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Exploration of outpatient stewardship practices and strategies for effective implementation · The SHEA Podcast

• 0:06
  SPEAKER_00: Welcome to Shay's podcast.
• 0:09
  SPEAKER_00: I am Dr.
• 0:09
  SPEAKER_00: Jonathan Ryder, an assistant professor in the Division of Infectious Diseases at University of Nebraska Medical Center, and a member of the Shea Antimicrobial Stewardship Committee.
• 0:20
  SPEAKER_00: I'm excited to serve in the role of today's moderator.
• 0:23
  SPEAKER_00: And before we get started, I'd like to introduce you to today's guest.
• 0:27
  SPEAKER_00: Dr.
• 0:27
  SPEAKER_00: Milner Staub is a assistant professor of medicine in the Division of Infectious Diseases within the Department of Medicine at Vanderbilt University Medical Center.
• 0:37
  SPEAKER_00: Dr.
• 0:37
  SPEAKER_00: Staub's interest and research are focused on helping providers and patients optimize antibiotic prescribing, particularly in the ambulatory setting.
• 0:47
  SPEAKER_00: Welcome to the podcast, Dr.
• 0:48
  SPEAKER_00: Staub.
• 0:49
  SPEAKER_00: I'm excited to hear your opinions on this important topic today.
• 0:54
  SPEAKER_01: Thank you so much for having me.
• 0:56
  SPEAKER_00: Let's start with what exactly does your work in ambulatory antimicrobial stewardship cover?
• 1:04
  SPEAKER_01: I am very fortunate.
• 1:05
  SPEAKER_01: I have a position as the director of adult outpatient-specific antimicrobial stewardship for Vanderbilt University Medical Center.
• 1:15
  SPEAKER_01: Vanderbilt has four hospitals in its system and something like 300 to 400 outpatient clinics.
• 1:24
  SPEAKER_01: So technically, my work covers any antibiotic prescribing and any of those 400 clinics.
• 1:32
  SPEAKER_01: But I can tell you that I make it a much more narrower scope, as you can imagine.
• 1:36
  SPEAKER_01: Thank goodness there's many clinics who never prescribe.
• 1:40
  SPEAKER_01: So I can sort of focus in on those that prescribe more often.
• 1:45
  SPEAKER_00: That's quite impressive.
• 1:46
  SPEAKER_00: And as you allude to, the majority of our antimicrobial use does occur in the ambulatory setting.
• 1:53
  SPEAKER_00: And so given the breadth of this, what areas are you targeting that are easy to implement and have a high return on investment, given, I mean, that many clinics, uh, different providers, uh, et cetera?
• 2:06
  SPEAKER_01: That's the question, right?
• 2:08
  SPEAKER_01: Whenever we read, there are millions, billions of antibiotics prescribed every year.
• 2:15
  SPEAKER_01: I mean, in Tennessee, where I live, every person gets on average one antibiotic per year.
• 2:22
  SPEAKER_01: And of course, we know that this concentrates several people get 10 a year and some get none.
• 2:27
  SPEAKER_01: So the way that we focused this, knowing that there's limited resources, is I usually suggest taking a look at your own system and figuring out number one, who is prescribing.
• 2:39
  SPEAKER_01: So we took all of our antibiotic prescriptions and we assigned them to each provider, or you could do each clinic, and then we lined them up from highest prescribers to lowest prescribers just in sheer volume.
• 2:52
  SPEAKER_01: And so granted, this doesn't get into appropriateness yet.
• 2:56
  SPEAKER_01: Um, but typically if you have a large volume, there's usually some wiggle room for there's probably ways you can optimize.
• 3:02
  SPEAKER_01: So we cumulatively added them and figured out that 50% of all of our antibiotic prescribing is done in two types of clinics, our walk-in clinics and our retail health clinics.
• 3:16
  SPEAKER_01: So I immediately started to develop relationships with these providers while I was trying to figure out how to get their data organized.
• 3:25
  SPEAKER_01: And again, what we found is unfortunately in those clinics, what they see is upper respiratory tract infections.
• 3:32
  SPEAKER_01: And I think people are tired of hearing about upper restroid tract infections, but I never tire of talking about it.
• 3:39
  SPEAKER_01: And it's because I think it plagues all of our patients.
• 3:43
  SPEAKER_01: Uh, patients have a poor understanding of what causes it despite the recent COVID epidemic.
• 3:49
  SPEAKER_01: And we do a poor job actually of training providers to one, identify that this is more likely viral compared to bacterial, or there are not those high-risk symptoms that require an antibiotic.
