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F-ASB ASH + ATH Project

Description

        • SMART Goal:
          • “50% of urinary cultures ordered within Astria Sunnyside Hospital are inappropriate and lead to excessive antimicrobial usage. Our goal is to reduce the inappropriate use of antibiotics at ASH by 10% by end of March 2022. The Astria Health System F-ASB team will accomplish this goal by adding a note to each positive culture report. Accomplishing this goal will result in increased provider awareness of asymptomatic bacteriuria and decreased antibiotic prescriptions”

          AMS Mission Statement (ASH and ATH):

          • To protect our patients and community from the unwanted consequences of antimicrobial use through the promotion of safe and effective antimicrobial usage

          We will accomplish this mission by:

          1. Obtaining support from leadership for the AMS mission
          2. Appointing a leader or leaders to be accountable for all aspects of the AMS
          3. Utilizing drug expertise to ensure the following aspects are carried out:
            1. Optimizing clinical outcomes of antimicrobial use, including appropriate selection, dosing, duration and route.
            2. Minimizing unintended consequences of antimicrobial use, including toxicity, adverse reactions, and development of resistance
            3. Integrating AMS efforts into all applicable committees
            4. Delivering feedback and sharing patient safety events as applicable to antibiotic prescribing providers
            5. Managing our limited patient and institutional resources
          4. Tracking and reporting AMS outcomes and safety events in all applicable committees (the board of the hospital, Pharmacy and Therapeutics, and others
          5. Educating and promoting safe antibiotic practices to our physicians, community, and clinical staff

          How AMS at ASH Meets the CDC Core Elements:

          Accountability

          • Jessica Zering, PharmD and P & T leadership (currently Ngozi Achebe, MD)

          Action

          • “Handshake Stewardship” (daily inpatient rounds)
          • Prospective Audit and Feedback (outpatient)
          • Facility-specific treatment guidelines
          • Cerner requires indication documentation for all antibiotics prescribed

          Drug Expertise

          • Jessica Zering, PharmD is the pharmacist lead at Astria Sunnyside Hospital

          Education

          • Flyers
          • Pearl of the Week (completed Dec 2021)
          • UTI Algorithm from toolkit
          • ASB FAQ Document
          • Monthly educations emailed to providers (typically short papers)
          • Educating on adverse drug reactions that occur due to antibiotics
          • Antibiogram on Intranet and physical copies posted in hospital, clinics
          • Stewardship tab on Intranet for central dissemination of information
          • Annual Healthstream module on antibiotic resistance for all clinical staff
          • Letter to provider as part of new provider orientation

          Leadership Commitment

          • Dedicated tools (MedMined, UW-TASP)
          • Dedicated time
          • Process support
          • Monthly hospital board reports
          • Signed statement of support (provider letter in orientation)

          Reporting

          • Monthly Astria Health ASB Cohort system meeting
          • Monthly ED Committee meetings
          • Monthly Board reports
          • Monthly P & T Committee reporting
          • Monthly WSHA DOT reporting

          Tracking

          • # of recommendations made by the stewardship pharmacist, along with % acceptance rate
          • Nursing time saved due to stewardship pharmacist interventions
          • Budget savings due to interventions
          • Specific metrics for ASB success:
            • DOT of ceftriaxone
            • # of RXs written by providers for UTI
            • # of UAs ordered
            • Data provided via the UW tool

Core Elements

Accountability

Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective.

Action

Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective.

Drug Expertise

Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective.

Education

Educating clinicians about resistance and optimal prescribing.

Leadership Commitment

Dedicating necessary human, financial and information technology resources.

Reporting

Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff.

Tracking

Monitoring antibiotic prescribing and resistance patterns.

PDSA Cycles

Progress on PDSA Cycle 7

This month, we will focus on sharing any applicable Mission Moments/Opportunities and also measuring the impact of our goal by creating dashboards for ED and outpatient prescribing of antibiotics for UTIs.

