Session 5 August 11, 2011 Christopher Ohl MD Diane Jacobsen, MPH Guest Presenters: Brenda A. Egan, PharmD, BCPSS Kristi Kuper, Pharm.D., BCPS WebEx Quick Reference Welcome to today s session! Please use Chat to All Raise your hand Participants for questions For technology issues only, please Chat to Host WebEx Technical Support: 866-569-3239 Dial-in Info: Communicate / Join Teleconference (in menu) Select Chat recipient Enter Text 2 1
When Chatting Please send your message to All Participants 3 Our Expedition Director Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI), is content director for Project JOINTS, directs the CDC/IHI Antibiotic Stewardship Initiatives, Expeditions on Antibiotic Stewardship and Sepsis, and serves as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI). Ms. Jacobsen also directed Expeditions on Preventing CA-UTIs, Reducing C. difficile Infections, Improving Flow in Key Areas and Improving Stoke Care. 2
Christopher Ohl, MD Christopher Ohl, MD, is the Medical Director for Antimicrobial Utilization Stewardship and Epidemiology at Wake Forest University Baptist Medical Center, and Infectious Diseases Associate Professor at Wake Forest University School of Medicine 5 Kristi Kuper, PharmD, BCPS Kristi Kuper, Pharm.D, BCPS is the Clinical Director of Infectious Diseases for Cardinal Health and is based in Houston,TX. Previously, she was a clinical pharmacy coordinator at Olathe Medical Center, in Olathe, KS. To date, she has worked in various capacities with over 160 hospitals nationwide. She is primarily responsible for developing programs to assist hospitals with antibiotic management, including antimicrobial stewardship. Her expertise in stewardship is derived from working directly with hospitals to implement on site programs, typically in the community hospital setting (i.e. ID resource deficient ). She is a member of ASM, IDSA, SHEA, and SIDP and several national pharmacy organizations. Dr. Kuper received her Doctor of Pharmacy from the University of Nebraska Medical Center, completed a post graduate pharmacy practice residency at the James A Haley Veterans Hospital in Tampa, FL, and maintains Board Certification as a Pharmacotherapy Specialist. 3
Overall Program Aim The Aim of this Expedition: To provide hospitals with the most effective ideas and practices in improving Antibiotic Stewardship in their organization. 7 Objectives Upon completion of this expedition, participants will be able to: Describe the impact of antibiotic overuse on complications, including Clostridium difficile and adverse drug reactions, length of stay, costs, and antimicrobial resistance Establish or enhance a multidisciplinary focus to heighten awareness of the challenges of antimicrobial resistance and support antibiotic stewardship Identify and begin improving at least one key process to optimize antibiotic selection, dose, and duration of antimicrobial agents in their hospital 8 4
Expedition Focus The expedition will focus on key high leverage changes to ensure timely and appropriate antibiotic utilization: Making antibiotics patient is receiving and start & stop dates visible at point of care Reconciling and adjusting antibiotics focused on care transitions within the hospital Stopping or de-escalating therapy appropriately Monitoring and providing feedback on process measure to assess progress over time Agenda Welcome and introductions Follow-up from Session 4 Stopping or de-escalating therapy appropriately - Review Assignment: what did you TEST? Chris Ohl MD & Diane Jacobsen Session 5 Focus - Insights and challenges in community hospitals - Bristol Hospital s Journey Towards Antibiotic Stewardship Brenda A. Egan, PharmD, BCPSClinical - Implementing stewardship in an ID resource challenged environment Kristi Kuper, Pharm.D., BCPS Preparing for the Final Session all teach, all learn Final Questions & Close 5
Session 4 July 28 th High Leverage Change: Stopping or de-escalating therapy appropriately Key Change Concepts: Establish process for prompt notification of culture and antibiotic susceptibility results Stop or de-escalate antibiotic based on culture result 11 What did you TEST since the July 28 th Session? Design a small test of change to ensure prompt notification of culture and antibiotic susceptibility results Ideas to consider. 1. Set a time frame within which culture results must be reported and to whom. 2. Develop a list of critical results to report to the physician via page or automated means, such as a text message (e.g., MDRO) 12 - Ensure that the reporting system includes mechanisms to alert responsible clinical staff when the attending physician is unavailable - Develop and monitor a standard timeframe for reporting and receiving critical results. 6
