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IC innovators form teams, improve communication

(Editor’s note: The first and second place winners, respectively, are described below for the category of Preserving Antibiotic Efficacy in our 2001 Infection Control Innovation Awards.)

A three-pronged approach against three troublesome antibiotic-resistant pathogens proved effective for a team of clinicians at Saint Mary’s Mercy Medical Center in Grand Rapids, MI. "The increase in multidrug-resistant organisms is an issue that requires action on the part of all infection control practitioners," says Mary Neuman, RN, BSN, MM, CIC, infection control program manager. "This was first addressed [here] in 1995 after the area’s first reported VRE [vancomycin-resistant enterococcus] was identified. However, efforts at that time were sporadic."

In 1998, a multidisciplinary "antibiotic team" was formed with the goal to create a system that would reduce resistance among three problematic bacteria: VRE, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeuroginosa. To address the antibiotic issues, the team concentrated on three processes: identifying patients with drug-resistant pathogens, educating care providers, and monitoring appropriate prescribing of third-generation cephalosporins, vancomycin, and fluoroquinolones.

Beneath those broad objectives, individual policies and actions put the program into action. Those included:

Developing a policy for identification and isolation of patients with the pathogens.
Presenting education offerings to a variety of disciplines using multiple learning modes.
Limiting use of vancomycin and fluoroquinolones through development of order sheets.
Adding ciprofloxacin to the hospital formulary to be used in place of levofloxacin for documented P. aeruginosa nosocomial infections.
Reviewing and revising physician standing orders and patient care pathways to assure appropriate use of targeted antibiotics.

Clinical and cost impact

As the measures took effect, improvements became apparent, including a 65% decrease in use of third-generation cephalosporins. Vancomycin use was cut by 43%, and positive cultures for MRSA dropped from 50 in the first quarter to nine positive cultures by the last quarter of 1999. That rate fell again slightly in 2000, when there were 33 positive MRSA cultures for the year. The program also has resulted in a 68% reduction in fluorquin-olone use, from a high of 830 g per quarter to 266 g per quarter.

Accordingly, this trend was attended by a 52% decrease in fluoroquinolone-resistant P. aeuroginosa. Cost analysis using third-generation cephalosporins shows an estimated savings of $67,200 per year. The team is in the process of evaluating the financial impact of vancomycin and fluoroquinolone interventions. "This above program has heightened the awareness within the entire community," Neuman says. "Citywide, infection control practitioners interface on a regular basis to address community concerns and will be collaborating to present community education," she explains.

Second place in the preserving antibiotic efficacy category went to Laura Hoogestraat, RN, infection control coordinator at Faith Regional Medical Center in Norfolk, NE. Hoogestraat and colleagues designed an innovative program to close communication gaps between physicians, the lab, and the pharmacy. It was identified through chart review that a potential lapse in patient care may exist when a culture and sensitivity report is finalized after a patient is discharged from the hospital, she explains. During the subsequent process of tracking patient outcomes, it became apparent that in some cases, the physicians, for various or unknown reasons, were not aware of the final culture and sensitivity report of some of their patients.

"When the culture report was not reviewed by the physician after the patients were dismissed, in some cases, it was found that patients should have been put on an antibiotic," she says. "Or they were put on an antibiotic at the time of dismissal that was not sensitive to the organism."

A work team was put together consisting of Hoogestraat, a pharmacist, and a laboratory supervisor. A process was designed to notify physicians of the final results of the culture and sensitivity report for patients recently discharged from the hospital. With input from the physicians, the following process was implemented:

1. Laboratory staff will notify the pharmacy by telephone and fax all finalized culture and sensitivity reports after a patient has been discharged from the hospital.

2. The pharmacy will screen the results of the culture and sensitivity reports. If antibiotic coverage is adequate, no further action is necessary. If uncertainty of antibiotic coverage exists, the pharmacy staff will notify the infection control coordinator for follow-up with the physicians.

3. The infection control coordinator reviews the patient chart to determine whether (a) an antibiotic was prescribed, and/or (b) whether the organism identified in the report was resistant to the antibiotic prescribed at discharge. The ICP will notify the physician by telephone of the findings and fax a copy of the final laboratory report, including the antibiotic selection, to the physician.

4. The physician will assess whether the patient requires an antibiotic or whether a change in the antibiotic prescribed is needed.

Physicians responded very favorably to this process because it enhanced the continuum of care for their patients, Hoogestraat says. In a follow-up survey, 82% of responding physicians said the program helped them provide more appropriate care for their patients. In addition, 47% said the information prompted them to order an antibiotic or change the current drug treatment. This process did not impact infection rates, but it did create a review process to ensure proper antibiotic use with patients after discharge from the hospital, she says.

"It also ensures judicious use of antibiotic selection and helps prevent antibiotic resistance," she says. "The staff time to carry out the process is minimal. A proper antibiotic may prevent an infection from spreading throughout the body, [thus] reducing the chance of an office visit or perhaps another hospital admission. In cases where it is determined an antibiotic is not needed, it will directly reduce cost to the patient."