1. University of Missouri Antimicrobial Stewardship Program : Patient Safety and NPSG Compliance
Performance Improvement Leadership Develop Program
University of Missouri – Columbia
February 19, 2010

2. Team Members Joe Cameron, Pharm.D., BCPS Gordon Christensen, MD
Ed Ege, Pharm.D.
Stephanie Lumley-Hemme, RPh
Jennifer Meyer, Pharm.D., BCPS
Stevan Whitt, MD

3. Focus Area
With the arrival of the Centers for Medicare & Medicaid's no-pay rules, The Joint Commission's National Patient Safety Goals, and the ever-growing emphasis on quality improvement of patient care, prevention has become the standard of care.
Participation in multiple quality improvement, automated data surveillance, and antimicrobial stewardship programs have garnered successes for hospitals in terms of improving systems, and in turn care and cost.

4. AIM Statement
University of Missouri Hospital aims to implement a process for monitoring and an intervention protocol intended to standardize the use of evidence based antibiotic regimens in the adult surgical intensive care unit.
The process starts with a list of new antibiotic orders and a daily culture and sensitivity report from the lab.
The process ends with conclusion of antibiotic therapy

5. AIM Statement Our goal is to standardize empiric antibiotic therapy
Our secondary outcomes include: improving patient outcomes, decreasing duration of antibiotic therapy, containing antibiotic costs, and decreasing antibiotic resistance and related adverse reactions compared to current practice.
It is important to work on this now b/c external accrediting agencies are demanding improvement and antimicrobial resistance is increasing

6. Institutional Strategic Goals
National Patient Safety Goal 7 : Reduce the risk of health care associated infections
New standards for 2009
NPSG : Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals.
NPSG : Implement best practices or evidence- based guidelines to prevent central line-associated bloodstream infections.
NPSG : Implement best practices for preventing surgical site infections.

7. Institutional Strategic Goals
Diagnosis Driven Therapy
Uniformity in Prescribing Practices
Cost Avoidance
Education

8. Project Timeline Data analysis and modification ECOMS Initial Approval
ID Acceptance
New Process Development
Lab Report
Order Sheet Creation with ID
Process Modification and Initiation
Presentation and Implementation of Program
August 2009
Sept 2009
Oct 2009
Nov 2009
Dec 2009
Jan 2010
Feb 2010
Current Process Evaluation
Discussion with PowerChart Documentation
ECOMS Approval to move forward
IV to PO Conversion Policy
Preliminary Data
SICU Intial Acceptance

9. Continued on Next Slide
Current Process
Continued on Next Slide

10. Current Process

11. Fishbone Diagram

12. Stakeholders Point of Change Stakeholders Upstream Stakeholders
Downstream
Stakeholders
Patients
Administration
Pharmacy
Infection Control
Units throughout hospital
Pharmacy
ICU Physicians
Attendings
Residents
Infectious Disease
Pathology
IT Dept.
Pharmacy

13. Interventions Considered
Strategy 1
Strategy 2 & 3
Active Intervention and Feedback
Location Based
Patient Based
Organism Based
Prior-authorization
ID Physician or Pharmacist with authority
Restricted Formulary
Partially implemented, no authority in Pharmacy
Education
Driven by Attending Physicians

14. Continued on Next Slide
Suggested Pathway
Yes No
Continued on Next Slide

15. Continued on Next Slide
Suggested Pathway
Yes No
Yes
Continued on Next Slide No

16. Suggested Pathway No
Yes
Yes No

17. Key Driver Diagram

18. Order Sheets

19. Order Sheet

20. Microbiology Reports

21. Microbiology Reports

22. Measurements Diagnosis Stated / Use of Preprinted Order Set
>75%
De-escalation
IV to PO Conversion

23. Baseline Data (2 Weeks) Diagnosis Stated Patients in SICU
Zero (0%)
Patients in SICU
21 Patients
Antibiotics Prescribed
37 Antibiotics
One Time Dose (Pre-op)
4 Antibiotics
De-escalation
2 Accomplished (40%)
3 Missed
IV to PO Conversion
None (0%)

24. Process and Outcomes Indicators
Outcome Indicators
Increased knowledge of appropriate therapy for common infectious diagnoses throughout the institution.
Bacteremia, Pneumonia, and Intra-abdominal Infections
Compliance with JCAHO NPSG 7
Process Indicators
De-escalation of therapy when appropriate
IV to PO Conversion

25. Anticipated Return on Investment / Benefits Realized
Increased resident understanding of appropriate empiric evidence based therapy and de- escalation
Consistent management of patient specific disease states
Decreased development of multi-drug resistant organisms
Decreased medication expenditure

26. Lessons Learned Health care team acceptance
Analysis of current practice
Prediction of program implementation
Process improvement application

27. Next Steps Encompass all intensive care units
Education of Pharmacists, Nurses, and Physicians
Increase number of disease state protocols
Increase roll out to all of institution
Successful reduction in multi-drug resistant organisms
Decreased length of antibiotic therapy and potentially patient stay

28. Joe Cameron Ed Ege Stephanie Lumley-Hemme Jennifer Meyer
Questions?
Joe Cameron
Ed Ege
Stephanie Lumley-Hemme
Jennifer Meyer

29. Thank You!