Improving Communication and Teamwork Around Antibiotic Prescribing Acute Care

Presenter— Sara Cosgrove Sara Cosgrove, MD, MS Title: Professor of Medicine, Division of Infectious Diseases, Director, Antimicrobial Stewardship Program, Associate Hospital Epidemiologist Place of work: Johns Hopkins School of Medicine Program email address: antibioticsafety@norc.org

Objectives Understand how to improve communication with other health care workers. Understand how to improve communication with patients and families. Understand how to work as a team to improve antibiotic use related to The Four Moments of Antibiotic Decision Making.

Improve communication and teamwork Effective communication strategies Understand and implement communication techniques among the stewardship and frontline team members, patients, families and others. Improved teamwork Develop strategies to enhance teamwork so that teams have ownership of approaches and actions to improve antibiotic use and prevent harm associated with antibiotics  

Process of Communication Message to send Message received Encode Message Medium Decode “We recommend that you use ceftriaxone for the E. coli bacteremia. ” Dayton, E, Henriksen, K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm Qual Patient Saf. 2007 Jan;33(1):34-47. PMID: 17283940.

Process of Communication Message received Message to send Decode Message Medium Encode ” I understand that you recommend stopping piperacillin / tazobactam and starting ceftriaxone. Is this correct? ” Dayton, E, Henriksen, K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm Qual Patient Saf. 2007 Jan;33(1):34-47. PMID: 17283940.

Four Key Components of Effective Communication Complete Clear Brief Timely TeamSTEPPS for Office-Based Care: Communication. Content last reviewed September 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/teamstepps/officebasedcare/module3/office_comm.html. Accessed June 28, 2017.

Use Assertive (Not Aggressive) Statements Standing up for your own or a patient’s interests. Remaining calm and positive. Not being actively or passively aggressive. Not accepting what is not right. Attacking (active) other’s opinions in favor of your own. Ignoring (passive) other’s opinions in favor of your own. Approach for effective communication Approach that impairs communication

Elements of Appropriate Assertion Assert opinion in a firm and respectful manner. Provide evidence or data to support your concerns. Focus on the common goals of quality care and the welfare of the patient. Avoid the issue of who’s right and who’s wrong. Actively avoid being perceived as judgmental. Be hard on the problem, not the people!

Advocacy and Assertion An assertive statement should: Open the discussion State the concern State the problem—real or perceived Offer a solution Obtain an agreement Follow Two-Attempt Rule Conflict Resolution (Slide Presentation). Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/conflict_resolution-slides/conflictresslides.html. Accessed June 28, 2017.

Anticipate Listen Empathize Explain Negotiate ALEEN ALEEN for Conflict with Patients and Families Anticipate Gather all the information about what is happening including patient and family expectations Listen ‘Can you help me understand why you feel this way or are so upset?’ Empathize ‘That is understandable.’ ‘You have every right to be upset’ or ‘You feel ill and want to feel better’ Explain ‘Would it be alright if I explained why things are happening as they are?’ or ‘why I’m making this recommendation’ Negotiate ‘Let’s try to agree on our path forward’ or ‘Let’s come up with a plan’ ALEEN Script. Johns Hopkins Medicine, Armstrong Institute. Kentucky Hospital Improvement Innovation Network. KY. July 2012. http://www.k-hen.com/Portals/16/Documents/PSCTCommunicationsLab.pdf Accessed Jun 19, 2017.

Ineffective Communication Good teamwork means I am asked for my input. Good teamwork means the nurse does what I say. Huang DT, Clermont G, Sexton JB, et al. Perceptions of safety culture vary across the intensive care units of a single institution. Crit Care Med. 2007 Jan;1(35):165-76. PMID: 17110876.

Teamwork Climate Across Michigan ICUs `` No CLABSI= 6 months or more w/ zero Percentage of respondents within an ICU reporting good teamwork climate No CLABSI 21% No CLABSI 44% No CLABSI 31% Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008 Jun;23(2):207.21. PMID: 18538214.

