PROJECT NAME: Antibiotic Stewardship: UTI/Cystitis As a Beginning

ABSTRACT

PROJECT NAME: Antibiotic Stewardship: UTI/Cystitis as a beginning

Institution: University of Texas Southwestern Medical School

Primary Author: Walter L. Green, MD

Secondary Author:

Project Category: General Quality Improvements

Overview: This project was completed in an urban emergency department in Dallas, Texas, at Parkland Memorial Hospital, with a yearly volume of over 120,000 patients. There is no standardization for choosing an antibiotic in emergency patients that will be discharged with a simple UTI or cystitis. Although inpatient protocols and order sets exist for some infectious diseases, outpatient infections generally have no standards for prescribing, especially in relation to local antibiotic resistance patterns. One of University of Texas Southwestern’s goals is to implement institution wide antibiotic stewardship to insure that outpatients receive the lowest cost antibiotic that is effective (high susceptibility/low resistance noted on an antibiogram) in treating the infection. Specifically, this project sought to increase the use of nitrofurantoin or cephalexin in simple urinary tract infection (UTI) or cystitis in emergency department patients while decreasing the use of less effective antibiotics such as ciprofloxacin and trimethoprim/sulfamethoxazole (TMP/SMZ).

Aim Statement:Increase nitrofurantoin or cephalexin antibiotic prescribing to greater than 75% in Parkland Emergency Department outpatients with simple urinary tract infections or cystitis byMarch 30, 2012.

Measure of Success: The emergency department at Parkland Memorial Hospital uses EPIC™, an electronic medical record, on every patient and the discharge diagnosis and medications are recorded and stored. A computerized search of all emergency department patients’ records was performed to identify diagnoses of UTI or cystitis and the prescribed antibiotic at discharge was identified. The initial rate of nitrofurantoin or cephalexin use was identified at about 40% when the records were searched before the study was implemented. The records were searched again 3 months after the study began and again at 6 months. The rate of usage for nitrofurantoin or cephalexin was compared to the initial rate to see if any improvement occurred.

Use of Quality Tools:Selecting an outpatient antibiotic for an emergency department patient that is going to be discharged is a complex process with several factors effecting the decision. A fishbone diagram was constructed to identify errors that result in the choice of an inappropriate antibiotic.

Interventions:The Infectious Disease Society of America identified inappropriate antibiotic prescribing for simple UTI or cystitis as a problem in a paper published in 2010. We wanted to increase the use of appropriate antibiotics from about 40% to 75%.

We initially planned to increase the proper antibiotic use by simply educating the prescribing physicians in the emergency department. However, after noting that the number of physicians prescribing antibiotics in the ED is high (over 80 attendings and over 80 residents, some of whom rotate into the ED monthly), our team realized we had to find another method that was more efficient and could be used throughout the Parkland system in the future. To implement the change, four attending physicians, three residents, one pharmacist, and 4 software specialists had input. We designed an order set, called a SmartSet, to be used at discharge for patients with a diagnosis of UTI or cystitis.

The change was communicated by a short 15-minute didactic lecture during a weekly emergency medicine resident conference at UTSouthwestern. Also, attending physicians and residents were individually tutored on the SmartSet for about 5 minutes during their clinical shift in the emergency department by one of the team members.

The timeline for implementation had to remain flexible. Development of a SmartSet is a complex process at Parkland that requires several levels of committee approval to assure compliance with hospital policy and for patient safety. Many committees only meet monthly which makes even the simplest approval a lengthy process. The initial goal of increasing usage to 75% in 6 months became a challenge as design and approval took over 4 months alone.

Innovations: Physicians often have to consult several resources to find the correct antibiotic of choice when discharging an emergency patient with an infection. We attempted to correct this problem by developing a SmartSet for discharge that included an up-to-date list of preferred antibiotics that were respectful of local resistance, recommended by the Infectious Disease Society, and also inexpensive. We also included a link to the IDSA paper and the Parkland Antibiogram in case the prescribing physician desired to consult these resources. Discharge instructions in English and Spanish and the window for actual discharge were also included in the order set to help streamline the process. Though streamlining and ease of discharge were not the aim of this project, the SmartSet became extremely popular and multiple physicians demanded more discharge SmartSets to improve patient flow and ease of prescribing for other diagnoses.

The old discharge process involved 7 pull-down menus, 26 mouse clicks, and at least 6 typewritten responses for each patient. We reduced the process to 1 pull-down menu, 7 mouse clicks, and only 2 typewritten responses.

Results: An examination of urinary bacterial pathogens and the antibiogram at Parkland confirmed national data concerning resistance in commonly used antibiotics:

Most notable is E. coli, the number one pathogen in urinary tract infections, which is resistant to ciprofloxacin and TMZ/SMZ.

We examined the initial antibiotics used for UTI/cystitis in the emergency department before anyone was aware that a change needed to be made. The following pie chart shows the distribution (note the high use of ciprofloxacin):

After the implementation of the SmartSet along with a simple 15-minute didactic lecture to the residents, nitrofurantoin and cephalexin use increased significantly in the spring of 2012:

Nitrofurantoin use increased from 37% to 64% and cephalexin use (a good second choice drug) increased from 3% to 9%.

Poor performing antibiotics for UTI/cystitis are ciprofloxacin and trimethoprim/sulfamethoxazole (Bactrim®). Their use declined with ciprofloxacin decreasing from 43% to 16% and tmp/smz decreasing from 10% to 8%.

The Old Process: Below is1 of the 7 pull-down menus that required opening to discharge a patient before the introduction of the SmartSet. This one menu (of 7!) required 7 mouse clicks and a minimum of 3 typewritten responses.

The New Process:The new UTI/cystitis discharge SmartSet is below. Note the listing of the antibiotics in preferred order per the Infectious Disease Society and the antibiogram above. There are also links listed below the antibiotics for the IDSA paper and the antibiogram that can easily be accessed. This is the only page required to discharge a patient with UTI/cystitis: a maximum of 7 mouse clicks and two typewritten responses are required.

Revenue Enhancement/Cost Avoidance/Generalizability:The obvious revenue enhancement of this project is in the prevention of return visits for resistant infections. When a poorly performing antibiotic is prescribed, cure rates are less; higher complications and return visits for costly treatments and repeated antibiotic prescriptions also occur. The most favorable savings for the physicians was time. The streamlined discharge process using the new SmartSet saved several minutes at each discharge because of the preferred antibiotic list, pre-calculated dosages, and instructions. The SmartSet is available now system wide at Parkland both in the emergency department and in all the Parkland clinics across Dallas. The other sites have not yet been formally encouraged to use the SmartSet, though several clinics have already adopted its use for speedy discharge.

Conclusions and Next Steps:We concluded that developing discharge order sets (SmartSets) that help the physician choose the best antibiotic are well received, especially when the process streamlines a burdensome electronic medical record. Very minimal education time was spent and a significant improvement was made.

Future discharge order sets for otitis media, odontogenic infections, pharyngitis, pneumonia, diverticulitis, and cellulitis will significantly impact antibiotic stewardship at Parkland. The goals at Parkland are to maximize appropriate antibiotic use in the thousands of outpatients seen each year in the emergency department and clinics – this design appears to have great promise due to its simplicity and improvement in the speed of use of the electronic medical record. Furthermore, several physicians have requested discharge SmartSets for other diagnoses such as back pain, headache, diabetes, hypertension, and abdominal pain.

We intend to develop SmartSets for otitis media, odontogenic infections, pharyngitis, pneumonia, diverticulitis, and cellulitis. Once developed, a system wide educational module will be developed to help physicians learn about the ease and rapidity of use.