Welcome to the New England QIN-QIO Medication Safety Webinar!

Transcription

1 Welcome to the New England QIN-QIO Medication Safety Webinar! Thank you for joining. Our presentation will begin shortly. If you haven t already, please dial in to the audio line: Passcode:

2 The New England Journey Enhancing Medication Safety Getting SMART- Antimicrobial Stewardship Across the Continuum Speakers: Marghie Giuliano, RPh ~ Regional Medication Safety Lead, New England QIN-QIO Shira Doron, MD, FIDSA ~ Associate Professor of Medicine Division of Geographic Medicine and Infectious Diseases & Associate Hospital Epidemiologist, Tufts Medical Center Kirthana Beaulac, PharmD, BCPS ~ Antimicrobial Stewardship Pharmacist, Tufts Medical Center Kerri Barton, MPH ~ Epidemiologist/ Antibiotic Resistance Coordinator, Massachusetts Department of Public Health March 22, :00pm 1:00pm This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy CMSQINC

3 Chat in Introduce yourself please type in your name, role, organization and state. 3

4 Speaker Disclosures Today s speakers have no relevant conflicts of interest to disclose In adherence to the regulation standards of the Connecticut Pharmacists Association, the Accreditation Council of Pharmacy Education, this notice confirms that the information contained in this presentation is free of commercial bias and the speakers have no related vested financial interest in any capacity, inclusion of shareholder, recipient of research grants, consulting or advisory committees. 4

5 Today s Speakers Marghie Giuliano, RPh Regional Medication Safety Lead New England QIN-QIO Shira Doron, MD, FIDSA Associate Professor of Medicine Division of Geographic Medicine and Infectious Diseases & Associate Hospital Epidemiologist Tufts Medical Center Kira Beaulac, PharmD, BCPS Antimicrobial Stewardship Pharmacist Tufts Medical Center 5

6 Learning Objectives Identify why antibiotic resistance is considered a nationwide threat; Describe the relationship between antibiotic use, drug resistance and C. difficile; Explain what an antibiotic stewardship program (ASP) does and its benefits; Identify key members, infrastructure, and activities necessary to successfully execute an ASP; and State why AS must be addressed across the continuum of care 6

7 7

8 Our National Goal... 8

9 Requires a Solution 9

10 Starting with Acute & Long Term Care 10

11 Expanding CDC s Core Elements to Outpatient 11

12 Antimicrobial Stewardship Across the Continuum Getting SMART About Antibiotics Shira Doron, MD and Kirthana Beaulac, PharmD

13 The bugs are becoming harder to treat 13

14 14 and antibiotic development isn t keeping up Ventola CL. PT. 2015; 40(4):

15 The drug development pipeline for antibacterials 15

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17 17

18 18

19 WHO, 27 Feb,

20 WHO, 27 Feb,

21 WHO, 27 Feb,

22 22 It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body.

23 23 Collateral Damage Cephalosporins Vancomycin-resistant Enterococci Methicillin-resistant Staphylococcus aureus Extended-spectrum β- lactamase producing Klebsiella pneumoniae Multidrug-resistant Acinetobacter baumanii Fluoroquinolones Methicillin-resistant Staphylococcus aureus Fluoroquinolone-resistant gram-negative bacilli E. coli resistance in the community Pseudomonas aeruginosa resistance in hospitals Extended-spectrum β- lactamase producing organisms Paterson DL. Clin Inf Dis. 2004; 38 (Suppl 4)S341-5.

24 Antibiotics are a risk factor for multidrugresistant bacteria acquisition 24 Table 3. Factors Associated with Acquisition of Multridrug-Resistant Gram-Negative Bacteria among Case Patients and Control Patients Matched According to Duration of Follow-up OFallon E; Kandel R; Schreiber R; DAgata EM. Infection Control & Hospital Epidemiology. 31(11): , 2010 Nov. DOI: / Copyright University of Chicago Press.

