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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 by March 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.
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ABSTRACT
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
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ABSTRACT
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 pulldown 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:
ORGANISM
Enterobacter
aerogenes
No.
Cefzoln Ciproflxacin Nitrofurantoin TMZ/SMZ
86
10
92
28
99
Enterobacter cloacae 129
5
94
28
82
Escherichia coli
2680
84
70
97
59
Klebsiella oxytoca
Klebsiella
pneumoniae
54
50
91
89
94
529
88
94
52
87
Proteus mirabillis
223
89
85
2
85
Staph., coag neg
185
30
100
65
Most notable is E. coli, the number one pathogen in urinary tract infections, which
is resistant to ciprofloxacin and TMZ/SMZ.
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ABSTRACT
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):
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ABSTRACT
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%.
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ABSTRACT
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%.
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ABSTRACT
The Old Process: Below is 1 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.
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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.
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ABSTRACT
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, precalculated 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.