How to Implement Antibiotic Stewardship at Urgent Care Clinics

Gaining support for antibiotic stewardship in the urgent care setting involves commitment from top leadership down to the clinic staff level.

The Urgent Care Association (UCA) is stepping up efforts to improve antibiotic stewardship at the country's urgent care centers.

Appropriate prescribing of antibiotics is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. Last year, CDC researchers published a study in JAMA Internal Medicine that found inappropriate prescribing of antibiotics for respiratory conditions was highest in the urgent care setting, at 45.7% of patient visits. 

This year, Warrenville, Illinois–based UCA and the UCA-affiliated College of Urgent Care Medicine launched their Antibiotic Stewardship Commendation program, which recognizes urgent care organizations that follow best practices for antibiotics prescribing.

A key requirement for earning the commendation is adhering to at least four core elements of the CDC's guidance for antibiotics stewardship in hospitals and long-term care: commitment, action for policy and practice, tracking and reporting, and education and expertise.

The CDC guidance has set the best practices for antibiotic stewardship, says Joseph Toscano, MD, a member of the board of directors at the College of Urgent Care Medicine.

"The CDC is regarded as an expert in this regard because of the resources and experience the organization possesses in the treatment of infectious diseases and public health, both of which are at play here. Currently, their core elements are proving successful and are being used by many organizations. They incorporate principles of change management and physician and patient behavior, which all have a bearing on changing antibiotic prescribing," says Toscano, who is chief of emergency medicine and an emergency physician at Northern California Emergency Medical Group, San Ramon Regional Medical Center in San Ramon, California.

Earning urgent care antibiotics stewardship commendation
 

Premier Health is one of the first urgent care organizations in the country to earn the UCA/College of Urgent Care Medicine antibiotic stewardship commendation.

Premier Health has followed all four of the UCA's recommended core elements for antibiotic stewardship in the urgent care setting, says Kevin DiBenedetto, MD, medical director of the Baton Rouge, Louisiana–based company.

1. Commitment: "This is the sort of thing you have to be all-in for. We're dedicated to optimizing antibiotic prescribing and patient safety. We want the people in our organization to be accountable for it. If you don't have the commitment, then nothing else falls into place," DiBenedetto says.

Premier Health has cultivated support for antibiotic stewardship from the company's top leadership to the clinic staff level, he says. "Having everyone onboard from the administration down to the clinical level and regional administrators is what is really pushing this effort out."

2. Action for policy and practice: "We have implemented antibiotics prescribing practices in our clinics and promoted antibiotics stewardship in our provider meetings as well as when we do reviews of charts. Part of that review is going over providers' records on how they are doing with antibiotics stewardship. We provide feedback to providers relative to the other providers as well as relative to the overall statistics for our company," DiBenedetto says.

3. Tracking and reporting: Monitoring clinician adherence to antibiotic prescribing best practices is crucial, he says. "For tracking and reporting, we worked with our electronic medical record vendor to be able to track and record compliance. If you can't track performance, then none of this works."

Premier Health is focusing on three diagnoses that are almost always viral conditions rather than bacterial conditions that respond to antibiotics: upper respiratory infections, pharyngitis that is not strep throat, and bronchitis and bronchiolitis. The company has set a goal to decrease antibiotic prescribing for the three conditions by 50%, DiBenedetto says. For all conditions treated at Premier Health clinics, antibiotics have been prescribed inappropriately in 30% of cases, and the company has set an initial goal of reducing that overall inappropriate prescribing rate to 25%, he says.

"There is a need to educate the providers to get the antibiotic prescribing down for the three targeted diagnoses. We have a goal to cut back to 25% of inappropriate prescribing within the first year of receiving our commendation. And we want to get even better after that," DiBenedetto says. "We thought this was a good starting point, so it is realistic as we push it out to the providers. We didn't want to give them an unrealistic goal of 8% or 10%, although that is ideally where you would like to be."

4. Education and expertise: In the urgent care setting, he says the educational challenge is two-fold: training clinicians in best practices for prescribing antibiotics and educating patients about appropriate utilization of antibiotics.

"We provide educational material and literature to our providers, some of which is mandatory as part of their educational process. It's not just important to know when to give an antibiotic—it's important to know that the right drug, the right dose, and the right duration is selected. A lot of people get caught up in whether to give an antibiotic or not, but there is more to it than that," DiBenedetto says.

To educate patients, Premier Health has posters about appropriate antibiotics prescribing in waiting rooms and exam rooms, along with literature that is provided to patients when they are discharged from a clinic. For patients who insist on receiving an antibiotic, face-to-face conversations with clinicians are very effective, he says.

"Those patients will say they always got an antibiotic in the past and they want one now because it has always worked for them. Providers must carve out extra time to talk with those patients to educate them on why antibiotics are not indicated and why antibiotics cannot be a good choice because of adverse effects, antibiotic resistance, and cost. There have been studies showing that doctors who take the extra time to explain proper use of antibiotics get better patient satisfaction scores than doctors who just write a prescription," DiBenedetto says.

Promoting clinician compliance
 

To monitor clinician compliance with antibiotic prescribing best practices, Premier Health is generating monthly reports by market and individual providers for upper respiratory infections, pharyngitis that is not strep throat, and bronchitis and bronchiolitis. "We've identified three basic diagnoses that we feel should always be diagnosed as viral—that's where you are going to get the most bang for your buck," DiBenedetto says.

For individual clinicians who prescribe antibiotics inappropriately at higher rates than their peers, presenting the data in a nonconfrontational manner is highly effective at gaining better compliance rates, he says.

"Most providers are people who excelled in school whether they are a doctor, a nurse practitioner, or other kind of clinician. They don't like to think that they are behind the crowd. So, when you present statistics and show clinicians that they are writing more antibiotic prescriptions than their peers and they are not meeting the standards you set in your organization, they respond to that. They don't like being at the bottom—they are used to being competitive and making good grades."