9/19/2016. Disclosure Statement. Learning Objectives. An Antimicrobial Stewardship Journey: Participation in the ASHP Mentored Impact Program

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1 An Antimicrobial Stewardship Journey: Participation in the ASHP Mentored Impact Program Serena Von Ruden, PharmD, BCPS, RN, BSN St. Francis Hospital CHI Franciscan Health P Disclosure Statement I have no actual or potential conflict of interest in relation to this presentation. I will not discuss off label use and/or investigational use in my presentation. Learning Objectives Perform SWOT analysis for current state of antimicrobial stewardship at your facility Identify strategies and technician-driven interventions for reducing time to effective antimicrobial therapy Design pharmacist-driven interventions to optimize management of healthcare facility (HCF)-onset, HCFassociated Clostridium difficile infection (CDI) Discuss pharmacist-driven interventions to reduce the use of medications known to put patients at risk for developing CDI Verbalize the importance of creating an antimicrobial stewardship brand 1

2 Pre-Test Assessment Questions What are some systemic reasons for delays in antimicrobial therapy administration? T/F: Mild-moderate CDI should always be treated with metronidazole. T/F: Severe CDI should always be treated with regimen that contains enteral vancomycin. Who is present this afternoon? St. Francis Hospital 134 bed non-profit community hospital Intensivist-managed 14 bed medical ICU General medicine, surgical, progressive care, and L&D/post-partum units Bariatric Surgery Center of Excellence Infectious Disease private physician group available by consultation 10.5 FTE pharmacists providing 24/7 clinical coverage 1 FTE internal medicine pharmacist specialist Combination centralized/de-centralized model Part of Catholic Health Initiatives (CHI) Franciscan Health Eleven hospital regional health system in Pacific Northwest EMR in use since 2013 CDSS in use since 2004 Joint formulary shared with Multicare Health System EMR = Electronic Medical Record; CDSS = Clinical Decision Support Software 2

3 Antimicrobial Stewardship Program Regional stewardship program since 2011 Monthly meetings with representation from ID physician group, hospitalist physicians, pharmacy, microbiology, infection prevention, nursing education, and informatics Education for providers and pharmacists Guidelines and algorithms for management of different infectious disease states Order set optimization Antibiogram creation and dissemination De-centralized pharmacists responsible for addressing daily CDSS alerts at each hospital site No dedicated ID pharmacist at project initiation CDC s Core Elements What is the status of antimicrobial stewardship at your facility? 3

4 ASHP Antimicrobial Stewardship Mentored Impact Program Application and Selection Process October Application submitted to multidisciplinary ASHP steering committee Included information on current status of stewardship activities and past initiatives Specific proposal for improvement Barrier assessment December Nine hospitals selected nationwide out of 90+ applicants 4

5 Preparation Work January 2014 Submit formal self-assessment including SWOT analysis Strengths Weaknesses Opportunities Threats Internal Factors External Factors Positive Negative Things to consider Staffing Administrative support Pharmacist champion Physician champion Relationships among pharmacists/providers IT resources (EMR, CDSS, etc) 5

6 Our Initial SWOT Analysis Preparation Work June Site visit by nationally recognized ID experts Dr. Debra Goff and Dr. George Karam Program assessment Meetings with stakeholders CE event open to all staff 6

7 Site Visit Report Program Timeline Overview Specific Outcome Projects Time to effective antimicrobial therapy Incidence of healthcare facility (HCF)-onset, HCFassociated C. difficile infection (CDI) Reduction in use of medications known to put patients at risk for developing CDI Reduction in number of patients receiving more than 3 antimicrobial agents per day 7

8 Time to Effective Antimicrobial Therapy Data Collection Provider order entry Pharmacist verification RN administration Evaluated first doses of IV antibiotics for treatment of infection in all inpatient units except L&D and post-partum Excluded surgical prophylaxis antibiotics Excluded patients in ED Time to Effective Antimicrobial Therapy Data Collection What was the maximum hang time identified on chart review? Time to Effective Antimicrobial Therapy Description of Problem Baseline data revealed prolonged times from provider order entry to RN administration Range from 15 minutes up to 11+ hours! 2013 Surviving Sepsis guidelines have set a goal to start antibiotics within 1 hour of triage time (grade 2C) Every hour of delay increases mortality by 7.6% Project goals: Less than 1 hour for septic patients Less than 2 hours for all other patients Gram negative coverage given first Crit Care Med 2006;34(6): Crit Care Med 2013;41(2):

