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1839. Expanding Antimicrobial Stewardship into the Community: Development of Patient and Provider Education Resources to Improve Antibiotic Awareness

Abstract Background Antibiotic stewardship programs are vital in the ambulatory setting to address the public health threat of antibiotic resistance. In 2016, the Centers for Disease Control and Prevention (CDC) released Core Elements of Outpatient Antibiotic Stewardship. These core elements were the basis for the development of the Carolinas HealthCare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), which collaborates with more than 150 Atrium Health ambulatory practices to improve antibiotic awareness across metropolitan, suburban and rural communities, touching approximately 1,060,000 patients. Methods Initial baseline research involved surveys with 190 patients and key informant interviews with four patients and 17 providers. A resource working group was formed during a follow-up strategic planning session involving more than 40 multidisciplinary stakeholders. Key concepts identified through patient and provider engagement were the focus for the development of stewardship education and resources with involvement from physicians, nurses and pharmacists, as well as representation from quality, marketing and patient experience. Results Identified opportunities were addressed with the design of a “Bacteria and Viruses” patient handout and symptoms checklists for over-the-counter recommendations for adults, teens and children—all with translation into an additional 11 languages; a commitment flyer for patient examination rooms; pediatric dosing guides for acetaminophen and ibuprofen; provider scripting; and two educational videos. Resources were introduced via a consumer webpage, a provider intranet site update, and media pitching featuring key providers in the community to coincide with the CDC’s National Antibiotic Awareness Week in November 2017. Additional focused provider and practice-site education sessions were held for ambulatory practice specialties of urgent care, family medicine, internal medicine and pediatrics. Conclusion Through multidisciplinary collaboration, CHOSEN developed a better understanding of patient and provider attitudes and experiences that led to the development of specific tools and a campaign to meet the identified needs for antibiotic awareness in the community. Disclosures E. Gentry, Duke Endowment: Grant Investigator, Grant recipient. C. Sweeney, Duke Endowment: Grant Investigator, Grant recipient. M. Spencer, Duke Endowment: Grant Investigator, Grant recipient. Eli Lilly and Company: Grant Investigator, Grant recipient. E. Handy, Duke Endowment: Grant Investigator, Grant recipient. L. Davidson, Duke Endowment: Grant Investigator, Grant recipient.


Background.
The CDC encourages all long-term care facilities (LTCF) to develop antibiotic stewardship programs (ASP) consisting of seven core elements (CE). These CE include leadership commitment, accountability, drug expertise, action, tracking, reporting and education. However, action include three essential sub-elements (SE): policy development, practice implementation and pharmacist involvement. Similarly, tracking has two major SE; antibiotic use and outcome measures. Typically, a multi-component CE is considered met if any of the SE is present. We evaluated application of a strict definition that requires all major SE to be present for the action and tracking CE to be considered met.
Methods. A group of consultant pharmacists (CP) was trained to evaluate and lead ASP in their LTCF. Baseline ASP evaluation was conducted by CP in 29 LTCF using the CDC CE checklist between November 2017 and January 2018. CE credits were assigned to LTCF ASP using conventional (any SE) and strict definitions (all SE required). Results were compared among LTCF ASP using both definitions.
Results. None of the LTCF has all seven CE regardless of the definition. A median of two CE (range 1-6) were present based on conventional definition (CD) and 1 (range 0-5) using the strict definition (SD). Less than a quarter of LTCF (n = 6, 20.6%) met five or more CE with the CD and only one (3.5%) using the SD. Interestingly, when utilizing the CD, all (100%) LTCF met at least one CE as compared with only 16 (55.1%) when using the SD. The action CE is most frequently met when using CD and least frequently met when using SD (Figure 1). CP reviewing a proportion of antibiotic orders as a part of their monthly drug regimen review was the most common action and was met by 89.7% of LTCF. Only 2 (6.9%) LTCF had stewardship policies and 4 (13.8%) had implemented at least one stewardship practice. Similarly, 20 (69.0%) LTCF had tracking based on the CD with a majority (55.2%) tracking outcome measures and some (41.4%) tracking antibiotic use. However, only a quarter (27.6%) of LTCF were tracking both outcomes and antibiotic use.
Conclusion. Many LTCF have some components of action and tracking CE in place but are missing important SE. Data on CE should be collected in a manner that makes it easier to identify these deficiencies during LTCF ASP evaluation.
for Disease Control and Prevention (CDC) released Core Elements of Outpatient Antibiotic Stewardship. These core elements were the basis for the development of the Carolinas HealthCare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), which collaborates with more than 150 Atrium Health ambulatory practices to improve antibiotic awareness across metropolitan, suburban and rural communities, touching approximately 1,060,000 patients.
Methods. Initial baseline research involved surveys with 190 patients and key informant interviews with four patients and 17 providers. A resource working group was formed during a follow-up strategic planning session involving more than 40 multidisciplinary stakeholders. Key concepts identified through patient and provider engagement were the focus for the development of stewardship education and resources with involvement from physicians, nurses and pharmacists, as well as representation from quality, marketing and patient experience.
Results. Identified opportunities were addressed with the design of a "Bacteria and Viruses" patient handout and symptoms checklists for over-the-counter recommendations for adults, teens and children-all with translation into an additional 11 languages; a commitment flyer for patient examination rooms; pediatric dosing guides for acetaminophen and ibuprofen; provider scripting; and two educational videos. Resources were introduced via a consumer webpage, a provider intranet site update, and media pitching featuring key providers in the community to coincide with the CDC's National Antibiotic Awareness Week in November 2017. Additional focused provider and practice-site education sessions were held for ambulatory practice specialties of urgent care, family medicine, internal medicine and pediatrics.
Conclusion. Through multidisciplinary collaboration, CHOSEN developed a better understanding of patient and provider attitudes and experiences that led to the development of specific tools and a campaign to meet the identified needs for antibiotic awareness in the community.
Background. The Carolinas HealthCare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN) collaborates with more than 150 primary care ambulatory practices to improve antibiotic use in the Charlotte, NC area. CHOSEN aims for a 20% reduction in outpatient antimicrobial prescribing over 2 years with a focus on acute respiratory conditions. Initial qualitative research of provider interviews with 17 providers at 13 practices revealed the need for improved clinician reporting of prescribing rates and trends.
Methods. Working with our research and analytics division, a strategy team including clinicians, quality and pharmacy identified key drivers of over prescribing and target conditions. Previous antibiotic prescribing data collected from 281,315 adult and pediatric patients seen by nearly 900 providers was analyzed and served as a baseline. ICD-9 and 10 codes associated with acute sinusitis, nonsuppurative otitis media, acute bronchitis, cough, non-bacterial pharyngitis, upper respiratory infection, common cold, allergic rhinitis and influenza were included. Prescribing data were abstracted at the encounter level. Prescribing rates were calculated for pediatrics, internal medicine, family medicine and urgent care practices to target a 10% reduction in 2018 compared with 2017.

