ICAP Project: Introduction to ICAP Project: Introduction to ICAP Project: Introduction to ICAP Project: Introduction to Quality Improvement, Change Quality Improvement, Change Quality Improvement, Change Quality Improvement, Change Package, & Antibiotic Stewardship Package, & Antibiotic Stewardship Package, & Antibiotic Stewardship Package, & Antibiotic Stewardship AUGUST 28, 2014 AUGUST 28, 2014 AUGUST 28, 2014 AUGUST 28, 2014 SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14TO THE VIP NETWORK ICAP QI PROJECT TEAMS
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ICAP Project: Introduction to Quality Improvement, …...Introduction to QI Methods MARK SHEN, MD SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION
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ICAP Project: Introduction to ICAP Project: Introduction to ICAP Project: Introduction to ICAP Project: Introduction to Quality Improvement, Change Quality Improvement, Change Quality Improvement, Change Quality Improvement, Change
Why do the nurses always continue the pulse oximeter?
Is there a Pulse Ox Fairy that comes turns it back on every evening?
Let’s stop the use of continuous pulse oximetry
If you don’t know where you’re going, you’ll end up If you don’t know where you’re going, you’ll end up If you don’t know where you’re going, you’ll end up If you don’t know where you’re going, you’ll end up someplace else.someplace else.someplace else.someplace else. –––– Yogi BerraYogi BerraYogi BerraYogi Berra
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
AIM AIM AIM AIM Statement Statement Statement Statement ---- SmarterSmarterSmarterSmarterThe aim of this project is to decrease the use of continuous pulse oximetry in normoxic patients with respiratory diseases (asthma, bronchiolitis, pneumonia) by 50% during the period, January 1, 2010 to June 30, 2010.
The process begins when a patient is admitted to the 4C unit and ends 4 hours after the patient has been on room air with normal oxygen saturations.
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
SMART AIMSMART AIMSMART AIMSMART AIM
SSSSpecific
MMMMeasurable
AAAAchievable
RRRRealistic
TTTTime-defined
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
The Model for ImprovementThe Model for ImprovementThe Model for ImprovementThe Model for Improvement
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Not SMARTNot SMARTNot SMARTNot SMART
“We keep giving difficult learners poor final evaluations
without any documented mid-rotation concerns. Let’s
create a new form.” (talked about every 3 years)
“Sign-out takes forever. Let’s all agree to just discuss
the basics.” (talked about every 6 months)
“Let’s discharge 50% of patients before noon.” (talked
about every month)
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
AIM SMARTAIM SMARTAIM SMARTAIM SMART
In Amsterdam, the tile under Schiphol’s
urinals would pass inspection in an
operating room. But nobody notices.
What everybody does notice is that each
urinal has a fly in it.
Look harder, and the fly turns into the
black outline of a fly etched into the
porcelain. It improves the aim. If a man
sees a fly, he aims at it. Fly-in-urinal
research found that etchings reduce
spillage by 80%. It gives a guy something
to think about. That’s the perfect
example of process control.
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Understand the Process: Pareto ChartUnderstand the Process: Pareto ChartUnderstand the Process: Pareto ChartUnderstand the Process: Pareto Chart
Reasons for Continuous Pulse
Oximetry
0
1
2
3
4
5
6
Nurse
comfort
It's
"standard"
for…
Not 4 hrs
yet
Not 8 hrs
yet
MD
directive
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Measurement is a Tool (Begin Early)Measurement is a Tool (Begin Early)Measurement is a Tool (Begin Early)Measurement is a Tool (Begin Early)
Continuous Pulse Oximetry Use in Patients on
Room Air > 4 Hours
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Week
(refined sampling
method)
Education initiated
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Understand the Process: Control ChartUnderstand the Process: Control ChartUnderstand the Process: Control ChartUnderstand the Process: Control Chart
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
11/1
5/20
0911
/22/
2009
11/2
9/20
0912
/6/2
009
12/1
3/20
0912
/20/
2009
12/2
7/20
091/
3/20
101/
10/2
010
1/17
/201
01/
24/2
010
1/31
/201
02/
7/20
102/
14/2
010
2/21
/201
02/
28/2
010
3/7/
2010
3/14
/201
03/
21/2
010
3/28
/201
04/
4/20
10
-Measured discharge communication within two days
-”Unstable” weeks were due to attendings that never got the memo
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Why these interventions?Why these interventions?Why these interventions?Why these interventions?
