Rangel QI 2012-2013: Antibiotic Stewardship in the Ambulatory Setting

1. Rangel QI 2012-2013:Antibiotic Stewardship in the Ambulatory Setting COS – May 15, 2013

2. Background Information • Antibiotic prescribing in the ambulatory setting occurs >1 in 5 visits • In study of pediatric office visits , antibiotics prescribed: • 44% of visits for the common cold • 75% of visits for bronchitis • Estimate at least 40-50% of inappropriate antibiotic use • While national antibiotic prescribing rates have decreased, more broad spectrum antibiotics are prescribed • Inappropriate antibiotic use contributes to antibiotic resistance, side effects, and increased cost Pediatrics. 2012; 130: 23-31. JAMA 2002; 287(23): 3096-3102.

3. Background Information 3-24 months 24-48 months 48-<72 months

4. Background Information

5. Questions • How well do we adhere to Clinical practice guidelines for promoting appropriate antimicrobial use? • How can we improve our practice? • How can we increase the Rangel Community’s understanding of viral/bacterial infections and the clinically accepted guidelines for therapy? • Focusing on common pediatric respiratory illnesses: • Upper Respiratory Infection (URI) • Acute Otitis Media (AOM) • Streptococcal pharyngitis

6. AIM Statement • AOM • 1a) for pt’s 3-17yo with uncertain diagnosis or non-severe illness, increase our observation rates from 60% to 80% • 1b) for pt’s 3-17yo with certain diagnosis and severe illness, increase our prescription of appropriate antibiotic from 73% to 90% • Streptococcal pharyngitis • 2) Improve the correct prescription (antibiotic, dose, duration) from 55% to 75% • Viral URIs • 3) For patients who present for sick visits and leave without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

7. Provider cycles/interventions

8. Pre-intervention provider survey • Survey Monkey survey of providers assessing knowledge, perceptions and practice of AOM diagnosis & management • For children < 2 years of age with suspected AOM, how often do you prescribe antibiotics at time of diagnosis? • 67% providers respond that they would always prescribe abx • For children > 2 years of age with suspected AOM, how often do you prescribe antibiotics at the time of diagnosis? • 17% providers responded that they would always prescribe abx

9. Didactics • Powerpoint presentation to all providers to review the clinical guidelines for both AOM and Strep pharyngitis

10. Clinic materials • Created handout materials & posters that highlighted the clinical guidelines and listed antibiotic options with dose and timing

11. 2004 AAP/AAFP Clinical Practice Guideline: Diagnosis of Acute Otitis Media • 3 major criteria for diagnosis of AOM: • acute onset of symptoms • signs of middle ear effusion • limited or absent mobility • bulging of TM • air-fluid level • otorrhea • signs and symptoms of middle ear inflammation • distinct erythema of TM • distinct otalgia Pediatrics 2004; 113(5):1451-1465.

12. Do you have a patient with AOM? **Certain diagnosis includes BOTH inflammation AND effusion *5-day treatment option if pt > 6 yo AND no h/o AOM in last 3-months

13. Antibiotic options for AOM *5-day treatment option if pt > 6 yo AND no h/o AOM in last 3-months

14. New 2013 AAP/AAFP AOM Guidelines *moderate or severe bulging of TM or new onset otorrhea, or*mild bulging of TM and recent onset (<48 hours) otalgia, or*mild bulging of TM and intense erythema

15. Do you have a patient with throat pain? Consider the rapid Strep test, IF AGE > 3 years AND >=2 of the following:

16. Antibiotic options for GAS-pharyngitis:

17. QI “Tip of the Week” emails

18. EMR tools • Acronym expander for both AOM and Strep pharyngitis for use in the EMR • .aom

19. EMR tools • Acronym expander for both AOM and Strep pharyngitis for use in the EMR • .aom • .pharyngitis

20. Provider Interventions: Results • For children < 2 years of age with suspected AOM, how often do you prescribe antibiotics at time of diagnosis?

21. Provider Interventions: Results • For children > 2 years of age with suspected AOM, how often do you prescribe antibiotics at the time of diagnosis?

22. Provider Interventions: Results • AIM Goal 1a: To increase our observation in pts 3-17yo with uncertain diagnosis or nonsevere illness from 60% to 80%

23. Provider Interventions: Results • AIM Goal 1b: To increase our prescription of appropriate antibiotic for pts 3-17yo with certain diagnosis and severe illness from 73% to 90%

24. Provider Interventions: Results • AIM Goal 2: Improve the correct prescription (antibiotic, dose, duration) of strep pharyngitis from 55% to 75%

25. Provider Interventions: Results • AIM Goal 2: Improve the correct prescription (antibiotic, dose, duration) of strep pharyngitis from 55% to 75%

26. Nurse/MA cycles/interventions

27. Nursing/MA interventions • Posted handouts around clinic and reviewed with RNs, ex. “how to triage patient with ‘sore throat’”.