9 Time to Effective Antimicrobial Therapy Description of Problem Few IV antibiotics stocked on inpatient units EMR defaulted all new orders to start at next standard administration time Electronic provider consults for pharmacy to dose not always seen in timely manner RNs unaware of need to prioritize 1 st dose antibiotics above other medications Time to Effective Antimicrobial Therapy Strategies for Improvement How could we improve? Time to Effective Antimicrobial Therapy Process Change We had a hospital-wide paradigm shift Consider all 1 st dose IV antibiotics as STAT orders Technicians more aware of need for prioritizing IVPB pull or compound of 1 st dose antibiotic orders Pharmacists to deliver 1 st dose antibiotics if technician occupied RNs to ensure adequate IV placement and procurement of pump (if needed) once IV antibiotic ordered and anticipate imminent delivery of medication HUCs to deliver IV antibiotics ASAP to RNs if received via pneumatic tube system 9

10 Time to Effective Antimicrobial Therapy Process Change More IV antibiotics placed in automated dispensing cabinets to reduce delivery time Ceftriaxone 1 g Ceftriaxone 2 g Levofloxacin 750 mg Piperacillin/tazobactam 4.5 g (Levofloxacin 500 mg) (Metronidazole 500 mg) Time to Effective Antimicrobial Therapy Process Change Bright orange NOW stickers applied to 1 st dose IV antibiotics coming from pharmacy Verbal reminder to RN to administer STAT antibiotic right away Increased focus on hand delivering to RN for units without pneumatic tube system Phone calls placed to RN/HUC after sending for units with tube system Time to Effective Antimicrobial Therapy Process Change IT ticket to default start time of Include Now for new IV antibiotics and place as STAT priority 10

11 Time to Effective Antimicrobial Therapy May 2014 Project Timeline Pre-Intervention Intervention Jan 2015 Post-Intervention May 2015 Initial lag in time to intervention due to significant issues Difficulty in pulling reports via EMR Difficulty in getting regional RN education approval Time to Effective Antimicrobial Therapy Education Presentations at multiple RN and hospitalist meetings regarding process changes Reminder placards to pneumatic tube stations, automatic dispensing cabinets, and provider computer banks Time to Effective Antimicrobial Therapy Education 11

12 Time to Effective Antimicrobial Therapy Education Partnered with unit-based nursing councils to provide targeted education and result tracking Data collected monthly by manual chart review and shared with Nursing and Pharmacy departments Feedback on individual performance and specific recognition for staff consistently meeting goal 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Time to Effective Antimicrobial Therapy Results Overall Hospital (n=225) ICU Patients (n=75) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% August 2014 February 2015 May 2015 August 2014 February 2015 May 2015 Surgical Floor (n=75) Medical Floor (n=75) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% August 2014 February 2015 May 2015 August 2014 February 2015 May 2015 Timely: Within 1 hour for septic patients and 2 hours for other patients Effective delivery: Timely and gram negative coverage hung first (or only one antimicrobial or no antimicrobial with GN coverage) Sample Monthly RN Feedback Report RN clinical leaders, Overall the data looks worse from last month but on 6 instances (out of 30 reviewed) the delay in therapy was related to pharmacy/providers NOT nursing (i.e. leaving default start times for the future or missing dosing consults to our In Basket). Excluding these 6 cases has patients receiving antibiotics within goal 79% of the time which similar to the trend line. The pharmacy department is continuing to work on improving our issues as well. Special congratulations to the following RNs who administered their antibiotics within goal 100% of the time:,,,, &. Way to go! 12

