Preserve the Power of Antibiotics

PROVIDERInsight News for providers in Northeast Nebraska April 2016 Preserve the Power of Antibiotics Antimicrobial stewardship interventions have been proven to improve individual patient outcomes, reduce the overall burden of antibiotic resistance, and save healthcare dollars. Implementation of an antimicrobial stewardship program in a healthcare facility helps ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration. As a result, there is reduced mortality, reduced risks of Clostridium difficile-associated diarrhea, shorter hospital stays, reduced overall antimicrobial resistance within the facility, and cost savings. Faith Regional s antimicrobial stewardship program went into effect in January 2015, and has made significant strides in the past year toward improvement of antibiotic use. The following is a list of things healthcare providers can do to help: Prescribe correctly Avoid treating viral syndromes with antibiotics, even when patients ask for them. Pay attention to dose and duration: The right antibiotic needs to be prescribed at the right dose for the right duration. Be aware of antibiotic-resistance patterns in your area so that you can always choose the right antibiotic. Reassess within 48 hours of starting antibiotics. Watch for culture results and adjust or stop the antibiotic if necessary. Collaborate with each other and with patients Talk to your patients about appropriate use of antibiotics. Include microbiology cultures, when possible, when ordering antibiotics. Work with pharmacists to ensure appropriate dose, duration, and avoid adverse events. Stop the spread Follow hand hygiene and other infection control measures with every patient. Embrace antibiotic stewardship at Faith Regional Please contact any member of the Antimicrobial Stewardship Team for assistance with antibiotics including the following: Solomon Connealy, MD - Hospital Medicine Jenna Preusker, PharmD,RP - Pharmacist Laura Hoogestraat, RN - Infection Control Thank you for all that you do to help preserve the power of antibiotics for patients! Source: Centers for Disease Control and Prevention Get Smart About Antibiotics Program FRHS Protocols Consent for Treatment Reminder Please remember that as a rule, a parent or court-appointed guardian must consent to treatment of a minor. In Nebraska, a child is a minor until he or she reaches the age of 19 years or is married. Blue Cross and Blue Shield of Nebraska announced that Faith Regional has been designated as one of the first hospitals to receive the Blue Distinction Center+ for Maternity Care designation. Blue Distinction Centers+ for Maternity Care are hospitals recognized for delivering quality, affordable specialty care safely and effectively, based on objective measures developed with input from the medical community. READ MORE > View this issue online at: Soarian Under Links Faith Regional Intranet Under Clinical www.frhs.org Under Education & Resources > For Healthcare Professionals > For Providers > Provider News