Given that ASB is very tough to measure on its own, # of RXs written for UTI will be our surrogate marker of success for our initiative. We will also look at # of UAs ordered

Observations:
[TBD]

Analysis:
[TBD]

Next steps:
[TBD]

Your organization has completed the following PDSA cycles. Click a heading to view a cycle's details.

This month, we are continuing to focus on obtaining Pathology’s signature, repeating our ASB quiz, creating a mission statement, sharing the UA data, and beginning to utilize Mission Moments and Opportunities

Observations:

Create the Mission Statement: Lani and I collaborated on this. We began with our personal reasons for why we love AMS and put it into this statement:

  • To protect our patients and community from the unwanted consequences of antimicrobial use through the promotion of safe and effective antimicrobial usage
  • We went further and put together our “How,” which incorporates the Core Elements:
    • Obtaining support from leadership for the AMS mission
    • Appointing a leader or leaders to be accountable for all aspects of the AMS
    • Utilizing drug expertise to ensure the following aspects are carried out:
      • Optimizing clinical outcomes of antimicrobial use, including appropriate selection, dosing, duration and route.
      • Minimizing unintended consequences of antimicrobial use, including toxicity, adverse reactions, and development of resistance
      • Integrating AMS efforts into all applicable committees
      • Delivering feedback and sharing patient safety events as applicable to antibiotic prescribing providers
      • Managing our limited patient and institutional resources
    • Tracking and reporting AMS outcomes and safety events in all applicable committees (the board of the hospital, Pharmacy and Therapeutics, and others)
    • Educating and promoting safe antibiotic practices to our physicians, community, and clinical staff
  • We plan to utilize Mission Moments and Opportunities to show to our clinical partners the importance of stewardship. Mission Opportunities might include adverse drug reactions suffered by a patient, safety events due to antibiotics, noticing resistant organisms . Mission Moments might include stories of support for AMS or moments where we witness good antibiotic prescribing practices

UA comment policy approval:

  • This was completed Feb 28th. Lab staff were trained on 3/16 to add the comment to all microscoped UAs as per the policy

Sharing the UA data:

  • I shared these with our Lab via email. It gave rise to the idea of making our next goal to get order set UA orders unchecked or removed entirely. Goal to be revisited in 2 mos’ time. It will require support from ED physicians to do, which will take more education to get to.

Analysis:

We will begin to share our Mission Moments in various forums (clinical meetings) and analyze effectiveness

Next steps:

We will adopt these changes and monitor effectiveness going forward

We focused this month on obtaining that UA report that we have been after! MedMined underwent a huge upgrade in January, which allowed us to build a UA report. We also continued to pursue Pathology’s signature on our UA comment policy. We continued to educate ED providers on ASB with the FAQ and a little bit of “handshake” stewardship.

Our partners for this cycle: MedMined, Lab, and ED staff.

We met as a system on Feb 17th. We introduced “Mission Moments or Opportunities.” These are moments that can be either a safety moment due to an antibiotic, or a kudos for good prescribing practices. Our first moment had to do with a patient who had ASB who suffered a severe ADR. We became inspired to write an official ASP mission statement! A timeline was decided for the repeat of the ASB quiz: March 11th, with the winner of a prize announced on the 18th.

Observations:

– UA report was officially built by MedMined in mid-Feb. We are able to now see # of UAs per dept. We are unsure if we are able to obtain data on reflex or not, will follow up with our MedMined consultant. We now have a read-out of # of UAs done in ED!

– Quiz timeline confirmed, will start on this in the beginning of March

Analysis:

Lessons Learned:

– Reports take a VERY long time to build and can undergo many revisions before you get them perfect. It is good to plan to plan in delays due to reports into your project time-line

Next steps:

Adopt:

– Continue with quiz timeline

– Continue to request Pathologist signature on the policy

We focused this month on sharing our process chart that we created in Dec, and we also continue to work on our UA policy update and process. We also pulled our local prescribing data for our ED and shared this with physicians

Our partners for this cycle are the lab, IT, and our ED staff

Resources needed include policy approval from our pathologist and education for microbiology on the new UA comment process and a report that allows us to see our UAs and if they reflex.

Observations:

We met as a system on Jan 12th.

Our lab/IT member presented the urine culture note process. Our lab system director discussed the UA policy update process. We came up with an education plan.

Education plan: email ASB FAQ, in-services in with ED nursing, repeat ASB quiz (tabled for next month), email ASB FAQ to all providers, present FAQ in committee meetings

Lessons learned:

  • The COVID pandemic and staffing issues are huge barriers to great planning! This was a HUGE challenge to us this month and in February.
  • Emailing the FAQ isn’t enough. Finding good ways to repeat the information in a manner that is respectful of time is key. The framework taught to us by Alyssa will be huge for this.

Adopt:

– Repeat the message

– Utilize Alyssa’s framework

– Continue to work on obtaining that UA report (pending MedMined upgrade)

This cycle occurred in December.

We focused on the creation of a process map.

To create this map, I will need to shadow the ED physician director and the lab technician who processes UAs. I will also need to see if there are any policies that dictate when UAs are drawn and if they are reflexed.

The end result will be a visual map to be shared with clinical staff

Tracking Documents:

Observations:

Interviewed Beth, medical technologist, and Dr. Gonzalez, ED physician director.

Discovered that there is a nursing protocol for altered mental status that calls for UAs to be done for pts presenting with this condition (future opportunity!)

The chart was created and is attached to this PDSA cycle

Analysis:

Lessons learned:

– There are many potential targets for intervention with ASB – the key is to take it step by step.

– Process map any process that you are looking to change. It is amazing how many small details there are that you can easily overlook

Next steps:

Adopt:

– Consider the altered mental status policy as a future target

– The biggest opportunity currently lies in the fact that it seems that our ED physicians use the UA result to decide on antibiotic prescribing! Our current education is aimed at trying to make physicians feel comfortable with not ordering UAs

– Share the process with ED clinical staff as per Zahra’s suggestion

– Look at reflex criteria (lab is currently doing this)

– Analyze the process and revisit it before making any major changes

  • What change are you testing?
    • Adding a report-out phrase to the top of + urine culture reports
  • What do you predict will happen and why?
    • We predict that physician knowledge of ASB will increase, and antibiotic prescribing will be reduced
  • Who will be involved in this PDSA?
    • Lab, myself, Infection Control, ED director, Quality department
  • Plan a small test of change
    • Report
  • How long will the change take to implement?
    • 2 months
  • What resources will they need?
    • Lab support, pathologist support, P & T approval, MEC approval, policy update (per lab), comment built into Cerner (completed)
  • What data needs to be collected?
    • UAs – which departments order the most, the # that went through reflex process
    • # of RXs for UTIs from ED (report was created last week for this)

Observations:

ATH/ASH team met on 11/3

We discovered that there is no native report in Cerner or MedMined that can quantify our UAs, including which ones go to reflux vs those that do not. Our lab manager will be working with us to build one over the next month). Current barrier is that she is covering both ATH and ASH, so this will delay our report.

We also discovered that the lab is currently working on upgrading the quality of UAs. A new analyzer was put in. The lab manager has identified that there are too many synonyms in Cerner. He will also be looking up promoting better usage of reflux criteria. These are all longer-term goals for them. Lab supports adding a report out phrase to positive cultures in addition to these efforts they are making. This was also supported by our P & T head, who approves the changes.

I got a spot on the ED’s meeting agenda and appreciated the support verbalized for the project from the ED director!

Analysis:

  • I have learned that education of our physicians will be the most important part of this initiative. There are many beliefs that are held about UTIs that will guide our education efforts (leukocyte esterace in a UA, altered mental status = UTI, for examples).
  • A success that I can report is the support our P & T head and the ED director for the initiatives. This was impressive and made me very happy.
  • I am learning how to frame intiatives such as this one as valuable in a way that speaks specifically to the needs of each audience (nursing, physician, lab) that I encounter.
  • Other barriers include Cerner CommunityWorks being incredibly limited in reports, lab personnel limited

Next steps:

Adopt:

  • Continue to educate, repeat key points
  • Continue to find ways that this initiative applies to each clinical profession