13 Sample Monthly RPh Feedback Report Dear (pharmacist colleague), Based on 7 cases reviewed in April, antibiotic orders you verified reached the patient within 60 minutes 67% of the time (ranked 5 out of 12 pharmacists). Remember when we verify an order for a 1 st dose IV antibiotic, it is our responsibility to ensure the medication gets delivered and administered to the patient in a timely manner. This includes ensuring a start time of NOW, assisting with delivery of medications (if possible), and calling RNs to notify them of new orders available in the automated dispensing cabinet. Be sure to check the In Box frequently throughout your shift to ensure consults are not missed. Thanks for all your help! Time to Effective Antimicrobial Therapy Lessons Learned Best results on ICU floor although all units showed improvement from baseline Multi-disciplinary approach essential with active involvement of nursing staff Individual monthly stats presented to RN units and pharmacy department resulted in significant improvements Virtual Poster presented nationally with recorded interview now available as 1.5 CE accredited for RPh, MD, PA-C, ARNP, and RNs 13

14 Time to Effective Antimicrobial Therapy Feedback? Critique? Questions? Specific Outcome Projects Time to effective antimicrobial therapy Incidence of healthcare facility (HCF)-onset, HCFassociated C. difficile infection (CDI) Reduction in use of medications known to put patients at risk for developing CDI Reduction in number of patients receiving more than 3 antimicrobial agents per day Incidence of HCF-onset, HCF-associated CDI Data Collection Received list of all St. Francis patients with positive Clostridium difficile PCR test from July Manual retrospective chart review to assess the following: Severity CDI antibiotic choice and duration of therapy Other antibiotics received and duration of therapy Complication rate (mortality, toxic megacolon, or total colectomy) Limited to inpatients only (i.e. excluded those discharged from ED) 14

15 Incidence of HCF-onset, HCF-associated CDI Background Severity defined by Hines VA score Multicenter observational study of 8 CDI severity indices found best correlation with Hines VA score J Infection 2007;55: Infect Control Hosp Epidemiol 2011;32(3): Incidence of HCF-onset, HCF-associated CDI Background Which of the following is correct about CDI treatment regimens? Incidence of HCF-onset, HCF-associated CDI Background Guidelines recommend oral vancomycin for severe CDI Treatment failure rate up to 50% in severe CDI treated with metronidazole in some studies Prospective RDBPCT (n=172) evaluating clinical cure rates Metronidazole Vancomycin p-value Mild CDI 90% 98% 0.36 Severe CDI 76% 97% 0.02 Clin Infect Dis 2005;40: J Antimicrob Chemother 2007;59: Clin Infect Dis 2007;45:

16 Incidence of HCF-onset, HCF-associated CDI Description of Problem Baseline incidence 16 per 10,000 adult patient days Retrospective review (n=78) Initial PO vancomycin for severe cases only 45% of the time Severe complication rate 15.4% Incidence of HCF-onset, HCF-associated CDI Process Change Created pharmacist-driven process for real-time assessment of all patients with positive C. difficile PCR result What are some items to include in this assessment? Incidence of HCF-onset, HCF-associated CDI Background Agent Evidence Summary Sources Antimicrobials Acid suppression Probiotics Well established link between CDI onset and use, # of agents, and duration of therapy Also shown to increase LOS by 62.7%, mortality 1.7 times, and readmission rates 1.2 times Associated with CDI and may increase rates of relapse (PPI > H2RA) Varying data as to CDI prevention, little basis for use in treatment Clin Infect Dis 2011;53(1):42. Pharmacotherapy 2012;32(8): Mayo Clin Proc 2013;88(10):1085. Infect Control Hosp Epidemiol 2013;34(4):407. Lancet 2013;382(9900):1249. JAMA 2012:307(18):1959. Ann Intern Med 2012;157(12):878. Infect Control Hosp Epidemiol 2010;31(5):431 16

17 Incidence of HCF-onset, HCF-associated CDI Process Change Pharmacist to perform standardized five point review CDI severity and antibiotic choice Other antibiotic orders Use of proton pump inhibitor Use of lactobacillus * Use of PRN anti-diarrheal agents * * Existing P&T approved protocol allowing for automatic pharmacist discontinuation in CDI Incidence of HCF-onset, HCF-associated CDI Process Change Pharmacist received text message via pager when positive C. difficile PCR result entered into EMR Decentralized vs centralized pharmacist Day shift vs evening/night shift pharmacist Pharmacist used algorithm to assist in evaluation Let s practice! 17

