Learning From Defects
Acute Care
SAY:
Thank you for joining us. This Webinar is entitled “Learning From Defects”. / Slide 1
Presenter – Pranita Tamma
SAY:
My name is Pranita Tamma. I am a pediatric infectious diseases physician at Johns Hopkins Hospital and I direct the Pediatric Antimicrobial Stewardship Program.
On the screen iscontact information for the project. If you have any questions or need to reach me after this Webex, please use this information. / Slide 2
Objectives
SAY:
By the end of this module, participants will be able to:
- Understand how to identify relevant system factors related to defects in antibiotic prescribing
- Develop interventions to reduce future risk related to unnecessary antibiotic use
- Ensure that interventions are effectively addressing defects related to antibiotic prescribing
Recap
SAY:
Let’s start off by reviewing what we learned so far.
CUSP improves the culture of safety while providing frontline staff with the tools and support needed to identify and tackle hazards that threaten their patients.
At this point, you understand that:
The 3 methods needed to eliminate unnecessary harm include standardizing practices, creating independent checklists, and learning from each new defect.
The Staff Safety Assessment is an important tool for identifying defects. It should be completed by all frontline staff whenever they identify a defect related to antibiotic use to better understand how they believe the next patient will be harmed in relation to antibiotic prescribing.
The Staff Safety Assessment should be reviewed and prioritized by unit leaders in conjunction with the Antibiotic Stewardship Team and any available frontline staff. This can be done once a month or more frequently. One approach would be to review any Staff Safety Assessment forms at the same time that the Team Antibiotic Review Forms are completed. In this module, we will discuss how to learn from defects related to antibiotic prescribing. / Slide 4
Let’s Start with a Case
SAY:
Let’s begin with a case.
A 65-year-old man presents to the hospital with right upper quadrant abdominal pain and is found to have ascending cholangitis associated with bile duct obstruction because of a gallstone.
He is febrile to 101 degrees Fahrenheit, his heart rate is 100 beats per minute and his blood pressure is normal at 121 over 75. He has an appropriate mental status.
He is admitted and started on vancomycin and piperacillin/tazobactam therapy.
On his second hospital day, he underwent an endoscopic retrograde cholangiopancreatography (ERCP) and the gallstone was removed.
During the afternoon of the procedure, blood cultures obtained at admission grew lactose fermenting Gram-negative rods.
His team continued to administer vancomycin and piperacillin/tazobactam after the Gram-stain results return. / Slide 5
Case Continues
SAY:
Although he defervesced and improved, his appetite is poor and he is unable to take enough fluids by mouth to stay hydrated.
On his third day of hospitalization, a vancomycin trough returns at 35 micrograms per milliliter and his creatinine increased from 1.0 milligrams per deciliter to 2.5 milligrams per deciliter.
During their routine post-prescription review of patients prescribed vancomycin, the antibiotic stewardship team noticed that the vancomycin trough was elevated and called the team.
After hearing the clinical story, the team suggested stopping vancomycin as biliary infections are generally not caused by MRSA.
As cultures grew a relatively susceptible E. coli, the ASP team recommended changing piperacillin/tazobactam to ceftriaxone.
The team was uncomfortable making these changes without talking to the gastroenterology consultant during rounds the next day about whether they were okay with the team making these changes. / Slide 6
Case Continues
SAY:
The following day, the vancomycin is stopped. The creatinine is now 2.7 mg/dL.
The patient is started on ceftriaxone but the provider forgets to stop the piperacillin/tazobactam.
The patient has a renal ultrasound to work up his acute renal failure and undergoes numerous blood draws to obtain vancomycin troughs as well as serum creatinine levels.
On day 5, his creatinine is improving and discharge planning is initiated. / Slide 7
Case Continues
SAY:
His nurse asks whether he needs a PICC inserted for receipt of IV piperacillin/tazobactam and ceftriaxone, prompting the team to realize that the piperacillin/tazobactam was never stopped when the ceftriaxone was started.
