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

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 address:

3. 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

4. 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

5. 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?

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

7. 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

8. 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

9. 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

10. 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

11. #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

12. #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

13. #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

14. #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?

15. #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

16. Using the Team Antibiotic Review Form

17. 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

18. Accessing and Uploading Data

19. Data to be Submitted
Days of antibiotic therapy / 1000 patient days present / unit by antibiotic using CDC NHSN AU definitions and methodology

20. 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)

21. Data to be Submitted
C. difficile lab event rates by unit using CDC NHSN MDRO/CDI module
Data submitted quarterly via program website
Teams should obtain these data from the hospital’s infection control department

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Antibiotic Stewardship Program (ASP) Development
Next Steps
Onboarding Call 2
Antibiotic Stewardship Program (ASP) Development
Questions?

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