• 4:04
  SPEAKER_01: And two, training our providers to effectively communicate to patients why an antibiotic is not appropriate.
• 4:11
  SPEAKER_01: So, in short, we definitely still focus on upper restroid tract infections because one-fifth of all of our visits have to do with uppersteroid tract infections in these two clinics, if not more.
• 4:24
  SPEAKER_01: And then, second, we're starting to wade into, you know, there's like the four big infections that get antibiotics in the outpatient setting that you can sort of put guidelines around.
• 4:34
  SPEAKER_01: It's upper restroid tract infection, it's urinary tract infection, skin and soft tissue.
• 4:41
  SPEAKER_01: And then now I'm forgetting the other one.
• 4:42
  SPEAKER_01: So there must be only three.
• 4:44
  SPEAKER_01: It'll come back to me.
• 4:46
  SPEAKER_01: So that's that's where we're sort of focusing and partnering with these providers to figure out how they're thinking and how we can help them change the way they're thinking and communicating with patients.
• 4:58
  SPEAKER_00: That's great.
• 4:59
  SPEAKER_00: So one of the things that we know have a huge impact on antibiotic use is the effect of penicillin allergy labels, which we can mitigate through delabeling processes.
• 5:11
  SPEAKER_00: And Shay actually recently released a free course on this with a grant from the CDC because it's such a big issue.
• 5:18
  SPEAKER_00: And so, how are you tackling this issue of uh antibiotic uh allergy labels or penicillin allergy labels specifically in the outpatient setting?
• 5:30
  SPEAKER_01: I am so glad that you highlighted this course and Shay's work in penicillin allergy delabeling.
• 5:36
  SPEAKER_01: I am fortunate enough that Cosby Stone, who I believe actually helped create that course, um, is at Vanderbilt in our allergy division.
• 5:46
  SPEAKER_01: He and I have collaborated along with a couple of our other stewards for many years now.
• 5:52
  SPEAKER_01: And his single passion for delabeling is I've never seen anything like it.
• 5:59
  SPEAKER_01: Uh, the man will show up on a Saturday at you know midnight if you needed him to delabel somebody because he's so passionate about people being delabeled.
• 6:08
  SPEAKER_01: Because he is so interested in that, and so are we, um, our work over aligns, and he actually uh has now included us in some work on a grant of his through AHRQ, where we're looking at a couple of different things.
• 6:21
  SPEAKER_01: So, one, we're specifically focusing right now with our surgical groups, and we're doing qualitative interviewing of the surgery about if you have the penicillin allergy delabeling information, right?
• 6:35
  SPEAKER_01: So somebody has been kind enough to do the risk assessment and realize that a patient is very low risk.
• 6:41
  SPEAKER_01: How can we get that information in front of you at the point of ordering?
• 6:45
  SPEAKER_01: So that's one of the things that we're trying to do because it's such an area where the outcomes, patient outcomes, the reduced surgical site infections for both outpatient and inpatient surgeries is it's statistically significant.
• 7:00
  SPEAKER_01: It's a patient outcome that's really important.
• 7:03
  SPEAKER_01: So that's one of the things.
• 7:05
  SPEAKER_01: The second is we're starting to think about how do we get patients similar to I would love for patients to come in every visit and say, do you really think the antibiotic is necessary?
• 7:15
  SPEAKER_01: I want patients to come in and say, I no longer want this burden on me.
• 7:20
  SPEAKER_01: I would like to be delabeled.
• 7:22
  SPEAKER_01: And interestingly, who is our wonderful administrator for the ID division, actually did this with Cosby like two weeks ago.
• 7:31
  SPEAKER_01: And she went in and said, I no longer want to have this label.
• 7:36
  SPEAKER_01: And they were able to delabel her.
• 7:37
  SPEAKER_01: And she was like, it was a freeing experience.
• 7:40
  SPEAKER_01: So I think focusing on how we get patients to ask for this and bring it up, not only when they absolutely need it in the hospital, but well before, right?
• 7:49
  SPEAKER_01: Like when we're doing preventive care visits.
• 7:51
  SPEAKER_01: So now we're trying to work on this tool and get it disseminated and have people feel comfortable in clinics that traditionally would not feel comfortable, you know, for the risk of anaphylaxis delabeling people.
• 8:03
  SPEAKER_00: That's really incredible work.
• 8:05
  SPEAKER_00: And I love how you're integrating that in the areas that are at highest need.
• 8:10
  SPEAKER_00: So, as you also talked about earlier with upper respiratory tract infection, we we know that antibiotics are not recommended in the treatment of acute uncomplicated bronchitis, but they're still often prescribed.