Although the E. coli was susceptible to ciprofloxacin, a PICC was placed for the patient to receive IV ceftriaxone for five more days. / Slide 8
The Four Moments of Antibiotic Decision-Making
SAY:
There are several defects in this case.
Let’s review the four moments of antibiotic decision-making that you have learned about in past webinars as it is helpful to use this framework to understand when defects occurred.
1. Does my patient have an infection that requires antibiotics?
2. Have I ordered appropriate cultures before starting antibiotics?
What empiric antibiotic therapy should I initiate?
3. A day or more has passed. Can I stop antibiotics?
Can I narrow therapy or change from IV to oral therapy?
4. What duration of antibiotic therapy is needed for my patient’s diagnosis? / Slide 9
The Four Moments of Antibiotic Decision-Making
SAY:
Let’s review some antibiotic-associated concerns in the care of this patient.
First, vancomycin was started empirically. MRSA is unlikely to be a pathogen in uncomplicated biliary infections and was unnecessary in this case. This is a moment 2 – related issue.
Similarly, piperacillin/tazobactam was prescribed empirically. This is also a moment 2 – related issue. This patient was not severely ill and did not have risk factors for Pseudomonas aeruginosa such as extensive health care exposure, extensive previous antibiotic use, immunocompromised status, or previous infections from P. aeruginosa. Therefore, an agent like ceftriaxone would have been sufficient.
Furthermore, the patient continued on vancomycin even after the blood cultures results indicated growth of a Gram-negative rod. This is an issue related to moment 3. The vancomycin should have been discontinued at this time. This may have prevented the development of acute kidney injury or AKI and additional laboratory tests and imaging to further evaluate the AKI could have been avoided.
After the ceftriaxone was started, the piperacillin/tazobactam was never discontinued. This is another moment 3 issue.
Additionally, after the antibiotic stewardship team informed the team that vancomycin could be discontinued, instead of stopping the vancomycin, they waited until clinical rounds the next morning to discuss with the GI consultant. This is also a moment 3 issue. The providers continued an antibiotic that they knew was unnecessary because of concerns related to prescriber etiquette.
When the vancomycin was finally discontinued, an order to discontinue ordering vancomycin troughs was never entered. This led to unnecessary patient inconvenience, costs, and personnel time. / Slide 10
The Four Moments of Antibiotic Decision-Making
SAY:
The patient remained on intravenous antibiotics for the duration of his hospitalization. This is another moment 3 issue. As soon as the patient demonstrated clinical improvement and was able to tolerate enteral medications, he should have been switched to an effective oral alternative. This could have led to avoidance of the PICC that was placed.
Finally, there was also a moment 4 issue. The patient received 10 days of antibiotics when a shorter duration of therapy should have been considered based on his early clinical improvement and no concerns for ongoing source control issues such as undrained intra-abdominal abscesses.
We will discuss appropriate therapy for intra-abdominal infections in more depth in future webinars. / Slide 11
Learning From Defects
SAY:
A staff member brings to your attention that this patient developed acute kidney injury and this might have been avoidable. During your next team meeting you may want to discuss this defect as a group. / Slide 12
Learning From Defects Tool
SAY:
On the project website, you will be able to access a “Learning From Defects” Tool that will assist you with identifying contributing factors to a defect and developing solutions for the defect to be avoided in the future. We suggest focusing on one defect at a time. The defects to focus on can come from completed Staff Safety Assessment forms or may be voiced by staff during team meetings or during clinical rounds. It is helpful to complete the Learning from Defect tool as a multidisciplinary group during a team meeting. / Slide 13
Why Did it Happen?
SAY:
While completing this tool, you will review the list of factors that contributed to the defect and check off those that negatively contributed and positively contributed to the defect.
Negative contributing factors are those that harmed or increased the risk of harm for the patient- these are factors you want to change.