The Four Moments of Antibiotic Decision Making 1. Does my patient have an infection that requires antibiotics? 2. Have I ordered appropriate cultures before starting antibiotics? What empiric therapy should I initiate? 3. A day or more has passed. Can I stop antibiotics? Can I narrow therapy or change from IV to oral therapy? 4. What duration of antibiotic therapy is needed for my patient's diagnosis?

Approaches to Improve Teamwork Around Antibiotic Use Improve communication among team members using previously described strategies Begin daily discussions, or briefings, regarding antibiotic use on all patients being started or on antibiotics on rounds or at a specific, pre-specified time Use Antibiotic Time Out Tool Add Four Moments of Antibiotic Stewardship questions to daily goals sheets Create your own method that works for your team Consult local guidelines and/or fast fact sheets during decision-making process

Antibiotic Time Out Tool Two page document

What is a Briefing? A briefing is a discussion between two or more people, often a team, using succinct information pertinent to an event. For this project, the event is a patient is on antibiotics A briefing: Maps out the care plan Identifies each team member’s role and responsibilities Heightens awareness of the situation Permits the team to plan for the unexpected Encourages team members’ participation

Approaches to Improve Teamwork Around Antibiotic Use Unscheduled huddles as needed for complex or controversial prescribing issues May involve the ASP, ID consultant, pharmacists, other consultants, nurses, respiratory therapists, etc. A huddle employs ad hoc planning to re-establish situational awareness, reinforce plans that are already in place, and assess any need to adjust the plan Gathers team members to review patient data and decide on a course of action Can be requested by any team member at any time

Approaches to Improve Teamwork Around Antibiotic Use Meetings between ASP and front-line providers once or twice a month to: Complete Team Antibiotic Review Forms Review Staff Safety Assessment Forms Complete and review the Learning from Defects Tool Discuss second order problem solving as it relates to the Safety Program Consider using the following format during these meetings to discuss issues around antibiotic prescribing on the unit or service What is going well? What should change? Are additional resources needed? Which problems are easy to solve and which are hard?

Team Antibiotic Review Form Two page document

Staff Safety Assessment Form

Learning From Defect Form Three page document

Summary Effective communication plays an integral role in the delivery of high-quality, patient-centered care. Identify opportunities to improve communication and teamwork by reviewing barriers the team identifies with tools and approaches from this program. The ASP and frontline providers should discuss how and where they want to improve communication.

Program Website Access ANTIBIOTICSAFETY@NORC.ORG

Questions THANK YOU FOR PARTICIPATING! Type in your questions using “Chat” or Speak up on conference line THANK YOU FOR PARTICIPATING!

Next Steps Identifying Targets for Improving Antibiotic Use (CUSP 2) Improving Antibiotic Use by Learning from Defects Improving Teamwork and Communication Team Approach to Stewardship of Asymptomatic Bacteriuria (ASB) and Urinary Tract Infections (UTIs) WebEx call Questions? antibioticsafety@norc.org

References Dayton, E, Henriksen, K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm Qual Patient Saf. 2007 Jan;33(1):34-47. PMID: 17283940. TeamSTEPPS for Office-Based Care: Communication. Content last reviewed September 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/teamstepps/officebasedcare/module3/office_comm.html. Accessed June 28, 2017. Conflict Resolution (Slide Presentation). Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/conflict_resolution-slides/conflictresslides.html. Accessed June 28, 2017.

References ALEEN Script. Johns Hopkins Medicine, Armstrong Institute. Kentucky Hospital Improvement Innovation Network. KY. July 2012. http://www.k-hen.com/Portals/16/Documents/PSCTCommunicationsLab.pdf. Accessed Jun 19, 2017. Huang DT, Clermont G, Sexton JB, et al. Perceptions of safety culture vary across the intensive care units of a single institution. Crit Care Med. 2007 Jan;1(35):165-76. PMID: 17110876. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008 Jun;23(2):207.21. PMID: 18538214.