Antibiotic stewardship in North Carolina hospitals

Introduction Antibiotic stewardship in North Carolina hospitals Ralph Raasch a, Laini Jarrett-Echols b, Carol Koeble c, Christine Pittman d The benefits of hospital-based antibiotic stewardship programs (ASP) have prompted the Centers for Disease Control and Prevention (CDC) to recommend that all acute care hospitals implement ASP. 1,2 Core elements of successful programs have been published 1, and the CDC has developed an assessment checklist/questionnaire to assist hospitals and health systems to evaluate their status in regard to these core elements. 2 The North Carolina Hospital Association (NCHA) is dedicated to improving the quality of healthcare in North Carolina. To that end in 2004, NCHA created the North Carolina Quality Center (NCQC); see www.ncqualitycenter.org. The mission of the NCQC is to partner with providers and communities on their improvement journey to provide safe, quality healthcare. To accomplish this mission, the Center engages NC healthcare organizations in educational programs and collaborative improvement networks, and provides analysis of quality and patient safety data. Each year, the NCHA Board of Trustees and the NC Quality Center adopt a patient safety goal. The NCQC assists healthcare organizations with the acceptance and implementation of the goal. In 2014, the Board s goal focus was directed towards hospital antimicrobial stewardship. The Board recommended that member hospitals: Pledge to develop and/or expand an Antimicrobial Stewardship Program (ASP) by dedicating the necessary human, financial and IT resources for the program to be successful, starting with dedicating a single leader to be responsible for the program by June 2015. Complete the Center for Disease Control s Checklist for Core Elements of Hospital Antibiotic Stewardship Programs. The NCQC provided information about the patient safety goal to all NCHA-member hospitals, and collected and analyzed the results of the CDC s ASP checklist. The purpose of this article is to summarize the ASP checklist data, and to discuss the successes and challenges associated with ASP in North Carolina to date. Priority areas for improvement of ASP core elements as well as the engagement of a statewide team of antibiotic stewardship champions will be identified and discussed. Methods The checklist or survey distributed by NCQC was a minor adaption of the previously referenced CDC checklist 2. The NCQC checklist is included as Appendix 1. In brief, the checklist allows an assessment of the following core elements: Leadership commitment Accountability and drug expertise Implementation of policies and interventions to improve antibiotic use Tracking and reporting of antibiotic use and outcomes Education Accompanied by a letter from the NCHA Board of Directors Chair and NCHA President, checklists were sent to Chief Executive Officers of all NCHA-member hospitals. Both the pledge to antimicrobial stewardship and core element checklist were distributed and 1

collected using Survey Monkey software. Monthly reminders were sent to each hospital CEO and the quality director. A NCQC project manager followed-up with a second announcement by phone and/or email to pharmacy directors informing them of the project and survey. Results The NCHA cover letter and ASP checklist were made available to 140 health-care facilities on June 18, 2014. Over a collection period between June 19, 2014 and June 25, 2015, 102 checklists were completed, for a response rate of 73%. The results of all 102 returned checklists were assessed. All but one of the 102 respondents (99%) pledged to develop or expand their ASPs and dedicate the necessary resources. All102 returned checklists included a name and title of an individual designated as the leader of the ASP efforts at their facility. The remainder of the response data will be presented in various Tables, in the same order in which questions/statements appear in the checklist (Appendix 1). Table 1 shows the responses to questions related to program leadership and accountability. Table 1. Leadership Commitment and Accountability* Question A: Does your facility have a formal, written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship)? Question B: Does your facility receive any budgeted financial support for antibiotic stewardship activities (e.g., support for salary, training, or IT support)? Question C: Is there a physician leader responsible for program outcomes of stewardship activities at your facility? Question Yes No No Response A 56 43 3 B 43 57 2 C 59 40 3 * The number of returned surveys was approximately equal to 100 (102). Thus, by noting the number of positive or negative answers, an assessment of the approximate percentage of responses can be made. Fewer than 60% of hospitals responding have a statement in administrative support of ASP, and fewer than 50% provide financial support for ASP efforts. Additionally, 60% of hospitals are able to recognize a physician leader (or leaders) responsible for ASP outcomes. Table 2 shows results pertinent to questions regarding pharmacy (drug) expertise and other support for ASP. Table 2. Pharmacy and Other Key Support for the Antibiotic Stewardship Program. Question A: Is there a pharmacist leader responsible for working to improve antibiotic use at your facility? Question B: Does any of the staff below work with the stewardship leaders to improve antibiotic use? 2