25 25 Antibiotics Cause C. difficile Rupnik M, Wilcox M, Gerding DN. Nature Reviews Microbiol. 2009; 7:

26 26

27 27 ANTIMICROBIAL STEWARDSHIP IDSA defines Antimicrobial Stewardship as an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy Goals of Stewardship Attenuate or reverse antimicrobial resistance Prevent antimicrobial-related toxicity Reduce the costs of inappropriate antimicrobials Decrease health care associated infections Dellit T, et al. CID. 2007; 44:

28 28

29 29 Benefits of an Antimicrobial Stewardship Program Financial savings Both short term and long term Decrease in resistant organisms Minimize adverse effects Decrease in superinfections Decrease in Clostridium difficile (C. diff) infections

30 30 Drug Resistance Trends newly acquired nosocomial multi-drug Carling P, et al. Inf Ctrl Hosp Epi. 2003; 24(9): Chastre J, et al. JAMA. 2003; 290(19): Raman K, et al. Crit Care Med Dellit TH, et al. Clin Inf Dis. 2007: 44: Institute of Medicine. Antimicrobial drug resistance: issues and options. Workshop report

31 31 Adverse Drug Reactions Compliance with established consensus guidelines are encouraged and enforced by Antimicrobial Stewards Deviation from established guidelines has led to: Increased treatment-related adverse effects associated with treatment of asymptomatic bacteriuria Potentially fatal arrhythmias from inappropriate use of fluoroquinolones Hemolytic anemia from inappropriately prolonged beta-lactam therapy Harding GK, et al. NEJM. 2002; 347(20): Dellit TH, et al. Clin Inf Dis. 2007: 44: Lapi F, et al. Clin Inf Dis. 2012; 55(11):

32 32 Allergy Avoidance Blumenthal KG, et al. J Allergy Clin Immunol Pract. 2014; 2(4):

33 33 Reduce Clostridium difficile Carling P, et al. Inf Ctrl Hosp Epi. 2003; 24(9): Valiquette L, et al. Clin Inf Dis. 2007; 45(S2): S112-S121.

34 34 C. difficile Risk from Specific Antibiotics Lawes T, Lopez-Lozano JM, Nebot Cesar, et al. Lancet Inf Dis. 2017; 17:

35 CDC core elements of antibiotic stewardship 35

36 GET SMART website- all the core elements 36

37 GET SMART website- all the core elements 37

38 GET SMART website- all the core elements 38

39 GET SMART website- all the core elements 39

40 GET SMART website- all the core elements 40

41 The Team 41

42 42 Who Needs to Buy in? P&T Committee (acute) Practice Managers (outpatient) Hospital and Health-system Administration Medical Staff Leadership Local Providers Acute care providers Primary Care Specialty/ Subspecialty Clinics EDs / Urgent Care Long Term Care Dellit TH, et al. Clin Inf Dis. 2007; 44:

43 43 The Key Players Infectious Diseases Specialist Infectious Diseases Pharmacist Coordinate policies and procedures Liason with other medical staff Execution and management of policies and procedures Reporting, monitoring, and surveillance

44 44 Expert Resources Clinical Pharmacists Information Technology Specialists Infectious Diseases Specialists Antimicrobial Stewardship Infection Control Professionals Other medical specialists Clinical Microbiologists Quality and Patient Safety Staff Infectious Diseases Trained Pharmacist

45 45 Authorizing Personnel Authorizations done by chief resident compared to no authorization needed No difference in antibiotic use Authorizations done by ID attending and ID pharmacist compared to ID fellow Improved antimicrobial appropriateness (OR 11.0, 95% CI , p<0.001) Trend towards decreased failure (OR 0.5, 95% CI , p=0.09) Trend towards improved economic outcome o o o Total hospital cost: $1396 (p=0.08) Cost attributable to infection: $695 (p=0.10) Cost of antimicrobials: $43 (p=0.09) DeVito JM, et al. Arch Intern Med. 1985; 145: Gross R, et al. Clin Infect Dis. 2001; 33(3):

46 46 Non-ID Trained Pharmacists Non-specialized clinicians can be effective in stewardship activities with guidance from ID-trained pharmacists or ID Physicians DiazGranados CA. AJHP. 2011; 68(18): Laible BR et al. Journal of Pharmacy Practice. 2010; 23:

47 47 Key Ingredients Dedicated Staff Culture change Provider education Use of appropriate metrics/benchmarking Use of the microbiology laboratory Use of technology and informatics

48 Technology 48

49 Technology 49

50 Guidelines and Protocols 50

51 Make the Right Choice the Easy Choice 51

52 52 Impact of Protocol Lancaster JW, et al. Pharmacotherapy. 2008;28(7):

53 The antibiogram 53

54 The antibiogram 54

55 55 The continuum Outpatient clinics (e.g. primary care, subspecialty, dental) Outpatient treatment facilities (e.g. infusion centers, dialysis centers) Acute care facilities EDs Nursing Homes (LTC/SNF)

56 56 The continuum Outpatient clinics (e.g. primary care, subspecialty, dental) Outpatient treatment facilities (e.g. infusion centers, dialysis centers) Acute care facilities EDs Nursing Homes (LTC/SNF)