18 Incidence of HCF-onset, HCF-associated CDI Pre-Intervention Project Timeline Intervention Post-Intervention May 2014 Oct 2014 Feb 2015 May 2015 Year long project by SJMC PGY-1 resident Tony Hoang, PharmD Incidence of HCF-onset, HCF-associated CDI Education One-on-one training with pharmacist staff Educational in-service presentations for hospitalist providers Algorithms posted at each pharmacist work station Prospective data collection via tracking form completed by pharmacists Pharmacy resident performed weekly chart audits to ensure compliance with procedure Gave summative and targeted feedback to staff Incidence of HCF-onset, HCF-associated CDI Results HO-HFA-CDA incidence per 10,000 patient days p value VRS(W Intervention period May June July Aug Sept Oct Nov Dec Jan Feb March April May Overall Average Overall Average Range from 1-5 cases per month without consistent pattern or trend Cluster outbreak March-April 2015 on several units thought related to improper contact precautions; increased education regarding appropriate gowning and handwashing Overall statistically significant reduction in average annual rate from baseline data 18

19 Slide 54 VRS(W3 one sided Z test Von Ruden, Serena (Federal Way), 7/2/2015

20 Incidence of HCF-onset, HCF-associated CDI: Results Baseline (n=78) Intervention (n=27) 100% acceptance rate for recommendation to stop PPI No patients who had PPI stopped developed GIB 26.7% reduction in non-cdi antibiotic use p value VRS(W1 Severe complication rate 15.4% 11.1% Relapse rate 10.3% 3.7% NS Initial PO vancomycin for severe cases 45% 100% NS Incidence of HCF-onset, HCF-associated CDI Barriers, Lessons Learned, and Next Steps Leveraged GI and ID specialist input in developing intervention Great support and buy-in from hospitalist staff led to high intervention acceptance rates Barriers included time for manual chart reviews and difficulties in gathering data via EMR Created P&T approved automatic pharmacist-driven protocol PPI discontinuation protocol Initial CDI treatment choice based on severity to ensure patients started on vancomycin when appropriate 19

21 Slide 55 VRS(W1 Chi squared for independent nominal variables Von Ruden, Serena (Federal Way), 6/22/2015

22 Incidence of HCF-onset, HCF-associated CDI Feedback? Critique? Questions? Specific Outcome Projects Time to effective antimicrobial therapy Incidence of healthcare facility (HCF)-onset, HCFassociated C. difficile infection (CDI) Reduction in use of medications known to put patients at risk for developing CDI Reduction in number of patients receiving more than 3 antimicrobial agents per day Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Data Collection Received list of all St. Francis patients with positive Clostridium difficile PCR from July Which medications have been shown to increase the risk of developing CDI? 20

23 Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Data Collection Manual retrospective chart review to assess the following: Total number and days of antibiotics received (non CDI) Use of acid suppression therapy (chronic use and new orders) Limited to inpatients only (i.e. excluded those discharged from ED) Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Background Cumulative antibiotic use associated with development of C. difficile infection HR 2.5 (95% CI ) for patients on 2 antibiotics HR 3.3 (95% CI ) for patients on 3-4 antibiotics Retrospective review (n=115) of patients with CDI 75.8% had received PPI Stress ulcer prophylaxis continued inappropriately in more than 85% ICU step-down patients Clin Infect Dis 2011;53(1):42. Pharmacotherapy 2008;28(8): Pharmacotherapy 2011;31(7): Mayo Clin Proc 2013;88(10): Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Description of Problem Retrospective review (n=78) PPI use in 56% of patients Received average 2 non-cdi antibiotics for average 6.5 days of therapy How can inpatient pharmacists affect the use of these medications? 21

24 Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Process Change Created process for pharmacist-driven review of all patients with multiple risk medications Two high risk antimicrobials One high risk antimicrobial + PPI High risk antimicrobials included: Fluoroquinolones Ceftriaxone Ceftazidime Clindamycin Meropenem Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Process Change CDSS alert fired for any patient meeting criteria De-centralized pharmacists reviewed these alerts on a daily basis Pharmacist used algorithm to assist in evaluation Let s practice! 22