Question Yes No No Response A 82 17 3 B: Clinicians 79 21 2 Inf. Prevention/ 81 19 2 Hosp. Epidemiology Quality 68 32 2 Improvement Micro Lab 80 20 2 Information 58 42 2 Technology Nursing 60 39 3 Eighty percent of hospitals could recognize a pharmacist leader(s) on their staff responsible for attempting to optimize antibiotic use. As expected, a high percentage of hospitals (~80%) involve staff from their infection prevention/hospital epidemiology and microbiology departments in their ASP efforts, but one fifth of hospitals do not include either expertise in their programs. Information technology is also not involved in many hospitals (~40%). Table 3 summarizes whether there are hospital/facility policies or broad interventions to support optimal antibiotic use. Table 3. Facility Policies or Broad Interventions to Support Optimal Antibiotic Use. Question A: Does your facility have a policy that requires prescribers to document in the medical record or during order entry a dose, duration, and indication for all antibiotic prescriptions? Question B: Does your facility have facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions? Question C: Formal procedure for all clinicians to review the appropriateness of all antibiotics 48 hours after the initial orders (e.g. antibiotic time out)? Question D: Do specified antibiotic agents need to be approved by a physician or pharmacist prior to dispensing (i.e., pre-authorization) at your facility? Question E: Does a physician or pharmacist review courses of therapy for specified antibiotic agents (i.e., prospective audit with feedback) at your facility? Question Yes No No Response A 18 81 3 B 88 11 3 C 18 81 3 D 38 61 3 E 75 24 3 Responses revealed that most hospitals (80%) do not require the documentation of a duration or indication of therapy when antibiotics are prescribed. Similarly, a regular antibiotic review for the appropriateness of continued therapy (eg, at 48 hours) is not performed. On the other hand, one-third of hospitals require pre-authorization by designated physician or pharmacist (presumably the ASP team) prior to dispensing of certain antibiotics. Most hospitals (75%) review courses of antibiotics during therapy. 3

How often these reviews led to a change in therapy (drug, dose or duration) was not assessed. Table 4 shows the responses to questions regarding whether there are certain pharmacy-driven intervention programs in place. Table 4. Pharmacy-Driven Interventions/Actions at Your Facility. Action A: Automatic changes from intravenous to oral antibiotic therapy in appropriate situations? Action B: Dose adjustments in cases of organ dysfunction? Action C: Dose optimization (pharmacokinetics/pharmacodynamics) to optimize the treatment of organisms with reduced susceptibility? Action D: Automatic alerts in situations where therapy might be unnecessarily duplicative? Action E: Time-sensitive automatic stop orders for specified antibiotic prescriptions? Action Yes No No Response A 71 27 4 B 97 1 4 C 93 4 5 D 56 42 4 E 56 42 4 Most notably, the vast majority of hospitals (>93%) report that pharmacy services include the modification of doses in cases of organ dysfunction, and that specific antibiotic pharmacodynamics/kinetics are considered in dosing determination in the treatment of infections caused by bacteria with reduced antimicrobial sensitivities. Less often (about 50%) do hospitals have alerts for duplicative therapy or automatic stop orders. Table 5 lists several common infections and circumstances (surgical prophylaxis) where antibiotics are prescribed. The question asked is whether the hospital/facility has specific interventions in place to address these situations. Presumably, those interventions would be formulated and endorsed by an infectious disease or antibiotic sub-committee, the P & T Committee, and/or the Executive Committee. Table 5. Diagnosis and Infections Specific Interventions. Are specific interventions in place to ensure optimal use of antibiotics for the following infections? Infection Yes No No Response CAP# 79 20 3 UTI 38 61 3 SSTI^ 33 66 3 Surgical prophylaxis 92 8 3 Empiric treatment of 51 48 3 MRSA** Non-C. difficile infection (CDI) antibiotics in new 37 62 3 4