28. Nursing/MA interventions • Didactics on Rapid Strep testing • Change in Rapid Strep testing workflow

29. Nursing/MA interventions • Didactics on Rapid Strep testing • Change in Rapid Strep testing workflow

30. Nurse Interventions: Results

31. Patient cycles/interventions

32. Pre-intervention Patient Questionnaire: • Paper/pen survey of random group of parents presenting for visits during a given block • 85% of patients believed that antibiotics are appropriate for one of the following: ANY FEVER, ANY INFECTION, or ONLY VIRAL INFECTIONS. • 45% of parents treat their children at home when sick • 45% of parents take their children to the ED when sick • Parents opt for the ED principally based on severity of illness, but also because they feel they are more likely to be seen by a doctor (rather than an allied health professional) and for convenience. • 15% of parents call the clinic or walk-in when their child is sick, with 1/3 of these patients opting occasionally to take their children to the ED instead

33. Patient Interventions • For patients discharged with viral diagnoses, providers were instructed to supply a viral prescription with written recommendations for care at home.

34. Patient Interventions • Providers instructed to have patients read back the most important instructions in the viral prescription to maximize retention and ensure understanding • In a study of critical laboratory values relayed by telephone to medical providers, physicians had an error rate of 5%, caught and corrected by a program of mandatory read back to laboratory technicians. Am J Clin Pathol 2004; 121:801-803.

35. Post-intervention Patient Questionnaire • AIM Goal 3: For patients who present for sick visits and leave without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

36. Post-intervention Patient Questionnaire • AIM Goal 3: For patients who present for sick visits and leave without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

37. Sustainability within our ACN clinics • Include lecture(s) on diagnosis of, and antibiotic prescription for, common outpatient presentations: AOM, Strep pharyngitis, CAP, bacterial sinusitis. • Handout materials above provider offices and RN/MA stations. • Acronym expander for AOM and Pharyngitis guidelines and other common outpatient walk-in visits. • Use of viral prescriptions with read back method. • Ensure availability of pneumatic otoscopy to increase accuracy of AOM diagnosis.

38. QI as a tool for improvement in Antibiotic Stewardship

39. Thanks to the entire Rangel Team! • Residents: ElShadeyBekeley, SandhyaBrachio, Karen Lee-Bride, Alicia Chang, Wee Chua, Kenny McKinley, Laura Perretta, PeltonPhinizy, Lauren Sanlorenzo, Andrew Wherman, Ronny Zviti • Preceptors: Evelyn Berger-Jenkins, HettyCunningham, Christine Krause, TawanaWinkfield-Royster • NP: Marcia Clarke • MAs: Wendy, Amarilys, Luisa • Nurses: Clara, Michelle, Cindy, Sharman • PFAs: Taina, Betty, Liz • Rangel Parents

40. References • Hersh, AL, et al.. “Antibiotic Prescribing in Ambulatory Pediatrics in the United States”. Pediatrics 2011; 129(6): 1053-1061. • Di Pentima MC, et al. “Benefits of a Pediatric Antimicrobial Stewardship Program at a Children’s Hospital”. Pediatrics 2011: 128(6): 1062-1070. • Coco, A, et al. “Management of acute otitis media after publication of the 2004 AAP and AAFP clinical practice guideline. Pediatrics 2010; 125:214. • Greene SK, et al. “Trends in antibiotic use in Massochusetts children, 2000-2009.” Pediatrics 2012: 3137. • McCaig LF, et al. “Trends in antimicrobial prescribing rates for children and adolescents.”JAMA 2002; 287(23): 3096-3102. • American Academy of Pediatrics and American Academy of Family Physicians – Subcommittee on Management of Acute Otitis Media. “Diagnosis and Management of Acute Otitis Media”. Pediatrics 2004; 113(5):1451-1465. • Shulman ST, et al. Infectious Diseases Society of America. “Clinical practice guidelines for the diagnosis and maangement of Group A Streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.”Clinical infectious diseases 2012; : doi: 10.1093/cid/cis629 • Chai, G, et al. “ Trends of outpatient prescription drug utilization in US children, 2002-2010.”Pediatrics 2012; 130(1): 23-31 • Barenfanger J, et al. “Improving patient safety by repeating (Read-Back) telephone reports of critical information.”Am J Clin Pathol 2004; 121:801-803.