770. Nurse Prompting for Prescriber-Led Review of Antimicrobial Use in the Critical Care Unit: A Quality Improvement Intervention with Controlled Interrupted Time Series Analysis.
Session: Poster Abstract Session: Stewardship: Program Implementation
Thursday, October 5, 2017
Room: Poster Hall CD
  • SUSTAIN_IDSA_Final.pdf (442.1 kB)
  • Background: Audit-and-feedback (A&F) is a core strategy for antimicrobial stewardship programs (ASPs). However, it is resource-intensive, and may not be practical in every setting. Recent guidelines support the non-ASP-led review of antimicrobials by prescribers (AM-REV) on a routine basis. A sustainable strategy for AM-REV in a critical care unit (CrCU) may improve antimicrobial utilization without additional ASP resources.

    Methods: Using a quality improvement framework, a prompt for AM-REV strategy was created. The primary outcome was antimicrobial utilization defined by days of therapy/1000 patient-days (AM-DOT). A secondary process outcome was the proportion of relevant cases for which an antimicrobial prompt was provided to the prescriber (AM-PRT). Balancing measures included CrCU mortality rates, length of stay, and 48-hr re-admission rates. Utilization data of a control class of medications (proton-pump inhibitors) was also collected. AM-DOT was collected for 34 months pre- and 14 months post-intervention. AM-PRT was collected for 3 months pre- and 12 months post-intervention. Segmented regression analysis was used for the primary outcome, with a descriptive analysis of secondary outcomes.

    Results: CrCU nurses were recruited to prompt AM-REV during CrCU rounds. A standardized script was developed to insert day of antimicrobial therapy into rounds; prescribers were primed to respond with affirmation, rationale, and clinical decisions. Plan-Do-Study-Act (PDSA) cycles further refined the intervention to include nursing reminders from CrCU pharmacists and increased engagement of nurses during formal A&F rounds. Prior to the intervention, monthly AM-DOT was 804 with a positive trend (7.3 DOT/1000PD, p<0.05). Post-intervention resulted in an immediate reduction of 217 DOT/1000 PD (p<0.05) with a non-significant negative AM-DOT trend, representing a 20% (95% CI –15%, -25%) reduction in AM-DOT per month. There was no significant change in utilization of the control class of medications. The ABX-PRT increased from 17% to 50% during the intervention period. Balancing measures were comparable pre and post-intervention.

    Conclusion: Nurse prompting of AM-REV can lead to significant reductions in antimicrobial utilization, providing a non-ASP mechanism of sustaining antimicrobial awareness.

    Sumit Raybardhan, ACPR BSc.Phm MPH, Bonnie Chung, ACPR BSc. Phm, Danielle Ferreira, RN BHSc MN, Marina Bitton, RN MN CNCC, Phil Shin, MD, Tiffany Kan, PharmD and Pavani Das, MD, North York General Hospital, Toronto, ON, Canada


    S. Raybardhan, None

    B. Chung, None

    D. Ferreira, None

    M. Bitton, None

    P. Shin, None

    T. Kan, None

    P. Das, None

    Findings in the abstracts are embargoed until 12:01 a.m. PDT, Wednesday Oct. 4th with the exception of research findings presented at the IDWeek press conferences.