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ASB 101

Description

Data Collection SMART goal:

Do a weekly chart review using a custom report in Labcrop and randomly select 5 cultures to enter (goal: 5 cultures/week)

SMART Goal #1:

Improper ordering of urinanalysis studies leads to inappropriate diagnosis of urinary tract infection and therefore excessive antibiotic use. Over the next 3 months, we will evaluate and map our procedure for ordering, obtaining and processing urine cultures. By March 2024, we will have a completed process map and identified at least 2 areas for improvement.

Core Elements

Education

Educating clinicians about resistance and optimal prescribing.

PDSA Cycles

Progress on PDSA Cycle 3

Engage stakeholders

Present on ASB 101 project and process map at family med, internal med, and hospitalist meetings

Progress on PDSA Cycle 2

Make a process map

Made a process map with IP

  • Good relationship with Dr. Johnson (chief of staff in ED) and several residents on AMS committee that ASB 101 team talked with
  • Consulted Jessica about lab procedures
  • Invited clinical informaticist to attend AMS to discuss order sets – prechecked & vague info

Identify 2 areas to improve on (interventions): criteria, order sets, provider education

  • In process map
    • Which urine samples are good enough to run
      • Some urine samples sit out and can’t be ran
    • Have auto reflex and lab person deciding if it needs to be cultured
  • Helped explain why providers are inadvertently doing something
  • Hard to pick where to start
  • Follow up with lab person as to how they make decision to culture – could standardize process
  • Create another SMART goal to decide intervention and next steps
  • How to present process map to other personnel
    • Next stewardship meeting in May

Progress on PDSA Cycle 1

ASB 101 Team 

  • Leslie (pharm) – run operations
    • IDT, discharge planning
  • Dan (pharm) – clinical shifts, SIDP training, manage AMS program

Characteristics 

  • 110 bed hospital – Tri-cities, WA
  • Have resident physicians
  • Hospitalist staff run through team health
    • A few staffed, a lot of locums
  • ED is also locum, outside group
  • Pharmacy staff small – 1 pharmacist at a time
  • Rounds – Dan/clinical shift will round in morning, Leslie rounds in evening
    • 3 different rounding teams – can only round with 1 at a time
  • Pharmacy software – Sentri 7 – have rules in EMR to pull reports during rounds
    • bug-drug mismatches, IV to PO
    • Review daily – any patients on antibiotics, leave notes
  • No micro on site – everything goes to an external lab – big problem
    • Urine cultures (turnaround time 2-5 days) – also blood and sputum
      • 48 hours to get positive CFUs, 2-3 days for sensitivities
    • Dipsticks – providers misinterpreting UAs
      • No nitrites, WBC, leukocytes
      • trying to convince providers it is colonization, will do antibiotics until urine culture is returned
      • Dan tries to get physicians to not start abx
    • All ED patients get urine cultures
  • Diagnostic stewardship could be focus
  • AMS committee: Leslie, Dan, hospitalist, 2 residents, nursing directors, CNO, IT
    • Grown a lot recently
    • Previously had ID provider not engaged
    • no ID physician – more involvement from hospitalist team

Data collection

  • Have access to Labcorp – pulling urine cultures from previous week (everything – ED, in patient)
    • Random account numbers – entering on Redcap

Goal

  • Hard to narrow down – waiting to see data to see where opportunity for improvement is
    • Take back results from ASB 101 to AMS quarterly meeting then deciminate to prescribers
  • Possible goals: defining process through which urine culture gets ordered (process mapping), amount of cases you want to submit
  • Quality reached out (CAUTI) and clinical documentation reached out that urine cultures/UTI diagnosis/treatment is not justified
    • Provider documentation on UTIs

2/29/2024 Check-in

  • Have gotten lots of buy-in, new IP joined and jumped in
  • 20 people at last AMS meeting
  • First SMART Goal: made process map, identify 2 areas of improvement

Data PDSA:

  • Submit 5 cases a week

 

Dan conducts chart review – make a custom report in Labcorp and randomly pick 5 numbers to enter

  • First 5 cases were selected for ASB

Look at data and process map to decide first intervention