1. Improving Communication and Teamwork Around Antibiotic Prescribing
Acute Care

2. 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 address:

3. 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.

4. 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

5. 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 Jan;33(1): PMID:

6. 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 Jan;33(1): PMID:

7. Four Key Components of Effective Communication
Complete
Clear
Brief
Timely
TeamSTEPPS for Office-Based Care: Communication. Content last reviewed September Agency for Healthcare Research and Quality, Rockville, MD. Accessed June 28, 2017.

8. 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

9. 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!

10. 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 Agency for Healthcare Research and Quality, Rockville, MD. Accessed June 28, 2017.

11. 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 Accessed Jun 19, 2017.

12. 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 Jan;1(35): PMID:

13. 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 Jun;23(2): PMID:

14. 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?

15. 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

16. Antibiotic Time Out Tool
Two page document

17. 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

18. 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

19. 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?

20. Team Antibiotic Review Form
Two page document

21. Staff Safety Assessment Form

22. Learning From Defect Form
Three page document

23. 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.

24. Program Website Access

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

26. 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?

27. References
Dayton, E, Henriksen, K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm Qual Patient Saf Jan;33(1): PMID:
TeamSTEPPS for Office-Based Care: Communication. Content last reviewed September Agency for Healthcare Research and Quality, Rockville, MD. Accessed June 28, 2017.
Conflict Resolution (Slide Presentation). Content last reviewed October Agency for Healthcare Research and Quality, Rockville, MD. Accessed June 28, 2017.

28. References
ALEEN Script. Johns Hopkins Medicine, Armstrong Institute. Kentucky Hospital Improvement Innovation Network. KY. July 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 Jan;1(35): PMID:
Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care Jun;23(2): PMID: