FHA Hospital Engagement Network Infection Prevention Roundtable

Transcription

1 FHA Hospital Engagement Network Infection Prevention Roundtable What s New in Infection Prevention; Updates, Challenges and Controversies June 18, 2014

2 Agenda Welcome Key Points from the National APIC Conference: What You Need to Know Linda Greene, RN, MPS, CIC, Highland Hospital, NY Highlights from the Chasing Zero Infections Infections-Part 2 Meeting: Antibiotic Stewardship Brian Mayhue, PharmD, Palm Beach Gardens Medical Center Suet-ping Lau, PharmD, Dr. Phillips Hospital Open Discussion / Q & A Upcoming Events 2

3 Annual APIC Conference 2014 Highlights ht Linda R. Greene, RN,MPS,CIC Manager of Infection Preventionention Highland Hospital Rochester, NY University of Rochester Medical Center rochester edu 3

4 Overview of SHEA Compendium CAUTI May publication SSI June C difficile June CLABSI July MDRO July VAE August Hand Hygiene August 4

5 CLABSI Update Majority of CLABSIs are outside ICU New independent risk factor femoral lines Transfusion of blood products in children New : Reduced Risk Antibiotic administration Minocycline impregnated catheters *CLABSI Update presented by Lynn Hadaway 5

6 Current Bundles Successful in patient safety culture Adherence to individual measures Recent data suggests that adherence to all bundle components is not necessary 6

7 Basic Practices Evidence based indications for CVC USE Re educate educate staff when infusion components change Use checklist by someone other than inserter in ICU and non ICU Avoid femoral in obese patients 7

8 Other Practices PICC use is not a strategy to reduce CLABSI Use ultrasound for internal jugular insertion Vigorously scrub injection ports no less than 5 seconds IV SETS replace at intervals no longer than 96 hours Use tpa weekly in hemodialysis i catheters 8

9 Barriers Lack of infusion specialist Maintenance checklist no singe episode to be witnesses reliability of self reported data 9

10 Challenges Other Departments Radiology, OR Patients transferred from other facilities 10

11 Abstract CLABSI Danielson et al. Texas Health 68% decrease in CLABSI rates with use of alcohol impregnated port protector Wawrzyniak et. al Loyola U Medical Center 2 year pre post observational study. Decrease by 68% overall with use of alcohol impregnated port prrotector 11

12 Hand Hygiene Alcohol vs. soap and water stress glove use Antimicrobial soap invasive procedures (Either is OK as long as gloves are used) UNRESOLVED Issue Hand Hygiene before donning gloves * Presented by Janet Haas 12

13 VAE The limitations of VAP surveillance definitions hinder interpretation of the VAP prevention literature. Many interventions have been shown to reduce VAP rates but few interventions have been shown to improve objective outcomes such as average duration of mechanical ventilation or mortality 13

14 Updates Basic Practices: Interventions with little risk of harm that decrease duration of mechanical ventilation, length of stay, mortality, and/or costs. Use non invasive positive pressure ventilation (NIPPV) whenever feasible Minimize the use of sedation when possible. Interrupt sedation daily (spontaneous awakening trials) for patients without contraindications Assess readiness to extubate daily (spontaneous (p breathing trials) in patients without contraindications Maintain and improve physical conditioning Minimize pooling of secretions above the endotracheal tube cuff ( Subglottic suctioning) Elevate the head of the bed to Change g the ventilator circuit only if visibly soiled or malfunctioning 14

15 Updates Special Practices: Interventions that decrease duration of mechanical ventilation, length of stay, and/or mortality but insufficient data available on possible risks. Decrease the microbial burden of the aerodigestive tract Special Practices: Interventions that may lower VAP rates but for which there are insufficient data at present to determine their impact on duration of mechanical ventilation, length of stay, and mortality. Oral care with chlorhexidine Prophylactic probiotics Ultrathin polyurethane endotracheal tube cuffs Automated control of endotracheal tube cuff pressure Saline instillation before tracheal suctioning 15

16 Future Bundle Process Measure Date Y/N Comments Continuous Subglottic Suctioning Assess readiness to extubate ( Spontaneous breathing trials) Interrupt sedation daily ( Spontaneous awakening trials) il) Ambulate according to protocol* Regular Mouth care (without chlorhexidine )* Elevate HOB Paired SBT s and SATs. Standardized process measures in development. If contraindications note here Note level Low Tidal Volume Identify: 16

17 17 Focus on Mobility

18 MRSA Horizontal vs. Vertical approach to MDROs Isolation still recommended for colonized and infected patients Perform a MRSA Risk assessment Universal decolonization i of adult ICU patients with ih daily chlorhexidine bathing Mupirocin ointment Active surveillance and targeted decolonization 18 * Presented by Julia Moody

19 Intended d and non intended d consequences of public reporting Public attention Administration attention Transparency The Truth: Protect patients Know when something is wrong intervene Get the help we need 19 * Susan Huang

20 Response to Gaming Validation Increased visibility for IPs What can we do: Believe Be a voice Be proactive Prove 20

21 Trial to eliminate MRSA Chlorhexidine Matters: Method Concentration Consistency Safety 21

22 Decolonization Massage into skin for sustained 24 hour activity No rinse Protocol: Attention to high risk skin areas Clean over non gauze dressings Proximal 6 inches of lines catheters, etc Perineum and wounds Many soaps and shampoos inactivate 22

23 Chlorhexidine 2% non rinse cloth most widely studied 4% no rinse more adverse skin events 4% rinse shower or bath lower concentrations 2 min contact time before rinse Mesh sponge works well for liquide application 23

24 Consistency 24 Hour Effect Daily application Assure all staff are trained Night and weekends Compliance checks 24

25 ANTIBIOTIC STEWARDSHIP Brian Mayhue, Pharm D, CGP Director of Pharmacy Palm Beach Gardens Medical Center 25

26 Magnitude of Antimicrobial Use Antibiotics are the second most commonly used class of drugs in the United States More than 8.5 billion dollars are spent on anti -infectives annually million antimicrobials prescribed annually 53% for outpatient use 30-50% of all hospitalized patients receive antibiotics Studies estimate up to 50% of antibiotic use is either unnecessary or inappropriate across all type of health care settings 26

27 Unnecessary Use of Antimicrobials in Hospitalized Patients Prospective observational study in ICU 576 (30%) of 1941 antimicrobial days of therapy deemed unnecessary Most Common Reasons for Unnecessary Days of Therapy Day ys of Therapy Duration of Therapy Longer than Necessary Noninfectious or Nonbacterial Syndrome 94 Treatment of Colonization or Contamination Hecker MT et al. Arch Intern Med. 2003;163:

28 Antibiotic Misuse Given when they are not needed Continued when they are no longer necessaryduration Given at the wrong dose-renal and weight-based dosing Broad spectrum agents are used to treat very susceptible bacteria The wrong antibiotic is given to treat an infection 28

29 Guidelines to develop an institutional Antimicrobial Stewardship Program (ASP) Antimicrobial Stewardship committee Computer surveillance and decision support software Proactive microbiology lab Monitoring of process and outcomes measures Elements of an ASP Active Strategies Supportive Strategies 29

30 Goals of Antimicrobial Stewardship Programs Optimize Patient Safety Reduce Resistance Decrease or Control Costs 30

31 Antimicrobial Stewardship Goals Improve patient outcomes Optimize selection, dose and duration of Rx Rd Reduce adverse drug events including ldi secondary infection if i (e.g. C. difficile infection) Reduce morbidity and mortality Limit emergence of antimicrobial resistance Reduce length of stay Reduce health care expenditures MacDougall CM and Polk RE. Clin Micro Rev 2005;18(4): Ohl CA. J. Hosp Med. In press. Dellit TH, et. al. Clin Infect Dis. 2007;4 31

32 PBGMC C. Diff Rate Rate based on cases per admissions Rate 32

33 Challenges Literature often not clear in Infectious Diseases Everyone thinks they know how to use antibiotics Providers perceive autonomy is lost Difficulty proving impact (no national measures) Financial pressures dictating decisions Pharmaceutical manufacturers Hospitals Insurance companies Patients 33

34 Getting Started Multidisciplinary team Physician champion Clinical pharmacist (with ID training) Decentralized (on the units) Additional clinical microbiology Information systems specialist Infection prevention professional/ hospital epidemiologist 34

35 Multidisciplinary Team Approach Hospital Epidemiologist Infection Prevention Medical Information Systems Microbiology Laboratory * Hospital and Nurse Infectious Administration Diseases AMP Directors Cl. Pharmacist Physician Champion Clinical Pharmacy Specialists Decentralized Pharmacy Specialist Director, Quality Chairman, P&T Committee Partners in Optimizing Antimicrobial Use such as ED, hospitalists, intensivists and surgeons *based on local resources Modified: Dellit et al. ClD 2007;44:

36 Physician Champion Basic knowledge of antibiotics*(does not have to be an infectious disease MD but helps) Must show interest tin taking a leadership role in the hospital Respected by his or her peers Good interpersonal skills Good team player Basic understanding of human factors and culture transformation 36

