4/4/2018. Pathway Health 1. Antibiotics - Are they OVERUSED?? Best Practice Approach to Antibiotic Stewardship: Essential Strategies for Compliance
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1 Best Practice Approach to Antibiotic Stewardship: Essential Strategies for Compliance Laura Chambers, RN, MSN, RAC-CT, CIMT Pathway Health Objectives Upon completion of this presentation, attendees should be able to: 1. List industry expert resources that will assist organizations with compliance with Phase 2 2. Discuss user friendly system inclusions for Antibiotic Stewardship 3. Outline three leadership strategies for oversight of the Antibiotic Stewardship Program for quality and compliance Antibiotics - Are they OVERUSED?? Pathway Health 1
2 Use of Antibiotics-CDC Are overused Are misused Reactions and Side Effects Can only work with infections=bacteria Resistance is growing Reactions and Side Effects 4 Definition of Antibiotic Stewardship The CDC Defines Antibiotic Stewardship as: a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use The Core Elements of Antibiotic Stewardship for Nursing Homes Antibiotic Stewardship-CDC Antibiotics are among the most frequently ordered drugs in nursing homes Up to 70% of residents in nursing homes receive 1 or more systemic antibiotics when they are followed for over a year 40-75% of antibiotics prescribed in Nursing Homes may be unnecessary or inappropriate Residents taking antibiotics are at risk for harm o C-difficile o Adverse drug events o Drug interactions o Colonization o Antibiotic Resistant Organisms The Core Elements of Antibiotic Stewardship for Nursing Homes Pathway Health 2
3 INDUSTRY EXPERT RESOURCES Let s Start with the Regulatory Requirements! CMS-State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities CMS-State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities F (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf Pathway Health 3
4 F881: Antibiotic Stewardship INTENT The intent of this regulation is to ensure that the facility: Develops and implements protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic; Reduces the risk of adverse events, including the development of antibioticresistant organisms, from unnecessary or inappropriate antibiotic use; and Develops, promotes, and implements a facility-wide system to monitor the use of antibiotics. Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf F881: Antibiotic Stewardship Guidance: As part of their IPCP programs, facilities must develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms. Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf F881: Antibiotic Stewardship The facility must develop an antibiotic stewardship program which includes the development of protocols and a system to monitor antibiotic use. This development should include leadership support and accountability via the participation of the medical director, consulting pharmacist, nursing and administrative leadership, and individual with designated responsibility for the infection control program if different Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf Pathway Health 4
5 F881: Antibiotic Stewardship The antibiotic stewardship program protocols shall describe how the program will be implemented and antibiotic use will be monitored, consequently protocols must: Be incorporated in the overall infection prevention and control program; Be reviewed on an annual basis and as needed; Contain a system of reports related to monitoring antibiotic usage and resistance data. Incorporate monitoring of antibiotic use, o including the frequency of monitoring/review. o Monitor/review when the resident is new to the facility; when a prior resident returns or is transferred from a hospital or other facility o during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic regimen review as requested by the QAA committee. F881: Antibiotic Stewardship Continued: In addition, establish the frequency and mode or mechanism of feedback (e.g., verbal, written note in record) to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols. Assess residents for any infection using standardized tools and criteria Include the mode (e.g., verbal, written, online) and frequency (as determined by the facility) of education for prescribing practitioners and nursing staff on antibiotic use (stewardship) and the facility s antibiotic use protocols. CMS: LTC Survey Pathways Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes: Written antibiotic use protocols on antibiotic prescribing, including the documentation of the indication, dosage, and duration of use of the antibiotics Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g. SBAR tool for urinary tract infection (UTI) assessment. Loeb minimum criteria for initiation of antibiotics). CMS - Infection Prevention, Control & Immunizations, CMS (5/2017): Survey-Pathways.zip Pathway Health 5