cases of CDI Culture-proven invasive (blood) infections 44 55 3 # = Community-acquired pneumonia. ^ = Skin and soft tissue infection. ** = Methicillin-resistant Staphylococcus aureus. Given the national effort to organize and standardize surgical antibiotic prophylaxis (Surgical Care Improvement Project, SCIP), most hospitals (> 90%) have a prophylaxis policy in place. However, specific interventions/recommendations for UTIs and skin and soft tissue infections are not as common. Table 6 reports on the monitoring conducted by ASP. Table 6. ASP Monitoring. Is your ASP active in monitoring the following adherence or compliance measures? Measure A: Adherence to a documentation policy (dose, duration, and indication)? Measure B: Adherence to facility-specific treatment recommendations? Measure C: Compliance with one of more of the specific interventions in place? Measure Yes No No Response A 21 79 2 B 39 61 2 C 48 52 2 In aggregate, less than half of the responding hospitals are involved in monitoring for adherence to facility-specific treatment recommendations. The low response rate (~20%) for the monitoring of adherence to a documentation policy is likely explained by the low number of hospitals who reported having such policies. (Table 3, Question A). Facility monitoring for rates of C. difficile infection (CDI) is very high (99 of 100 hospitals monitor those rates, 2 hospitals did not reply). Similarly, the vast majority of facilities produce an antibiogram -- Yes 96; No 2; No Response 2. However, the frequency at which these cumulative antibiotic susceptibility reports are produced was not assessed. Table 7 addresses whether or not facilities monitor for the consumption of antibiotics, based on three different metrics. Table 7. Monitoring of Antibiotic Use. Does your facility monitor antibiotic use (consumption) by one of the following metrics? Metric A: By counts of antibiotic(s) administered to patients per day (Days of Therapy; DOT)? Metric B: By number of grams of antibiotics used (Defined Daily Dose, DDD)? Metric C: By direct expenditures for antibiotics (purchasing costs)? Metric Yes No No Response A 32 68 2 B 27 73 2 C 66 34 2 5

Fewer than one-third of hospitals compile information regarding the amount of antibiotics used per patient per day, or the amount of antibiotics used per day within the hospital system. Interestingly, one-third of checklist respondents do not know how much they are spending (purchasing) on antibiotics. Finally, Table 8 summarizes the type of feedback given to prescribers. Table 8. ASP Feedback to Prescribers. Question A: Does you stewardship program share facility-specific reports on antibiotic use with prescribers? Question B: Has a current antibiogram been distributed to prescribers at your facility? Question C: Do prescribers ever receive direct, personalized communication about how they can improve their antibiotic prescribing? Question D: Does your stewardship program provide education to clinicians and other relevant staff on improving antibiotic prescribing? Question Yes No No Response A 39 61 2 B 72 28 2 C 71 29 2 D 64 36 2 Less than half of hospitals report information on their facility s antibiotic use to prescribers. Distribution of antibiograms is more widespread. About two-thirds of ASP provide feedback/education to prescribers on a personalized basis, and provide further education to clinicians and staff on rational antibiotic use. The specific method whereby the education is conducted was not assessed. Discussion The 2014 NCHA annual patient safety goal has been accomplished, and based on a checklist/survey response rate of 73%, a 2014-2015 snapshot of the state of antibiotic stewardship programs in North Carolina is documented. A one-year return period occurred after distribution of the checklist, thus, it is unlikely that waiting more time for the collection of more results would change the overall conclusions of the survey. The pledge to develop or expand hospitals ASP was wholeheartedly endorsed by respondents. Most surveys were returned in mid-2014. Thus, this strong endorsement is encouraging, and it is hoped that survey completion and results review will stimulate further improvement. Based on our results at the time of the survey, certain ASP core measures and processes will be discussed next. Critical financial support for ASP is not specifically budgeted in over half of hospitals. Therefore, key physician and pharmacist salary support must come from other budget sources. As a consequence perhaps, 40% of hospitals currently cannot identify at least one physician leader who is responsible for ASP outcomes, because financial support for that position may not exist. More hospitals (82%, Table 2) are able to identify at least one pharmacy leader with attention to antibiotic stewardship. To significantly impact and influence the prescribing of antibiotics, physician leaders working with a pharmacist are more likely to change prescribing and antibiotic use monitoring than pharmacists alone. 2 Financial support and leaders who are accountable are improvements necessary to enhance the ASP efforts in NC hospitals. 6

