AHRQ Safety Program for Improving Antibiotic Use Acute Care: Onboarding Call #2

Presenter— Pranita Tamma Pranita Tamma, MD, MHS Title: Assistant Professor of Pediatrics, Division of Infectious Diseases and Director of the Pediatric Antimicrobial Stewardship Program Place of work: Johns Hopkins School of Medicine Program email address: antibioticsafety@norc.org

Housekeeping Keep phone on mute Use ‘chat’ feature in WebEx if you need to speak Hold off most questions until the end during Q&A Participate when asked

Objectives of Onboarding Call #2 Apply the Four Moments of Antibiotic Decision-Making Understand how the CUSP approach can improve safety culture Understand how to use the “Team Antibiotic Review Form” to review antibiotic use with frontline staff Understand how data requirements for the project and upload data on the AHRQ Safety Program website

The Four Moments of Antibiotic Stewardship 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?

An Overview of the Comprehensive Unit Based Safety Program (CUSP)

ASP Leaders Must Tackle both Technical & Adaptive Challenges Problems with a clear technical solution Problems that require changes in priorities, beliefs, habits, loyalties, role, way of thinking Fix by providing resources to complete the task Fix by mobilizing people to tackle challenges together AS example: lack of awareness of new guidelines Solution: develop a method to get guidelines to the point of care AS example: prescribers don’t believe the recommendations Solution: discuss concerns and different opinions and work to achieve workable consensus

ASP Leaders Must Tackle both Technical & Adaptive Challenges “The most common cause of failure in leadership is produced by treating adaptive challenges as if they were technical problems.” Ron Heifetz The Practice of Adaptive Leadership

Why CUSP? CUSP aims to improve the safety culture of a unit or other team Values wisdom of frontline staff Empowers staff to be actively engaged in safety improvements by learning from mistakes Helps reduce barriers between staff and senior leadership Linked with improvements in clinical outcomes

CUSP Steps for Antibiotic Stewardship Partner with a senior executive Educate staff on how improving antibiotic use is a safety issue Identify defects with current antibiotic use Learn from defects and develop solutions Improve teamwork and communication

#1: Partner with a Senior Executive Align program goals to the organization’s strategic goals Identify financial resources for the Antibiotic Stewardship Program (ASP) and its activities Connect team to necessary stakeholders Assist with reducing barriers to progress Ensure ASP leadership is included in high-level meetings Assist with “outlier” clinician prescribing practices

#2: Improving Antibiotic Use is a Safety Issue Antibiotics save lives when used appropriately Antibiotic use can have negative consequences— Clostridium difficile infections Organ dysfunction Allergic reactions Antibiotic resistance on a patient and population level CUSP assists teams with focusing on system factors that result in antibiotic overuse or misuse All team members involved in prescribing and administering antibiotics should participate in CUSP

#3: Identify Defects Teams should work together to identify safety concerns (“defects”) related to antibiotic use Teams should be proactive and think about how the next patient may be harmed from suboptimal antibiotic use Moment One Antibiotics started when not needed Moment Two Needed cultures not obtained before antibiotics Empiric therapy too broad or narrow Moment Three Vancomycin not stopped Surgical prophylaxis not stopped Therapy not narrowed based on culture data or not stopped when another diagnosis is found Moment Four Duration too long Day of therapy not accurately recorded at time of transition of care

#4: Learn from Defects and Develop Solutions What happened? How did it happen? What did you do to reduce the risk? What can be done in the future to prevent this defect?

#5: Improve Teamwork and Communication Develop strategies to enhance teamwork so that teams have ownership of approaches and actions to improve antibiotic use and prevent harm associated with antibiotics Effective communication strategies Understand and implement communication techniques among the stewardship and frontline team members

Using the Team Antibiotic Review Form

Team Antibiotic Review Form Data collection form and completion guide to assess antibiotic courses based on the Four Moments Completed by frontline teams along with the Antibiotic Stewardship Program Ten reviews per month beginning in July 2017 The purpose of the form is to facilitate and guide a collaborative team discussion regarding how antibiotics are being used in their patients

Accessing and Uploading Data

Data to be Submitted Days of antibiotic therapy / 1000 patient days present / unit by antibiotic using CDC NHSN AU definitions and methodology https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdf

Data to be Submitted Data submitted monthly via program website Data does not have to be reported to the CDC NHSN system No EMAR or barcode data on antibiotic administration? Submit dispensed antibiotic data (as long as the data extraction approach remains consistent over the baseline and intervention period)

Data to be Submitted C. difficile lab event rates by unit using CDC NHSN MDRO/CDI module https://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf Data submitted quarterly via program website Teams should obtain these data from the hospital’s infection control department

Data to be Submitted Data from the Team Antibiotic Review Form Structural assessment surveys results Basic information about the institution, unit and current activities in the area of patient safety and antibiotic stewardship Aggregate results of the Hospital Survey on Patient Safety Culture

Data to be Submitted What: In-person interviews of providers (<1 hour) When: Baseline and toward the end of the safety program (May-July 2017 and January-March 2018) Who: The members of the Antibiotic Stewardship Team, and a subset of physicians, NPs, PAs and nurses on the unit or ward

AHRQ Safety Program for Improving Antibiotic Use— Electronic Data Collection Collection of the following data elements will occur electronically through NORC’s Liberty platform: EHR extracts (antibiotic use data and C. difficile lab event data) Team Antibiotic Review Form data Structural assessment Data from Hospital Survey on Patient Safety Culture

AHRQ Safety Program for Improving Antibiotic Use— Electronic Data Collection The three categories of users will have access to the platform to do the following: Participating sites: fill out surveys and upload clinical data AHRQ: view anonymized and aggregate results NORC research team: edit surveys, download data, update dashboard with anonymized and aggregate results

Data Collected, Analyzed, and Reported Participating sites Public Website Content Private Website Content Antibiotic safety resources organized by care setting Project overview List of participating sites Information on National Project Team Data Collection Tools Dashboard of Aggregate Findings from Data Collection Tools Available through standard web form fields Updated routinely Login using unique credentials

Navigating to Data Collection Tools You get unique credentials to log in You can also register through the website homepage Once you’ve logged in, navigate to the Data Collection Tool, complete surveys and upload clinical data

Antibiotic Stewardship Program (ASP) Development Next Steps Onboarding Call 2 Antibiotic Stewardship Program (ASP) Development Questions? antibioticsafety@norc.org

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