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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. Influence of Telephone Communication on Antibiotic Prescribing in Nursing Homes. Christopher J. Crnich, MD MS 1, 2.

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Influence of Telephone Communication on Antibiotic Prescribing in Nursing Homes

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  1. The 2011 Wisconsin Health Improvement and Research Partnership Forum Fluno Center, Madison, WI September, 15 2011 Influence of Telephone Communication on Antibiotic Prescribing in Nursing Homes Christopher J. Crnich, MD MS1, 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

  3. “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

  4. “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

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

  6. The Antibiotic Pipeline

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

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

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

  10. Abx Stewardship: Reduces Costs 12.9% • 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 Slide courtesy of Barry Fox, Director of UWHC Antibiotic Stewardship Program

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

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

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

  14. 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

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

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

  17. Why?

  18. Antibiotic Start Process: Hospital versus Nursing Home

  19. Antibiotic Start Process: Hospital versus Nursing Home

  20. Antibiotic Start Process: Hospital versus Nursing Home

  21. Antibiotic Start Process: Hospital versus Nursing Home

  22. Antibiotic Start Process: Hospital versus Nursing Home

  23. Antibiotic Start Process: Hospital versus Nursing Home

  24. Antibiotic Start Process: Hospital versus Nursing Home

  25. Antibiotic Start Process: Hospital versus Nursing Home

  26. 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 J Am Med Dir Assoc 2005; 6(2): 109-12

  27. Antibiotic Start Process: Hospital versus Nursing Home

  28. 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

  29. 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 Gerontol 1989; 29(4): 502-10

  30. 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

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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. Thank You

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