1. Influence of Telephone Communication on Antibiotic Prescribing in Nursing Homes The 2011 Wisconsin Health Improvement and Research Partnership Forum Fluno Center, Madison, WI September, 15 2011 The 2011 Wisconsin Health Improvement and Research Partnership Forum Fluno Center, Madison, WI September, 15 2011 Christopher J. Crnich, MD MS 1, 2 1 University of Wisconsin School of Medicine and Public Health, Madison, WI 2 William S. Middleton Veterans Affairs Hospital, Madison, WI

2. We can look forward with confidence to a considerable degree of freedom from infectious diseases at a time not too far in the future. Indeed … it seems reasonable to anticipate that within some measurable time… all the major infections will have disappeared. T. Aidan Cockburn, 1963

4. Antibiotic therapy, if indiscriminately used, may turn out to be a medicinal flood that temporarily cleans and heals, but ultimately destroys life itself. Felix Marti-Ibanez, 1955

5. At the beginning of the 21st century, antimicrobial resistance is common, has developed against every class of antimicrobial drug, and appears to be spreading into new clinical niches. Stephan Harbarth & Matthew Samore, 2005

6. Global Resistance Ryback et al. Pharmacotherapy 2005; 24(12 part 2): 203S - 15S

7. The Antibiotic Pipeline

8. Improving Antibiotic Use McCaig et al. Emerg Infect Dis 2003; 9(4): 432-7

9. Abx Stewardship: Reduces Rates of MDROs Valiquette, et al. Clin Infect Dis 2007; 45:S112. Tertiary care hospital; Quebec, 2003-2006

10. Abx Stewardship: Improves Clinical Outcomes RR 2.8 (2.1-3.8)RR 1.7 (1.3-2.1)RR 0.2 (0.1-0.4) Percent AMP = Antibiotic Management Program UP = Usual Practice Fishman N. Am J Med. 2006;119:S53.

11. Abx Stewardship: Reduces Costs Team consists of a clinical pharmacist, an an ID physician and Clinical Laboratories Methods – Development of evidence-based guidelines – Antibiotic utilization software to identify targeted interventions – Daily interdisciplinary rounds – Education of staff Antimicrobial portion of inpatient drug budget: 22.9% (FY05), 20.5% (FY08) Cost-avoidance in 2009 Budget = $600,000 12.9% Slide courtesy of Barry Fox, Director of UWHC Antibiotic Stewardship Program

12. Resistance in Nursing Homes Jarvis WR. Emerg Infect Dis 2001; 7(2): 170-3 ????

13. MDRO in NHs: MRSA Crnich et al. IDSA 2010

14. MDRO in NHs: FQRB Crnich et al. IDSA 2010

15. Antimicrobial Use in LTCFs Accounts for 40% of the medications used in LTCF residents in older studies 3-13% of residents are receiving antimicrobials at any time 50-70% of residents will receive at least one antibiotic during the year 25-75% of antibiotics given for inappropriate indications

16. Antibiotic Use in WI NHs Crnich et al. J Am Med Dir Assoc 2011, submitted

17. Antibiotic Use in WI NHs No. Subjects = 449 No. Abx(+) = 293 (65%) N = 92 (21%)

18. Why?

19. Antibiotic Start Process: Hospital versus Nursing Home

27. J Am Med Dir Assoc 2005; 6(2): 109-12 221 post-acute care residents admitted to 7 Georgia NHs followed for a year 105/221 (48%) received at least one course of antibiotics 50% were NH-initiated 43% of NH-initiated courses had no documentation of infection in medical record 67% of NH started antibiotics initiated over the phone

28. Antibiotic Start Process: Hospital versus Nursing Home

29. Nurse-Physician Communication Ineffective communication involved in 60% of medical errors Improving N-P communication in LTCFs became a NPSG in 2008 Quality of interactions viewed as suboptimal by both parties

30. Gerontol 1989; 29(4): 502-10 40/83 (48.2%) considered avoidable 70% due to inadequate diagnostic or treatment facilities 15% due to pressure from family/staff 15% due to suboptimal communication – MD not available – Assessment of resident suboptimal

31. 15 of 21 nurses viewed preparation as critical to effective N-P communication Barriers to preparation –Relevant clinical information not all in one place –Assessment incomplete at time of call –Delays in MD returning call J Patient Saf 2009; 5(3): 145-52

32. Research Question: Does the quality of telephone/fax communication between nursing staff and off- site prescribers influence the appropriateness of antibiotic prescriptions in NHs?

33. Research Objectives Understand how the communication process influences decisions to start antibiotics in NHs Use this information to promote more effective communication between NH staff and off-site prescribers Reduce unnecessary and suboptimal antibiotic use in NHs

34. Study Aims Specific Aim #1: Assess the content of telephone/fax communication between nursing staff and off-site prescribers Specific Aim #2: Determine if the absence of specific elements of content are associated with higher rates of inappropriate antibiotic prescribing Specific Aim #3: Explore the influence that factors other than communication have on the prescription of antibiotics

35. Study Design Mixed-methods observational study Core data collection methods will be developed and validated in a single pilot facility Plan to expand to multiple facilities following the pilot

36. Measurement of Communication The content of communication events associated with an antibiotic start will obtained: –Telephone conversations between NH staff and off-site providers will be recorded –Copies of fax communications will be obtained The conveyance of specific elements with each communication event will be abstracted onto standard case report forms

38. Assessment of Appropriateness of Antibiotic Starts Data related to each antibiotic start will be collected and abstracted onto standard CRFs Structured implicit review will be used to determine appropriateness –Each member of an expert multidisciplinary panel will review CRFs independently –Score as appropriate, inappropriate, indeterminate –Consensus on discrepancies between panel members will be achieved through group consensus

39. Assessment of Non- Communication Factors Semi-structured interviews with NH staff and off-site prescribers involved with antibiotic start events will be performed. Audio tapes of communication events will be used to facilitate memory of prescribing event. Transcripts of interviews will be analyzed using a grounded theory approach

40. Thank You