What did you TEST since the July 28 th Session? Design a small test of change to Stop or de-escalate antibiotic based on culture result Ideas to consider. 13 1. Develop a process to discontinue antibiotics - When positive cultures most likely represent colonization rather than infection. - If cultures are negative or alternative non-infectious agent is diagnosed in 48 to 72 hours. - Permit physicians to opt out of automatically discontinuing antibiotics based on negative culture results, but require documentation of the rationale. 2. If indication for antibiotics is clearly identified, deescalate therapy to target the susceptibilities of the pathogen. 3. Standardize all hand offs to include review of culture results or pending culture results, antibiotic duration, and current plans for antibiotic discontinuation. Today s Focus Insights and challenges in community hospitals considerations in: Making antibiotics patient is receiving and start & stop dates visible at point of care Reconciling and adjusting antibiotics focused on care transitions within the hospital Stopping or de-escalating therapy appropriately Monitoring and providing feedback on process measure to assess progress over time 14 7
One Community Hospital s Experience Brenda A. Egan, PharmD, BCPS Pharmacy Clinical Manager Bristol Hospital Bristol, CT Bristol Hospital s Journey Towards Antimicrobial Stewardship Brenda A. Egan, PharmD, BCPS Clinical Manager Bristol Hospital, CT August 11, 2011 Copyright 2010,1Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. 8
About Bristol Hospital 134 bed community care hospital Services lines: Inpatient acute care medicine Medical/surgical ICU Labor and delivery Same day admissions/peri-op center Outpatient Cancer Care Center Pharmacy staff: Current hybrid of decentralized and centralized where an ICU pharmacist attends M-F rounds on the unit. 5.6 pharmacist FTEs and all perform clinical activities with varying strengths. Prescribers of antibiotics: ID physicians Hospitalists Intensivists Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Pharmacy Antimicrobial Stewardship Activities Conducted staff training in Fall 2010 Completed a 4 hour proprietary antibiotic stewardship workshop ASHP JCAHO competency assessment Participated in a live webinar on antimicrobial stewardship Speaker from Cardinal Health Infection Preventionist in attendance 18 Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. 9
Pharmacy Antimicrobial Stewardship Activities New class of pharmacist interventions created entitled, MDRO Prevention Interventions, to better track the work done towards NPSG 07.03.01 Later re-titled to Antimicrobial Stewardship Interventions Dramatic improvement in interventions as evidenced by increased documentation 19 Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. External to Pharmacy Antimicrobial Stewardship Activities Integrated stewardship into Infection Control Committee One clinical staff pharmacist greatly involved in the monthly Infectious Disease Committee where she provides quarterly Antibiotic Stewardship activity reports from the pharmacy Interactions with members of the microbiology team to streamline reporting in terms of hiding non-formulary agents Coordination with nurses for timely blood draws to obtain vancomycin or aminoglycoside levels 20 Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. 10
External to Pharmacy Antimicrobial Stewardship Activities Interactions with intensivists and/or ID physicians at daily rounds in the ICU Daily length of stay huddles (LOSH) Attended by nursing, social work, case managers and unit clinical coordinators PRN attendance by Medical Director Pharmacy focus IV to PO conversion opportunities Identify opportunities for de-escalation if not already picked up on daily review of target drug reports 21 Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Pharmacy MDRO Interventions Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. 11
New Policies and Education Antimicrobial Stewardship Policy and Procedure Defines an antimicrobial stewardship program (ASP) Outlines the procedure of the pharmacist s ASP activities that involves a multidisciplinary effort Formulary Restriction Policy Formulary restrictions for antibiotics requiring an Infectious Diseases consultation in the effort to control usage, decrease resistance and control overall costs IV to PO Policy Auto-Conversions 13 out of 17 medications are antibiotics Passed by the ID and P&T Committee Featured articles in the medical staff & pharmacy newsletters P&T Committee requested an early report of physician acceptance Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Stewardship Interventions Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. 12
IV to PO Conversions Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Breakdown of Interventions 1 st Quarter 2011 Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. 13
$/APD 8/9/2011 Antibiotic Purchases Nov 2009 thru Oct 2010 12-month Antibiotic Trend Benchmark $20.00 $18.00 $16.00 $14.00 $12.00 $10.00 $8.00 $6.00 $4.00 $2.00 $0.00 Nov Dec Jan Feb Mar Apr May Prior Year Jun Jul Aug Sep Oct Antibiotic Stewardship activities have resulted in proper utilization of antibiotics and favorable resistance trends Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. An Estimated Cost Value Placed on ASP Intervention Class Quantity Estimated Cost Avoidance Antibiotic Recommendations 16 $3,210.00 Antibiotic Renal Dosing 50 $12,998.00 Antibiotic/Microbiology Assessment PK Evaluation- Aminoglycoside 315 $83,348.00 3 $600.00 PK Evaluation-Vancomycin 52 $6,834.00 Total 436 $106,990.00 28 Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. 14
Lessons Learned Empower staff to get involved in stewardship May not necessarily be an ID trained pharmacist Look to engage staff that have a passion or interest in ID Staff education is key Serves to increase the knowledge base and allow for increased confidence during prescriber interactions Integrate into your hospital culture Don t just put the whole burden on pharmacy If all eyes are on the target, we ll achieve much more Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Lessons Learned Document, document, document Once you ve gathered enough data to see a difference, brag about it to everyone that will listen Lastly, attitude is everything! Rome wasn t built in a day and being a smaller community hospital shouldn t stop you from thinking big. Grabbing pieces and owning parts of an antibiotic stewardship program is better than doing nothing at all Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. 15
Take Home Points We were doing great work, but we didn t know it Creation of a stewardship specific intervention in electronic intervention program helped to quantify number of interventions Allowed us to better measure the program s performance through objective data Provided great information to share with those outside of Pharmacy Multi-disciplinary involvement was key Next steps: External marketing campaign to drum up excitement Posters in elevators and bulletin board throughout facility Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Questions and Discussion 32 16
Implementing Stewardship in an ID Resource Challenged Environment Kristi Kuper, PharmD, BCPS Clinical Director, Inf. Diseases Cardinal Health Pharmacy Solutions kristine.kuper@cardinalhealth.com Analogy Quiz Implementing stewardship in an ID resource challenged hospital can be like: A. Making ice in the desert B. Trying to start a fire in a blizzard C. Driving a car from Texas to California with only two tires D. All of the above 34 17
What is ID Resource Challenged? No Infectious Diseases physician on staff Based on a 2009 survey of 97 hospitals, 42% did not have an ID physician on staff ID physicians not engaged ID physician engaged, but not full time No pharmacist on staff with formal ID training 35 Data on file: Cardinal Health Getting Started It is an exciting time for stewardship Excess excitement often leads to wanting to do something right away We are going to have a meeting! Ready, Fire, Aim! 36 18
Before You Have a Meeting Stop and take an inventory of what you are currently doing related to stewardship Many hospitals are doing stewardship, they just don t define it as such Pharmacy specific Organizational activities Four IHI high leverage changes 37 Before You Have a Meeting Gather Pharmacy metrics Drug costs (per census metric) Utilization Antibiotic intervention data De-escalation Staff resources current and proposed Gather data from other departments Infection Control reports Microbiology/Laboratory Quality 38 19
