 12

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SAY:

Another opportunity for intervention was when the patient was discharged from the ICU. There was no discussion by either the transferring team or the floor team to discontinue antibiotics. When all of the holes lined up, the patient was harmed.

It is important to remind ourselves that the clinical status of a patient evolves on a daily basis, and sometimes we start antibiotics when we are unsure if a patient has an infection. But as we receive more information in subsequent days, it is important, as a team, to readdress the issue of whether antibiotics are still needed or if therapy can be adjusted.

This conversation should occur on a daily basis and involve all team members. For example, respiratory therapists and nurses taking care of this patient could have been asked whether purulent secretions have been noted or if the patient had required increased ventilator support or oxygen. This information would have helped the clinician decide whether the diagnosis of pneumonia was likely.

It is important to foster a culture of safety where all team members understand that they can contribute to improving care of their patients and reducing unnecessary harm. No one should stay quiet when they know they should speak up. You should never worry about offending the clinician who initiated the antibiotic course. Conversely, a clinician should never feel attacked if questioned about an antibiotic course. A culture of respect and the best interest of the patient should allow you to speak up and question others when you are concerned about patient harm.

The Importance of Antibiotics Slide 13

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SAY:

Antibiotics have revolutionized modern medicine and have saved countless lives. The prompt administration of the correct antibiotic at the right dose is critical to improving the outcomes of patients with serious infections.

However, we must remind ourselves that antibiotics, whether necessary or not, are not entirely benign. They can be associated with adverse events, and when administered to patients who do not need them, can cause more harm than good.

Antibiotic Development is on the Decline

SAY:

The number of new antibiotics being developed or in the advanced phases of development has significantly decreased over the past few decades. Antibiotics remain a very precious resource, and appropriate antibiotic use is critical to preserve the efficacy of existing and future agents.

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Antibiotic Overuse

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Approximately 50 percent of hospitalized patients receive at least one antibiotic during their hospital stay. However, 30-50 percent of these antibiotics are considered unnecessary.

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Antibiotic- Associated Adverse Events Slide 16

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SAY:

All antibiotics have the potential to harm patients. Every time we prescribe an antibiotic to a patient, it is important to remind ourselves of the potential side effects associated with the antibiotic. Often, these adverse events occur after a patient is discharged from the hospital.

Patients may present to their primary care physician, to local emergency departments, or to other hospitals with antibiotic-associated adverse events, and we may not always be aware of the harm associated with antibiotics we have prescribed.

Antibiotics Alter the Bacteria in the Gut

SAY:

Antibiotics also disrupt the microbiome. They increase the likelihood that resistant bacteria and C. difficile flourish and persist. They also increase the likelihood that these organisms will lead to clinical infections. In the figure on this slide, four patients received a 7-day course of clindamycin. The purple bacteria represent resistant bacteria and you can see that the quantity of resistant bacteria increase while patients received antibiotics and persisted after the clindamycin was discontinued.

How long do people think the resistant bacteria persisted?

The answer might surprise you but it took two years before the intestinal microbiome returned to how it was prior to antibiotic use!

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Antibiotics & Clostridium difficile

SAY:

Virtually all antibiotics can increase the risk of a subsequent Clostridium difficile infection. However, the greatest risk occurs with clindamycin, third-generation cephalosporins, and fluoroquinolones.The risk is highest when patients are still receiving antibiotics, but this risk remains elevated for several months after antibiotics are discontinued.

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Clinical Case

SAY:

Let’s discuss another case. A 76-year-old female presents to her primary care clinic for her annual visit. She complains of difficulty falling asleep but otherwise reports feeling well. Her doctor sends a urinalysis and a urine culture in case her symptoms are related to a urinary tract infection.

She has evidence of pyuria, urine containing ≥10 white blood cells per high powered field, and has over 100,000 colony forming units per mL of a pan-susceptible E. coli in her urine culture. Another clinician in the practice sees the results when they are available 2 days after the clinic visit and prescribes a 7-day course of ciprofloxacin for a urinary tract infection.

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Clinical Case, Continued

SAY:

The patient completes the antibiotic course. Two months later, she has fevers, dysuria, and flank pain. She presents to her local emergency department and is febrile and hypotensive. She is admitted and initiated on cefepime.

Her urine culture grows greater than 100,000 colony-forming units per mL of E. coli resistant to ciprofloxacin, but sensitive to multiple other classes of antibiotics.

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She completes a 7-day course of cefepime for pyelonephritis and is discharged on hospital day 8.