25 Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Pre-Intervention Project Timeline Intervention Post-Intervention May 2014 Oct 2014 Feb 2015 May 2015 Year long project by SJMC PGY-1 resident Tony Hoang, PharmD Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Education One-on-one training with pharmacist staff Educational in-service presentations for hospitalist providers Algorithms posted at each pharmacist work station Prospective data collection via tracking form completed by pharmacists Pharmacy resident performed weekly chart audits to ensure compliance with procedure Gave summative and targeted feedback to staff Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Results N=189 patients prospectively screened over 4 month period 82.1% acceptance rate for recommendation to stop PPI No patients who had PPI stopped developed GIB 22.8% reduction in use of high risk antimicrobial agents None of the patients screened developed CDI 23

26 Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Lessons Learned and Next Steps Leveraged GI and ID specialist input in developing intervention Providers more likely to accept recommendation to stop PPI based on GI-approved list of exclusion criteria Great support and buy-in from hospitalist staff led to high intervention acceptance rates On several instances, providers called discharged patients at home to remind them to stop PPI while receiving antibiotic Created P&T approved automatic pharmacist-driven PPI discontinuation protocol Reduction in Use of Medications Known to Put Patients at Risk for Developing CDI Feedback? Critique? Questions? 24

27 Specific Outcome Projects Time to effective antimicrobial therapy Incidence of healthcare facility (HCF)-onset, HCFassociated C. difficile infection (CDI) Reduction in use of medications known to put patients at risk for developing CDI Reduction in number of patients receiving more than 3 antimicrobial agents per day Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Data Collection Used CDSS to pull list of all inpatients receiving 3 antimicrobials from August November 2014 Excluded those on topical, ophthalmic, or oral antibiotics or receiving antibiotics for non-infectious indication (e.g. macrolide for GI motility, azithromycin for antiinflammatory) Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Data Collection Manual retrospective chart review to assess the following: Antibiotic indication Presence of procalcitonin level Presence of MRSA PCR nasal swab Cultures obtained and growth pattern Duration of triple antibiotic therapy 25

28 Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Background For which bacterial infections has procalcitonin been validated in identifying? Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Background Procalcitonin (PCT) Precursor of calcitonin has rapid release during bacterial infection PCT levels aid in the evaluation of bacterial sepsis and lower respiratory infections Bacterial vs viral Trend antibiotic response Studies in outpatient primary care, ED, inpatient, and ICU settings Cut off value 0.5 mcg/l for sepsis, 0.25 mcg/l for LRTI Generally able to de-escalate or discontinue antibiotics when > 80% drop from baseline Expert Rev Anti Infect Ther 2010;8(5): Am J Health-Syst Pharm 2012; 69: Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Background MRSA PCR nasal swab testing Nasal colonization associated with MRSA infection Retrospective cohort study of admitted patients (n=435) with positive bacterial pneumonia Sensitivity of 88% Specificity of 90.1% PPV 35.4% NPV 99.2% Only valid for respiratory tract infections in patients otherwise at low risk for MRSA Antimicrob Agents Chemother 2014;58(2):

29 Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Description of Problem Retrospective chart review (n=50) SFH patients from Aug Nov 2014 receiving 3 or more IV antimicrobials Pneumonia most common indication (51%) followed by sepsis (15%) Pro-calcitonin drawn in 45% of patients with pneumonia or sepsis MRSA PCR ordered in 57% of patients with pneumonia Positive cultures returned for only 40% of patients Average duration of triple therapy 2.3 days Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Process Change Focus on pneumonia as most common indication for 3 or more antimicrobials Created literature-based risk stratification algorithm for HCAP to identify patients at highest risk for MDRO Patients with few MDRO risk factors to be initiated on 1-2 antibiotic regimen instead of 3+ agents Updated pneumonia order set Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Background HCAP definition is poor at determining who might have these pathogens Overtreat areas of low MDR prevalence Undertreat areas of high MDR prevalence Need to look at other risk factors Excess mortality of HCAP primarily attributable to age and comorbidities Several studies done to evaluate outcomes in HCAP patients treated with CAP regimens Clin Infect Dis 2014;58(3):

