Overview

A multidisciplinary team at Stanford Health Care created a nurse telephone triage protocol to improve guideline-concordant prescription of appropriate antibiotics for uncomplicated cystitis to help prevent antimicrobial resistance.  

Organization Name

Stanford Health Care

Organization Type

• Academic Medical Center

National/Policy Context

• Antimicrobial Resistance (AMR) is an epidemic projected to cause 10 million deaths each year by 2050, surpassing the number caused by cancer. Antibiotics are one of the most frequently prescribed medications, yet they are inappropriately used over 50% of the time, contributing to antimicrobial resistance. Antibiotic stewardship programs focus on improving prescribing practices, decreasing multi-drug resistance, and limiting patient morbidity & mortality.  
• Simple cystitis is a highly prevalent and straight-forward condition that is treated by providers in many specialties.  Antibiotics are frequently prescribed to treat simple cystitis for inappropriately prolonged durations, which can lead to adverse effects and collateral damage.
• The Infectious Diseases Society of America (IDSA) published updated simple cystitis guidelines in 2011 to address antimicrobial resistance by incorporating local resistance patterns into the clinical decision making process.  
• According to the Institute of Medicine 2010 Future of Nursing report, nurses should work to their fullest extent of their license.
• To address these points, an RN telephone triage was created to facilitate standardized management of simple cystitis.

Local/Organizational Context

• In 2015, an internal assessment of antibiotic prescription for uncomplicated urinary tract infections (UTIs) in the primary care setting of the Stanford Health Care system was completed. It revealed that some providers inappropriately prescribed second-line antibiotic treatments and that these regimens were often given for inappropriately prolonged durations of treatment. 

Patient Population Served and Payor Information

• Based on the diagnostic criteria of simple cystitis, the targeted population was healthy, non-pregnant females with no known urological abnormalities or co-morbidities.
• Stanford Health Care (SHC) provides primary and specialty care; it accepts various insurance plans including private / employer plans, CalPERS, Medi-Cal, Medicare, Tricare and also provides counseling for uninsured patients.

Leadership

• The project was initiated through Stanford’s Clinical Effectiveness Leadership Training (CELT) program, which provides clinical teams with training and resources to implement quality-improvement projects.
• Ongoing project leadership:
  • Lori Guelman, FNP
  • Kelly Sanderson, FNP
  • Marcie Levine, MD
  • Mark Ramirez

Funding

• Funding for this project came from Stanford Health Care’s budget.

Research + Planning

• In the summer of 2018, a multidisciplinary team consisting of primary care clinicians, infectious disease clinicians, clinical nurses, clinic managers assessed the current state and workflows, identified root causes and barriers, and designed a solution to standardize management of simple cystitis based on the institution’s most recent local antibiogram, so that patients would consistently receive guideline-concordant care.
• The team designed, tested, and launched a standardized RN telephone protocol and standing orders for management and empiric treatment of simple cystitis in one Stanford Health Care primary care clinic sites before rolling out across the enterprise.
• The protocol was designed to be reviewed annually and updated as needed based on local resistance patterns in order to incorporate the most recent guideline into the clinical practice and improve continued “guideline-concordant” care.
• Primary care providers were surveyed regarding individual practice patterns, evaluation and management of simple cystitis as well as their comfort with an RN-led protocol and standing orders. The telephone protocol and data from the early pilot was presented at team meetings in each local Stanford Health Care primary care clinic; background literature was reviewed in detail and the protocol was updated based on primary care input.  

Tools or Products Developed

• Standardized UTI RN Telephone Triage Protocol: A stepwise protocol for RNs to triage eligible female patients for possible evaluation and treatment of simple cystitis via telephone interview utilizing standardized questions instead of having the patient schedule an office visit.
• Standardized EMR templates defining the protocol and guidelines for documentation of each step in the UTI algorithm
• Standardized, pre-filled data set of the medication, dose and duration to be used for prescribing the medications specifically for this simple cystitis protocol

Training

• Clinic-based triage nurses were educated on the protocol. Additionally, they were provided a written reference guide which outlined their action items including SmartPhrases within Epic (electronic health record) and appropriate documentation.  The team is currently working on creating sample patient scenarios for training purposes.
• It will be expected that RNs demonstrate competency with the protocol before being allowed to implement it independently.

Tech Involved

• Electronic medical record
• Telephone

Team Members Involved

• NPs
• PAs
• RNs

Workflow Steps

• A patient with symptoms concerning for a UTI calls the primary care office.
• The RN on the telephone triages the patient based on the developed protocol.
• In the current phase of the project, if a patient is deemed eligible and wants to go through the protocol, the RN will place an antibiotic request in EPIC and a prescribing provider needs to co-sign the prescription in real time.

Figure 1: Decision-making protocol for first-line antibiotic treatment for UTI and/or subsequent escalation of care.

 

Budget Details

• Estimated: Cost of time for physicians and nurse practitioners on multidisciplinary team to develop triage protocol.
• Estimated: Cost associated with training and ongoing quality assurance of the protocol implementation

Where We Are

• This intervention is ongoing.
• The team is currently working on institutional approval of a standardized protocol which allows the RN to submit the antibiotic prescription directly to the pharmacy, per protocol, with co-signature by the primary care provider within 24-48 hours.

Outcomes

• Post-intervention rate of provider adherence: The intervention achieved 80% (P=0.011) uptake of the protocol and adherence by the physicians and NPs who prescribed antibiotics to patients with UTIs.
• Number of patients treated vs. patients screened: In July and August 2018, 49 patients were screened for potential telephone treatment,and 15 of those patients met criteria for receiving treatment.
• Outcomes: Follow-up with patients showed that only one patient out of the eligible population did not fully improve with treatment, and she was later discovered to have not taken her antibiotics as prescribed.

 

Future Outcomes

• The triage protocol will be reviewed annually and updated as needed, based on local antibiotic resistance patterns.

Benefits

• The high adherence rate to guideline-concordant care by providers demonstrated that creating a standardized antibiotic schedule integrating national guidelines and local antibiotic susceptibility patterns can improve the prescription of appropriate antibiotics and help prevent resistance.
• Change in culture regarding awareness of the IDSA acute cystitis guidelines and accounting for local resistance patterns (referencing the outpatient antibiogram).  
• The project is dependent on team-based care, where all team members work to the top of their license.

Unique Challenges

• In general, this project was well-received, as it not only supports antibiotic stewardship but also helps improve access to care in Stanford Health Care clinics.
• There was initial pushback by some providers regarding evaluation based on symptoms alone (without urinalysis testing). Education sessions focused on literature review were very helpful in eliciting their support.

Sources

• This primer was developed by CareZooming from in-person interviews with the author(s) and based on our analysis of a research poster that was used with verbal and written permission of the author(s). Authors were able to review the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
• Guelman, L., Sanderson, K., Levine, M., Ramirez, M. Antibiotic Stewardship of Simple Cystitis using an RN Phone Triage System. Poster session. 13 April 2019. Institute for Healthcare Improvement Summit on Improving Patient Care. San Francisco, California, United States. Used with written permission from poster authors. Image of poster can be accessed at: https://drive.google.com/file/d/0BxiGKwn0eJjCVXcwMFJlcVJqTWMwTjFUQ0RLNGNaSXJTa2JF/view
• Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):103-20.
• Financial Counseling – Stanford Health Care (n.d.). Retrieved May 4, 2019, from https://stanfordhealthcare.org/for-patients-visitors/financial-counseling.html
• Health Insurance Plans- Stanford Health Care (n.d.). Retrieved May 4, 2019, from https://stanfordhealthcare.org/for-patients-visitors/financial-counseling.html