Where Are the Defects in This Case?

SAY:

Let’s review this case.

When the patient first presented to her primary care clinic, she did not have any signs or symptoms consistent with a urinary tract infection. During this visit, a urinalysis and urine culture did not need to be obtained.

The lack of clinical symptoms consistent with a urinary tract infection despite the results of her urinalysis and urine culture, are consistent with a diagnosis of asymptomatic bacteriuria.

As we will discuss in a later Webinar entitled “The Team Approach to Stewardship of Asymptomatic Bacteriuria and Urinary Tract Infections,” it is not uncommon for postmenopausal women to have pyuria and bacteriuria without any clinical signs or symptoms of a UTI.

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Where Are the Defects in This Case?

SAY:

A second defect occurred when another clinician in the practice decided to treat the patient with antibiotics for asymptomatic bacteriuria. Asymptomatic bacteriuria does not require antibiotic therapy. In fact, data show that treating women with asymptomatic bacteriuria increases the risk of subsequent, clinically significant

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UTIs and increases the risk that these future UTIs are caused by antibiotic-resistant organisms.

Treating asymptomatic bacteriuria can be harmful to patients.

Commonly, when we see culture results on a patient, we make an almost reflex decision to treat with antibiotics. The prescribing clinician should have called the patient to see if she was symptomatic before making the decision about whether to start antibiotics.

Where Are the Defects in This Case?

SAY:

The second physician in the practice should not have to worry about “offending” the physician who ordered the urine culture if he decided to not treat with antibiotics. This case highlights the need to promote a culture of safety where the ultimate goal is to do what is best for our patients. If the prescribing clinician called the patient and she did have dysuria, a different agent, such as nitrofurantoin, for 3 days would have been sufficient.

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Where Are the Defects in This Case?

SAY:

After the patient was hospitalized with pyelonephritis, cefepime was initiated. When antibiotic susceptibility data became available and it was clear that there were narrower spectrum antibiotic choices available, cefepime should have been narrowed to another agent, such as trimethoprim-sulfamethoxazole, to continue the treatment course for pyelonephritis.

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Where Are the Defects in This Case?

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Similarly, as soon as the patient was able to tolerate an oral option, an oral antibiotic option could have been explored instead of subjecting this patient to the daily risks, inconvenience, and costs associated with intravenous antibiotics.

Social Determinants of Antibiotic Prescribing

SAY:

As is probably apparent from the two cases you heard, medicine is often an art and not an exact science. There are a number of social factors that influence antibiotic prescribing decisions beyond clinicians’ knowledge of infections and antibiotics. Some of these decisions are related to relationships between clinicians. Clinicians may worry that they will be viewed as dismissive or disrespectful if they stop or change antibiotics initiated by another clinician. They may worry about what patients or families will think of them if they don’t prescribe antibiotics.

There may be other emotional issues involved too. For example, if a patient is at the end of life, clinicians may start antibiotics just to “do something” because they feel helpless. They may forget that these antibiotics can cause unnecessary harm and inconvenience for their patients, and may provide no benefit.

To promote a culture of safety around antibiotic prescribing, the potential harms associated with antibiotic use must be conveyed to prescribers, patients, and family members so that the potential risks versus benefits are considered every time an antibiotic is prescribed.

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CUSP—Helps Reduce Antibiotic-Associated Harm

SAY:

The Comprehensive Unit-Based Safety Program (CUSP) improves the culture of safety while providing frontline providers with the tools and support needed to identify and tackle the hazards that threaten their patients. CUSP strives to reduce preventable harm.

The CUSP approach identifies defects that cause harm to patients. These defects can be technical or behavioral or both. CUSP then encourages a team-approach to fix the defects.

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The Steps of CUSP

SAY:

There are several steps to CUSP.

First, it involves understanding the importance of a culture of safety.

Next, it involves engaging frontline providers to tell you how they think patients are harmed. They are interacting with patients every day. They know what the issues are and perhaps how to eliminate them.

Third, it involves approaching an executive to adopt the unit. For this project, the physician and pharmacist involved in the antibiotic stewardship program can assist with this role, although it is still helpful to have a senior executive involved. Have senior executives periodically do walk rounds with the clinical team to see what the issues are. They are here to help coach you through problem solving because they know the resources within the hospital. This also results in a reduction in hierarchy because you have frontline staff working with executives.

The fourth step involves trying to tackle the defect identified as a group.