30 Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Background Retrospective study (n=228) No difference in clinical cure rate, readmission rate, mortality HCAP group had longer duration of IV antibiotics, longer LOS, more superinfection or colonization VA cohort study (n=15,071) Ann Pharmacother 2013;47:9-19. Eur Respir J 2011;38: Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Background Prospective multicenter cohort study (n=445) Stratified by MDRO risk factors and assigned treatment to CAP or HCAP regimen Low risk HCAP patients had low rates of MDRO Similar mortality for patients with CAP and those with 0-1 MDR risk factor HCAP treated with CAP regimen (p=0.346) Clin Infect Dis 2013;57:

31 Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Process Change CDSS pharmacist alert for patients on two or more specific broad-spectrum antibiotics to ensure de-escalation within hours, if appropriate Meropenem Ceftazidime Fluoroquinolones Placed electronic flag prompting future pharmacist follow up if unable to de-escalate immediately Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Process Change Pharmacist and hospitalist staff education on parameters to support antibiotic de-escalation Pro-calcitonin use for sepsis and pneumonia patients MRSA PCR for ruling out MRSA pneumonia in low risk patients CDSS pharmacist alert for all pro-calcitonin values to ensure timely assessment and intervention, if appropriate Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Project Timeline Bundled Step-wise Intervention HCAP Algorithm PCT education CDSS alerts PNA order set updated Post-Initiative May 2014 July 2014 Oct 2014 Feb 2015 May

32 Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Results Patients with pneumonia or sepsis indication Pro-calcitonin drawn for pneumonia or sepsis indications MRSA PCR ordered for pneumonia indication Average days of triple antibiotic therapy Baseline (n=50) Post- Intervention (n=50) 66% 75% NS p value VRS(W2 45% 83% % 93% days 2.5 days NS Mortality 15.4% 11.8% NS Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Results 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Duration of therapy for patients on triple antibiotics DOT > 2 days DOT > 3 days DOT > 4 days DOT > 5 days Baseline Post-Intervention Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Results Low baseline frequency of patients on 3 or more antimicrobials for > 72 hours made it difficult to show impact More post-intervention patients managed by ID Several patients with prolonged courses for osteomyelitis and complicated intra-abdominal infection 30

33 Slide 88 VRS(W2 Chi square test for independent nominal variables T test for continuous independent variable Von Ruden, Serena (Federal Way), 6/22/2015

34 Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Lessons Learned Most difficult intervention to implement Although risk-stratified pneumonia algorithm was created Spring 2014, changes to order set in EMR were not finalized until February 2015 Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Barriers Presence of piperacillin/tazobactam shortage (Jan 2015 May 2015) affected antibiotic selection leading to use of multiple concomitant agents (i.e. cefepime + metronidazole to give approximate coverage to piperacillin/tazobactam) HCAP Algorithm Project Timeline Bundled Step-wise Intervention PCT CDSS education alerts piperacillin/tazobactam shortage PNA order set updated Post-Initiative May 2014 July 2014 Oct 2014 Feb 2015 May 2015 Reduction in Number of Patients Receiving More than 3 Antimicrobial Agents Per Day Feedback? Critique? Questions? 31

35 Our Stewardship Journey Obtaining Administration and Interprofessional Support Multi-disciplinary stewardship committee already well developed Restructured to include more representation from each site hospitals Physician champion and pharmacist site liaison Obtaining MAD-ID certification for lead pharmacist at each system hospital St. Joseph Medical Center hired ID Pharmacist Specialist Justin Jellison, PharmD to help oversee regional program MAD-ID = Making a Difference in Infectious Diseases Our Stewardship Journey Obtaining Administration and Interprofessional Support Our Stewardship Journey Participation Results Face-to-face discussions with patients on importance of stewardship towards preventing CDI when assessing for ability to stop PPI Great collaboration with nursing colleagues led to significant practice change Hospitalists have incorporated changes with regard to PPI use into their practice, circumventing need for pharmacist intervention in many cases 32

36 Our Stewardship Journey Participation Results Frequent face-to-face interaction with providers helpful to strengthen collaborative relationships Increased visibility of stewardship efforts throughout hospital Importance of identifying stewardship team members to staff The Face of Stewardship at St. Francis Hospital Marketing of Antimicrobial Stewardship Program brand ASP Branding 80% 33

