You are here

Article Text

Article menu
XML
Quality improvement report
Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis
  1. Morgan Clouse Johnson1,
  2. Todd Hulgan2,3,
  3. Robin G Cooke4,
  4. Ruth Kleinpell1,5,
  5. Christianne Roumie1,6,
  6. Carol Callaway-Lane1,
  7. Lauren D Mitchell1,
  8. Jacob Hathaway7,
  9. Robert Dittus1,8,
  10. Milner Staub1,3
  1. 1Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
  2. 2Infectious Diseases, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
  3. 3Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  4. 4Pharmacy, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
  5. 5School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
  6. 6Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  7. 7Primary Care, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
  8. 8Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  1. Correspondence to Dr Morgan Clouse Johnson; morgan.johnson4{at}va.gov

Abstract

Background Antibiotics are not recommended for treatment of acute uncomplicated bronchitis (AUB), but are often prescribed (85% of AUB visits within the Veterans Affairs nationally). This quality improvement project aimed to decrease antibiotic prescribing for AUB in community-based outpatient centres from 65% to <32% by April 2020.

Methods From January to December 2018, community-based outpatient clinics’ 6 months’ average of prescribed antibiotics for AUB and upper respiratory infections was 63% (667 of 1054) and 64.6% (314 of 486) when reviewing the last 6 months. Seven plan–do–study–act (PDSA) cycles were implemented by an interprofessional antimicrobial stewardship team between January 2019 and March 2020. Balancing measures were a return patient phone call or visit within 4 weeks for the same complaint. Χ2 tests and statistical process control charts using Western Electric rules were used to analyse intervention data.

Results The AUB antibiotic prescribing rate decreased from 64.6% (314 of 486) in the 6 months prior to the intervention to 36.8% (154 of 418) in the final 6 months of the intervention. No change was seen in balancing measures. The largest reduction in antibiotic prescribing was seen after implementation of PDSA 6 in which 14 high prescribers were identified and targeted for individualised reviews of encounters of patients with AUB with an antimicrobial steward.

Conclusions Operational implementation of successful stewardship interventions is challenging and differs from the traditional implementation study environment. As a nascent outpatient stewardship programme with limited resources and no additional intervention funding, we successfully reduced antibiotic prescribing from 64.6% to 36.8%, a reduction of 43% from baseline. The most success was seen with targeted education of high prescribers.

  • antibiotic management
  • quality improvement
  • PDSA
  • audit and feedback
  • control charts/run charts

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2020-001275

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

    View Full Text

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Twitter @MorganJohnsonNP, @Rkleinpell

    • Contributors MCJ, MS, TH, RGC, RK, CR, RD, JH and CC-L contributed to the project plan. Project implementation was carried out by MCJ, MS, TH and JH. Data collection was completed by MCJ, MS and LDM. Data analysis was completed by MCJ, MS and CR. MS and MCJ drafted the manuscript and edits were executed by MCJ, MS, RK, CR, RGC, TH, CC-L and RD. Final edits and approval were fulfilled by all authors.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.