March 17-20, 2016 ¥ Gaylord Palms Resort & Convention Center ¥ Orlando, FL “FINDING PNEUMO: Antibiotic Stewardship Principles Used in a QAPI Project to Decrease Inappropriate Antibiotic Use in Respiratory Tract Infection in a Long Term Care Facility in Northern Wisconsin-A Case Report: 2014-2015” Joe Boero MD CMD Park Manor Nursing Home Park Falls, WI dr.boero.pfrmc@gmail.com

Speaker Disclosures Dr. Boero has disclosed that he has no relevant financial relationship(s).

Learning Objectives By the end of the session, participants will be able to: Understand the importance of performing audit and providing feed-back in the context of the daily routine to nursing staff in a successful LTC Abx Stewardship Program Recognize the potential of physician peer-profiling as a useful Abx Stewardship technique

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Background 100 bed private, for profit, ESOP, skilled nursing facility Average census 80-90 No ventilators, no hemodialysis, no on-site specialists. There is Tele-health capability Local attending physician staff-satellite of a large multi-specialty group practice 90 m. So. Antibiotic Stewardship Program since 2007 2013 Abx use for RTI > UTI

FINDING PNEUMO 2014

As simple as possibly stated, antibiotic stewardship in LTC is: Deciding on facility best practice criteria for antibiotic use Creating a system for gathering data(AUDIT) Determining whether antibiotic use for that infection is within the institutional best practice criteria Providing feed-back to the prescribing providers and nursing staff so they can help providers be better doctors (FEEDBACK) Measuring outcomes

FINDING PNEUMO designed Jan 2014 Team: ICIP, DON, Administrator, MD Definitions/Metrics: Respiratory tract infection criteria, Abx appropriate vs inappropriate Interventions: Provider letter; Abx use Report Card Nurse in-service: Facility best practice criteria for RTI, EMR resp. nurse note, Patient change of condition Scripts Mandatory nursing skills module in chest/lung exam

sample script Date of onset: 09/16/15 Vitals: Temp 98.9 , Apical Pulse 68, Resp 28, B/P 112/72, O2 sat on RA 91% Allergies: Sulfa Change in condition: Resident is afebrile. No respiratory distress noted. She does have a new dry cough and sore throat. She has no headache, abd pain or general body aches. Lungs clear. Bowel sounds present in all four quads. Urine in unremarkable. Appetite has been 100% over past 24 hours. Acetaminophen 650 mg p.o. was administered at 9:20am for fever and pain. Placed in droplet precautions this morning. This is to inform you of a change in condition. According to our facility best practice, evidence based policy on respiratory tract infection, this resident has symptoms consistent with a viral URI. May we administer cough suppressant according to standing orders and monitor condition for 48 hrs? We will notify you of changing status. Please Advise .

ASP=AUDIT+FEEDBACK Audit: Spreadsheet based: IP/DON in context of daily nurse morning report with review of nurse actions in respiratory illness COC Feedback-nurse: daily critique of completion of nurse resp EMR note, use of appropriate script Feedback-physician: initial letter from med dir, nurse challenge Abx order, end of year Report Card, outlier letters

Annual Antibiotic Utilization PMNH 2006 2007 2008 2009 2010 2011 2012 Year Antibiotic Abx/Kdays Abx/Ures 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 503 400 343 360 351 295 315 352 212 209 11.75 10.68 9.68 9.72 9.93 8.14 8.30 9.41 6.04 7.62 3.73 3.08 2.12 2.32 2.95 2.08 1.84 2.13 1.57 1.26

Antibiotic for RTI- PMNH Year Total Abx for RI Abx/Kdays Abx/Ures 2011 2012 2013 2014 2015 104 88 157 72 64 2.9 2.3 4.2 2.1 .73 .51 .95 .53 .39

for Treatment of Respiratory Infection 2014 PMNH Antibiotic Report Card for Treatment of Respiratory Infection 2014 Provider Antibiotic Starts Appropriate Not* Percent not Da 38 36 2 5.3 Ka 24 23 1 4.2 Ci 8 6 25.0 Gu 0.0 Ad PMNH Cumulative 72 67 5 6.9 *Resident’s clinical symptoms met McGeer’s Surveillance Criteria for diagnosis of Viral Respiratory Infection

PMNH Antibiotic Report Card for Treatment of Respiratory Infection 2015 Provider Antibiotic Starts Appropriate Not* Percent not Da 30 Ka 25 Gu 9 PMNH Combined 64 *Resident’s clinical symptoms met McGeer’s Surveillance Criteria for diagnosis of Viral Respiratory Infection

Insights Nursing staff education/empowerment Success of antibiotic stewardship in LTC depends Nursing staff education/empowerment Consistent data collection and audit Nursing staff feed-back on resident assessment, documentation and physician communication Physician feed-back