Empowering Nurses to Prompt Prescribers to Review Antibiotic Use in the Intensive Care Unit (ICU): A Novel Mechanism for Improved Antibiotic Awareness and Utilization.
CCCF ePoster library. Ferreira D. Oct 31, 2016; 150900; 23
Ms. Danielle Ferreira
Ms. Danielle Ferreira
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Topic: Quality Assurance & Improvement

Empowering Nurses to Prompt Prescribers to Review Antibiotic Use in the Intensive Care Unit (ICU): A Novel Mechanism for Improved Antibiotic Awareness and Utilization.

Pavani Das1 MD, Tiffany Kan1 PharmD, Bonnie Chung1 BScPhm ACPR, Danielle Ferreira1 RN BHSc MN, Marina Bitton1 RN MN CNCC, Phil Shin1 MD, Michelle Zahradnik2 BSc MSc, Madelyn P. Law3 Ph.D, Sumit Raybardhan1 BScPhm ACPR MPH
1North York General, Toronto, Canada; 2St Michael’s Hospital, Toronto, Canada; 3Brock University, St Catharines, Canada


INTRODUCTION: Antimicrobial stewardship programs (ASPs) are established to improve the choice, duration, and use of antibiotics, however limited healthcare resources place pressure on ASPs to apportion strategies. As a result, the resource-intensive practice of audit-and-feedback (A&F) by an ASP team, while effective, is rarely performed on a daily basis. In the 2016 ASP guidelines, the Infectious Diseases Society of America supports the independent, non-ASP-led review of antibiotics by prescribers on a routine basis1. Studies in the Critical Care Unit2,3 (CrCU) suggest strategies that involve the prompting of prescriber-led review of antibiotics are more likely to be successful than those without.

OBJECTIVE: Using the Model for Improvement4, the objective was to develop a sustainable mechanism for the prompting of prescriber-led antibiotic review in the CrCU.

METHODS:  A project team was assembled including CrCU nursing leadership, medical director, pharmacists and the ASP physician and pharmacists. Brainstorming sessions included a review of project aims and measures together with the construction of a Fishbone diagram and Five Whys tool to identify the barriers to prescriber-led antibiotic review. Plan-Do-Study-Act cycles were then conducted to test and refine the change intervention.  The primary measure was the proportion of relevant cases for which an antibiotic prompt was provided to the prescriber (ABX-PRT). A secondary measure was the number of duration interventions conducted by the ASP team during formal A&F rounds which occurred three times per week (DUR-INT).

RESULTS:  Using the Fishbone diagram, the ASP team determined that ICU nurses were in an ideal position to prompt a review of antibiotic duration of therapy (DOT). The Five Whys pinpointed a lack of prioritization of antibiotics within ICU rounds as the primary barrier.  Areas identified for improvement included increasing nursing awareness and education about antibiotics, and establishing an expectation for including antibiotic DOT during ICU rounds.  ICU nurses were provided with a script for inserting DOT into rounds and prescribers were primed to respond with affirmation, rationale, and if possible, clinical decisions. The rationale for including antibiotics on a daily basis was emphasized during ICU nursing staff meetings and amongst the physicians. A one-page overview of common antibiotics used in the ICU was provided to nurses and posted in the unit. After two PDSA cycles, ICU pharmacists provided reminders to nursing staff during ICU rounds, the ASP team engaged nurses regarding changes made to antibiotics during A&F rounds, and ICU nursing leaders revised the ICU rounds template to provide a definitive place to insert DOT.  Preliminary data demonstrate an increase in the ABX-PRT from 17% to 38%. ASP DUR-INT during formal A&F declined by 57% during the study period, suggesting that clinical decision-making about antibiotic duration had increased during ICU rounds.

CONCLUSIONS: The Model for Improvement provides an effective method for the testing and implementing a prescriber-led antibiotic review. ICU nurses can prompt prescribers to review antibiotic DOT during rounds, increasing awareness of antimicrobial use and early clinical decision making. By providing nursing staff with continued multidisciplinary support and supplementary education augmenting their antimicrobial knowledge, the ASP team can promote and sustain the culture of antibiotic awareness. 



  1. Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016 May 15;62(10):e51-77
  2. Weiss CH, Persell SD, Wunderink RG, Baker DW. Empiric antibiotic, mechanical ventilation, and central venous catheter duration as potential factors mediating the effect of a checklist prompting intervention on mortality: an exploratory analysis. BMC Health Serv Res 2012; 12:198–204.
  3. Weiss CH, Dibardino D, Rho J, Sung N, Collander B, Wunderink RG. A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization. Crit Care Med 2013; 41:2563–9.
  4. Health Quality Ontario. Quality Improvement Guide. Toronto, Ontario: Queen’s Printer of Ontario; 2012. Available at: http://www.hqontario.ca/portals/0/documents/qi/qi-quality-improve-guide-2012-en.pdf 

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