Antimicrobial Stewardship the State Health Department Perspective

Transcription

1 Antimicrobial Stewardship the State Health Department Perspective Marion A. Kainer MD, MPH, FRACP, FSHEA Healthcare Associated Infections and Antimicrobial Resistance Program NIAA Antibiotic Stewardship: From Metrics to Management Nov. 4, 2015

2 Acknowledgements CDC Funding support: ELC, EIP, CSTE HAI fellow National Healthcare Surveillance Network [NHSN] infrastructure Technical support Reporting partners: Laboratories, healthcare facilities, infection preventionists, pharmacists, clinicians Multidisciplinary Advisory Group on HAI & AMR Tennessee Department of Health [TDH] Surveillance systems and informatics Healthcare associated infections & antimicrobial resistance No conflicts of interest

3 Multidisciplinary Advisory Group on HAI & AR

4 Every Infection/HAI Prevented, Represents: One less episode of antibiotic use and thus one less opportunity for the development of resistance One less exposure to a potentially resistant infection CLABSI in Adult/Ped ICU, TN

5 Standardized Infection Ratio (SIR): Risk Adjusted Summary Measure SIR= Observed (O) HAIs Predicted (P) HAIs To calculate O, sum the # of HAIs among a group To calculate P, requires the use of the appropriate aggregate data (risk-adjusted rates) (e.g., national NHSN data for ) SIR > 1.0: # infections are HIGHER than predicted SIR= 1.5: # infections = 50% HIGHER than predicted SIR < 1.0: # infections are LOWER than predicted SIR= 0.4: # infections = 60% LOWER than predicted

6 CLABSI* Adult/Pediatric ICUs, TN 1/ /2014 Start CLABSI Collaborative: CUSP * Central Line Associated Blood Stream Infections [CLABSI] HHS Goal

7 CLABSI Adult/Pediatric ICUs, TN 1/ /2014 Start CLABSI Collaborative: CUSP First report sent to hospitals with hospital specific data

8 Hospital A: CLABSIs in Adult & Pediatric ICU

9 Targeting facilities: TAP Strategy using the CAD (or Number Needed to Prevent) CAD = Cumulative Attributable Difference = Obs FACILITY - (Exp FACILITY *HHS Goal SIR) 2013 HHS Goals SIR=0.75 (SSI, CAUTI, MRSA) SIR=0.50 (CLABSI) SIR=0.70 (CDI) See also: Soe, MM et al. A Mathematical Model to Prioritize Healthcare Facilities for High Prevention Impact on Healthcare-Associated Infections. CSTE Annual Conference Soe M, Gould CV, Pollock D, Edwards J. Targeted assessment for prevention of healthcare-associated infections: a new prioritization metric. Infect Control Hosp Epidemiol 2015 (in press).

10

11 TN HAI Prevention Calculator

12 CLABSI Neonatal ICUs, TN 7/ /2014

13 Emerging Infections Program (EIP)

14 183 hospitals in 10 States (EIP) [25 hospitals in TN] 11,282 patients; HAI prevalence: 4% Most common HAI pathogen: Clostridium difficile Extrapolation: estimate 721,854 HAIs in the US in 2011

15 Overall Prevalence: 49.9% TN: highest: 56.3% [lowest state: 43.9%]

16 AU Prevalence in Different Hospital Locations ICUs Medical Surgical Med/Surg Hem/Onc Overall: 49.9%

17 Infection Sites for Which Patients Received Antimicrobial Treatment Lower Resp tract UTI Skin, soft tissue GI Empiric BSI 34.6% 22.3% 16.1% 12.6% 8.5% 9.4%

18 5 Most Common Antibiotics: Community Onset (CO) vs Healthcare Facility Onset (HO) CO HO

19 Proportion of Patients on Antibiotics, by Facility Size, TN, % 52.4% 54.6% Small Medium Large Slide shown at TN MDAG, March 27, 2012; TN provisional data

20 Route of Administration by Facility Size, TN, % 83.6% IV/IM Oral Enteral 67.9% 31.7% 10.9% 16.1% Small Medium Large Slide shown at TN MDAG, March 27, 2012; TN provisional data

21 Rationale for Antimicrobial Administration at Patient Level, TN, % 9.6% 1.6% 0.3% 2.4% Treatment of Active Infection Surgical prophylaxis Medical prophylaxis Non infection None documented Slide shown at TN MDAG, March 27, 2012; TN provisional data

22 Most Common Antimicrobial Agents Given for Active Infection, TN, 2011 Meropemen Doripenem Moxifloxazine Linezolid Clindamycin Fluconazole Ciproflaxin Metronidazole Azithromycin Pip/tazo Levoflaxin Ceftriazone Vancomycin Proportions of Antimicrobials Given Slide shown at TN MDAG, March 27, 2012; TN provisional data

23 Assessment of Appropriate Antimicrobial Use Among Patients in Acute Care Hospitals in Tennessee (EIP Pilot) High proportion Inadequate microbiology testing Inappropriately tailored antimicrobial therapy

24 Antimicrobial Stewardship Annual Hospital Survey 2014

25 Core Elements of Hospital Antimicrobial Stewardship Programs

26 7 Core Elements of Antimicrobial Stewardship Leadership commitment: Dedicate necessary human, financial, and IT resources Accountability: Appoint a single leader responsible for program outcomes. Drug expertise: Appoint a single pharmacist leader to support improved prescribing Act: Take at least one prescribing improvement action, such as requiring reassessment after 48 hours to check drug choice, dose, and duration Track: Monitor prescribing and antibiotic resistance patterns Report: Regularly report to staff prescribing and resistance patterns, and steps to improve Educate: Offer education about antibiotic resistance and improving prescribing practices

27 Core Elements: TN vs US (national), 2014 The seven elements of antibiotic stewardship in TN compared to the US. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Accountability Action Drug-expertise Education Leadership Reporting Tracking Nationwide (N=4,091) Tennessee (N=112)

28 Aggregate Core Elements: TN vs US, % Aggregated number of core elements 90% 80% 70% 70% 60% 50% 40% 30% 30% 42% 58% Nationwide (N=4,091) Tennessee (N=112) 20% 10% 0% 4 or less 5 or more

29 Tennessee Healthcare Coalitions/EMS Regions and Number of Acute Care Hospitals, EMS regions, numbered from East to West 9 to 20 hospitals per EMS Region EMS 7 Region 7 N=14 EMS 5 Highland Rim N=20 EMS 4 Upper Cumberland N=10 EMS 2 Knox/East N=20 EMS 1 Northeast/Sullivan N=11 EMS 8 Mid South N=15 EMS 6 South Central N=9 EMS 3 Southeast/Hamilton N=13 TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS

30 >5 Core Elements of Stewardship by EMS Region, 2014 TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1 58% 47% 50% 44% 60% 50% 61% 100% 18%

31 Leadership: Salaried Support TN, 2014 Facilities with salaried support for antibiotic stewardship activities (N=112). 23% (N=26) Yes No 77% (N=86) Q26. Does your facility provide any salary support for dedicated time for antibiotic stewardship activities?

32 Leadership: Written Support TN, 2014 Facilities with a written statement designed to improve antibiotic use (N=112). 55% (N=62) 45% (N=50) Yes No Q23. Does your facility have a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship)?

33 Action as a Component of Antimicrobial Stewardship, Hospitals, TN, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% The five components of action towards antimicrobial stewardship. Policies present Document Indication Treatment recommendations Review of treatments Time out Antibiotic approval by a physician Antibiotic review by a physician

34 >3 Core Elements of Action by EMS Region, 2014 TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1 50% 40% 64% 33% 55% 50% 31% 65% 45%

35 Action-Policies: Indication Documented, 2014 TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1 21% 53% 36% 11% 5% 10% 100% 30% 18% 27. Does your facility have a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry?

36 Action-Treatment Review ( Time-Out ), 2014 TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1 22% 13% 29% 33% 25% 10% 23% 30% 9% 29. Is there a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g. antibiotic time out)?

37 Antimicrobial Stewardship Recommendations, THA Board Adopted (October 2015) 1. Hospital demonstration of commitment to antibiotic stewardship via a written statement of support and consideration of dedicated pharmacy, clinician and IT staff time for antibiotic stewardship activities. 2. All hospitals commit to reporting to the National Healthcare Safety Network antimicrobial use and resistance modules within specified timeframes. 3. All hospitals commit to a policy requiring documentation of indications for antibiotic therapy.

38 Antimicrobial Stewardship Recommendations, THA Board Adopted (October 2015) 4. All hospitals commit to implementing a policy requiring an antibiotic review at hours to allow for appropriate review of clinical indication of need, response and any therapeutic revisions that might be appropriate. 5. Participation by hospitals in an antibiotic stewardship collaborative to encourage best practice / lessons learned sharing, and development of appropriate educational programing, as well as any other steps or activities that would assist with antibiotic stewardship.

39 National Healthcare Safety Network (NHSN) NHSN is a surveillance system that serves multiple users and uses NHSN is used by >17,000 healthcare facilities to track HAIs, antimicrobial use and resistance, and adherence to prevention guidelines; guide prevention efforts; submit data for public reporting and quality measurement purposes Health departments for surveillance, prevention, and public reporting CMS for quality measurement and reporting, reimbursement, and prevention HHS to measure national progress

40 NHSN Antimicrobial Use & Resistance Module Only electronic data submission using CDA (clinical document architecture). NO MANUAL data entry Antimicrobial Use [AU] emar (electronic medication administration record) or BCMA (bar code medication administration system ADT (admission, discharge, transfer) or registry data Antimicrobial Resistance [AR] LIMS (laboratory information system) ADT (admission, discharge, transfer) or registry data

41 Reporting Data to NHSN AUR Module Stakeholder Meeting March, 2015: THA (Tennessee Hospital Association) CMO Society (Chief Medical Officer) TN Pharmacy Coalition TDH (Tennessee Dept of Health) Objective: Prepare hospitals and health systems for the expected state and federal reporting requirements on antibiotic use and resistance (AUR) to NHSN. Data submission to NSHN is electronic only and involves multiple sources of data (ADT, LIMS, emar/bcma). Requires lead time time and resources

42 Facilitating Reporting to NHSN AUR Module Sharing lessons learned from two TN hospitals reporting data to the NHSN AU module Holston Valley Medical Center (major teaching hospital) Maury Regional Medical Center (medium size) Inventory of electronic systems in use at TN healthcare facilities: ADT BCMA emar LIS 3 rd party software

43 Interim Measurement Solution Until More Facilities Report to NHSN: Serial Point Prevalence Surveys

44

45 Facility AV: Reduction in Antimicrobial Use

46 Example Report: Facility vs Collaborative All Antibiotics and Quinolone use

47 Distribution of Patients on Quinolones TN, % 12% 20% 28% 36%

48 Pharmacist Training Antimicrobial Stewardship Training Programs Basic Program Advanced Program Antimicrobial Stewardship: A Certificate Program for Pharmacists

49 Outpatient Antibiotic Use Rates (2010) Number of dispensed outpatient antibiotic prescriptions per 1,000 inhabitants California =555 per 1,000 inhabitants Alaska =511 per 1,000 inhabitants Tennessee =1,159 per 1,000 inhabitants U.S. Average =801 per 1,000 inhabitants Center for Disease Dynamics, Economics & Policy < Hicks et al. U.S. Outpatient Antibiotic Prescribing, N Engl J Med 2013; 368:

50 Governor Proclamation: Get Smart About Antibiotics Week Governor Haslam has declared November 16-22, 2015 as Get Smart About Antibiotics Week in Tennessee appropriate-antibiotic-use

51

52 CSTE PS 14-ID-01 Recommendations for Strengthening Antimicrobial Stewardship in the US, including Role of State and Local Health Departments 1. CSTE recommends all state health departments evaluate and incorporate stewardship activities across healthcare settings into their HAI programs. The degree to which health departments can include these programs depends upon the resources, including training and access to subject matter. Examples of activities that can be conducted with current and with expanded funding levels are presented in Appendix CSTE recommends that CDC identifies a standardized metric for measuring inpatient antimicrobial use to facilitate risk-adjusted benchmarking and evaluation of national trends of antimicrobial usage over time using data reported to the National Healthcare Safety Network s Antimicrobial Use and Resistance (AUR) Module and train health departments on the use of these metrics. These data can then be used by state and local health departments in their antimicrobial stewardship efforts. 3. CSTE recommends that CDC evaluates existing measures for monitoring outpatient antibiotic prescribing practices and determine whether expansion of existing measures or development of new measures are needed.

53 Appendix 1: Sample Antimicrobial Stewardship (AS) Activities 1. Convene a State Workgroup on AS 2. Assess AS Activities and Needs Surveys and Assessment Tools Focus Groups 3. Support Interest and Efforts to Collect and Evaluate Antimicrobial Use Data: Encourage NHSN AUR module Interim options (acknowledging delays in all HCFs submitting data to NHSN AUR module): Point prevalence surveys Days of Therapy (DOT ) per 1,000 days present Behavioral Risk Factor Surveillance System 4. Educate and Provide Tools for AS 5. Support, Coordinate and/or Participate in State and Local Prevention Collaboratives on AS

54 Appendix 1: Sample Antimicrobial Stewardship (AS) Activities 1. Convene a State Workgroup on AS 2. Assess AS Activities and Needs Surveys and Assessment Tools Focus Groups 3. Support Interest and Efforts to Collect and Evaluate Antimicrobial Use Data: Encourage NHSN AUR module Interim options (acknowledging delays in all HCFs submitting data to NHSN AUR module): Point prevalence surveys Days of Therapy (DOT ) per 1,000 days present Behavioral Risk Factor Surveillance System 4. Educate and Provide Tools for AS 5. Support, Coordinate and/or Participate in State and Local Prevention Collaboratives on AS

55 Position Statement 15-ID-02

56 CDC & State Health Departments Consider for Implementation Any Number of Strategies Below as Resource Allow (Appendix)

57 Contact: (615) (24/7, 365) Thank You!