Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis

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.

Keywords: PDSA; antibiotic management; audit and feedback; control charts/run charts; quality improvement.

Figure 1

PDSA cycles completed throughout the QI project from January 2019 to March 2020. PDSA, plan–do–study–act; QI, quality improvement.

Figure 2

SPC p-chart for monthly AUB/URI-NOS cases. *Χ² comparison of the central limits of the three intervention periods had a p value=0.002. AUB, acute uncomplicated bronchitis; CL, control limit; LCL, lower control limit; NOS, not otherwise specified; SPC, Statistical Process Control; UCL, upper control limit; URI, upper respiratory tract infection.

Figure 3

Proportion of encounters for acute bronchitis or respiratory tract infection, not otherwise specified (NOS) with antibiotic prescription, by clinic type. AUB, acute uncomplicated bronchitis; CL, control limit; LCL, lower control limit; UCL, upper control limit; URI, upper respiratory tract infection; VA, Veterans Affairs.

Figure 4

Balancing measures for (a) emergency room/urgent care visits, (b) return calls/messaging and (c) return to clinic visits. CL, control limit; UC, upper control limit.