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Cohort 2 Learning Action Forum Sharing Infection Prevention Strategies that Work Antibiotic Stewardship June 1, 2017

Open Discussion Please use the all chat or raise hand feature to ask a question to the subject matter experts or to start a discussion with your peers. 4

Today s Agenda Antibiotic Stewardship Programs: A Call to Action Implementation and Challenges of an Antimicrobial Stewardship Program Antibiotic Stewardship: Creating a Business Case Upcoming Events and Dates 5

Today s Presenters Payal Patel, MD, MPH Medical Director of Antimicrobial Stewardship VA Ann Arbor Healthcare System Shelby Lassiter, BSN, RN, CPHQ Clinical Content Development Lead HRET 6

ANTIBIOTIC STEWARDSHIP PROGRAMS: A CALL TO ACTION 7

Antibiotic Resistance is a Growing Problem Every year 2 million people get sick with antibioticresistant infections Every year 23,000 die from antibiotic-resistant infections Costs as much as $20 billion in direct health care expenses per year Additional lost productivity of $35 billion a year (Antibiotic Resistance Threats in the United States, CDC, 2013) 8

Fighting Back Against Antibiotic Resistance (Antibiotic Resistance Threats in the United States, CDC, 2013) 9

Goals of Antibiotic Stewardship 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. The Goal is to have the RIGHT DRUG for the RIGHT PERSON over the RIGHT TIME FRAME (Core Elements of Hospital Antibiotic Stewardship Program, CDC, 2014) 10

CDC s Core Elements of Antibiotic Stewardship for Acute Care Hospitals 1. Leadership Commitment: Dedicate resources 2. Accountability: Appoint a leader responsible for implementation 3. Drug Expertise: Appoint a pharmacist leader 4. Actions to Improve Use: Implement at least one recommended action 5. Tracking: Monitor antibiotic prescribing and resistance patterns 6. Reporting: Regularly report on antibiotic use and resistance 7. Education: Train staff, patients and families about resistance and optimal prescribing 11

Percent of Hospitals with Antibiotic Stewardship Programs 12

Learning Action Discussion Poll 1: Do you have the following AS elements in place? A written statement of commitment for AS from executive leadership A physician leader to oversee implementation of AS efforts A dedicated pharmacist to support AS activities Track antibiotic prescribing patterns Provide education to staff about resistance and optimal prescribing 13

Key Concepts: CDC Core Elements Core Element Leadership Commitment Accountability Drug Expertise Actions to Improve Use Actions Dedicate resources Appoint a leader responsible for implementation Appoint a pharmacist leader Implement at least one recommended action Tracking Reporting Education Monitor antibiotic prescribing and resistance patterns Regular report on antibiotic use and resistance Train staff, patients and families about resistance and optimal prescribing 14

IMPLEMENTATION AND CHALLENGES OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM 15

One Hospital s Initiation of Antimicrobial Stewardship Program Small committee formed fall of 2012 Pharmacy clinical coordinator (chair) ID physician (now gone) Infection Preventionist Microbiology supervisor Staff pharmacist Reviewed core and supplemental strategies from 2007 IDSA guidelines to perform gap analysis 16

Staff pharmacist driven Current Activities Near daily review of all patients on antibiotics Indication, cultures, duration, dose Recommendations made verbally or documented in progress notes All positive cultures reviewed (paper report from lab) Dose any antibiotic requested (all Vanco and aminoglycosides) Aggressive IV to PO conversion Automatic renal dose adjustments Automatic stop dates on most antibiotics Several extended infusion antibiotics (pip-tazo, meropenem, cefepime) 17

Current Reporting Quarterly report presented to Infection Control/P&T Pharmacist interventions Cost of total antibiotics and targeted antibiotics per quarter Targeted=high cost/ broad spectrum Days of Therapy (DOT) per quarter for target antibiotics Converted from defined daily doses (DDD) last fall 18

Let s Hear from Participants Questions for Participants (Please speak up or type your responses into the chat box all share, all learn.) How do you conduct audits and provide feedback at your facility? What are some types of antibiotic misuses for which your stewardship team monitors? 19

Pharmacist Education MAD-ID program required for all decentralized pharmacists 4 years ago Continuous education in weekly pharmacy newsletter on guidelines, new therapies Currently 7 pharmacists going through Society of Infectious Diseases Pharmacists (SIDP) program Elective, paid for by hospital, can choose level of program (3 phases) 20

Gaps with Joint Commission Requirements EP 1: Leaders establish antimicrobial stewardship as an organizational priority Presentation made to senior leadership Letter of support from CEO within the week Greater emphasis on need for ID specialist in Medical Staff office Telemedicine contract in negotiation 21