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Pathways and Order SetsPathways and Order SetsPathways and Order SetsPathways and Order Sets
Clinical pathways and order sets
should be customized by your
interdisciplinary team to reflect:
• Hospital culture
• Local antibiotic susceptibility
patterns
• Project metrics
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Antimicrobial Stewardship Antimicrobial Stewardship Antimicrobial Stewardship Antimicrobial Stewardship Program (ASP) Program (ASP) Program (ASP) Program (ASP) for Hospitalistsfor Hospitalistsfor Hospitalistsfor Hospitalists
MARY ANN Q UEEN, MDMARY ANN Q UEEN, MDMARY ANN Q UEEN, MDMARY ANN Q UEEN, MD
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Antimicrobial StewardshipAntimicrobial StewardshipAntimicrobial StewardshipAntimicrobial Stewardship“Optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection with minimal toxicity to the patient and minimal impact on subsequent resistance”
Gerding DN. Joint Commission J Qual Improv 2001;27:403–4.
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Education: Educating clinicians about resistance and optimal prescribing
2014 CDC recommends all acute care hospitals implement ASP.Source: CDC ASP Web site
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Components of ASPComponents of ASPComponents of ASPComponents of ASPProspective audit
and feedback
Formulary
restriction
Preauthorization
for specific
antibiotics
Clinician education
Clinical Pathways
Integration of
newer diagnostic
technology
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Prospective audit and feedbackProspective audit and feedbackProspective audit and feedbackProspective audit and feedback
Recommendations agreed upon provided in patient chartRecommendations agreed upon provided in patient chartRecommendations agreed upon provided in patient chartRecommendations agreed upon provided in patient chart
Discuss with teams and physicians about recommendations of ASPDiscuss with teams and physicians about recommendations of ASPDiscuss with teams and physicians about recommendations of ASPDiscuss with teams and physicians about recommendations of ASP
Appropriateness and duration determinedAppropriateness and duration determinedAppropriateness and duration determinedAppropriateness and duration determined
Review patients on monitored antibiotic two calendar days after initiationReview patients on monitored antibiotic two calendar days after initiationReview patients on monitored antibiotic two calendar days after initiationReview patients on monitored antibiotic two calendar days after initiation
All inpatients 7 days a weekAll inpatients 7 days a weekAll inpatients 7 days a weekAll inpatients 7 days a week
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Antibiotics for monitoringAntibiotics for monitoringAntibiotics for monitoringAntibiotics for monitoringCeftazidime
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
ASP RecommendationsASP RecommendationsASP RecommendationsASP Recommendations
Narrow antibiotic therapy
Optimize antibiotic choice for
clinical situation
Optimize antibiotic dosing and
monitoring
Set and adjust therapy duration
Discontinue unnecessary
antibiotics
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Antibiotic “Time outs”Antibiotic “Time outs”Antibiotic “Time outs”Antibiotic “Time outs”Revisit antibiotic selection after more clinical & lab data available
Review at 48 hrs
◦ Does patient have an infection that will respond to antibiotics?
◦ If yes, is patient on right antibiotics(s), dose & route?
◦ Can more targeted antibiotics be used?
◦ How long should patient receive the antibiotic(s)?
Source: CDC Core Elements of ASP
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Morning HuddleMorning HuddleMorning HuddleMorning HuddleBuild in your own accountability system
◦ Peer mentoring
Start each day assessing new admits in past 24 hours
◦ Appropriate therapy
◦ Appropriate dose
◦ Estimated duration
Start each day discussing all new orders for monitored antibiotics
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
What antibiotics should be restricted?What antibiotics should be restricted?What antibiotics should be restricted?What antibiotics should be restricted?
Carbapenems?
Polymyxins?
Linezolid?
Fluoroquinolones?
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
EducationEducationEducationEducation
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Staffing needs for ASPStaffing needs for ASPStaffing needs for ASPStaffing needs for ASP•Minimum ideally . . .
– Pharmacist
– Physician champion/medical director
•How can community hospitals make ASP work?
– CPGs
– Collaboration with health system partners
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Hospitalists as ASP PhysiciansHospitalists as ASP PhysiciansHospitalists as ASP PhysiciansHospitalists as ASP PhysiciansWhy hospitalists?
– Inpatient providers (bulk of ASP interventions)
– Specialty based on providing the highest inpatient quality of care possible
– Provides salary support/security
– Smaller hospitals=No Peds ID
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS
Developing ASP for community IP PediatricsDeveloping ASP for community IP PediatricsDeveloping ASP for community IP PediatricsDeveloping ASP for community IP PediatricsIdentify team members
– Pharmacist
– Hospitalist
– ID specialist (content consultation)
– Microbiology department
– Administrative support, IT, Data analyst
Adult counterparts are better than no collaborators!
SLIDE USED WITH PERMISSION FROM M SHEN, M QUEEN, AND J NAZIF, “ICAP PROJECT: INTRODUCTION TO QUALITY IMPROVEMENT, CHANGE
PACKAGE, & ANTIBIOTIC STEWARDSHIP” ORIGINALLY PRESENTED 08/28/14 TO THE VIP NETWORK ICAP QI PROJECT TEAMS