Sustainability of a Self-Stewardship Time-Out Program (SSTOP) for Vancomycin (VAN) and Piperacillin-Tazobactam (P-T) at a Veterans Affairs Medical Center

Background:

In 2013, our facility implemented a policy requiring self-renewal by providers upon completion of an antibiotic renewal template on day 4 for VAN and P-T. We assessed early and late response to the intervention.

Methods:

We assessed antibiotic utilization following SSTOP implementation and compared rates of guideline-discordant self-continuation of VAN or P-T through day 5 (as determined by expert chart review) before (6 months) and after (1 year) SSTOP implementation. We also compared rates of discordancy during the 1^st (4-10/2013) and 2^nd (10/13-4/14) 6 month periods of SSTOP, the latter when research support had been completed. 

Results:

Of 276 VAN time-out-eligible events, templates were completed in 127 (46%) and VAN was continued in 80 (29%). VAN was active through day 5 despite no template in 21 (7.6%). It was allowed to expire without a template in 128 (46%). 13 (4.7%) continuations of VAN via template were guideline-discordant vs. none before SSTOP (p=0.001).  Overall VAN discontinuation was higher during SSTOP than the pre-intervention period: 175/276 (63%) vs. 96/199 (48%) p=0.001.  More providers completed the VAN template in the 2^nd 6 months compared to the 1^st (54% vs 37%, p=0.0054) but VAN discontinuation was similar: 64% vs 63% (p=0.80).  There was no significant difference in inappropriate continuation between the 1^st and 2^nd 6 months for VAN: 4.8% vs. 4.5% (p=0.77).

Of 225 P-T time-out-eligible events, templates were completed in 115 (51%) and P-T was continued in 81 (36%). P-T was active through day 5 despite no template in 7 (1.9%).  It was allowed to expire without a template in 103 (46%). 22 (9.8%) continuations of P-T via template were guideline-discordant vs. 2/93 (2%) before SSTOP (p=0.019).  Overall P-T discontinuation was similar during SSTOP vs. pre-intervention: 137/225 (61%) vs 58/93 (62%), p=0.90. Between the 1^st and 2^nd 6 months, there was no significant difference in template use: 50% vs. 52% (p=0.69); discontinuation at day 5: 64% vs. 56% (p=0.085), or inappropriate continuation via timeout: 8.6% vs. 10.8% (p=1.0). 

Conclusion:

With SSTOP, VAN was discontinued more frequently, and guideline discordant continuations were infrequent.  These effects were sustained in the 2^nd 6 months post-implementation during which research support for the program halted.