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Integrate and Operationalize Institutional Guidelines for UTI and CAP
Background, Rationale and Suggested Implementation Strategies
- Educate providers, including hospitalists, internal medicine, family medicine, emergency medicine physicians, residents, advanced practice professionals (APPs), nursing staff about antibiotic resistance and appropriate antimicrobial prescribing.
- Educate patients and families about antibiotic resistance and appropriate antimicrobial prescribing.
- During educational sessions, highlight HMS data, showing opportunities for improvement.
- Communicate and promote institution-specific guidelines with front-line providers, including physicians, APPs, nursing, and pharmacy to ensure use of recommendations (morning report, grand rounds, medical staff meetings, division meetings).
- Integrate recommendations into key processes within the healthcare system such as into order sets, individual orders, discharge planning/processes, required yearly education for staff, etc.
- Build systems that can help modify provider behavior. Examples include (but are not limited to): clinical decision support tools and pharmacist review of antibiotic prescribing.
- After 3 months of guideline use, obtain provider feedback from multiple groups (including hospitalists, internal medicine, emergency department, etc.), and modify accordingly.
- Consider social factors in marketing guidelines to front-line providers. Highlight their participation in creation of the guidelines, and try to overcome viewpoints of loss of provider autonomy. Instead, emphasize improvement in quality and outcomes.
- Involve hospitalist champions in the education and dissemination process.
Resources and Tools
- Review HMS institution specific data for areas of local improvements
- Clinical Decision Support Tool for CAP (See Appendices A-C in Supplementary Data file)
- UTI Order Set Example (Michigan Medicine)
- Patient Education Example (Michigan Medicine)
- Presentations (For HMS Members – Additional authentication may be required):
- Henry Ford Antimicrobial Stewardship Team at the March 21, 2018 HMS Collaborative Wide Meeting: Implementation of a Short Course Antibiotic Initiative
- Dr. Sara Cosgrove (Director of the Antimicrobial Stewardship Program, Johns Hopkins Hospital) at the July 12, 2018 HMS Collaborative Wide Meeting: Optimizing Antimicrobial Use in the Inpatient Setting
- Dmitriy Martirosov (Infectious Disease Pharmacist, Beaumont Health System) at the March 8, 2019 HMS Collaborative Wide Meeting: Curtailing Diagnosis and Treatment of Asymptomatic Bacteriuria (ASB)
- Dr. Larissa May (Director of Emergency Department Antibiotic Stewardship, University of California-Davis) at the November 12, 2019 HMS Collaborative Wide Meeting: Doing What’s Best for Our Patients: Antibiotic Stewardship in the ED Setting
- Dr. Stephanie Burdick (Medical Director, Clinical Standardization – Corewell Health Grand Rapids) at the November 2, 2022 HMS Collaborative Wide Meeting: Community Acquired Pneumonia – Growing a Culture of Stewardship
- Order set examples from this presentation
- Henry Ford River District Antimicrobial Stewardship Team at the March 15, 2023 HMS Collaborative Wide Meeting: Journey of a Small Hospital – The CAP Experience
References
- Ciarkowski CE, et al. A Pathway for Community-Acquired Pneumonia with Rapid Conversion to Oral Therapy Improves Health Care Value. Open Forum Infect Dis 2020.
- This study noted a shorter length of IV antibiotic therapy when a clinical decision support-driven CAP pathway was implemented, along with active antimicrobial stewardship review.
- Haas MK, et al. Effects of a Syndrome-Specific Antibiotic Stewardship Intervention for Inpatient Community-Acquired Pneumonia. Open Forum Infect Dis 2016.
- Reduced duration of CAP treatment by development of institutional guidelines and integration into CPOE for treatment of non-ICU CAP using key stakeholders and hospitalist physician champions
- For education/dissemination: utilized emails, posters in work rooms, presentations in Grand Rounds and division meetings
- Hartley S, et al. Evaluating a Hospitalist-Based Intervention to Decrease Unnecessary Antimicrobial Use in Patients With Asymptomatic Bacteriuria. Infect Control Hosp Epidemiol 2016.
- Reduced treatment of ASB with educational sessions and pocket cards for hospitalists at all sites, and a pharmacist-led review of positive urine cultures at one site
- Malani A, et al. Harnessing the Electronic Health Record to Improve Empiric Antibiotic Prescribing. JAMA 2024.
- About half of hospitalized U.S. adults receive antibiotics, with many prescriptions being unnecessary or suboptimal, contributing to harm and resistance. The INSPIRE trials showed that integrating CPOE prompts into hospital workflows significantly reduced empiric extended-spectrum antibiotic use for pneumonia and UTI without compromising patient safety, offering a scalable model for antimicrobial stewardship.
- Meeker D, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med 2014.
- Displayed poster-sized commitment letters to avoid inappropriate antibiotic prescribing for Acute Respiratory Infections (ARIs) in exam rooms, providing patient/family education and behavioral “nudge”
- Mercuro N, et al. Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge. JAMA Netw Open 2022.
- A pharmacist-driven intervention targeting antimicrobial prescribing at discharge was associated with higher frequency of optimal antimicrobial regimens compared with before the intervention. Patients in the postintervention group had similar rates of mortality, readmission, and clinical resolution and fewer severe antimicrobial-related adverse effects compared with the preintervention group.
- Scymzcak J, et al. Pediatrician Perceptions of an Outpatient Antimicrobial Stewardship Intervention. Infect Control Hosp Epidemiol 2014.
- Qualitative study interviewing pediatricians after a stewardship intervention
- Found skepticism of accuracy of audit and feedback reports
- Vaughn V, et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual & Saf 2018.
- A critical step in improving clinician behavior is recognizing that most decisions occur with little active deliberation. When making rapid choices, clinicians are being influenced by EHR design, defaults, diagnostic stimuli, emotion, and social norms – whether purposeful or not. To improve, we must recognize these tendencies and use thoughtful design to capitalize on the potential of the EHR to improve patient care.
- Vaughn V, et al. Antibiotic Overuse at Discharge in Hospitalized Patients with Bacteriuria or Treated for Pneumonia: A Multihospital Study. Infect Con Hosp Epi 2020.
- Antibiotic overuse at discharge is common, varies widely between hospitals, and is associated with patient harm. Antibiotic overuse at discharge is strongly correlated between two disparate diseases, suggesting that prescribing culture or discharge processes contribute to overprescribing.
- Vaughn V, et al. Antibiotic Overuse and Stewardship at Hospital Discharge: A Multi-Hospital Cohort Study. Clin Inf Dis 2021.
- Antibiotics are commonly prescribed to patients as they leave the hospital. The aim was to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection.