HRET HIIN Diagnostic Error Virtual Event

Transcription

1 HRET HIIN Diagnostic Error Virtual Event Promoting Diagnostic Stewardship: Effectively Reducing Diagnostic Errors September 19,

2 Jordan Steiger, MPH Program Manager, HRET WELCOME AND INTRODUCTIONS 2

3 Webinar Platform Quick Reference Mute computer audio Today s presentation Chat with participants Download slides/resources Register for upcoming events 3

4 Poll: How did you hear about this event? How did you hear about today s virtual event? a. HRET HIIN flyer b. HRET HIIN website c. HRET LISTSERV d. State hospital association e. QIN-QIO f. Your organization/colleague g. Other, please specify 4

5 Today s Agenda Topic Welcome and Introductions Putting Diagnostic Error in Context How often do we over diagnose? What can we do to implement diagnostic stewardship? Interactive Panel Discussion Speakers Jordan Steiger, MPH Bruce Spurlock, MD Daniel J. Diekema, MD, MS Daniel J. Morgan, MD, MS Bruce Spurlock, MD (facilitator) Daniel J. Diekema, MD, MS Preeti Malani, MD Daniel J. Morgan, MD, MS Wrap Up Jordan Steiger, MPH 5

6 Bruce Spurlock, MD President and CEO, Cynosure Health PUTTING DIAGNOSTIC ERROR IN CONTEXT 6

7 Connecting Diagnostic Error to the HIIIN Most of the interventions to prevent or mitigate a HIIN HAC are process or system oriented A delayed diagnosis of HAPI, sepsis can also exacerbate those conditions Over diagnosis is also a problem with CAUTI and CDI, with potentially important harms. Other conditions have a strong tie with appropriate testing as well. 7

8 8 Source: AHRQ

9 THE CASE FOR IMPLEMENTING DIAGNOSTIC STEWARDSHIP Daniel J. Diekema, MD, MS University of Iowa Health Care Director, Division of Infectious Diseases Clinical Professor of Internal Medicine, Infectious Diseases Clinical Professor of Pathology Daniel J. Morgan, MD, MS University of Maryland School of Medicine Associate Professor, Epidemiology and Public Health 9

10 What is Diagnostic Stewardship? modifying the process of ordering, performing, and reporting diagnostic tests to improve the treatment of infections and other conditions 10 Morgan, Malani & Diekema JAMA 2017

11 The Problem Antibiotics are unnecessarily used 30-50% of the time Antibiotics lead to Adverse drug events (~20% of use) C. difficile infection Antibiotic resistant infections 11

12 Infections vs. colonization Most infections are syndrome and + test UTI: dysuria + urine leucocytes & culture C. difficile: diarrhea & + C. diff test Most HAI publicly reported rates/actual use of antibiotics rely on positive test alone

13 C. difficile in hospitalized patients Morgan et al 2015; Magill et al 2014; Zacharioudakis et al

14 Variation in Diagnostic Imaging NYT

15 Definitions Overuse* Overdiagnosis and diagnosis of abnormalities not related to disease (false positives) Overtreatment Overdiagnosed disease Wrong practice Unwanted care *including overtesting and other unnecessary medical evaluations Morgan et al BMJ 2015 IOM 2001

16 Lists of Choosing things not to do per wisely physician societies >250 Choosing Wisely Choosingwisely.org Morgan et al ICHE 2015

17 Diagnostic Stewardship vs. Standard Stewardship/Infection Control Modifying testing can impact a large population Clinician education only required for some aspects Relies on QI to make appropriate decisions to guide clinician decisions 17

18 Poll and Discussion What are the common practices at your hospital? (choose as many as appropriate): 1. Our lab will not test for CDI unless the stool sample meets specific criteria (i.e. is unformed). 2. Our hospital uses computer decision support to help guide CDI testing (e.g. best practice alert to avoid testing if patient has been on laxatives in prior 48 hours). 3. Our lab limits urine cultures to those samples that meet certain criteria for inflammation (e.g. white blood cells on urine microscopy). 4. Our hospital uses selective reporting of microbiology test results (i.e. susceptibility test results) to help guide treatment of infections. 18

19 Diagnostic Stewardship: Examples How can we modify process of ordering, performing and reporting diagnostic tests? Goal: improve treatment and outcomes Opportunities for diagnostic stewardship: Pre-analytic Ordering Collection Transport Processing Testing Analytic Post-analytic Reporting Intervention

20 Pre-analytic Interventions Computer decision support to guide testing Alert when ordering C. difficile in patient receiving laxatives in prior hours Reject formed stool samples for C. difficile testing Guideline based alerts for urine cultures 20 White DR, et al. Infect Cont Hosp Epidemiol 2017;1-5.