37 PBGMC Antibiotic Stewardship Program Prospective audit with intervention and feedback Streamlining or de-escalation of therapy Dose optimization Formulary restriction and pre-authorization Parenteral to oral conversion 37

38 Prospective Audit and Feedback Back-end Approach Physician writes order Antibiotic Dispensed At a later date, time antibiotics reviewed Prescribing physician contacted and recommendations made 38

39 Prospective Audit and Feedback Advantages Prescriber autonomy maintained Educational opportunity provided Patient information can be reviewed before interaction Inappropriate p antibiotic use decreased De-escalation 39

40 Prospective Audit and Feedback Disadvantages Voluntary compliance Identification of patients require computer support (IT pharmacist helpful) Prescribers reluctant to change if patient is doing well Some inappropriate antibiotic use permitted 40

41 Dose Optimization New evidence for duration of therapy Uncomplicated urinary tract infection: 3-5 days 1 Community-acquired pneumonia: 3-7 days 2 Ventilator-associated pneumonia: 8 days 3 CR-BSI Coagulase-negative staphylococci: 5-7 days 4 Acute Hem Osteomyelitis in children-21 days 5 Meningococcal meningitis-7 i i days 6 Uncomplicated secondary peritonitis with source control: 4-7 days 7 Avoid day course of antibiotic therapy 41

42 Dose Optimization Other steps taken at PBGMC Implementation of extended infusion of Pip/Tazo (started in Feb 2013) Dosing based on renal function (either Pip/Tazo 3.375g 375 IV q12hrs or q8hrs over 4 hr period) Renal Dosing Policy Allows pharmacist to change dose/ frequency based on renal function 42

43 Pip/Tazo purchases Pip/Tazo 43

44 Formulary Restriction Restrict high cost antibiotics to infectious disease physicians Examples: daptomycin, linezolid, tigecycline 44

45 IV to PO Conversion Develop a policy specifically targeting antibiotics which have same bioavailability to change to oral if certain criteria are met. Azithromycin Fluconazole Fluoroquinolones (ciprofloxacin, levofloxacin) Metronidazole Linezolid Clindamycin Doxycycline 45

46 IV to PO Conversion Inclusion Criteria (must meet one) Tolerating a regular or modified diet for at least 24 hours Tolerating enteral nutrition for at least 24 hours Receiving other scheduled medications by the oral route Signs and symptoms of infection have resolved or are improving 46

47 IV to PO Conversion Exclusion criteria (must have none) Unable to swallow, NPO, high risk for aspiration Active N/V/D, GI obstruction, ti IBS, malabsorption, or ileus Signs and symptoms of infection have not improved Experienced severe trauma within last 72 hrs Ati Active GIbleed Neutropenia (ANC<5000 Documented CNS infection or endocarditis Pneumonia with AIDS or severely immunocompromisedi Pseudomonas infection and on antibiotics <24 hrs Candidemia treated <7 days Other infections where IV therapy is the preferred standard d of care (osteomyelitis) 47

48 Other Interventions Post antibiogram on line through our physician portal Work with Pharmacy Informatics to get computer generated reports to help clinical pharmacists identify opportunities Future opportunities (procalcitonin)to identify sepsis 48

49 PBGMC Antibiotic Spending

50 Lessons Learned Physician push back was a huge problem Education does not always work- because they know better A peer (trusted colleague/ physician champion) is the key to success Showing physicians financial data vs their peers does work 50

51 Lessons Learned One ID physician changing prescribing habits can make all the difference Getting simple policy and procedures thru P&T is not always simple Whatever is the driving force for starting an ASP it can be successful and can help substantially cut medication costs 51

52 Conclusion Effective empiric antimicrobial selection based on your particular hospital (antibiogram) Optimize dose and route of administration Administer for the shortest duration possible De-escalate once susceptibility known Stop if no infection i identified ifi d 52

53 Overview: Antimicrobial i Stewardship Program at DPH Suet-ping Lau, Pharm.D. Infectious Diseases Clinical Pharmacist Dr P Phillips Hospital Orlando Health 53

54 Before ASP The highest utilization of broad & costly abx at OH: Meropenem, linezolid, daptomycin etc The highest abx Cost / PDE at OH: $33.6 at DPH vs. $22.9 at OLM The usage of meropenem was above the national average DPH OLM SSH 54

55 Overview Antimicrobial Stewardship Program (ASP) Daily antimicrobial agents monitoring & surveillance: IV to PO switch Bug-drug Mismatch Possibility de-escalationescalation per culture results Decrease the duration of antimicrobials Formulary alternatives per culture results, allergies, pharmacotherapy Dose optimization i i per renal l/h hepatic function Discontinue surgical prophylaxis antimicrobial agent(s) Allergies investigation (Antimicrobial Allergy Team) Monitor high cost / broad spectrum / high toxicity / national shortage agents: Meropenem, tigecycline, linezolid, daptomycin, colistin, aminoglycosides, ampho-b, IV acyclovir 55

