Evaluation of Clinicians' Acceptance Pattern and Perception of

Antimicrobial Stewardship Treatment Recommendations at

Vancouver General Hospital

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Tim T.Y. Lau & Salomeh Shajari

On behalf of the ASPIRES team

Dr. Jennifer Grant, Dr. Titus Wong, Felicia Laing, Dr. Daljit Ghag

AntimicrobialStewardshipProgrammeInnovationResearchEducationSafety

Conflict of Interest

None to declare

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Outline

I. What is Antimicrobial Stewardship?

II. What is Prospective Audit and Feedback?

III. How Did Audit and Feedback Start at VCH?

IV. How Did We Do in Year One and Two?

V. What Do Clinicians Think About Audit and Feedback?

VI. Our Final Thoughts?

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What is Antimicrobial Stewardship?

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• Optimizing antimicrobial use

• Accreditation Canada Required Organization Practice

• Clinical Care Management

• ASPIRES (Antimicrobial Stewardship Programme)

under Quality & Patient Safety at Vancouver Coastal Health

Image reference: http://www.emsa-europe.eu/2014/11/european-antibiotic-awareness-day-2014/

What Do We Do?

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• Education

• Prescribing Resources

• Measurements + Evaluation

Image reference: http://www.emsa-europe.eu/2014/11/european-antibiotic-awareness-day-2014/

Inappropriate

Anti-Infective Prescriptions

Resistance

and SuperbugsHealthcare

Costs

Patient Adverse

Drug Events

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Audit and Feedback

Mainstay of Antimicrobial Stewardship Programs

What is Prospective Audit and Feedback?

Image Source: Silhouette. Image by Snapdragon Snippets

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Collaboration with clinicians

and their acceptance of the interventions are essential to the success

of Audit and Feedback programs

Our awesome infectious disease physician

and pharmacist … hard at work

Reviewing charts for patients on Target

Antimicrobials: Broad-Spectrum + IV

Optimizing therapy: Narrowing Spectrum

IV to PO

Communicating recommendations with clinicians

Reminding them to check Culture at day 3 to narrow

spectrum!

What is Prospective Audit and Feedback?

Image Source: Silhouette. Image by Snapdragon Snippets

• Engagement + Collaboration

•Leadership support

•Relationship building

•Culture change

• Evaluation plan + Data Collection

•Meaningful, measurable metrics

•Data collection from start

•Ask “How are we doing?” Stakeholder Feedback

•Identify areas for improvement

• Enhancement + Improvements

How Did Audit and Feedback Start at VCH?

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Roll Out

• March 2013: VGH (Medicine)

• Broad-Spectrum + IV

• Evaluation plan

• Concurrent with guidelines, pre-printed orders, RAD

• Automated patient screening to increase efficiency

Expansion:

How Did Audit and Feedback Start at VCH?

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Rural Coastal

RHLGHVGH

Acute Wards

Aug 2013 Oct 2013 Apr 2014 Present Day

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0.0%

50.0%

100.0%

150.0%

200.0%

250.0%

Chart Reviews =794 Treatment Optimization = 515 Acceptance

How Did We Do … in Year One and Two?

64%

76%

Audit and Feedback at Vancouver General Hospital, March 2013 – March 2014

Year 1Chart Review = 794

Treatment Optimization = 515

Acceptance Rate = 76%

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How Did We Do … in Year One and Two?

Audit and Feedback at Vancouver General Hospital, March 2013 – November 2014

50%

Acceptance Rate = 77%

Year 2

0%

50%

100%

150%

200%

250%

Chart Reviews =2078 Treatment Optimization = 1058 Acceptance

Discontinuation or narrowing spectrum

66%

IV to PO 25%

Other, 8%

Chart Reviews = 2,078

Treatment Optimization= 1,058

What Do Clinicians Think About Audit and Feedback?

Audit and Feedback Study

Study Background

Physician Perception of Audit and Feedback Interventions

Stake holder feedback

Study Goals

• To identify factors that impact acceptance of Audit and Feedback

interventions

• To enhance program to meet stakeholder needs

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What Do Clinicians Think About Audit and Feedback?

Study Method

• 4-month study at Vancouver General Hospital

• April 1 - July 15, 2014: assessed acceptance of interventions within 72

hours

• Compared acceptance rates by

• Medical disciplines

• Types of interventions

• June 1 - July 15, 2014: clinician interviews to determine

• Reasons for acceptance and refusal of interventions

• Feedback for interventions and program

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What Do Clinicians Think About Audit and Feedback?

Results

• N Interventions = 193

• Overall Acceptance Rate = 78%

• Type of Service: Medicine = 87% and General Surgery = 68% (p<0.05)

• Type of Recommendations:

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0%

20%

40%

60%

80%

100%

Discontinue Anti-Infective

IV to PO Step-Down Start Anti-Infective ID Consult

75%64%

56%

24%

Acc

ep

tan

ce R

ate

s

Reasons for acceptance

• “Team agreed with recommendations made by antimicrobial

stewardship”

• “Primary team had independently arrived at the same clinical

decision”

Reasons for non-acceptance

• “Not aware of antimicrobial stewardship recommendations”

• “Suspected new or worsening infections”

General feedback

• “Audit and Feedback is a great educational tool”

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What Do Clinicians Think About Audit and Feedback?

• Audit and Feedback as an educational tool

• Detailed notes

• Supplemented with PPOs and Guidelines

• Awareness an issue on busy wards

• Direct conversations

• Promotion

• Complicated patients’ status changes

• Follow-up on complicated patients

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What Do Clinicians Think About Audit and Feedback?

Final Thoughts…

• Audit and Feedback is A COLLABORATIVE EFFORT!

• Support from leadership and stakeholders is the first step.

• Feedback from collaborative partners is essential for quality

assurance.

• In the end, it’s all for our patient…

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Dr. Tim Lau Salomeh Shajari

Pharmacy Lead, ASPIRES Statistical Analyst, ASPIRES

Email: Tim.Lau@vch.ca Salomeh.Shajari@vch.ca

Thank-You