Through dedicated intervention efforts and free technical assistance from the TMF Quality Improvement Network Quality Innovation Organization (QIN-QIO), the Community Health Center of Lubbock (CHCL), Texas, decreased its antibiotic use for adult bronchitis patients from 100% to 20% in just one year.
Starting in September 2017, key team members audited ICD-10 codes J.20.4 to J.20.9 to determine the number of acute uncomplicated adult primary bronchitis patients seen and they found that all of them received antibiotics. According to the Centers for Disease Control and Prevention (CDC), antibiotics are not recommended for routine viral treatment of uncomplicated acute bronchitis. At least 2 million illnesses and 23,000 deaths each year are due to antibiotic resistance, and the CDC estimates that at least 30% of antibiotics prescribed in the outpatient setting are unnecessary.
To decrease antibiotic use, CHCL enlisted physicians and mid-level providers in using evidence-based protocols. It initiated an antibiotic stewardship educational program for staff and then for patients and families. Hanging posters, as well as having patients and families read educational handouts before being seen by the providers, presented opportunities for patients and family to ask questions of their providers.
CHCL is a federally qualified health center that has eight clinics within the city of Lubbock. It also operates two mobile units that provide medical services to surrounding counties. The administration suspected that CHCL’s antibiotic use was higher than recommended and signed an agreement to participate in the TMF QIN-QIO’s Outpatient Antibiotic Stewardship initiative. Providers and staff received specific antibiotic stewardship education and patients and families were given a laminated handout to review before seeing a provider to help explain appropriate antibiotic use and the harm of unnecessary antibiotic use.
Dr. Allan Camacho, CHCL medical director, said the initiative spread. “Our administrator sent out weekly emails on infection prevention strategies to remind the staff of hand hygiene, flu shots and environmental cleaning,” he said. The administration also contracted a consulting group to review and scan high-touch inanimate contact items (such as phones, keyboards, etc.) to quantify the levels of soils contamination. Those results, as well as appropriate correctional education information, were important feedback for the staff. This helped engage the staff to prevent infections, which is a significant strategy in antibiotic stewardship.
“TMF’s Karen Rypkema Degtoff also helped us by providing educational materials for staff and patients, quarterly webinars, plus resources to assist our ambulatory services’ antibiotic stewardship program with suggested protocol and guidelines,” Dr. Camacho said. CHCL found the TMF QIN-QIO’s strategies to improve physician styles of communication to aide patient understanding so useful that the health center’s new provider orientation now includes the TMF QIN-QIO recording of Rita Mangione-Smith, MD, professor and chief of the Division of General Pediatrics and Hospital Medicine at the University of Washington Department of Pediatrics.
Another tool that CHCL used when prescribing antibiotics was an antibiogram, which quantifies the sensitivity of bacteria found on the cultures to various antibiotics for gram-positive and gram-negative organisms. The antibiogram can help tracks changes in antibiotic susceptibility over time. “The availability and information derived from the local antibiogram was beneficial and offered reinforcement for appropriate antibiotic use for our patients,” said Dr. Camacho. CHCL also provided feedback to each provider’s antibiotic utilization for patients diagnosed with acute uncomplicated adult primary bronchitis in a timely manner. The providers could also see how they compared anomalously to the other providers within the practice.
Because of these efforts, CHCL achieved an 80% decrease in antibiotic usage among adults with acute bronchitis by September 2018. The clinics continue to encourage providers to use antibiograms consistently for appropriate antibiotic use according to evidence-based protocols and guidelines. CHCL also wants to expand its current monitoring to include uncomplicated adult female urinary tract infections.
The TMF QIN-QIO works with outpatient providers in Arkansas, Missouri, Oklahoma, Puerto Rico and Texas to develop a comprehensive antibiotic stewardship program to combat antibiotic-resistant bacteria. This coordinated initiative promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance and decreases the spread of infections caused by multidrug-resistant organisms. For more information, contact ABSnetwork@tmf.org.
This material was created by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. This content does not necessarily reflect CMS policy. 11SOW-QINQIO-C3.10-19-07 Revised 05/2020