Positive contributing factors are factors that limited the impact of harm. When we are learning from defects, sometimes we forget to acknowledge the factors that mitigated potential harm from the defect. It is important to list these so we make sure they remain in place or can be enhanced in some way, if necessary. / Slide 14
Example: Patient Develops AKI
SAY:
There were some negative contributing factors which increased the risk of harm for this patient including the unnecessary initiation of vancomycin and not discontinuing vancomycin when the cultures revealed E. coli.
Also, the team waited until the next morning during rounds to discuss stopping vancomycin with the GI service.
But there were some positive contributing factors too. For example, the antibiotic stewardship team reviewed the case and identified unnecessary vancomycin use. It was also helpful that the team was monitoring serum creatinine and vancomycin trough were also monitored. We want to make sure these positive contributing factors remain in place. / Slide 15
How Do You Reduce the Risk of the Negative Contributing Factors Happening Again
SAY:
Let’s discuss some potential solutions for the negative contributing factors we just reviewed.
Vancomycin was unnecessarily started empirically. Some solutions to this include:
-Developing local guidelines for intra-abdominal infections Remember, creating guidelines will standardize practices as we learned in the first CUSP Webinar on the Science of Safety.
-Ensure guidelines are available at the point of care so clinicians know where to find them and that they are easy to refer to when making antibiotic-related decisions.
-If you have the resources available, implement a pre-prescription authorization system for vancomycin. As a minority of patients who receive vancomycin empirically actually need it, this is an agent that might be worth restricting so the stewardship team can weigh in on whether vancomycin is needed or not. / Slide 16
How Do You Reduce the Risk of the Negative Contributing Factors Happening Again?
SAY:
Vancomycin was not discontinued when cultures revealed E. coli. To reduce the likelihood of this occurring again, you can:
- Develop guidelines for intra-abdominal infections that discuss when therapy should be de-escalated and reasonable regimens to consider when cultures are available and when they are not available.
- Educate nursing about reviewing culture results. Although nurses may not feel comfortable suggesting antibiotics to prescribe, if they notice their patient is receiving an antibiotic which is indicated as “resistant” in the medical record, they should feel comfortable discussing this. Similarly, if their patient is receiving meropenem and they know this is a restricted antibiotic because it has such broad-spectrum activity, and they see “susceptible” next to several other antibiotic agents, they should feel comfortable asking the prescribing clinician if it might be reasonable to adjust the antibiotic therapy. The comfort level of nurses to review culture results may vary but they should feel comfortable voicing any concerns.
- Implement an antibiotic time-out form to be reviewed on rounds. This creates an independent check to review all the antibiotics a patient is receiving and to make sure an antibiotic is not accidentally being continued when it is no longer necessary.
- You may want to consider vancomycin auto-stops at 48 or 72 hours.
How Do You Reduce the Risk of the NegativeContributing Factors Happening Again?
SAY:
The team waited to discuss stopping vancomycin with the GI service until the next morning during rounds instead of writing the order to discontinue it as soon as they knew it was no longer necessary and potentially causing harm. To prevent this from happening again:
- Educate all staff about the potential for AKI with vancomycin so they understand that vancomycin should be discontinued as soon as it is no longer needed.
- Nurses can be educated about vancomycin trough levels that are highly likely to be nephrotoxic. They can provide an invaluable resource in informing teams if they notice an unusually high vancomycin trough level when reviewing their patient’s labs. Additionally, if they notice a notable decrease in urine output or elevation in serum creatinine that may correlate with the development of AKI, they can assist the team with the early recognition of vancomycin-associated nephrotoxicity.
- Providers should be comfortable not worrying so much about prescriber etiquette if a delay in stopping therapy could cause patient harm. We will discuss this further in our teamwork and communication webinar.
What Should You Do When You Identify a Defect?