2014-2015 Antibiogram Charts Faith Regional Pharmacy provides the following Antiobiogram charts for your use and reference. For questions related to these protocols, contact: Jenna Preusker, Pharm.D., RP ph: (402) 644-7523 fx: (402) 644-7267 jpreusker@frhs.org Faith Regional Health Services - Urine Antibiogram 2014-2015 Period: Jan 2014 - Dec 2015 Gram Positive # isolates 63 106 603 107 63 53 Staph epi (coag. neg.) 37% Enterococcus 63% Gram Negative # of isolates: 169 # of isolates: 826 Escherichia coli 73 % Klebsiella pneumoniae 13 % Additional Pharmacy Contacts: Microbiology: (402) 644-7528 Infection Prevention: (402) 644-7662 Inpatient Pharmacy: (402) 644-7523 Proteus mirabilis 8% Pseudomonas aerug. 6% Relative Cost Usual Dose Assumes normal renal function. Dosage adjustments may be necessary in renal dysfunction. Ampicillin IV/Amoxicillin PO 92 51 R 83 $ 1 gram q6h Amoxicillin/Clav (Augmentin) PO 84 95 97 $ 875 mg q12h Aztreonam (Azactam) IV 95 100 100 85 $$$$ 2 grams q8h Cefazolin (Ancef) IV - 92 97 98 $$ 1-2 grams q8h Cefepime IV - 97 100 100 87 $$ 1-2 grams q12h Cefotaxime (Claforan) IV - 96 100 100 R $ 1-2 grams q8h Ceftazidime (Fortaz) IV 97 100 100 85 $$ 1-2 grams q8h Ceftriaxone (Rocephin) IV - 95 100 100 R $ 1-2 grams q8h Cefuroxime (Zinacef) IV - 93 97 98 - $ 0.75-1.5 grams q8h Ertapenem (Invanz) IV 100 100 100 R $$$$ 1 gram q24h Gentamicin IV 92-89 99 92 74 $ Rx to Dose Imipenem/Cilastatin (Primaxin) IV - 100 100 83 $$$$ 500 mg q6h Levofloxacin PO/IV 48 59 81 100 75 70 $ 500 mg q24h Linezolid (Zyvox) PO/IV 100 100 $$$$ 600 mg q12h Meropenem (Merrem) IV - 100 100 100 88 $$$ 1 gram q8h Nitrofurantoin (Macrobid) PO 98 95 99 65 R $ 100 mg q12h Penicillin PO/IV 92 $ 5 million units q6h Piperacillin/Tazobactam (Zosyn) IV - 99 97 100 91 $$ 3.375 grams q6h Tetracycline PO/IV 86 23 70 87 R - $ 100 mg q12h TMP/SMX (Bactrim/Septra) PO/IV 56-76 94 68 - $$ 10 mg/kg TMP/day Tobramycin IV 90 97 95 94 $ Rx to Dose Vancomycin IV 100 95 $ Rx to Dose R = intrinsic reistance (-) = drug not tested or drug not indicated For serious enterococcal infections, ampicillin should be combined with gentamicin For serious Pseudomonas infections, use double antibiotic coverage Nitrofurantoin NOT effective in pyelonephritis and is contraindicated if CrCl < 40 E. coli susceptibility to cefazolin is a surrogate for oral cephalosporin activity (cefazolin = cephalexin susceptibility)

Faith Regional Health Services - Blood & Tissue Antibiogram 2014-2015 Period: Jan 2014 - Dec 2015 Gram Positive Gram Negative # of isolates: 461 # of isolates: 322 # isolates 24 158 129 34 116 141 56 37 26 62 Strep pneumoiae 5% Staph aureus (MSSA) 34% Staph aureus (MRSA) 28% Staph epi (coag. neg.) 8% Enterococcus 25% Escherichia coli 44% Enterobacter cloacae 18% Klebsiella pneumoniae 11% Proteus mirabilis 8% Pseudomonas aeru. 19% Relative Cost Usual Dose Assumes normal renal function. Dosage adjustments may be necessary in renal dysfunction. Ampicillin IV/Amoxicillin PO - - - - 93 55 R R - - $ 1 gram q6h Augmentin PO 88 100 R - 84-95 85 - $ 875 mg q12h Aztreonam (Azactam) IV 93 87 100 100 81 $$$$ 2 grams q8h Cefazolin (Ancef) IV - R - 72 R 97 77 - $$ 1-2 grams q8h Cefepime IV 100 - - - - 95 93 100 100 92 $$ 1-2 grams q12h Cefotaxime (Claforan) IV 100 - - - - 92 69 100 100 R $ 1-2 grams q8h Ceftazidime (Fortaz) IV 96 84 100 100 92 $$ 1-2 grams q8h Ceftriaxone (Rocephin) IV 100 - - - - 92 50 100 100 R $ 1-2 grams q8h Cefuroxime (Zinacef) IV 71 - - - - 89 R 92 100 - $ 0.75-1.5 grams q8h Clindamycin (Cleocin) PO/IV 75 88 73 71 - $$ 600 mg q8h Daptomycin (Cubicin) 100 100 $$$$$ 500 mg q24h Ertapenem (Invanz) IV - - - - - 100 96 100 100 R $$$$ 1 gram q24h Gentamicin IV - 98-94 - 88 98 100 81 79 $ Rx to Dose Imipenem/Cilastatin (Primaxin) IV - - - - - 99 98 100-85 $$$$ 500 mg q6h Levofloxacin PO/IV 100 83 34 71-75 98 100 91 77 $ 500 mg q24h Linezolid (Zyvox) PO/IV - 100 100 100 99 $$$$ 600 mg q12h Meropenem - - - - - 100 100 100 100 92 $$$ 1 gram q8h Nafcillin IV/Dicloxacillin PO - 100 R 36 - $$$ 1-2 grams q4h Penicillin PO/IV 46 - - - 93 $ 5 million units q6h Piperacillin/Tazobactam (Zosyn) IV - - - - - 97 81 100 100 90 $$ 3.375 grams q6h Tetracycline PO/IV 75 92 94 82 40 72 89 89 - $ 100 mg q12h TMP/SMX (Bactrim/Septra) PO/IV 67 99 100 76-78 100 97 77 - $$ 10 mg/kg TMP/day Tobramycin IV 89 98 100 88 95 $ Rx to Dose Vancomycin IV 100 100 100 100 96 $ Rx to Dose R = intrinsic reistance (-) = drug not tested or drug not indicated ** For serious enterococcal infections, ampicillin or penicillin should be combined with an aminoglycoside ** For serious Pseudomonas infections, use double antibiotic coverage until susceptibilities are available ** In serious Enterobacter infections, a beta-lactam should be combined with an aminoglycoside

