Objectives Understand the application of Antibiotic Stewardship regulations in LTC Understand past barriers to antibiotic management concepts Understand benefits of adoption of antibiotic stewardship regulations Understand the ancillary benefits to LTC not evident in the regulations alone Recognize case examples from early experiences with antibiotic stewardship
Goals Antibiotic stewardship refers to a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.
Goals Reducing treatment failures, lengths of stay, morbidity, and mortality Increasing infection cures and the frequency of appropriate, cost-effective prescribing for therapy and prophylaxis Reducing adverse effects of antibiotics, the incidence of C. difficile associated diarrhea, and antibiotic resistance Improving pathogen susceptibility profiles
CDC Elements of ABX Stewardship Leadership Accountability Drug Expertise Action Tracking Reporting Education
Leadership Can your facility demonstrate leadership support for antibiotic stewardship through one or more of the following actions? Written statement of leadership support to improve antibiotic use Antibiotic stewardship duties included in medical director position description Antibiotic stewardship duties included in director of nursing position description Leadership monitors whether antibiotic stewardship policies are followed Antibiotic use and resistance data is reviewed in quality assurance meetings
Accountability Has your facility identified a lead(s) for antibiotic stewardship activities? Medical director Director or assistant director of nursing services Consultant pharmacist Other:
Drug Expertise Does your facility have access to individual(s) with antibiotic stewardship expertise? Consultant pharmacist has staff trained/is experienced in antibiotic stewardship Partnering with stewardship team at referral hospital External infectious disease/stewardship consultant Other:
Action Does your facility have policies to improve antibiotic prescribing/use? Requires prescribers to document a dose, duration, and indication for all antibiotic prescriptions Developed facility-specific algorithm for assessing residents Developed facility-specific algorithms for appropriate diagnostic testing (e.g., obtaining cultures) for specific infections Developed facility-specific treatment recommendations for infections Reviews antibiotic agents listed on the medication formulary Other:
Actions Has your facility implemented practices to improve antibiotic use? Utilizes a standard assessment and communication tool for residents suspected of having an infection Implemented process for communicating or receiving antibiotic use information when residents are transferred to/from other healthcare facilities Reports summarizing the ABX susceptibility patterns (ex: facility antibiogram) Implemented an antibiotic review process / antibiotic time out Implemented an infection specific intervention to improve antibiotic use Indicate for which condition(s):
Actions Consultant RPh Does your consultant pharmacist support antibiotic stewardship activities? Reviews antibiotic courses for appropriateness of administration and/or indication Establishes standards for clinical/laboratory monitoring for adverse drug events from antibiotic use Reviews microbiology culture data to assess and guide antibiotic selection
Tracking Does your facility monitor one or more measures of antibiotic use? Adherence to clinical assessment documentation (signs/symptoms, vital signs, physical exam findings) Adherence to prescribing documentation (dose, duration, indication) Adherence to facility-specific treatment recommendations Performs point prevalence surveys of antibiotic use Monitors rates of new antibiotic starts/1,000 resident-days Monitors antibiotic days of therapy/1,000 resident-days Other:
Tracking Does your facility monitor one or more outcomes of antibiotic use? Monitors rates of C. difficile infection Monitors rates of antibiotic-resistant organisms Monitors rates of adverse drug events due to antibiotics Other:
Reporting Does your facility provide facility-specific reports on antibiotic use and outcomes with clinical providers and nursing staff? Measures of antibiotic use at the facility Measures of outcomes related to antibiotic use (i.e., C. difficile rates) Report of facility antibiotic susceptibility patterns (within last 18 months) Personalized feedback on antibiotic prescribing practices (to clinical providers) Other:
Education Does your facility provide educational resources and materials about antibiotic resistance and opportunity for improving antibiotic use? Clinical providers (e.g., MDs, NPs, PAs, PharmDs) Nursing staff (e.g., RNs, LPNs, CNAs) Residents and families Other:
Goals The goals of antimicrobial stewardship programs include attenuating or reversing antimicrobial resistance, preventing antimicrobial-related toxicity, and reducing the costs of inappropriate antimicrobial use and health care- associated infections.
Past Barriers Patient is a bother Chronic prophylaxis Bactrim DS Nitrofurantoin Empiric treatment Nurse reporting / education Nursing Home Perceptions
Current Regulations A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.75(e) and accepted national standards; - Identified Infection Control person, hand washing standards, isolation protocols, tracking to ensure spread is limited during breakouts.
Proposed Regulations Requirements for the facility to perform a facility-specific assessment of their resident population and facility ( 483.70) Integration of the infection prevention and control program (IPCP) with the facility s QAPI processes ( 483.75) Revising the description of the infection control program and adding a requirement to periodically review and update the program ( 483.80)
Proposed Regulations Requiring an antibiotic stewardship program that includes antibiotic use protocols and a system for monitoring antibiotic use ( 483.80) Designation of specific infection prevention and control officers (IPCOs) ( 483.80) Written policies & procedures for the IPCP ( 483.80) Education or training related to the infection control program ( 483.80)
Early Adoption Experience Recognizing that the industry will face increased regulatory requirements consistent with the CDC recommendations, we assembled local experts from hospitals and long term care to build an off the shelf antibiotic stewardship program as a value add to our consultant pharmacist role.
Sales.. Consultant RPh Vaccinations Roster Billing Prevnar example Part A cost reduction strategy Highest line item costs Create competitive advantage in admissions Take those patients that others cannot
Barriers
Implementation Evaluate current systems: Lab Referring Hospital collaborations Identify Steward within hospitals Admission Review Chronic NH management systems UTI Management Utilization Vaccination protocols Sophistication rest home, rural vs urban, IV use
Tailored Approach Evaluate current systems: Lab Referring Hospital collaborations Identify Steward within hospitals Admission Review Chronic NH management systems UTI Management Utilization Vaccination protocols Sophistication rest home, rural vs urban, IV use
Basic System Antibiogram (Tracking / Reporting) Utilization Matrix (Tracking / Reporting) Admission review (Action) MRR (Action) Updated Protocols (Action / Education) Integrations into QA (Reporting / Education)
Culture and Sensitivity
Culture and Sensitivity
Early Lessons Patient assessment ex. UTI Not new, collaboration with MDs, NPs and nurses, education Recognition of referral Anti-biogram information Prescribing patterns sometimes based on discharge location Daptomycin vs Vancomycin Surveillance of Hospital Stewardship
Early Lessons I prescribed Cubicin because we were discharging to a nursing home and they can t manage vanc dosing. The ID doc doesn t like to be questioned. Initial percentage of IV antibiotic admissions that included culture and sensitivity lab work: 0% After 45 days: 18%, but almost 60% post admission
Early Lessons Wins Pharmacists are commonly stewards in hospitals Helps mediate difficult prescribers Good conduit for information (anti-biogram, C&S) Cost savings from changing to less expensive, but appropriate antibiotics in improving facility cost risk and changing the view on whether or not admissions can be considered. Increased level of care in nursing homes
Pharmacist Perspective Utilization Management Integration of vaccines Focus on PPI use Formulary Understanding payer environments Collaboration with hospital stewards
Questions