1. Integrating and Focusing Local Resources to Impact Community Health: Using a Driver Diagram to Facilitate Effective Collaboration between Health Care and Public Health Focusing on Antibiotic Stewardship Micaela Kirshy, MPH, LICSW Jack Moran, PhD Public Health Foundation Monday, November 17, 2014, 12:30 PM ET 142nd APHA Annual Meeting and Exposition Session: 3250.0 Location: MCC, 232 Organizer: Health Administration

2. Micaela Kirshy, MPH, LICSW and John Moran, Ph.D. (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3. PHF Mission: We improve the public’s health by strengthening the quality and performance of public health practice www.phf.org Healthy Practices Healthy People Healthy Places

4. Today We Will Discuss  How to develop a successful framework for health care and public health to work in partnership, with defined roles and responsibilities, and to impact the health of a community.  This framework for successful collaboration focuses on engaging the health care and public health communities to address appropriate use of antibiotics (piloted in three jurisdictions), oral health and diabetes.

5. Examples of Driver Diagrams to Facilitate Effective Collaboration between Health Care and Public Health:  Antibiotic Stewardship  Independence MO Health Department and CenterPoint Hospital  Connecticut Department of Health and Long Term Care Facilities (LTCs)  Maine Center for Disease Control (Maine CDC)  Oral Health  Diabetes

6. Background of the PHF Public Health Antibiotic Stewardship Program IHI/CDC Initiative 8 Hospitals Driver Diagram for Hospitals Year Long Collaborative PHF represented PH PHF developed PH Driver diagram Implemented at 3 pilot sites

7. Current Challenges of Antibiotic Use in U.S. Hospitals  63% of hospitalized patients in academic medical centers in 2006 received antibiotics  10% increase over 4 years prior  Up to 50% of use is believed to be inappropriate (Pakyz AL, et al. Arch Intern Med. 2008.) (Dellit TH, Clin Infect Dis. 2007)

8. Antibiotic Stewardship Driver Diagram Primary DriversSecondary Drivers Timely and appropriate antibiotic utilization in the acute care setting Develop and make available expertise in antibiotic use Ensure expertise is available at the point of care Timely and appropriate initiation of antibiotics Appropriate administration and de-escalation Data monitoring, transparency, and stewardship infrastructure Decreased incidence of antibiotic-related adverse drug events (ADEs) Decreased prevalence of antibiotic resistant healthcare- associated pathogens Decreased incidence of healthcare-associated C. difficile infection Decreased pharmacy cost for antibiotics Monitor, feedback, and make visible data regarding antibiotic utilization, antibiotic resistance, ADEs, C. difficile, cost, and adherence to the organization’s recommended culturing and prescribing practices Availability of expertise at the point of care Promptly identify patients who require antibiotics Obtain cultures prior to starting antibiotics Do not give antibiotics with overlapping activity or combinations not supported by evidence or guidelines Determine and verify antibiotic allergies and tailor therapy accordingly Consider local antibiotic susceptibility patterns in selecting therapy Start treatment promptly Specify expected duration of therapy based on evidence and national and hospital guidelines Make antibiotics patient is receiving and start dates visible at point of care Give antibiotics at the right dose and interval Stop or de-escalate therapy promptly based on the culture and sensitivity results Reconcile and adjust antibiotics at all transitions and changes in patient’s condition Monitor for toxicity reliably and adjust agent and dose promptly

9. Antibiotic Stewardship Team Multidisciplinary Team Approach to Optimizing Clinical Outcomes* Hospital Epidemiologist Infection Prevention Medical Information Systems Microbiology Laboratory Infectious Diseases Director,QualityDirector,Quality Chairman, P&T Committee Partners in Optimizing Antimicrobial Use such as ED, hospitalists, intensivists and surgeons Hospital and Nurse Administration Cl. Pharmacist Physician Champion AMP Directors Cl. Pharmacist Physician Champion Clinical Pharmacy Specialists Decentralized Pharmacy Specialist Modified: Dellit et al. ClD 2007;44:159-177. *based on local resources Public Health