SAY:
Once a defect is identified (as in this case AKI), bring together a multidisciplinary team (including your antibiotic stewardship team) to identify contributing factors and to develop potential solutions. It might be necessary to bring in other members as needed. For example, if the defect was a case of ventilator-associated pneumonia, it would be helpful to involve a respiratory therapist.
Make sure everyone on the team knows what their role is in identifying and implementing potential solutions. Develop target dates to determine when to check back to review progress. These are all clearly outlined in the Learning from Defects Tool.
Seek input from a senior executive, as needed, particularly if resources are needed that are beyond the scope of the units leaders or stewardship team.
Determine if something can be measured to demonstrate if a reduction in harm has occurred over the next few weeks to months and if there is increased compliance with the new practice. / Slide 19
Make Sure Risks are Being Reduced
SAY:
Follow-up in several weeks or months to make sure the potential solution has been successfully implemented and that it has not led to unforeseen negative consequences. Check to see if your staff knows about the changes you implemented. Ask them to make sure the knowledge has been disseminated. Notice if staff isusing the procedure as intended. Assess if staff believe risks were reduced. / Slide 20
Factors Associated with Defects
SAY:
Remember that there are negative contributing factors that increased the risk of harm for the patient. We want to change these.
And, there are positive contributing factors that limited the impact of harm for the patient. We want to keep these. / Slide 21
Factors Associated with Defects
SAY:
On the Learning From Defects tool, your team can review the 5 categories of factors that contribute to defects.
These are patient factors, technical factors, healthcare worker factors, team factors, and institutional factors.
Patient factors are those related to the clinical or emotional condition of the patient/family.
Negative patient factors include an unclear clinical diagnosis or the family strongly prefers a certain antibiotic regimen.
Positive patient factors include a clear clinical syndrome or a patient informed about stewardship issues (for example, the patient wants to review what antibiotics he or she is receiving).
Technical factors are those related to stewardship resources including information technology resources.
Negative factors include the lack of guidelines; knowledge gaps in education; too many dose options in the electronic health record; difficulties with ordering the desired cultures; no ordersets; or day of antibiotic therapy not documented in progress notes.
Positive technical factors include the existence of local guidelines; a mechanism to work with IT to develop reports, ordersets, etc. / Slide 22
Factors Associated with Defects
SAY:
Healthcare worker factors are those related to individual members of the patient care team.
Negative factors include the provider has too many responsibilities or the provider doesn’t know who to contact for additional antibiotic decision-making guidance, etc.
Positive factors include an interest in stewardship; dedicated time to perform interventions.
Team factors are those related to communication and teamwork- which you will hear more about in the fourth and final CUSP module.
Negative team factors include no mechanism for daily review of antibiotics; poor written or verbal communication during handoffs; or the treatment plan not discussed as a group
Positive team factors includethe existence of a daily briefing about antibiotic regimens with the clinical team.
Finally, institutional factors are those related to institution culture and resources.
Negative institutional factors include stewardship is not prioritized or there is a lack of resources available for stewardship.
And positive factors include the institution endorses stewardship or there is acknowledgement of good stewardship. / Slide 23
Your Turn
SAY:
Your turn! Another defect that was identified was continuing to obtain vancomycin troughs after the vancomycin was discontinued. What might be some patient factors, technical factors, healthcare worker factors, team factors, and institutional factors that might have contributed? And, what are some potential solutions for these? / Slide 24
Program Website Access
SAY:
You have been sent login credentials to the AHRQ Safety Program for Improving Antibiotic Use website. Please log in to the website to access project resources such as the project schedule, recorded webinars, and slide decks with scripts. The website is updated routinely with new resources. Please note that recorded webinars may take up to 5 days after the presentation date to be posted on this website.
If you have any questions about login credentials or website content please email / Slide 25
Questions
SAY:
Questions? / Slide 26
Next Steps
SAY:
During your next WebEx,we will discuss Improving Teamwork and Communication around Antibiotic Prescribing.
Contact us at between now and your next call if you have any questions or concerns. / Slide 27