57 57 The continuum Outpatient clinics (e.g. primary care, subspecialty, dental) Outpatient treatment facilities (e.g. infusion centers, dialysis centers) Acute care facilities EDs Nursing Homes (LTC/SNF)

58 58 The continuum Outpatient clinics (e.g. primary care, subspecialty, dental) Outpatient treatment facilities (e.g. infusion centers, dialysis centers) Acute care facilities EDs Nursing Homes (LTC/SNF)

59 59 The continuum Outpatient clinics (e.g. primary care, subspecialty, dental) Outpatient treatment facilities (e.g. infusion centers, dialysis centers) Acute care facilities EDs Nursing Homes (LTC/SNF)

60 60 The continuum Outpatient clinics (e.g. primary care, subspecialty, dental) Outpatient treatment facilities (e.g. infusion centers, dialysis centers) Acute care facilities EDs Nursing Homes (LTC/SNF)

61 61 The continuum Outpatient clinics (e.g. primary care, subspecialty, dental) Outpatient treatment facilities (e.g. infusion centers, dialysis centers) Acute care facilities EDs Nursing Homes (LTC/SNF)

62 62 The continuum Outpatient clinics (e.g. primary care, subspecialty, dental) Outpatient treatment facilities (e.g. infusion centers, dialysis centers) Acute care facilities EDs Nursing Homes (LTC/SNF)

63 63 Impact of Coordinated Efforts Slayton RB, Toth D, Lee BY, et al. MMWR Aug 7; 64(30):

64 64 Sample Case A 72 year old man is sent back to his long-term care facility after a brief stay at an acute care hospital The transfer paperwork shows he is on intravenous vancomycin for bloodstream infection This is continued for 4 weeks, at which point the patient develops a brain bleed When his labs are checked he is found to have severely low platelets, presumably a side effect of the vancomycin The blood culture results had been incomplete at the acute care hospital at the time of transfer. As it turned out, when the organism was finally identified, it was one typically associated with blood culture contamination rather than infection, and the patient should not have received any antibiotics.

65 65 What could have been done differently? Improve communication and coordination Acute care hospital could have communicated to long-term care facility the plan re duration of antibiotics and the pending lab result A system could be in place for the hospital to follow up on the culture results of a patient no longer in their care and communicate with the long term care facility

66 Create Your Network 66

67 Let s Chat... Panel & Participant Discussion Moderated by: Alyssa DaCunha, Massachusetts Antibiotic Stewardship Lead New England QIN-QIO Panelists Marghie Giuliano, RPh Shira Doron, MD, FIDSA Kira Beaulac, PharmD, BCPS Kerri Barton, MPH 67

68 A critical priority Key Takeaways Effort aligns with current requirements (e.g., ED - joint commission) and reimbursement (e.g., MIPS improve activity) Success requires a community approach Support is available 68

69 Interested in the NE QIN-QIO Antibiotic Stewardship Collaborative? Contact us... Connecticut Carol Dietz Massachusetts Alyssa DaCunha ext.3241 New Hampshire Margaret Crowley Rhode Island Maureen Marsella Maine Amanda Gagnon Vermont Regina-Anne Cooper Questions regarding CE status may be submitted to Ileizy Victor at 69

70 The New England Journey - Enhancing Medication Safety Lunch & Learn: A special webinar series addressing high-risk/high opportunity medications March 3/28: Antibiotic Stewardship Practices from the Field May 5/9: Anticoagulation in the Ambulatory Setting - Clinical Guidelines and Protocols 5/23: Best Practices in Care Transitions for Patients with Anticoagulants July 7/11: Maintaining Glycemic Control 7/25: Tools and Tips to Enhance Safe Care Transitions for Type II Diabetics 70

71 Antibiotic Stewardship Upcoming Learning Events Community-Based Approach March 28 th : Lessons Learned - One Provider's Community-Based Antibiotic Stewardship Experience Focus in Long-Term Care February 28 th : Introduction to Antimicrobial Stewardship in Long Term Care: What is Antimicrobial Stewardship and Why is it Important? March 28 th : Antimicrobial Stewardship: Strategies for Implementation April 25 th : Approach to the Patient with Suspected UTI June 1 st : Antibiotic Selection, De-Escalation, and Duration June 27 th : How to Get an A on Your Report Card: Prevention and Management of C. difficile and Other Healthcare Associated Infections July 25 th : Measure Your Success: Monitoring and Tracking Data Learn more, view archived events or register for upcoming session on our event page

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