11. PHF Convened a Panel of Subject Matter and Public Health Experts to:  Identify the primary and secondary drivers of inappropriate antibiotic utilization in community health settings, as well as unique and shared responsibility for drivers  Identify the elements of a potential change package (i.e., a menu of intervention options)  Actions at various handoff points in patient care system  Potential policy changes  Opportunities for health departments to improve messaging and education, and answer questions  Aimed at consumers/customers  Within and between community health settings  Home health nurses  Pharmacists  Physicians

12. Independence (MO) Health Department Goals of the Initiative  CenterPoint Medical Center, one of eight hospitals, began collaborating with the Health Department  Reduce the spread of antibiotic resistance  Preserve antibiotics for the future  Decrease demand by the public for practices that lead to inappropriate use  Provide opportunities for collaboration between public health and healthcare  Improve patient care  Educate

13. Public Health and Health Care Collaboration  Empiric Antibiotic Guidelines  Inpatient  Outpatient  Distribution  Sharing data  Resistance trends  Case reports  Physician education  Community Education

14. Connecticut Department of Health - Goals of the Initiative  To strengthen or build partnerships between public health (DPH) and the medical provider community across the spectrum of healthcare  To build public health capacity and action in HAI prevention – expand from our surveillance role  To share and complement public health’s strengths with medicine’s strengths  To build the methods and tools of Quality Improvement into public health as well as medical care  To prevent C. difficile and MDROs (MRSA)

15. Maine CDC - Goals of the Initiative  Augusta hospital was first in Maine to report deaths from Clostridium difficile infection (CDI) from virulent strain NAP1  In past 2 years, four of five area nursing homes had reported CDI outbreaks  To reduce CDI, this pilot focused on:  1) reducing transmission  2) reducing acquisition of CDI  This pilot project used a regional multi-facility “cluster” approach  It involved a hospital, five area nursing homes, and outpatient physicians/medical directors in Augusta  The outcome measure is a decrease in the CDI rate for each facility (# CDI/10,000 patient days) and a reduction of CDI outbreaks

16. Public Health and Health Care Collaboration  Collaboration was key  Maine CDC had limited resources -1 staff person  Organizations that Maine CDC collaborated with:  Northeast Health Care Quality Foundation (QIO) in pilot project  Maine Medical Association/ Maine Independent Clinical Information Service (MICIS) for physician education  University of New England School of Pharmacy for antibiogram analysis

17. Lessons for Future Initiatives  Public health cannot do it alone/be a silo  Develop a trusting relationship between public health and health care  Network to find out what organizations are interested in the same type of work for possible collaboration. QIO/ICN/Hospital Associates/LTC Associations/etc.  Public health/Quality Collaborators need to get into the facilities (face-to-face)  Site visits, repeated circuit riding  Use the data to inform the site visits  Hospital association/ICN

19. Exercise 2 – What Could Go Wrong In Health Care and Public Health Collaborations?  Use a Process Decision Program Chart Drive to the Pharmacy What Could Go Wrong? Flat Tire No Spare Spare Flat Out of Gas Accident Likelihood LHMLLHML Countermeasures

20. Exercise 3: Driver Diagram Overview  Driver diagrams can be used to plan improvement project activities. They provide a way of systematically laying out aspects of an improvement project so they can be discussed and agreed on.  A driver diagram organizes information on proposed activities so the relationships between the aim of the improvement project and the changes to be tested and implemented are made clear.  A driver diagram has three columns - Outcome, Primary Drivers and Secondary Drivers.

21. Driver Diagram Overview  Outcome: Can be derived using the Aim Tool – clear and concise  Primary Drivers: A set of factors or improvement areas that we believe must be addressed to achieve the desired outcome. They should be written as straightforward statements rather than as numeric targets.  Secondary Drivers: Specific areas where we plan changes or interventions. Each secondary driver will contribute to at least one primary driver. They should be process changes that we have reason to think will impact the outcome (should have an evidence base). They should be necessary and (collectively) sufficient to achieve the aim.

22. Driver Diagram Overview  By defining the Aim and the changes we will test and implement very explicitly it allows us to determine what measures we will need to track to answer the question:  'How will we know that a change is an improvement?'

23. Reduce Hospital Re-Admissions

24. Q&A

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