6 CMS: LTC Survey Pathways Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes: A process for periodic review of antibiotic use by prescribing practitioners; for example, review of laboratory and medication orders, progress notes and medication administration records to determine whether or not an infection or communicable disease has been documented and whether an appropriate antibiotic has been prescribed for the recommended length of time. Determine whether the antibiotic use monitoring system is reviewed when the resident is new to the facility, when a prior resident returns or is transferred from a hospital or other facility, during each monthly drug regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic drug regimen review requested by the QAA committee Enrollment and Certification/GuidanceforLawsAndRegulations/Downloads/LTC Survey Pathways.zip CMS: LTC Survey Pathwayscontinued Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes: Protocols to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotic; A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner Did the facility conduct ongoing review for antibiotic stewardship YES NO F881 Enrollment and Certification/GuidanceforLawsAndRegulations/Downloads/LTC Survey Pathways.zip CDC Centers for Disease Control and Prevention 18 Pathway Health 6
7 Best Practice Resources: The Core Elements of Antibiotic Stewardship for Nursing Homes CDC 20 CDC 21 Pathway Health 7
8 AHRQ-Agency for Healthcare Research and Quality Nursing Home Antimicrobial Stewardship Guide 22 Antibiograms An antibiogram is a tool aimed at improving appropriate antibiotic prescribing. Report that displays the organisms present in diagnostic clinical specimens that nursing homes send for laboratory testing Referring to an antibiogram report helps the physician make prompt, empirically based decisions. Intended to improve the use of antibiotics in nursing homes by helping prescribing clinicians select the most appropriate therapies for residents with suspected infections 23 Example: AHRQ Tools for Infection Criteria ne-whether-to-treat/index.html Pathway Health 8
9 AHRQ-Another GREAT RESOURCE Catheter Associated UTI s CAUTI-Catheter Associated Urinary Tract Infections AHRQ toolkit Developed based upon 500 nursing homes across the country Was a 3-year implementation project Toolkit is organized in 3 main sections o Implementation o Sustainability o Resources Examples of Infection Control Risk Assessment Tools Pathway Health 9
10 CDC Toolkit for Influenza CDC - Guidance on the Use of Antivirals antivirals/antiviral-use-influenza.htm C-Diff CDC has developed a Toolkit 30 Pathway Health 10
11 Antibiotic Stewardship Antibiotic stewardship involves a system that will lead staff and practitioners to: Follow a process to identify the microbe responsible for disease, based on evidence based definitions; Selection of the appropriate antibiotic with documentation to indicate the indication for use and rationale as well as to include the appropriate dose, duration and route of medication; and To ensure that the antibiotic is discontinued when no longer needed. 31 User Friendly System Inclusions! Resources Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria Nimalie D. Stone, MD, 1 Muhammad S. Ashraf, MD, 2 Jennifer Calder, PhD, 3 et. all Infect Control Hosp Epidemiol Oct; 33(10): doi: / Pathway Health 11
12 Resources Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Loeb M 1, Bentley DW, Bradley S, Crossley K, Garibaldi R, Gantz N, McGeer A, Muder RR, Mylotte J, Nicolle LE, Nurse B, Paton S, Simor AE, Smith P, Strausbaugh L. Infect Control Hosp Epidemiol Feb;22(2): Good access weblink: Do you have user-friendly systems/forms? Tracking Log Pathway Health 12
13 Infection Preventionist Tools There is a requirement to establish the frequency and mode or mechanism of feedback (e.g., verbal, written note in record) to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols. Guidance/Guidance/Manuals/downloads/som107ap_pp_g uidelines_ltcf.pdf Audit Tools Leadership Strategies for Oversight of the Antibiotic Stewardship Program Pathway Health 13
14 Leadership Commitment Policies and Procedures Job Descriptions Identification of a solid communication system Culture Change **All these efforts assist the facility with oversight of proper and safe antibiotic use 40 Policies and Procedures Include policies for criteria for infection Use Evidence-Based Standards of Practice Professionally Accepted Resources CDC: Core Elements of Antibiotic Stewardship AHRQ: Nursing Home Antimicrobial Stewardship Guide Loeb, M., Brazil, K., Lohfeld, L., McGeer, A., Simor, A., Stevenson, K., Zoutman, D..Walter, S.D. (2005). Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial. BMJ, 331, Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria 41 Policies and Procedures Other Areas to Consider when drafting P&P s: Antibiotic Ordering and Use Drug, Dosage, Duration, etc. Prophylactic Antibiotic Ordering Diagnostic Testing and Reporting Medical Director Involvement Pharmacy Consultant Involvement Communication and Education Staff Residents Families 42 Pathway Health 14
15 Job Descriptions Antibiotic Stewardship Responsibilities should be included in the job descriptions of: Infection Preventionist Director of Nursing Licensed Nurses Medical Director Pharmacy Consultant 43 Communication: Do you have a good system? Nurse to Practitioner Nurse to DON Medical Director Families Residents Pharmacy Consultant 44 Culture 45 Pathway Health 15