21 Guideline-based Intervention to Reduce Urine Culture Ordering Pre-post study with control arm (2 VA systems) Diagnostic algorithm based upon IDSA guidelines Audit and feedback Case based presentations Results: Reduced urine cultures Decrease in overtreatment of asymptomatic bacteriuria 1.6 to 0.6/ 1000 bed days 21 Trautner, et al. JAMA Intern Med 2015;175:

22 Analytic Interventions Change testing algorithms to improve utility Reflex urine cultures (presence of pyuria) Include toxin EIA in C. difficile testing algorithm Do rapid identification or susceptibility tests on certain critical positives (e.g. + blood cultures) PNA-FISH, multiplex PCR panels, MALDI-TOF Timbrook, et al. Clin Infect Dis 2017;64: Sarg, et al. Infect Cont Hosp Epidemiol 2016;37:

23 Impact of Reflex Urine Culture Reflex protocol in ICU pts Culture only if >10 WBC/hpf Results: Fewer cultures Lower bacteriuria rates Fewer antibiotic starts for index urine culture (23% vs. 41%, p=0.002) Sarg, et al. Infect Cont Hosp Epidemiol 2016;37:

24 Post-analytic Interventions Modify reporting to improve practice Combine with active antimicrobial stewardship team Selective reporting or cascading of results To guide to optimal or preferred therapy Clear explanations to reduce inappropriate therapy Likely skin contaminants C difficile PCR + but toxin negative, possible colonization 24

25 Selective Reporting ( Cascading ) of Susceptibility Test Results Rather than reporting all tested agents, report only a limited number, algorithm driven: Resistance pattern, allergies, cost, other Helps to direct prescribers to antibiotic choices preferred in local/national guidelines Demonstrated to change prescribing behavior 25 Tan TY, et al. J Antimicrob Chemother 2003;51: McNulty CA, et al. J Antimicrob Chemother 2011;66:

26 Selective reporting and treatment guidelines: A prospective randomized case-vignette study 26 Coupat C, et al. Eur J Clin Microbiol Infect Dis 2013;32:

27 Diagnostic Stewardship Right testing, right time, right patient Modify ordering, performing and reporting tests to improve patient care and outcomes As technology advances, clinical context and assessment of pre-test likelihood of disease becomes increasingly important 27

28 For More Information Free article download from JAMA 28

29 PANEL DISCUSSION Preeti N. Malani, MD Professor of Medicine, University of Michigan Health System Daniel J. Diekema, MD, MS Daniel J. Morgan, MD, MS Bruce Spurlock, MD 29

30 We want to hear from you! Do you have questions for our speakers about what they have covered so far? Additional topics for discussion: Other conditions with diagnostic stewardship traps Implementation challenges EHR challenges and opportunities Raising clinician awareness and making it stick! Identifying allies with diagnostic stewardship implementation Measuring impact 30

31 Jordan Steiger, MPH Program Manager, HRET WRAP UP 31

32 DIAGNOSTIC ERROR RESOURCES Minimizing Diagnostic Error: 10 Things You Could Do Tomorrow The PIAA publication for the medical professional liability community provides useful tips and specific steps for avoiding misdiagnosis for physicians, patients and health care organizations. Improving Diagnosis in Health Care The National Academy of Sciences brief details the imperative need for a focus in the health care field on diagnostic error. Learn more about the definition of diagnostic error, the diagnostic error process and goals for improvement. For more diagnostic error resources, please visit 32

33 Upcoming Events HRET HIIN SOAP Up Virtual Event Topic: UP Campaign, SOAP Up Thursday, September 21 1:00 2:00 p.m. CT Register here. HRET HIIN Opioid Safety Fishbowl Series 5 Topic: Adverse Drug Events Tuesday, September 26 11:00 a.m. 12:00 p.m. CT Register here. 33

34 Thank You! Find more information on our website: Questions or Comments: 34