Intermountain is partnering with the CDC and United Nations General Assembly to launch a patient-centered initiative targeting outpatient antibiotic prescribing. The initiative will include novel antibiotic prescribing metrics with prescriber feedback, electronic health record tools, education for patients and providers, and a public awareness campaign. Intermountain will also launch the Healthy Patient Initiative to build on current infection prevention activities, including improving patient hygiene, environmental hygiene, and caregiver infection prevention. Watch Intermountain Stories for more details and ways you can get involved.
Intermountain’s efforts are discussed in a new podcast discussion with Eddie Stenehjem, MD, an infectious disease specialist and Intermountain’s antibiotic stewardship medical director, Whitney Buckel, system antibiotic stewardship pharmacist manager, and Shannon Phillips, MD, chief patient experience officer.
“The development of drug resistance leads to worse outcomes and worse patient experience,” Dr. Stenehjem says. “It leads to higher cost of care and it leads to high rates of death. We need to be stewards of these resources for generations to come. We're not going to get around this by making new drugs. We're always going to have drug resistance and so we have to slow that tide.”
Dr. Stenehjem says many patients want to be prescribed an antibiotic for every ailment, and that’s a tough expectation for prescribers to change. “This is incredibly challenging,” he says. “There’s a sentiment out there that antibiotics can fix everything and I think it's up to us as a healthcare system to help educate the public. We need to let patients know that when they come to us for an illness or for a symptom — common cold, cough, whatever it might be — we're going to take care of them. We're going to treat their symptoms. But that may not include an antibiotic.”
Antibiotics often aren’t an effective treatment. Dr. Stenehjem gives this example: “It's a very common misconception that sinusitis — the most common diagnosis that receives antibiotics across the U.S. and here at Intermountain — gets significantly better with antibiotics. It doesn't. In most studies, regardless of where you look in the U.S. or elsewhere, antibiotics are very, very minimally effective on sinusitis and not using them hasn’t been shown to worsen long term outcomes. When you look at treatment versus non-treatment, outcomes are the same.”
Not only are they not always effective, but antibiotics can cause more harm than good, Whitney and Dr. Stenehjem say. “One in five patients who receives an antibiotic will have an adverse effect — such as gastrointestinal problems, damage to the kidneys or to the bone marrow, or really bad diarrhea caused by C. difficile,” Whitney says. “I think our main goals are to prevent resistance and also to prevent patient harm by using antibiotics appropriately.”
Dr. Stenehjem adds: “Antibiotics are the number one cause of an ED visits for adverse drug reactions in pediatrics and adolescents, and it's number two most common in adults.”
“I think Intermountain can lead forward on this and say, ‘This is not what we're going to do. This is our practice and this is best care,’” Dr. Stenehjem says. “We're not there yet, we definitely see variability and variation across our system, but I think that's where we should go.”
Three examples of things we’re working on:
- We’re building antibiotic stewardship into the regular flow of our work. “We've talked with a number of physicians in the community, both urgent care and primary care, and their biggest desire is to build this into clinical workflow,” Dr. Stenehjem says. “Build it into documentation and build it for those key areas that they see commonly, like sinusitis, otitis media, ear infections, pharyngitis, and sore throats. If we can effectively build it into their clinical workflow and provide patients symptomatic therapies aside from just antibiotics, then I think we can be successful.”
- We’ve established antibiotic stewardship programs in all of our 22 hospitals. “We have a group of committed people in all our hospitals that work together to improve antibiotic use,” Whitney says. “That usually includes a review by a pharmacist and a discussion with the provider about what's the best route and what's the right agent to pick. A lot of those efforts are aided by computer decision support programs. We've done a lot working with the order sets to be able to help providers pick the right one initially, tools and trigger functions so that we know when to switch patients from an intravenous to an oral drug, or to adjust the patient’s dose.”
- A telemedicine antibiotic stewardship program provides antibiotic stewardship support and infectious disease consultation to 16 of Intermountain’s small hospitals. The program has empowered local teams to take ownership of their stewardship efforts. “That's been what our tele-leadership has been saying from the get go,” Dr. Stenehjem says. “We're the content experts but we want you to own this. We've had hospitals step up to the plate, and our tele-staff guides them in the right direction.”
Dr. Stenehjem says: “I feel that Intermountain's in an incredible position to really bend the curve. We need to focus on outpatient, inpatient, and also the community in terms of culture. I think Intermountain is well poised to do that. I think from the outpatient standpoint we need to change the culture and the discussion around antibiotics. We need to reach the community and at the same time we need to be consistent and have a standard within all of our Intermountain practices — whether it be in our Intermountain clinics or the clinically integrated network. We all need to be practicing the same way. And we need to ensure that the patients understand why we're doing this. I hope this will then filter into other hospitals and clinics that may not be part of Intermountain.”