Gaps with Joint Commission Requirements EP2: Education of staff and LIPs involved in antimicrobial ordering, dispensing, administration and monitoring- occurs upon hire and periodically thereafter Created computer based learning (CBL) modules specific to nurses, prescribers, and pharmacists Handouts made for hospitalists Added to nursing orientation Grand rounds for clinic physicians Prescribers still a challenge 22

Gaps with Joint Commission Requirements EP3: Hospital educates patients and their families as needed regarding appropriate use of antibiotics Interpretation can vary- all inpatients, or those discharged on antibiotics? Education done for nurses on requirement, sent to nurse managers Recommended giving drug specific education sheet on discharge Section in patient folder given to all patients on admission 23

Future Directions Procalcitonin Levels- RPh to be authorized to order EPIC upgrade to add new tools Measure total days of therapy from different admissions, outpatient + inpatient Notification on scorecards for positive culture results, bug/drug mismatch Ability to have antibiotic time out? Hard stops for all antibiotics discussed Rapid diagnostic tests 24

Let s Hear from Participants Question for Participants (Please speak up or type your responses into the chat box all share, all learn.) How are you using your EMR (electronic medical record) for antibiotic stewardship? Please share your experience. 25

The Role of Nursing Presentation made at Nursing Education Shindig and CBL for all nurses Make sure prescriber aware of new culture results/ signs & symptoms of infection Suggest oral therapy if patient can tolerate Ask WHY the patient is on antibiotics- on admission and if infection has resolved Watch for s/s CDI- see if unnecessary antibiotics can be discontinued if develops 26

The Role of Nursing Importance of timely administration- associated with increased survival Patient education Proper use, possibility of C diff, why they DON T need an antibiotic (outpatient areas), allergy vs side effect Allergy differentiation and correction in chart Proper hand hygiene Antibiogram awareness Use Pharmacy as a resource! 27

Learning Action Discussion Poll 2: Which of the following AS actions do you have in place? Formal review antibiotic time-out at 48-72 hours Pre-authorization of specific antimicrobials Physician or pharmacist review with feedback IV to PO conversion protocol Alerts for duplicative therapy Treatment guidelines for commonly diagnosed infections 28

Taking an Antibiotic Time Out An ACTION that can be taken for antibiotic stewardship Review antibiotics after 48 hours Does this patient have an infection that will respond to antibiotics? Is the patient on the right antibiotic, dose and route of administration? Can a more targeted antibiotic be used? How long should the patient receive the antibiotic? Every provider should perform the time out 29

Implementing an Antibiotic Stewardship Barriers Lack of support from leaders Program Strategies Share statements on the importance of antibiotic stewardship programs from groups known to the C-Suite such as the National Quality Forum, the American Hospital Association, and the Leapfrog Group Lack of coordination of different disciplines (silos of care) Providers and antibiotic stewardship team overwhelmed by scope of interventions Establish a multidisciplinary team (including physicians, pharmacists, lab, and nursing staff) with clear team goals and metrics and identify clinical and executive champions Develop a priority matrix and start with one stewardship intervention based on the organization s local needs and available data and guidance in literature; establish a sequential rollout that is inclusive of key stakeholders. Focus on 1 or 2 outcomes at a time Reporting perceived as punitive Use measures and stories that resonate with clinicians and patients, frame reports with non-threatening language (Antibiotic Stewardship in Acute Care: A Practical Playbook, National Quality Forum, 2016) 30

Learning Action Discussion Poll 3: Do you feel like your organization currently has the resources to implement an effective antibiotic stewardship program? Yes No 31

ANTIBIOTIC STEWARDSHIP: CREATING A BUSINESS CASE 32

Elements of an Antibiotic Stewardship Program Business Case Needs Evidence Proposal Antimicrobial Stewardship Program Buy-in 33

Recruit Physician and Pharmacy Champions Develop a common purpose, e.g. patient safety, efficiency View physicians and pharmacists as partners and leaders, not barriers Identify clinical champions early Standardize evidence-based processes Provide support from senior leaders (Reinertsen JL, IHI Innovation Series White Paper, 2007) 34

Identify Proposal Audience Identify audience (C-suite personnel? Who?) Vice President, Quality/Safety Chief Medical Officer (CMO) Vice President, Patient Care Services and Chief Nursing Officer (CNO) Chief Financial Officer (CFO) Chief Operating Officer (COO) 35

Determine Needs and Develop Shared Global (examples): Vision for the Program Preserve effective antibiotic therapy Mitigate resistance development Regulatory compliance (new Joint Commission standards) Local (examples): Prevent Clostridium difficile infection (CDI)/ multi-drug resistant organism (MDRO) development Readmissions Regulatory compliance gaps Reimbursement impact Value-Based Purchasing (VBP) Hospital Acquire Condition (HAC)) Cost of unnecessary/prolonged antibiotic administration 36