16 Accountability Medical Director DON Infection Preventionist Consultant Pharmacist Lab 46 Drug Expertise Pharmacist Identify what specific training does the consultant pharmacist (and pharmacists at the contracted pharmacy) **You can work with your Pharmacy Consultant on attending a course Physicians o Enlist Medical Director Hospital Partners 47 Action **Identify ONE area that can improve antibiotic use practices for care improvement Put into QAPI Process! One example is an Antibiotic Time-Out After culture results obtained (24-48 hours) talk to physician and re-evaluate the therapy o Still necessary o Appropriate (based on lab results) o Can even assist in plan (i.e. duration) 48 Pathway Health 16
17 QAPI Action Plan 49 Tracking and Reporting In order for organizations to be able to appropriately monitor success of the antibiotic stewardship program, organizations will need to have a solid system to be able to track data. CMS has outlined information on how to track process measures, antibiotic use measures and antibiotic outcome measures as well as costs at: 50 Auditing Example: Appropriate Antibiotic Use Diagnosis Practitioner Order Site of Infection Start/Stop Date of Medication Resident presents with signs/symptoms of infection (using evidence based definitions of infection) Organism identified through laboratory testing (i.e. C&S) Care Planning 51 Pathway Health 17
18 Reporting Nursing Staff Appropriate Use Prescribing Practices Pharmacy Consultant Leadership Team Medical Director 52 Facility Staff Education CDC Core Elements of Antibiotic Stewardship for LTC Facilities Infection Criteria (McGeer s Criteria, Loeb, AHRQ, etc.) Facility Policy and Procedures Multidrug Resistant Organisms Prevention Treatment 53 Clinician Education Required! Include the mode (e.g., verbal, written, online) and frequency (as determined by the facility) of education for prescribing practicitioners and nursing staff on antibiotic use (stewardship) and the facility s antibiotic use protocols Develop an action plan in association with: Pharmacy Consultant Medical Director Determine opportunities for improvement Utilize evidence-based best practice Determine method of delivery 54 Pathway Health 18
19 Resident/Family Education - CDC 55 Additional Clinical Processes Key Clinical Processes Ongoing analysis that includes: Auditing all antibiotic use in the facility o Review nurse assessment information o Root cause analysis: what information was discussed with the physician? (Criteria for Infection?) o Documentation Ensure that the resident is taking the right antibiotic for the right amount of time Appropriate discussion with practitioner regarding antibiotic use - may need to involve the Medical Director and the Pharmacy Consultant 57 Pathway Health 19
20 Facility Assessment The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Must be reviewed/revised annually Must be reviewed/revised when any change would require a substantial modification to the assessment Assessment must address a facility-based and community-based risk assessment using an all-hazards approach The results of the facility assessment must be used to establish and update the Infection Prevention and Control Program, including policies and procedures TB screening per State requirements Facility Assessment Administrative Measures Risk Assessment Education Antibiotic Use Evaluation and Antibiotic Stewardship Surveillance Hand Hygiene Standard and Transmission Based Precautions Environmental Measures 59 Leadership Strategies Stay up to date with the most current recommendations, guidelines, evidence based standards of practice and regulatory requirements. 60 Pathway Health 20
21 Summary 1. Become familiar with the regulatory requirements (F881) for Antibiotic Stewardship 2. Understand best practices for infection criteria 3. Work with the IDT, Medical Director, Pharmacy Consultant and hospital partners to ensure a solid system (Policies, Procedures, Preadmission Process, etc.) 4. Education! 5. Surveillance, tracking, data analysis, audits 6. QAA involvement Resources 62 References and Resources CMS State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities: Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf. pdf 63 Pathway Health 21
22 References and Resources CDC - Core Elements of Antibiotic Stewardship for Nursing Homes U.S. Department of Health & Human Services: AHRQ: Nursing Home Antimicrobial Stewardship Gide 64 Resources National Healthcare Safety Network (NHSN) LTC facilities Tracking Infections o Training o Protocols o Forms o Support Materials o And More! 65 Resources Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria Pathway Health 22
23 References and Resources AHRQ: CAUTI - Catheter Associated Urinary Tract Infections m_content=2&utm_campaign=ahrq_cauti4ltc_2017 Resources and References World Health Organization Antibiotic Resistance 68 References and Resources Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases Advance Access published April 13, html 69 Pathway Health 23
24 Resources CDC: Antibiotic Stewardship Statement for Antibiotic Guidelines Recommendations of the Healthcare Infection Control Practices Advisory Committee 70 Questions? Disclaimer This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health. Pathway Health 24
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