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Christiana Care Sees 39 Percent Decrease in Urgent Care Prescribing After First Year with Antibiotic Stewardship Program

Posted on by CDC's Safe Healthcare Blog

Harold P. Kramer, M.D., Lead Physician at Christiana Care Health System’s Medical Aid Units

Harold P. Kramer, M.D.
Harold P. Kramer, M.D.

“Primum non nocere,” the Latin phrase which means “First, do no harm,” holds a significant relevance today as physicians strive to adhere to principles of antibiotic stewardship.

While we recognize that antibiotic stewardship in ambulatory settings should be a top priority for every practice, we also know that following through on this effort can seem daunting.

At Christiana Care Health System, we learned firsthand that when it comes to establishing a robust antibiotic stewardship model, the most important step is to take that first step.

I oversee Christiana Care’s five Medical Aid Units – these urgent care facilities employ 30 providers and provide care for more than 70,000 patients each year. When we consulted with our organization’s antibiotic stewardship team, we learned that we were not prescribing antibiotics correctly every time; however, we did not know our actual antibiotic prescribing rates. Despite the missing information, we knew that the first step to improving our antibiotic prescription patterns was to understand whether or not we were correctly diagnosing bacterial infections, which would subsequently determine if antibiotics were being prescribed appropriately. 

While antibiotic utilization data are helpful, it is not necessary to begin making a positive difference. Using U.S. Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship (Commitment, Action, Tracking and Reporting, Education and Expertise), we partnered with our providers to establish a common ground with which to make a specific diagnosis that was supported by a documented history of the patient as well as a physical exam. We determined our preferred antibiotic choices, dosing strategies, and durations of therapy, then shared this information with our clinicians. We began reporting daily on our progress and compliance with these new prescribing patterns through meetings and group emails. Chart reviews also were performed almost daily based on diagnoses made in order to review what antibiotics, if any, were being prescribed.

Through these steps, we were creating a culture of antibiotic stewardship and accountability. Now, when a clinician missed the mark, we would speak with them directly to help course-correct. It didn’t take long before my colleagues were actively helping each other make the better choices. They also knew that I as the leader was actively reviewing their prescribing patterns.

To educate our patients, and to help us prevent old prescribing habits from resurfacing, we distributed antibiotic stewardship educational resources – brochures, symptomatic treatment Rx pads, etc. – to both our providers and our patients. We even included these resources in our patients’ discharge packets to help propel our conversations with them about appropriate use of antibiotics. We also displayed educational posters in the waiting and exam rooms.

We serve together at Christiana Care, guided by our values: Excellence and Love. A key to our success was to forge strong partnerships with a diverse team. Our Medical Aid Unit team collaborated with infectious disease specialists, pharmacists and information technology (IT) specialists in order to implement our antibiotic stewardship program. We rallied together in this endeavor to use resources wisely and effectively, and to be exceptional today and even better tomorrow. We were united in the goal of delivering optimal health care to our patients.

Even though we lacked baseline data, we were able to work together for our common goal to decrease total antibiotic use rate across our Medical Aid Units. Our antibiotic stewardship interventions began in January 2017. Here are the fruits of our efforts:

  • When comparing the period of January-June 2017 to July-December 2017, the total use of antibiotics decreased by 25 percent.
  • The total use of azithromycin decreased by 44 percent in the above time periods.
  • The rate of azithromycin prescriptions per 100 visits also decreased by 44 percent.
  • Our antibiotic prescription rate decreased to 41 antibiotics per 100 visits in February 2018, compared to 67 per 100 visits in January 2017, the month in which the intervention was initiated. That’s a whopping decrease of 39 percent.
  • Specifically, our azithromycin prescription rate decreased to 3 antibiotics per 100 visits in March 2018, compared to 13 per 100 visits in December 2016. That decrease is even more extraordinary: a drop of 77 percent.

We were able to achieve this success without the need to publicize individual provider rates and we have received relatively few complaints from patients about this effort. In fact, countless patients have expressed their gratitude that we’ve partnered with them to ensure that we provide them antibiotics only when medically appropriate.

By sharing our experience via this post, my Christiana Care colleagues and I hope to provide our ambulatory peers with a roadmap to implement or improve their own antibiotic stewardship programs.

I conclude by referencing its beginning, at which I brought up the Latin medical phrase that means “First, do no harm.” While I am unsure what the Latin phrase is for medicine’s Quadruple Aim, I can assure you that our antibiotic stewardship intervention achieved every one of those aims: the improvement of quality and safety, a reduction in costs, the improvement in patient experience and – as we observe the continuous improvement in the care we provide – a joyful enrichment of the provider experience.

More on this topic: http://www.christianacare.org/whoweare

Harold P. Kramer, M.D., is the lead physician at Christiana Care Health System’s five Medical Aid Units, which offer patients convenient access to a medical professional every day of the week. Christiana Care Health System is one of the country’s largest health care systems, ranking as the 22nd leading hospital in the nation and 11th on the East Coast in terms of admissions. The health system includes two hospitals with 1,100 patient beds as well as The Medical Group of Christiana Care (a network of primary care physicians, medical and surgical specialists, home health care, preventive medicine, rehabilitation services, and patient/family advisors for core healthcare services). Christiana Care is a not-for-profit teaching hospital affiliated with Sidney Kimmel Medical College at Thomas Jefferson University and is recognized as a regional center for excellence in cardiology, cancer, and women’s health services. Christiana Care has an extensive range of outpatient services and works closely with its medical staff to achieve better health for its patients, improve access to care, and reduce healthcare costs. Christiana Care is home to Delaware’s only Level I trauma center, the highest capability center, and the only one of its kind between Philadelphia and Baltimore. Christiana Care features a Level III neonatal intensive care unit, the only delivering hospital in Delaware that offers the highest level of care to the most critically ill newborns.

Posted on by CDC's Safe Healthcare Blog

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