How executives are rethinking quality initiatives to improve proper antibiotic use: 4 insights

Amid the rise of antibiotic resistance and the further adoption of value-based reimbursement models, executives are challenged to prioritize quality initiatives, particularly antibiotic stewardship programs, which optimize infection treatment and decrease potentially harmful events linked to antibiotic use.

This article is sponsored by Accelerate Diagnostics, Inc.

Kathleen G. Beavis, MD, medical director of the microbiology and immunology laboratories and medical director of Laboratories' Quality at the University of Chicago Medicine, joined more than 15 hospital and health system leaders from across the U.S. to discuss experiences within their own organizations during an executive roundtable at Becker's Hospital Review 9th Annual Meeting in Chicago on April 12, 2018.

During the roundtable presentation, Dr. Beavis, who focuses on clinically relevant, cost-effective diagnoses of infectious diseases, shared how antibiotic stewardship programs have evolved throughout the past few decades, moving from ensuring patients receive the right drug at the correct time to incorporating The Joint Commission's requirement that all hospitals have an antimicrobial stewardship program involving collecting, analyzing and reporting relevant data.

In working to improve these programs, hospitals can decrease mortality, length of stay, readmission and reduce associated care costs. "If we put our focus on timely and improved  patient care, the costs savings will ultimately follow," Dr. Beavis said. Additionally, Dr. Beavis noted that for hospital executives, when implementing any quality initiative, it is important to engage those responsible for data and analytics, as well as the nursing, medical, and other caregivers whose performance is being measured.

The group of executives, which included multiple CMOs and CNOs, discussed the top quality initiatives at their institution, the most significant challenges they face in successfully implementing these quality initiatives and how they measure the effects of antibiotic stewardship as part of their facility's quality improvement strategy.

Here are four insights from the discussion:

1. Identifying critical quality initiatives. Numerous executives kicked off the discussion by sharing the quality initiatives they are paying particular attention to, such as examining infection control efforts more closely, investigating sepsis mortality rates, reducing patients' length of stay and combating issues with streamlining blood culture processes.

"We're doing a lot of antibiotic stewardship on the outpatient side in our urgent care clinics and emergency department in terms of diagnosis and whether or not it's appropriate to prescribe antibiotics — then we complete chart reviews and develop protocols," said the CMO of a critical access hospital in the Pacific Northwest. The CMO said the hospital has a team that reviews a patient's diagnosis and considers what percentage of time the hospital appropriately or inappropriately prescribes antibiotics to patients with comparable diagnoses before issuing an antibiotic prescription.

2. How technology affects quality initiatives. A number of executives noted how evolving clinical documentation technologies affect their facility's quality initiatives, including day-to-day IT issues, and more specifically, physician burnout linked to IT problems.

"About a year ago we launched an antibiotic stewardship program and we are lucky to have the clinical pharmacy support for the program, which is unique for our type of facility," said the medical director of a 160-bed pediatric acute care hospital in the South. "One of the things we've encountered is that not all EMRs are equal, and Epic is touted for having a lot of potential, but sometimes the resources and infrastructure can be quite onerous to reach."

3. Top challenges in implementing quality initiatives. The CNO of a 123-bed hospital in the Southeast highlighted the importance of the involvement of nurse leadership in the implementation of quality initiatives. As critical frontline providers, nurse buy-in is essential to the success of any quality initiative.

"A lot of these quality initiatives have to be co-managed by nursing. Nursing is a big driver when it comes to [healthcare-associated infection] reduction, looking at length of stay and the teaching involved with readmissions," she said. "Like many hospitals, where we're struggling is around sepsis mortality. We are a surgical hospital, so our mortality rate is low, but it's not where we want it to be." The CNO attributed the hospital's ongoing issue with sepsis mortality to a failure to quickly recognize and treat the infection before a patient's condition deteriorates. "Raising this recognition will have to involve closely looking to improve both nurse and provider behavior."

The CMO of a 241-bed acute care facility in the Midwest agreed, adding that sepsis is the most complicated core measure providers have ever had to address. "It's a mess because we have the issue of getting the antibiotic in quickly, making sure it's the right antibiotic at exactly the right milliliter. We have a lot of infection control problems, but sepsis and Clostridium difficile are some of the biggest issues."

4. Measuring the effect of antibiotic stewardship as part of quality improvement strategy. When discussing how to evaluate the efficacy of antibiotic stewardship programs as a component of a hospital's quality improvement strategy, executives said they are examining days of antibiotic therapy, days of IV antibiotic therapy compared to other therapies, the number of interventions enacted by the clinical pharmacy team and C. diff rates.

However, moving forward, numerous executives brought up the potential for improving antibiotic stewardship programs and treatment across hospital departments through the use of clinical data. "For our facility, it would be interesting to see the data on how earlier notification of infection susceptibility drives length of stay," said the CNO of the 123-bed hospital in the Southeast.

Additionally, executives discussed how antibiotic stewardship programs can help reduce contamination rates in various hospital departments, working toward overall cost reduction. "I'm intrigued by reducing the treatment for false positives on our cultures during antibiotic stewardship programs," said the CMO of a pediatric hospital in the Midwest. "That seems like another potential for these initiatives because we've worked to increase the reliability of cultures obtained in our emergency department, which has the highest contamination rate, but haven't necessarily had the same experience in other departments of the hospital."

As healthcare providers address the growing number of costly infections caused by bacteria resistant to antibiotics, hospital leaders should look to enhance their facility's antibiotic stewardship programs to not only cut costs related to these "superbugs," but also significantly improve care quality. Stewardship programs that leverage clinical documentation technology and automated antibiotic susceptibility testing can help increase infection cure rates, reduce treatment failure and significantly cut hospital rates of antibiotic resistance.

More articles on clinical leadership and infection control: 
State declares 'immediate jeopardy' for 8th time at UC San Diego hospital over dirty surgical instruments
8 hep C cases confirmed at Washington hospital amid investigation
Patient sues UPMC after nurse exposes 4,700 to tuberculosis

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