1. 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: ”
Joe Boero MD CMD Park Manor Nursing Home Park Falls, WI

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

3. 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

4. *

5. 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

6. FINDING PNEUMO 2014

7. 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

8. 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

9. 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 .

10. 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

11. 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

12. 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

14. 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

15. 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

16. 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