With Critical Care Documentation, Time is Critical! Best Practices Critical Care is attention given by a physician or qualified health care professional directly to a critically ill or injured patient. A critical illness is defined as an acute impairment of one or more vital organ systems which creates a high probability of imminent or life-threatening deterioration. Treatment of these conditions include advanced technology, complex and urgent procedures, and life-saving measures. Although location does not matter, critical care is typically provided in a coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or in the emergency room. Management of these types of patients requires a high level of complex decision-making skills and are entitled to a higher level of reimbursement. But time is of the essence! This service is coded and billed based upon the number of minutes spent with the patient so it is extremely important to document this in the record. Your documentation must reflect the total amount of time spent on the care of that patient. This includes direct patient care, review of testing results, discussing the patient s care with other physicians, and documenting in the record. Your attention must be directed only at that patient during this time you cannot count any time spent reviewing or seeing other patients. Thank you for all that you do to provide accurate documentation and thank you for your time! Important Soarian Update Information Soarian Updates Several updates have recently occurred in Soarian information. Please review the three different updates below. 1.) Echo and Stress Test Orders All Echo and Stress Test orders have been collected into one mini-order-set with guidance for use. There is also a detail form for guidelines on when/how to order these tests in accordance with evidence based standards. There is also a Link that will display the Decision Tree upon which the Order Guidelines were created so that providers may use one or both.

Echo and Stress Test Orders

Echo and Stress Test Orders

2.) Lactic Acid Lab Requirements for Sepsis When using the Inpatient Sepsis Order Set there are two pre-checked Lactate orders. Even with these orders, the form will display as described below. If a Lactate result is already available from ER, please consider un-checking the first Lactate (if not already done in ER) to save patient expense and avoid clarification phone calls. Any time the lab is ordered the form will open with a field showing the last date/time that a lactate was resulted if available and includes a notice on the sepsis requirements. If ordering for sepsis, please include a Comment/Special Instructions to that effect. 3.) EKG/ECG and Cardiology Orders Whether you search for an EKG order or select it from 9. CardioPulmon/Respiratory pick list, when the form opens you will need to select the reason, as usual, however, now you will also need to assign an over reading physician. This change is part of the project to make orders flow from Soarian to Epiphany (the EKG system). By automating this order flow Faith Regional staff will be more efficient if providing a service that is vital to patient safety and diagnosis. We appreciate your help with this change. Please review the following process for more details. 1. Select the EKG Order 2. Enter the Reason 3. Use the Cardiologist On Call link if needed to determine which Cardiologist will be reading EKG s on that date. 4. If you over read your own EKG s then select your own name from the drop-down list. 4. If you over read your own EKG s then select your own name from the drop down list. 4.) New Single Sign-on for Sorian/Network Login On March 29, Soarian login was incorporated into your Network login. There is now a new icon for Soarian but a single sign-on that automatically uses this new access to sign you in as usual. With the single sign-on process, it is easier to manage password changes for your login. Your Soarian password will automatically stay in-sync with your Network login. Please contact the IT Help Desk for questions related to your login process.