Influence of telephone communication on antibiotic prescribing in nursing homes
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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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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 MS1, 2

1 University of Wisconsin School of Medicine and Public Health, Madison, WI

2 William S. Middleton Veterans Affairs Hospital, Madison, WI


T aidan cockburn 1963

“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


Influence of telephone communication on antibiotic prescribing in nursing homes

“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


Influence of telephone communication on antibiotic prescribing in nursing homes

“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


Global resistance

Global Resistance

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


The antibiotic pipeline

The Antibiotic Pipeline


Improving antibiotic use

Improving Antibiotic Use

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


Abx stewardship reduces rates of mdros

Abx Stewardship: Reduces Rates of MDROs

Tertiary care hospital; Quebec, 2003-2006

Valiquette, et al. Clin Infect Dis 2007; 45:S112.


Abx stewardship improves clinical outcomes

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.


Abx stewardship reduces costs

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


Resistance in nursing homes

Resistance in Nursing Homes

????

Jarvis WR. Emerg Infect Dis 2001; 7(2): 170-3


Mdro in nhs mrsa

MDRO in NHs: MRSA

Crnich et al. IDSA 2010


Mdro in nhs fqrb

MDRO in NHs: FQRB

Crnich et al. IDSA 2010


Antimicrobial use in ltcfs

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


Antibiotic use in wi nhs

Antibiotic Use in WI NHs

Crnich et al. J Am Med Dir Assoc 2011, submitted


Antibiotic use in wi nhs1

Antibiotic Use in WI NHs

No. Subjects = 449

No. Abx(+) = 293 (65%)

N = 92 (21%)


Influence of telephone communication on antibiotic prescribing in nursing homes

Why?


Antibiotic start process hospital versus nursing home

Antibiotic Start Process: Hospital versus Nursing Home


Antibiotic start process hospital versus nursing home1

Antibiotic Start Process: Hospital versus Nursing Home


Antibiotic start process hospital versus nursing home2

Antibiotic Start Process: Hospital versus Nursing Home


Antibiotic start process hospital versus nursing home3

Antibiotic Start Process: Hospital versus Nursing Home


Antibiotic start process hospital versus nursing home4

Antibiotic Start Process: Hospital versus Nursing Home


Antibiotic start process hospital versus nursing home5

Antibiotic Start Process: Hospital versus Nursing Home


Antibiotic start process hospital versus nursing home6

Antibiotic Start Process: Hospital versus Nursing Home


Antibiotic start process hospital versus nursing home7

Antibiotic Start Process: Hospital versus Nursing Home


Influence of telephone communication on antibiotic prescribing in nursing homes

  • 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


Antibiotic start process hospital versus nursing home8

Antibiotic Start Process: Hospital versus Nursing Home


Nurse physician communication

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


Influence of telephone communication on antibiotic prescribing in nursing homes

  • 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


Influence of telephone communication on antibiotic prescribing in nursing homes

  • 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


Research question

Research Question:

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


Research objectives

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


Study aims

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


Study design

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


Measurement of communication

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


Assessment of appropriateness of antibiotic starts

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


Assessment of non communication factors

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


Thank you

Thank You


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