56 Meropenem Utilization at DPH vs. ORMC Use of Meropenem DPH vs. ORMC in # of 500mg vials ORMC DPH Nov-11 Sep-11 Jul-11 May-11 Mar-11 Jan-11 Nov-10 Sep-10 Jul-10 May-10 Mar-10 Jan-10 56

57 Antimicrobial Agent Cost Saving at DPH (Before vs. After ASP): Year Antimicrobial agents yearly expenditure $1,630,546 Cost reduction from year of 2009 without ASP (baseline) Cost Reduction from the previous year Cost Reduction from the previous year (%) $1,374,318 $256,228 $256, % $863,932 $766,614 $510, % $788,461 $842,085 $75,471-9% $550,106 $1,080,440 $238,355-30% Potential Cost Saving in 4 years: $2,945,365 57

58 Overall Intervention Acceptance Rate Type of Interventions in 2013 (N=1217) Therapy recd accepted 96% Formulary Alt Accepted 96% Cut Duration of abx Accepted 95% Dose Optimization Accepted 98% IV to PO Accepted De-Escalation Accepted 100% 94% Overall Acceptance Rate: 96%

59 1 st CAUTI Rounds at DPH Established the FIRST CAUTI prevention Rounds at DPH with the Infectious Diseases Physician Weekly rounds with ID physician Educated Staff and family member to remove unnecessary Foley catheter Developed electronic CAUTI Progress Note Assisted other OH sites to establish site wide CAUTI rounds Successfully reduced the CAUTI rate at DPH since Fiscal Year # of CAUTI (till April)

60 C.diff Prevention Developed dc.diff diffinfection Quality Monitoring i Form Review each HACDI with the attending Review all HACDI cases monthly y( (CQO, ID physicians, Infection Preventionist) C.diff task force: launched hand-washing Champaign Reduced unnecessary antimicrobial usage Floroquinolones restriction at Orlando Health Reduced proton pump inhibitor (PPI) usage Fiscal Year # of HACDI (Till April) 60

61 DPH Antibiogram ( ) Pseudomonas aeruginosa Amikacin Cefepime Ciprofloxacin Pipercillin- Tazobactam Meropenem

62 DPH Antibiograms Comparison DPH antibiogram ( ) MDR Rate MRSA 55% 55% 50% 50% VRE 17% 13% 19% 17% ESBL: E. Coli 8% 5% 6.6% 4.4% K. pneumoniae 15% 12% 9% 8.1% CRE: KPC 2.4% 1.8% 1.6% 0.6% (No other CRE cases!!) MRSA No reported 2.5% (N=6) 4.5% (N=9) 0% (N=0)!!! vancomycin MIC 2 62

63 Sharing ASP Experience It was tough to start but it is rewarding with the accomplishments! NEVER EVER give up! Remember: we are the physicians teammates NOT enemies! We can be a police but we have to be friendly! Be SMART and SWEET! Find out what are the problems then tackle each one! 63

64 Questions? Preguntas? Thank you! 64

65 65 Open Discussion / Questions?

66 Upcoming Events June 19 June 19 June 20 June 23 June 23 June 24 June 24 June 24 June 25 June 25 June 25 June 25 June 26 June 26 Sept VAE Office Hours (12-1pm) Role of Pharmacists in Transitions of Care Services (1-2pm) Data Coordinator Webinar Live Encore (11:30am-2pm) OB & Failure to Rescue Webinar (11:30am-2:30pm) Patient & Family Engagement Master Class (3-4pm) Junior Fellows Open Office Hours (11am-12pm) Patient & Family Engagement Office Hours (12-12:30pm) Care of Children in General Hospitals (3-4pm) Florida CAUTI Coaching Call (11am-12pm) Monthly OB Coaching Webinar (1-2pm) HAI Affinity Group Meeting (1-2pm) ILF Virtual Meeting (2-4pm) Falls & Procedural Harm Webinar (11:30am-2:30pm) NPLH Readmissions Office Hours (12:15-1pm) TeamSTEPPS Master Trainer Class (Deerfield Beach, FL) HEN Education & Event Details are posted at as they are available (To receive the Weekly FHA HEN Events via , send a request to HEN@fha.org to be added) 66

67 We are here to help! FHA Contacts Sally Forsberg RN Director of Quality & Patient Safety (407) , Kim Streit VP/Healthcare Research & Information Services (407) , Phyllis Byles RN Quality Coordinator (407) , 67