It is not surprising that a minority of hospitals (~20%) require prescribers to document the indications and duration for ordered antibiotics, and support an organized review of therapy after 48 hours (Table 3). These requirements are not applied to other drugs prescribed, but the rationale for these core elements should then be an educational objective for prescribers that can be conducted by ASP. Note though that some hospital case management departments are active in educating nursing and pharmacy of the need to proactively request indication and length of treatment, as these factors impact diagnosis-related group (DRG) classifications and discharge planning. On the other hand, the very high response to pharmacy-based dose adjustment of antibiotics based on renal function, and pharmacokinetic/dynamic considerations is reassuring and somewhat surprising, simply because these efforts are occurring at almost all hospitals responding, regardless of bed size, location and academic affiliation. Stronger IT efforts would be beneficial in implementing automatic stop orders and automatic alerts for duplicative therapy (Table 4). Tables 5 and 6 display some disappointing results. Despite several published treatment guidelines for urinary tract infections and skin and soft tissue infections, fewer than 50% of hospitals appear to follow these evidence-based recommendations. Certainly, the use of these guidelines can be another topic of education conducted by ASP. Similarly, the monitoring for adherence to ASP treatment recommendations and specified interventions is poor. Programs should be interested in whether or not their work makes a difference; without monitoring, the effectiveness of the program will not be known. The amount of antibiotics used in hospitals in a variety of metrics (per patient, per day, per amount purchased) is not commonly measured (Table 7). Perhaps because the metrics still require further definition or consensus (days of therapy, defined daily dose), many hospitals do not currently track the amount of antibiotics dosed or purchased for their facility. The amount of antibiotics used is information where additional technology can assist in assessing these metrics and help to measure changes over time. Most stewardship programs distribute information to prescribers (Table 8) via antibiogram distribution and/or prescriber feedback (which is likely to be prescriber and ASP personnel discussion, or perhaps via newsletter). As antibiotic use is not commonly tracked (Table 7), that information is generally not available to prescribers from the ASP. The manner of providing education to prescribers (conducted by about two-thirds of hospitals) regarding rational antibiotic use was not assessed. A higher percentage of hospitals able to conduct effective educational efforts could improve the overall antibiotic prescribing. ASP efforts and their core elements (with the resultant checklist) are strongly endorsed by the CDC and professional societies. 1-3 For a variety of reasons, antibiotic therapy, particularly in hospitals, is becoming less effective, as increasingly resistant bacteria are responsible for significant infections of the respiratory tract, blood, abdomen, skin, and urinary tract. ASP efforts have been shown to reduce the use of unnecessary antibiotics and slow the pace of emergence of resistance. 3 On the basis of the results of the checklist distributed by NCQC, North Carolina is progressing reasonably in efforts to conduct more comprehensive stewardship efforts. Areas that will continue to need to be addressed are financial support, IT support, compliance with facility-based and evidence-based treatment recommendations, monitoring for adherence to these recommendations, and feedback to prescribers, pharmacists, and other relevant personnel on the amount of antibiotics used, and where the utilization is greatest. 7