The final step involves implementing teamwork and communication tools to reduce errors related to antibiotic prescribing. You want to create an environment where clear, concise, and respectful communication occurs between the antibiotic

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stewardship team and health care workers, between health care workers, and between health care workers and patients and their families to minimize the possibility of miscommunication leading to errors in antibiotic decision making.

The project team will work closely with you over the next year to coach you through CUSP by integrating important defects and solutions related to antibiotic prescribing.

Step 1: The Science of Safety

SAY:

There are three basic principles of safe design:

First, you should standardize care and eliminate any unnecessary steps. When there is a routine with standardized steps, there is less of a chance for unintentionally forgetting to do something or missing a step. An example of standardized care outside of health care is an ATM machine. Some ATM machines have you put your card in, then they give you money, and finally your card comes back out. It was recognized that some people would forget to wait for the last step and would leave before their card was returned. Now there is a system in which the card is swiped, but never leaves your hand. Workflow has been simplified.

Within your workspace, develop local guidelines, order sets, and other tools that will help standardize care. Make them available at the point of care so clinicians know how to use them and where to find them. During the course of the AHRQ Safety Program we will provide you templates for many of these tools.

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Step 1: The Science of Safety

SAY:

Second, create independent checks to confirm you are not accidentally ordering a test that isn’t indicated or prescribing a drug that might cause harm. A non-health–care-related example is seatbelts. . A system of lights on the dashboard as well as that annoying dinging noise were implemented to remind drivers to buckle up. We can apply the concept of independent checks to antibiotic stewardship. For example, review antibiotic decision-making using a time-out tool on rounds.

You should seek input from nonprescribers (e.g., nurses, respiratory therapists, pharmacists). Request assistance from infectious diseases physicians, if available, and/or the antibiotic stewardship team, for decisions that are more complex or when the clinical team is unsure of the solution.

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Step 1: The Science of Safety

SAY:

The last principle is to learn from defects. As a group, when a defect related to antibiotic prescribing occurs, ask—What happened? Why did it happen? What did you do to reduce the risk of it happening again in the future? And finally, how do you know it worked? We will discuss identifying defects and learning from defects in more detail in later webinars.

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Successful CUSP Teams

SAY:

It is important to select a multidisciplinary team as your CUSP team. We would suggest selecting a physician leader, pharmacist leader, and a nurse leader for the unit or clinical service selected to participate in the AHRQ Safety Program for Improving Antibiotic Use. All frontline staff should be viewed as essential members of the team and should interact regularly with the CUSP team.

If there is already an existing safety structure with the unit, decide if that team already contains the appropriate CUSP leaders for this work. If not, form a new team with the necessary skillset to receive training and to work with others on technical and adaptive approaches to improve antibiotic prescribing.

Remember that successful CUSP teams have a few key elements. They are composed of multidisciplinary teams, they meet regularly, perhaps every other week or every month, and the CUSP leaders work closely with frontline staff to make decisions. As the focus of the AHRQ Program for Improving Antibiotic Use is to improve the outcomes of patients prescribed antibiotics, your team should meet regularly with your antibiotic stewardship program to discuss defects related to antibiotics and potential solutions.

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Summary

SAY:

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In summary, CUSP improves the culture of safety while providing frontline staff with the tools and support needed to identify and tackle hazards that threaten their patients.

Remember the three methods that can help eliminate unnecessary harm: standardizing practices, creating independent checks, and learning from each new defect.

Program Website Access

SAY:

You have been sent login credentials to the AHRQ Safety Program for Improving Antibiotic Use website. Please log in to the website to access project resources such as the project schedule, recorded webinars, and slide decks with scripts. The website is updated routinely with new resources. Please note that recorded webinars may take up to 5 days after the presentation date to be posted on this website.

If you have any questions about login credentials or website content please email AHRQ-AS-SUPPORT@NORC.OR G

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Science of Safety Video

SAY:

From that site, you can access the Science of Safety Video. This video talks about errors and defects in patient care and the use of a systems approach to addressing these errors.

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Questions

SAY:

Thank you all for your attention. At this time, please ask any question you have about the science of safety or any of the other content covered in this Webinar. You can type in your questions or speak up on the conference line.

Thanks!

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Next Steps

SAY:

This concludes the onboarding call for this series. During your next WebEx, we will discuss Behavior Change Theory for Antibiotic Stewardship Leaders. Contact us at antibioticsafety@jhmi.edu between now and your next call if you have any questions or concerns.

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