• 8:23
  SPEAKER_00: And so, what are your recommendations for successful interventions for this particular condition that, as you said, is extremely common?
• 8:32
  SPEAKER_01: So I think there's four areas for successful interventions.
• 8:38
  SPEAKER_01: Number one, I've realized even though on the hierarchy of effectiveness, which is my single favorite figure in quality improvement, uh, education is at the very bottom.
• 8:50
  SPEAKER_01: It also is the infrastructure to every successful intervention.
• 8:54
  SPEAKER_01: And I have found that education, repeat education, is absolutely necessary to having effective interventions in any sort of change.
• 9:06
  SPEAKER_01: So it also has helped us develop relationships with the people with whom we're trying to work.
• 9:13
  SPEAKER_01: So, for instance, in our walk-in and retail clinics, one of their biggest challenges when we were first getting to know them that they expressed was that they really don't have an opportunity to connect with other providers in the healthcare system.
• 9:26
  SPEAKER_01: They sort of feel isolated because of what how they practice.
• 9:30
  SPEAKER_01: And also, they didn't have a series where it was really focused on unplanned care setting care.
• 9:37
  SPEAKER_01: So we developed a monthly CME opportunity where we invite experts from different fields to come.
• 9:44
  SPEAKER_01: And obviously, I think nine out of 12 months is in like around infection, because I'm I'm organizing it.
• 9:51
  SPEAKER_01: Um, but they can also request, like we had an EKG review and you know, we had a hand surgeon come talk about, you know, when to refer.
• 9:58
  SPEAKER_01: So we do try and incorporate other needs that they would have.
• 10:02
  SPEAKER_01: But you have an expert come and they talk about, you know, what's new in this field, how do we diagnose?
• 10:08
  SPEAKER_01: When do you need an antibiotic?
• 10:09
  SPEAKER_01: What's the harm of the antibiotic?
• 10:11
  SPEAKER_01: And when you refer.
• 10:13
  SPEAKER_01: And now they have a face in the community.
• 10:16
  SPEAKER_01: They have diagnostic criteria about when to give an antibiotic, but also when to refer on.
• 10:21
  SPEAKER_01: And we have gotten massive good feedback about this, but it also means that every time I open the CME, I'm updating and I sent out the invite the day before with their data, right?
• 10:33
  SPEAKER_01: So it's the prescribing data, but also the announcement for the CME.
• 10:37
  SPEAKER_01: And then I reiterate the prescribing data and how we're doing.
• 10:40
  SPEAKER_01: You know, we set institutional goals for these clinics.
• 10:44
  SPEAKER_01: So I think in that, I have a monthly forum set up that's giving them something they need, but also gives me a chance to interface with them.
• 10:53
  SPEAKER_01: And it's also meant that I get call, you know, phone calls, messages in the chart all the time.
• 10:58
  SPEAKER_01: They see me as an ID provider that they can sort of express their frustrations or challenges to.
• 11:05
  SPEAKER_01: So it's allowed me to then educate more, right?
• 11:08
  SPEAKER_01: We talk about issues more, it comes up more often.
• 11:10
  SPEAKER_01: So that's number one.
• 11:12
  SPEAKER_01: I think number two, you have to give providers their data.
• 11:15
  SPEAKER_01: CDC has said this, it's a you know, a core goal of both inpatient and outpatient stewardship.
• 11:21
  SPEAKER_01: And there's a reason, and it's because humans never think we're the problem, which is great.
• 11:27
  SPEAKER_01: Right.
• 11:27
  SPEAKER_01: Uh, but if you then see that you're an outlier compared to your peers, we also, most of us have an innate sense of we want to do the right thing.
• 11:37
  SPEAKER_01: And so a lot of times that alone is corrective.
• 11:41
  SPEAKER_01: People will start asking their peers, wait, I'm missing something.
• 11:43
  SPEAKER_01: How, why am I doing this differently?
• 11:46
  SPEAKER_01: So I will say ideally, you give providers their data and at the patient level.
• 11:52
  SPEAKER_01: So they can actually go back and see how did I affect the patient?
• 11:56
  SPEAKER_01: That is by far the most changing and it's the most effective, but it's really labor-intensive.
• 12:02
  SPEAKER_01: And I think we can all recognize that.
• 12:05
  SPEAKER_01: So there have been other people like Dr.
• 12:07
  SPEAKER_01: Gerber out of top, who has shown that actually if you just give group level data on the clinic setting, it can still be really effective.
• 12:15
  SPEAKER_01: So I think, you know, you start where you can, but definitely give data.
• 12:18
  SPEAKER_01: Number three, work with individual providers that are outliers.
