“Drivers” of appropriate antibiotic use in the inpatient setting: Exploring Practical Approaches

November 13th, 2012 1:31 pm ET - .

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Authors: Diane Jacobsen MPH, CPHQ, Director, Institute for Healthcare Improvement
Don Goldmann MD, Vice President, Institute for Healthcare Improvement

Did you ever wonder why a practical change idea can be more than a simple challenge? For example, how do you get the right antibiotic to the right patient for the right amount of time?

In 2009, The Centers for Disease Control and Prevention (CDC) and the Institute for Healthcare Improvement (IHI) invited experts to create a set of key changes for appropriate and timely antibiotic use for patients cared for in the hospital. We created a Driver Diagram as a way of organizing our theories of what it would take to bring about change. We also organized the change ideas in an easy to use guide called a change package and developed a measurement framework. Drivers and changes were chosen to reflect the causal pathway towards appropriate antibiotic utilization and reduction of adverse drug events, antibiotic-associated colitis, cost of care, and antibiotic resistance. We wanted to make it practical and easy for hospitals to test and deploy at the front line.

We asked eight “pilot testing” hospitals to try out the changes, to test them and let us know what worked and what didn’t work; to give us even more ideas and to let us know what was truly practical. Each hospital secured senior leadership support for the project and was asked to engage a multi-professional team to test the changes.
Each hospital tested changes, in at least two of the following “Drivers”:

Timely and appropriate initiation of antibiotics
Appropriate administration and de-escalation
Data monitoring, transparency and stewardship infrastructure
Availability of expertise at the point of care

Based on their work, we made revisions to the change package. Here is our current theory, depicted in the Driver Diagram.
On November 2, 2012, we began a new initiative to improve antibiotic stewardship based on the work of the eight pilot hospitals. In this initiative, hospitalists are leading the effort in 5 hospitals by 1) identifying and defining interventions that are readily incorporated into the normal work flow at the point of care and 2) engaging specialists in hospital medicine to lead antibiotic stewardship interventions.
Here are the key interventions:

Documentation/visibility at the point of care: antibiotic, day of therapy, indication, and expected duration
Appropriate length of treatment
(based on GLs for treatment duration for the 3 most common dx in the hospitalists program)
72 hour antibiotic time out to facilitate de-escalation/discontinuation of antibiotics, as appropriate

We’re excited about the journey ahead and look forward to sharing more of what we learn from the Hospitalist-led Antibiotic Stewardship initiative.