When eBrightHealth LLC, a statewide collaborative of five hospitals in Delaware, looked at what clinical practices its members could work on jointly to improve care delivery across the small Mid-Atlantic state, it formed a Choosing Wisely work group and decided to focus on antimicrobial stewardship, including the inpatient setting.
All of the hospitals took steps to reduce antibiotic prescribing for upper respiratory infections with ambulatory patients. Additionally, three of them set a goal of reducing antibiotic patient days by 10 percent over a year, largely through implementation of 48- to 72-hour antibiotic time-outs. Two to three days after starting a patient on an antibiotic, the physician re-evaluates its appropriateness to determine if the medication should be decreased or discontinued.
The antibiotic “time-out” is an effective means to adjust the broad-spectrum antibiotics often given to admitted patients who show signs of infection before the specific cause is identified through cultures. Narrow-spectrum use of antibiotics will help reduce Clostridium difficile, or C. diff, a serious gut infection that has become more prevalent in hospital settings, and is consistent with new antibiotic stewardship standards set by the Joint Commission in 2017.
Beebe Healthcare, which operates a 210-bed hospital in southern Delaware, achieved a 32 percent reduction in its C. diff infection rate from fiscal 2017 to fiscal 2018 under the time-out practice. In the first five months of its effort, the number of therapy days for Ertapenem, a broad-spectrum antibiotic treatment, declined nearly 60 percent.
“We are definitely in the early stages of changing our culture,” said Elizabeth Richardson, MSN, MPH, RN, manager of infection prevention at Beebe. “Often, hospitals over-treat. Sometimes antibiotics that could do the job in three to five days are given for seven to 10 days.”
Beebe used a number of strategies to support the time-outs in its medical-surgical ICU, including pharmacist education, EMR alerts, data analysis and feedback for specific antibiotics, recruitment of hospitalists as champions and using a time-out tool from the Agency for Healthcare Research and Quality’s Safety Program for Improving Antibiotic Use. The tool requires front-line clinical teams to answer five questions during daily rounding to determine whether an antibiotic therapy is still needed. The questions help clinicians narrow the scope of antibiotics given, de-escalate from intravenous to pill dosages, and eliminate antibiotic usage altogether.
Beebe team leaders also did “deep dives” for all hospital onset cases of C. diff, providing one-on-one provider coaching and feedback, Richardson said.
Robert Dressler, MD, MBA, the Quality and Safety Officer for Christiana Care Health System, said that one of the distinctions of the eBrightHealth collaborative was its role in integrating the Choosing Wisely campaign into clinical practice change across the state.
“In Delaware, the conversation started with the health systems, who invited many community partners to the table,” said Dressler, adding that in many states the impetus for the statewide Choosing Wisely campaigns started with external stakeholders such as consumer, medical society and employer groups.
But in the case of Delaware, health system leaders believed that, despite being competitors, there were areas that collaboration would benefit the community. “Much of our focus has been on building pathways to enhance the delivery of high-value care, but we also need to add ‘What care is low-value?’ to the conversation. It can be a nuanced difference,” he said.
Janelle Caruano, PharmD, a clinical pharmacist at Bayhealth Kent General Hospital in Dover, said she was pleased with the initial results of their antimicrobial stewardship project, noting that having a dedicated pharmacist supporting hospitalists and ICU intensivists was crucial to success.
Bayhealth Kent used the AHRQ time-out tool in its intensive care unit and incorporated best-practice alerts into EPIC, its electronic health record platform, for a 72-hour stop for the intravenous antibiotics piperacillin/tazobactam and ceftriaxone with hospitalized patients.
At the Kent campus, the rate for hospital-acquired C. diff declined nearly 10 percent from fiscal year 2017 to fiscal year 2018. The targeted antibiotics, regularly used to prevent infection from surgery, were either de-escalated or discontinued 13.7 percent of the time as a result of the new EHR alerts.
“It’s actually better to form rapport and a relationship to have the same person asking the (AHRQ) form questions. They know what to expect and develop a better relationship with the physicians, who would maybe make changes more readily” to the antibiotic prescribing, she said.
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