• 12:23
  SPEAKER_01: Oftentimes, if you can change even two or three providers that are really huge outliers, you can change your entire data, which is a little bit scary.
• 12:33
  SPEAKER_01: So I actually will take a portion of a provider's, what I think is inappropriate or potentially inappropriate prescribing, and I'll dive into the encounter and I'll create an Excel that says, this is what you documented for the exam.
• 12:46
  SPEAKER_01: This is what the patient said they came in, this was your assessment and plan.
• 12:49
  SPEAKER_01: And I'll send them the sheet and say, Hey, can we chat about it?
• 12:52
  SPEAKER_01: I'm I'm either missing something, which is fine, and then we can talk about sort of maybe how you're you could correct that in your documentation.
• 13:00
  SPEAKER_01: Or number two, it's likely that there is some sort of misconception that they learned in training, or don't feel comfortable diagnosing something as a virus, and then I can help them.
• 13:11
  SPEAKER_01: I can either go visit them in clinic and help them, or they feel pressure from patients so we can give them supportive material that way.
• 13:18
  SPEAKER_01: So I think working with those individuals is really important.
• 13:22
  SPEAKER_01: And then number four, and we do not do this enough, is we have got to figure out what the patient aspect is.
• 13:30
  SPEAKER_01: Patients are actually a huge, they are cited as a main driver of why providers give antibiotics.
• 13:37
  SPEAKER_01: And yet, when you talk to just regular people who have great jobs, who are working in communities, who may be leaders in their communities, but have don't have that science background, their understanding of how disease works and how antibiotics works is really dismal.
• 13:55
  SPEAKER_01: We do not do a good job of preparing patients to have a shared decision-making model.
• 14:01
  SPEAKER_01: So I think we got to figure out that piece.
• 14:12
  SPEAKER_00: So longer term, where do you think we need more research to test our assumptions and add interventions?
• 14:18
  SPEAKER_00: What's the next frontiers for outpatient stewardship?
• 14:23
  SPEAKER_01: Based on what I just said, I personally think that the patient is first and foremost what we need to be focusing on.
• 14:31
  SPEAKER_01: I think that we have flogged providers over and over again about their prescribing.
• 14:36
  SPEAKER_01: And I think until we start figuring out how do we help patients advocate for what's right so that everyone can meet in the middle?
• 14:44
  SPEAKER_01: Um, but that's also, you know, how do we effectively reach patients?
• 14:48
  SPEAKER_01: Is it via the new YouTube, TikTok, you know, Instagram, or is it the old pamphlets we used to give people?
• 14:55
  SPEAKER_01: Like, you know, what's effective?
• 14:57
  SPEAKER_01: And then when do you do it?
• 14:59
  SPEAKER_01: Is it sort of, you know, should we start educating children from the time they're five up through high school about viruses and you should not be taking antibiotics because your antibioome is going to get, you know, horribly destroyed and you're going to end up having early Crohn's disease.
• 15:15
  SPEAKER_01: You know, do we start that?
• 15:17
  SPEAKER_01: And then eventually that that has payoffs, or is it both?
• 15:20
  SPEAKER_01: I'm not sure.
• 15:21
  SPEAKER_01: I definitely think we need research on that.
• 15:23
  SPEAKER_01: And then the second I think we also need research on is what do we do in areas like upperstruid tract infection where we have some diagnostics, right?
• 15:33
  SPEAKER_01: So you can say pretty quickly in an outpatient clinic is this RSV, flu, or COVID, but there's literally thousands of viruses that we don't test for.
• 15:43
  SPEAKER_01: Do we work on testing for more viruses?
• 15:47
  SPEAKER_01: Or is it really going to have to go back for from a cost-effective way?
• 15:50
  SPEAKER_01: No, we're going to have to train people to recognize that just because you don't have one of those three viruses doesn't mean that this isn't viral.
• 15:57
  SPEAKER_01: So I think some more about how we incorporate diagnostics and, you know, how to use diagnostics to there to optimize your prescribing.
• 16:08
  SPEAKER_00: Well, thank you so much, Dr.
• 16:09
  SPEAKER_00: Staub, for sharing your perspectives and experiences today.
• 16:13
  SPEAKER_01: Thank you so much for having me.
• 16:16
  SPEAKER_01: I just love and appreciate the opportunity to talk about outpatient stewardship because I think it's so exciting.
• 16:24
  SPEAKER_00: I agree.
• 16:25
  SPEAKER_00: That concludes today's episode of the Shea podcast.
• 16:29
  SPEAKER_00: And thank you so much for tuning in.