37 ASP Branding Next Steps for Our Journey Applied for and received Washington State DOH grant for IT upgrade to allow better antibiotic use data tracking and participation in CDC Antibiotic Use Module Continued momentum with QI project focused on UTI/asymptomatic bacteriuria (ASB) for Significant reduction in ASB treatment rates across 5 of the 9 hospitals in CHI FH Trend towards reduction in duration of therapy for UTI project focused on IDSA HAP guidelines 34

38 Next Steps for Your Journey Next Steps for Your Journey Monthly Safe Table web conferences (next October 19, 2016) 35

39 Post-Test Assessment Questions What are some systemic reasons for delays in antimicrobial therapy administration? T/F: Mild-moderate CDI should always be treated with metronidazole. T/F: Severe CDI should always be treated with regimen that contains enteral vancomycin. Questions and Discussion? Serena Von Ruden, PharmD, BCPS, RN, BSN St. Francis Hospital CHI Franciscan Health References Fazili T, et al. Role of procalcitonin in guiding antibiotic therapy. Am J Health-Syst Pharm 2012; 69: Johnston BC, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systemic review and meta-analysis. Ann Intern Med 2012;157(12):878. Chen JI, et al. Outcomes of health care-associated pneumonia empirically treated with guideline-concordant regimens versus community-acquired pneumonia guideline-concordant regimens for patients admitted to acute care wards from home. Ann Pharmacother 2013;47:9-19. Dangerfield B, et al. Predictive value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab PCR assay for MRSA pneumonia. Antimicrob Agents Chemother 2014;58(2):859. Musher DM, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 2005;40: Zar FA, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007;45: Stevens V, et al. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis 2011;53(1):42. Maruyama T, et al. A new strategy for healthcare-associated pneumonia: a 2 year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy. Clin Infect Dis 2013;57: Chalmers JD, et al. Healthcare-associate pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014;58(3): Kumar A, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34(6): Dellinger RP, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: Crit Care Med 2013;41(2): Attridge RT, et al. Guideline-concordant therapy and outcomes in healthcare-associated pneumonia. Eur Respir J 2011;38: Schuetz P, et al. Procalcitonin for guidancy of antibiotic therapy. Expert Rev Anti Infect Ther 2010;8(5):

40 References Cohen SH, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 2010;31(5):431. Fujitani S, et al. Comparison of clinical severity score indices for Clostridium difficile infection. Infect Control Hosp Epidemiol 2011;32(3): Hebert C, et al. Electronic health record-based detection of risk factors for Clostridium difficile infection relapse. Infect Control Hosp Epidemiol 2013;34(4):407. Musher DM, et al. Clostridium difficile colitis that fails conventional metronidazole therapy: response to nitazoxanide. J Antimicrob Chemother 2007;59: Belmares J, et al. Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system. J Infection 2007;55: Hempel S, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-anaylsis. JAMA 2012:307(18):1959. Allen SJ, et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhea and Clostridium difficile diarrhea in older inpatients (PLACIDE): a randomized, double-blind, placebo-controlled, multicenter trial. Lancet 2013;382(9900):1249. Barletta JF, et al. Proton pump inhibitors and the risk for hospital-acquired Clostridium difficile infection. Mayo Clin Proc 2013;88(10):1085. Murphy CE, et al. Frequency of inappropriate continuation of acid suppressive therapy after discharge in patients who began therapy in the surgical intensive care unit. Pharmacotherapy 2008;28(8): King RN, et al. Incidence of Clostridium difficile infections in patients receiving antimicrobial and acid-suppression therapy. Pharmacotherapy 2011;31(7): Harpe SE, et al. Characterization of continued antibacterial therapy after diagnosis of hospital-onset Clostridium difficile infection: implications for antimicrobial stewardship. Pharmacotherapy 2012;32(8): Time to Effective Antimicrobial Therapy Description of Problem Few IV antibiotics stocked on inpatient units EMR defaulted all new orders to start at next standard administration time Electronic provider consults for pharmacy to dose not always seen in timely manner RNs unaware of need to prioritize 1 st dose antibiotics above other medications 37