136 - Don’t Sweat the Small Stuff: Solutions for Large-Scale Stewardship Obstacles

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Presenting Author(s)

Joanne Huang

Clinical Pharmacist - Infectious Diseases
Massachusetts General Hospital , Massachusetts
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Co-Author(s)

Zahra Kassamali Escobar

Clinical Pharmacist, Infectious Diseases
UW Medicine Valley Medical Center
Renton, Washington
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Rupali Jain

Clinical Associate Professor
University of Washington Medical Center-Montlake
Seattle, WA
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
JC

Jeannie D. Chan

Antimcirobial Stewardship Pharmacist
University of Washington
Seattle, Washington
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
John B. Lynch

Professor
Harborview Medical Center/University of Washington
Seattle, WA
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Marisa A. D'Angeli

Medical Epidemiologist
Washington State Department of Health
Shoreline, WA
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Larissa May

Director Emergency Department Antibiotic Stewardship
University of California Davis
Sacramento, California
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Chloe Bryson-Cahn

Medical Director, Antimicrobial Stewardship Harborview Medical Center
Harborview Medical Center
Seattle, Washington
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Background: In an effort to support stewardship endeavors, the MITIGATE (a Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings) Toolkit was published in 2018, aiming to reduce unnecessary antibiotics for viral respiratory tract infections (RTIs). At the University of Washington, we have incorporated strategies from this toolkit at our urgent care clinics. This study aims to address solutions to some of the challenges we experienced.Challenges and Solutions

Methods: This was a retrospective observational study conducted at Valley Medical Center (Sept 2019-Mar 2020) and the University of Washington (Jan 2019-Feb 2020) urgent care clinics. Patients were identified through ICD-10 diagnosis codes included in the MITIGATE toolkit. The primary outcome was identifying challenges and solutions developed during this process.

Results: We encountered five challenges during our roll-out of MITIGATE. First, using both ICD-9 and ICD-10 codes can lead to inaccurate data collection. Second, technical support for coding a complex data set is essential and should be accounted for prior to beginning stewardship interventions of this scale. Third, unintentional incorrect diagnosis selection was common and may require reeducation of prescribers on proper selection. Fourth, focusing on singular issues rather than multiple outcomes is more feasible and can offer several opportunities for stewardship interventions. Lastly, changing prescribing behavior can cause unintended tension during implementation. Modifying benchmarks measured, allowing for bi-directional feedback, and identifying provider champions can help maintain open communication.

Conclusion: Resources such as the MITIGATE toolkit are helpful to implement standardized data driven stewardship interventions. We have experienced some challenges including a complex data build, errors with diagnostic coding, providing constructive feedback while maintaining positive stewardship relationships, and choosing feasible outcomes to measure. We present solutions to these challenges with the aim to provide guidance to those who are considering using this toolkit for outpatient stewardship interventions.