Results. A dashboard was developed in Microsoft
Power BI with means to view prescribing data by indication and antibiotics, comparing year-to-year and rolling 24-months. Dashboard capabilities include option to drill down to the practice and provider level. An overall CHOSEN target rate for 2018 was set at 41.9% based on a baseline prescribing rate of 45.7%. Final target rates for specialties, pediatrics, internal medicine, family medicine and urgent care, were 40.8%, 38.7%, 40% and 47.2%, respectively. Provider and practice leaders were educated on use of the dashboard, along with tips to address high prescribing. Data are updated monthly and highest prescribing groups are targeted for additional onsite education.
Conclusion. The development of an innovative antibiotic prescribing dashboard is achievable. CHOSEN successfully designed and applied a dashboard with focus on reduction of inappropriate antibiotic prescribing in an ambulatory care setting.
Disclosures Background. Fluoroquinolones are often overprescribed in outpatient settings; however, stewardship programs designed to prevent overuse are not well described. The primary purpose of this study was to evaluate the change in overall and appropriate fluoroquinolone prescribing rates by primary care providers within internal medicine primary care clinics at the Houston VAMC before and after implementation of an audit and feedback intervention.
Methods. All fluoroquinolone prescriptions written by internal medicine primary care providers were included in this study. A medical chart audit to assess the appropriateness of fluoroquinolone prescriptions was conducted, and face to face feedback was given to providers regarding prescribing patterns. Aggregate monthly fluoroquinolone utilization data were also provided. Monthly face to face academic detailing sessions were provided regarding the treatment of common outpatient infectious diseases, appropriate fluoroquinolone use, and suggested alternatives. Study objectives were assessed before and after the intervention time period using segmented regression time series analysis including non-intervention internal medicine primary care comparator clinics.
Results. In the intervention clinics, rates of fluoroquinolone orders decreased from 9.4 ± 5.8 orders per week per 1,000 patient visits in the pre-intervention time period to 6.9 ± 6.6 orders per week per 1,000 patient visits in the post-intervention time periods. Using segmented regression analysis, controlling for change in prescribing rates in the non-intervention clinics, and changes in the rate of prescribing over time, the intervention was associated with a 3.1 ± 0.99 decrease in fluoroquinolone orders per week per 1,000 patient visits (P = 0.0019). The percentage of orders deemed appropriate increased from 50 ± 31% in the pre-intervention time period to 66 ± 53% in the post-intervention time period (P = 0.06). Rates of fluoroquinolone orders did not change in the non-intervention clinics.
Conclusion. An audit and feedback intervention in ambulatory care clinics was able to reduce the rate of fluoroquinolone orders and increase the percent of orders deemed appropriate.
Disclosures. All authors: No reported disclosures.