Using Nursing Home Antibiograms to Improve Antibiotic Prescribing and Delivery

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Slide 1

Using Nursing Home Antibiograms to Improve Antibiotic Prescribing and Delivery

AHRQ Annual Meeting
September 10, 2012

Abt Team:

• Jeremiah Schuur, MD, MHS, Brigham and Women’s Hospital.
• Rosanna M. Bertrand, PhD.
• Donna Hurd, MSN.

Denver Health/University of Maryland Team:

• Jon Mark Hirshon, MD, MPH, PhD.

Slide 2

Background

• Antibiotics are frequently prescribed in Nursing Homes (NHs).
• NH residents are frequently transferred to emergency departments (EDs) for acute conditions and given antibiotics.
• Initial antibiotic decisions are empiric – based on:
  • Patient factors (e.g. age, symptoms).
  • Facility factors (type of NH, historical experience, formulary).
  • Preference / knowledge, etc.

Slide 3

Background

• Antibiogram: A tool that presents local microbiologic sensitivity data to assist clinicians in making empiric prescribing decisions.
• Hospitals have used antibiograms to:
  • Identify important local resistance patterns.
  • Increase antibiotic prescribing for acute infections.
• Agency for Healthcare Research and Quality (AHRQ) contracted with two ACTION teams to investigate the feasibility of creating NH antibiograms:
  • Can NH antibiograms be created?
  • Can NH antibiogram programs be effectively implemented?
  • Can antibiograms be transferred to local EDs?
  • Do antibiograms affect prescribing?

Slide 4

Sample Antibiogram

Image: A line graph compares the percentage change in Abx prescribing for the Invention Group and Comparison Group for all Indicators.

Slide 5

Abt NH Antibiogram Project

• Funded by AHRQ
  • ACTION Network: Contract # HHSA290200600011I TO13.
• Research Team
  • Abt Associates
    • Project Director: Rosanna Bertrand, PhD.
    • NH Clinical Expert: Donna Hurd, MSN;
    • Jennifer DeAngelis, BA; Laura Goodman, BA.
• Brigham and Women’s Hospital
  • Principal Investigator: Jeremiah Schuur, MD, MHS.
  • Allen Gold, BA.

Slide 6

Project Details

• Developed an antibiogram at three Boston-area NHs
  • Used NH-specific micro data from the clinical lab.
  • Created a one page antibiogram with key findings.
• Educated NH prescribers and staff about antibiogram.
• Designed a process for antibiogram transfer to local ED.
• Evaluated
  • Provider knowledge and perceptions of antibiograms with survey and interviews.
  • Transfer rate of NH antibiogram to ED.
  • Prescribing patterns at NH and ED (pre/post).

Slide 7

Abt’s Key Findings

• Feasible to create NH antibiograms but technical limitations
  • Simple to use NH micro data – difficult to integrate local hospital data.
  • Sample size issues limit the number of microorganism that can be described (CLSI standard is at least 30 results per organism).
• Most useful results for urine infections
  • Most data came from urine cultures (75-90%).
  • Significant resistance to common antibiotics among gram-negative organisms that frequently cause UTIs (E. coli, Klebsiella):
    • Quinolone sensitivity for E. coli in urine was limited (45-60%).
• Prescribers report using antibiograms, but no evidence found
  • When given an antibiogram with E.coli resistance to quinolones they said they would change their prescribing for urine infections.
  • No significant change in use of quinolones or broad spectrum antibiotics.

Slide 8

Key Challenges & Lessons Learned

• Changing NH prescriber behavior is challenging
  • Diverse group of providers (MD/DO, NP, PA).
  • Geographically separated.
  • Time pressed.

• Antibiogram impact limited unless implemented as a QI program
  • Does prescriber see antibiogram at time of prescribing?
  • Is their prescribing behavior followed (QA/QI)?

• Ensuring ED prescribers receive NH antibiogram is challenging
  • NH transition of care is complex -- another paper form transfer is difficult.
  • NH paper forms not always seen by ED prescribers (lost, not reviewed, etc.).
  • Usefulness of an online antibiogram is limited unless available for all NHs
    • Providers won’t look for a rare event.

Slide 9

Denver Health/ University of Maryland- Nursing Home Antibiogram Project

Funded by Agency for Healthcare Research and Quality

ACTION Contract No. 290-2006-00-20, Task Order No. 9

Research Team

Denver Health
ACTION PI: Thomas D. MacKenzie, MD, MSPH
Susan Moore, Josh Durfee

University of Maryland
Principal Investigators: Jon Mark Hirshon, MD, MPH, PhD and Jon Furuno, PhD.

Slide 10

Denver-Maryland NH Antibiogram Project Details

• Project implemented at 3 separate NHs in Maryland
  • Urban, rural, suburban.
• Chart reviews conducted
  • At each NH and their affiliated acute care hospital.
• Antibiogram created for each NH
  • Pocket size, laminated index card.
• Needs assessment performed through interviews with the infection control/QA nurse.
• In-services conducted at each NH for nursing staff and physicians
  • Shared findings from chart reviews.
  • Educated staff on use of the antibiogram.
• Post implementation evaluation at one NH
  • Prescribing patterns at one NH and affiliated ED (pre/post).
  • Knowledge of ED physicians of antibiogram.

Slide 11

Characteristics of the 3 NHs

Slide 12

Chart Reviews Findings

• Reviewed 623 NH and 216 ED (hospital) charts.
• NHs differed in the number of residents transfer each month (9-20 transfers).
• UTI was most common infection and urine cultures were the most common type ordered.
• Escherichia coli (E. coli) and Proteus mirabilis (P. mirabilis) were the two most prevalent organisms isolated in cultures.
• NH Physicians prescribed mainly one antibiotic where ED physicians started patients on at least two.
• Oral antibiotics were prescribed in NH and IV in ED
  • NH physicians mainly prescribed fluoroquinolones (ciprofloxacin or levofloxacin) as an initial antibiotic (20-35% of initial prescribing instances).
  • Empiric antibiotic prescribing was very common in all three NHs (84-87% of initial antibiotics prescribed).
  • For the culture positive treated infections, empiric prescribing was correct only 25-33% of the time.
  • Definitive antibiotic prescribing occurred in 32-52% of culture positive treated infections.

Slide 13

Evaluation of the Antibiogram in one NH/ED

• In NH, ciprofloxacin was again the most frequently prescribed initial antibiotic but was prescribed 15% of the time versus 22%.
• Cefuroxime was prescribed14% of the time, up from 3% during the initial chart review period.
• In NH, empiric prescribing was correct 45% of time, up from 30%.
• No changes in prescribing patterns were found in the ED.

Slide 14

Key Challenges and Lessons Learned

• Challenges
  • Availability of NH staff/physicians
    • Only interviewed one fulltime ED physician who had not seen antibiogram.
  • Time required for chart review.
  • Small number of cultures.
• Lessons Learned
  • NH antibiograms can be created using chart review but this is time consuming.
  • NH relationships with their laboratories differ based on the NH.
  • NH antibiograms mainly represent UTIs as, 90 to 100 percent of suspected urinary tract infections are cultured, but rarely any other suspected infections are cultured.
  • Culture information from ED transfers did not add to the NH antibiogram unless the NH had a high number of transfers.