This ASP checklist effort was only the first part of a planned effort by the NCQC to promote rational antibiotic use in hospitals. Three aggressive stewardship goals have been established by NCQC, as follows: Every hospitalized patient gets optimal antibiotic treatment when required. Every hospital in NC has an active antibiotic stewardship program to accomplish the goal. Every stewardship program uses best practices. Efforts to promote the achievement of these goals are going forward, and include the recruitment of a network of antibiotic stewardship champions comprised of pharmacists representing each of the participating hospitals who attend monthly webinars to discuss priorities and strategies in approaching these goals. The framework for these further approaches is based in the CDC s Antibiotic Stewardship Driver Diagram and Change Package described in reference 4. The webinar-based discussions are just beginning, but conversation thus far has included strategies to promote the acquisition of cultures prior to the administration of antibiotics and the identification of priorities for further promotion of rational antibiotic use in hospitals. For example, based on the checklist results summarized above, the stewardship champions have identified that more hospitals in North Carolina should implement evidence-based guidelines for the treatment of skin and soft tissue infection. 5 In addition, the relatively low percentage of hospitals that follow consensus treatment recommendations for urinary tract infections has been recognized. Needless to say, organizing a statewide effort in antibiotic stewardship is a huge undertaking, and the initiatives begun by the NCQC are just getting started. However, the assessment of antibiotic stewardship core elements in North Carolina in 2014-2015 accomplishes an important first step. Over time and with the continued efforts of NCQC and the stewardship champions, it is believed that the aggressive stewardship goals listed above can be effectively pursued and accomplished. In several years, these efforts should be re-assessed by a repeat distribution of the stewardship checklist to determine what further progress has occurred. Such a comprehensive effort is necessary as the medical/pharmacy community strives to address the emergence of antibiotic resistant bacteria, and the effect of infections due to these bacteria on patient morbidity and mortality. This review of the NCQC survey is the first of several articles planned on ASP in North Carolina. Hospitals are working on their programs, and future articles will tell some of those stories. If pharmacists wish to learn more about NCQC s ASP efforts, and perhaps to participate actively as a member of the stewardship champions network, please contact Ms. Laini Jarrett-Echols at NCQC (Ljarrett-echols@ncha.org). a Ralph Raasch, PharmD, FCCP, BCPS, Interim Editor, North Carolina Pharmacist. b Laini Jarrett-Echols, BS, Project Manager, NC Quality Center. c Carol Koeble, MD, MSc, CPE, Executive Director, NC Quality Center. d Christine Pittman, BS Pharm, RPh, Clinical Staff Pharmacist, LifeCare Hospitals of NC. The authors thank Ms. Julie Henry, Vice President of Communications, North Carolina Hospital Association for her review of the manuscript. 8

References 1. Pollack LA, Srinivasan A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis 2014;59(S3):S97-100. (http://cid.oxfordjournals.org/content/59/suppl_3/s97.full.pdf. Accessed July 17, 2015). 2. http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed July 13, 2015. 3. Dellit TH, Owens RC, McGowan, Jr. JE et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-77. (http://cid.oxfordjournals.org/content/44/2/159.full.pdf. Accessed July 17, 2015). 4. Antibiotic Stewardship Driver Diagram and Change Package. (http://www.cdc.gov/getsmart/healthcare/pdfs/antibiotic_stewardship_change_package _10_30_12.pdf. Accessed July 17, 2015). 5. Stevens DL, Bisno AL, Chambers HF et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e10-e52. (http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full.pdf+html. Accessed July 17, 2015). 9