• 2 new providers – Sandy had orientation with them, reviewed AMS/TASP, had a good conversation

• Group has provided tools to continue this work at facility
  • Community, accountability, resources (data is very useful)
• Sustainability is hard – need to have a prescriber champion
  • Succession planning
  • Build framework for work to continue
• One prescriber that was doing well – would go back to longer durations

• Culture follow up to cancel abx from ED is not common
• Seeing progress with diagnostic stewardship – fewer UAs ordred; discuss flouroquinolone use
  • Comparison of drugs and duration are helpful
• Breakdown by physician type is skewed since mid-level is in charge of urgent care; action items/insight is short (go over those in a coaching session; develop this more)

criteria for lab reflex to culture

Less than 10 squamous epithelial cells per high power field.

Positive leukocyte esterase (1+ or greater)

with present of 10 WBC on microscopic examination

Positive nitrite

Bacteria 3+ (1+ for catheter Samples) with few or none squamous epithelial cells

children 3 years and under are automatic culture if any of the following:

positive leukocyte

positive Nitrite

WBC seen in microscopic examination

Set Smart Goals

1. Reduce un-needed ABX prescriptions by examining lab culture criteria, specific providers (our employee, MD-ARNP-PA, locum), and un-needed urine sample.

2. Reduce days of therapy for Macrobid and Bactrim to 5days for Macrobid and 3days for bactrim

3. Achieve 0% prescribing of fluoroquinolones

Tracking Tool:

1. Assigned a letter to each provider linked to specific patient encounters, so to be able to track prescribing and ordering practices of each provider. Will use information to specifically provide education.

Unexpected Outpatient EMR issues identified for ER and Clinic: 3dy and 5 dy option not available

Plan: Nov 28th P&T approval then Med staff approval, followed by Cerner IT changes (all work being done with PharmD)

a. provider is looking at Cerner Retail order sentences that are incorrect; need to change to:

1. Need to add trade name to nitrofurantoin macrocrystals) (MACRODANTIN). This is dosed QID (5 days women and 7 days males) or at bedtime for continuous prophylaxis. Add 5 day option. Remove 10 and 14 day option.

2. Need to add trade name to nitrofurantoin macrocrystals –monohydrate (MACROBID). Need a 1 cap BID x 5 days duration option. Remove 7, 10, 14 day duration.

3. sulfamethoxazole-trimethoprim 800mg-160mg oral tablet (BID x3 days), option for .5 tab and oral tab once (Hard Stop).

A. sulfamethoxazole-trimethoprim 800mg-160mg: Prophylaxis: 800 mg/160 mg – 1 tab QHS, ½ tab QHS. Tx: Have a 3 day option as

the primary 800/160 mg 1 tablet Q12 hours/BID and ½ tablet Q12/BID. Susp? Remove 14 day options? Remove 10 and 14 day

options for tablets

B. sulfamethoxazole-trimethoprim IV is non-formulary at CMC. Is not a typical medication to be ordered as a retail prescription.

Remove options?

1. Identified provider with consistent 7-10-14 days of therapy for Macrobid and Bactrim. Kindly provided education to that provider.

2. Talked with ER provider who would like to see order set in EMR reflect 5 and 3 day therapy for Macrobid and Bactrim. Will follow-up with pharmacist

3. Placed following poster on wall in all stations where prescribers chart and order: Will study the effectiveness over 3 months

Uncomplicated Cystitis

Macrobid: 5-day treatment duration

Bactrim:    3-day treatment duration

Fluoroquinolones not recommended for any case of uncomplicated cystitis in men or women

Be a steward of stopping resistance and preserving our life saving antibiotics

• P&T combined with ACUTE care committee, PharmD, 3 physicians, IT lead, ER and Acute Managers, discharge planner

Includes new agenda item antimicrobial Stewardship

• Identified Issues with regards to EMR and physician prescribing, Pharm D and IT to work on EMR drug dictionary, picking top 50 meds prescribed (includes antibiotics).
• Initiated quarterly award to a provider and approved by administration for Excellence in UTI Prescribing, Excellence in Antibiotic Choice and Duration. Identified one clinic provider who received our 1st award. I talked to this provider about needs in improvement for UTI prescribing in the clinic. This provider sees the majority of UTI complaints. Since then the provider has recognized ASB and has not treated. When TX is appropriate has prescribed the appropriate ABX and duration every time. Recognition on provider board, sent out to all providers and was personally given award with gift of coffee mug and coffee gift card with a cookie. Provider felt valued and appreciated.
• 4/17/24; submitted to Dr. Chaffee 5 fluoroquinolone cases (between Sept 23 through Feb 24) for review. 4 out of the 5 cases were determined to be complicated and fluoroquinolone justified. It was also determined that we do not have a pattern of inappropriate fluoroquinolone use. This review by our champion Dr. Chaffee was also very educational for the RN champion Sandy Edwards RN.
• 4/17/24; ESBL case submitted to Dr. Chaffee for review. Dr. Chaffee communicated review to 2 prescribers involved in case and gave best recommendations.
• 4/16/24: Sandy Edwards RN approached hospitalist about 48 hr timeouts and purposeful daily rounding and charting on patients who receive ABX. This was well received by the doctor and he offered great plans and will be actively involved in instituting purposeful rounding, documentation in the EHR, and 48 hr ABX timeouts. First step will be acute care committee meeting, discussion with nurse informatics nurse, followed by discussion in Med Staff monthly meeting. Timeline should be a few months for implementation.
• 4/23/24: hospitalist implemented 48hr ABX time out and documentation template for physicians in Acute Care. Will monitor over rest of year for effectiveness or any barriers for physicians.