Tips for a Successful Proposal Pilot the program before formally proposing if possible Focus the initial proposal on the must-have resources Provide global/national rationale and data but do not leave it at that provide credible local data to support proposal Pre-wiring is important Timing is important Document clearly any regulatory or legal requirements that the program helps to fulfill Write a credible plan that addresses cost and revenue accurately 37

Resources for Business Case Development Making the Business Case for ASP Antimicrobial Stewardship Program Proposal Sample Joint Commission Standards on Antibiotic Stewardship Programs 38 How to Pitch an Antibiotic Stewardship Program

Additional Resources CDC Get Smart for Healthcare Core elements checklist Stewardship educational resources Appropriate antibiotic use assessment tools CDC Targeted Assessment for Prevention (TAP) for C. diff toolkit Multiple examples of tools and resource to reduce C. difficile through antibiotic stewardship National Quality Forum Antibiotic Stewardship in Acute Care: A Practical Playbook Practical strategies to implement core elements and overcome barriers 39

Let s Hear from Participants Question for Participants (Please speak up or type your responses into the chat box all share, all learn.) What antibiotic stewardship strategies have you implemented at your facility? Were they successful? 40

QUESTIONS? We Want To Hear From You!!! 41

Project Next Steps Check out the modules on Antibiotic Stewardship and Business Case for Infection Prevention Abx 101: Antibiotic Stewardship Key Components Abx 102: Targeting Urinary Tract Infection to Enhance Antibiotic Stewardship Efforts Abx 103: Targeting Community-Acquired Pneumonia to Enhance Antibiotic Stewardship Efforts BC 101: Key Elements for Effective Business Case BC 102: Tools and Resources to Create Business Case BC 103: Integrating Business Case into Hospital Priorities Reach out to your State Partners for help Mark your calendar for the next Learning Action Forum: Thursday July 6 at 1:00 pm CT Clostridium difficile Infection Prevention Strategies 42

Thank You! Event Evaluation

References Antibiotic Resistance Threats in the United States, 2013. US Department of Health and Human Services. Centers for Disease Control and Prevention, CDC. 2013. Available at: http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf Antimicrobial Stewardship, A Certificate Program for Pharmacists. Society for Infectious Diseases Pharmacists. Accessed on August 5, 2016. Available at http://www.sidp.org/page-1442823 Antimicrobial Stewardship Programs. Making A Difference in Infectious Diseases, MAD-ID. Accessed on August 5, 2016. Available at http://madid.org/antimicrobial-stewardship-programs Avidic E, Cushinotto LA, Hughes AH, et al. Impact of an Antimicrobial Stewardship Intervention on Shortening the Duration of Therapy for Community-Acquired Pneumonia. Clin Infect Dis. 2012; 54(11): 1581-7. Core Elements of Hospital Antibiotic Stewardship Programs. US Department of Health and Human Services, CDC. 2014. Available at http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf Doron S, Davidson LE. Antimicrobial Stewardship. Mayo Clin Proc. 2011; 86(11): 1113-23. Get Smart Healthcare. Centers for Disease Control and Prevention. Accessed July 13, 2016, Available at http://www.cdc.gov/getsmart/healthcare/index.html Healthcare-Associated Infections (HAIs). The Targeted Assessment for Prevention (TAP) Strategy. Centers for Disease Control and Prevention. Accessed on May 21, 2016. Available at http://www.cdc.gov/hai/prevent/tap.html Magill SS, Edwards JR, Beldavs ZG, et al. Prevalence of Antimicrobial Use in US Acute Care Hospitals, May-September 2011. JAMA. 2014; 312(14): 1438-46. National Quality Partners Playbook: Antibiotic Stewardship in Acute Care. National Quality Forum, National Quality Partners, Antibiotic Stewardship Action Team. National Quality Forum. 2016. Available at http://www.qualityforum.org/publications/2016/05/antibiotic_stewardship_playbook.aspx Reinertsen JL, Gosfield AG, Rupp W, et al. Engaging Physicians in a Shared Quality Agenda. Institute for Healthcare Improvement. 2007. Available on www.ihi.org. Solomon DH, Van Houten L, Glynn RJ, et al. Academic Detailing to Improve Use of Broad-Spectrum Antibiotics at an Academic Medical Center. Arch Intern Med. 2001; 161(15): 1897-902. Spellberg B, Guidos R, Gilbert D, et al. The Epidemic of Antibiotic-Resistant Infections: A Call to Action for the Medical Community from the Infectious Diseases Society of America. Clin Infect Dis. 2008; 46(2): 155-64. Stop Spread of Antibiotic Resistance. Making Health Care Safer CDC Vital Signs. Centers for Disease Control and Prevention, CDC. 2015. Available at http://www.cdc.gov/vitalsigns/pdf/2015-08-vitalsigns.pdf 44