Before You Have a Meeting Find a physician champion May be ID, may not be Engage CMO or Administrative support Give specific thought to key participants Clearly outline the first meeting Send out agenda ahead of time Tell the story with the data Set goals or define specific actions Set frequency to meet back 39 Ask Yourself These 3 Basic Questions 40 What objective (not subjective) data do you have that shows that there is an issue with inappropriate antibiotic use in your institution? How will you know (again objectively) if your program is successful? What personnel will comprise your team? Do not make your program an island of 1 20
Assessing Program Motivators Not so good answers To only save money My CFO requested it I enter a lot of orders for antibiotics Antibiotic resistance is bad There just seems to be a lot of antibiotic overruse 41 Good Answers To employ cost effective, quality care in our institution. To create a multi-disciplinary program that will encourage appropriate antimicrobial use in our institution. Antibiotic utilization has increased by 17% in the last year. Our goal is to reduce this number to 5% growth for FY11 Based on a review of 100 general medical and surgical patients who received > 3 antibiotics, only 30% of patients had therapy de-escalated after culture and susceptibility reports were returned. Our goal is to improve this number to 60% by year end 42 21
43 Other Suggestions Identify which of the defined problems or issues you plan to address with your stewardship program? Rome wasn t built in a day Please don t make the blanket statement that you are going to decrease ALL antibiotic resistance http://www.idsociety.org/content.aspx?id=11840 Emerg Inf Dis 2007;13(6):838-46 44 Other Suggestions Formalize stewardship policy Set up a stewardship scorecard Antibiotic utilization by month Antibiotic cost per month (e.g. $/APD) Select resistance: Carbapenem resistant Pseudomonas Intervention rates Quality metrics (CMS) HAI rates 22
45 Sample Scorecard 46 Define Implementation 1. How will the day to day activities of the ASP be set up? 2. Who will perform the streamlining functions? 3. Which personnel are assigned to the program (based on hours per week)? 4. Most hospitals are more successful in implementing the stewardship program in stages vs. all at once Use "culture of the month" principles First month only do bug-drug matching on urine cultures, then blood cultures, etc. 23
47 Identify Additional Resources Assess resources that are available (personnel and tools) Personnel The most successful programs are inter-disciplinary Look for program extenders Nursing, Case Management, technicians Maximize technology if you can Make friends with your hospital IT department Network with others that have the same IT system Tools Intervention tracking Other systems within the hospital For example, look at Infection Control tools available Build your own!! 48 Identify Additional Resources Education Home grown Commercial products State and national societies Basic bugs and drugs Nursing Microbiology (obviously more drugs than bugs) Grand rounds Pocket cards and 5 minute consult in-services 24
49 Market the Program Advertise the program before it starts and clearly communicate that this is not just a cost issue Continue to advertise or communicate the results in newsletters or unique communiqués Recognize the successes and acknowledge those individuals who contributed to the success of the program 50 Stewardship Resources 25
On the Web 51 Society of Infectious Diseases Pharmacists www.sidp.org Johns Hopkins Antibiotic Guide http://www.hopkinsguides.com/hopkins/ub Nebraska Medical Center ASP Homepage http://www.nebraskamed.com/careers/education/asp/ University of Kentucky Chandler Medical Center http://www.hosp.uky.edu/pharmacy/amt/default.html KU Medical Center Antibiotic Homepage http://www2.kumc.edu/pharmacy/abxuseguide/table%20of%20conten ts.htm WHO DDD http://www.whocc.no/atc_ddd_index/ In Print 52 Septimus EJ, Owens RC. Need and potential of antimicrobial stewardship in community hospitals. Clin Infect Dis 2011;53(S1):S8-S14 Antimicrobial Stewardship Programs: Interventions and Associated Outcomes. Expert Rev Anti Infect Ther. 2008;6(2):209-222. Antimicrobial Resistance Problem Pathogens and Clinical Countermeasures (Owens RC, Lautenbach E, editors) Antibiotics Simplified. (Gallagher JC, MacDougall C, editors) 26
Sources of Comparison Data Pharma Sponsored Name (Sponsor) Data Source Website Comments T.E.S.T Tigecycline Evaluation and Surveillance Trial (Pfizer, Formerly Wyeth) Susceptibility of Gram Positive Pathogens (Cubist) MYSTIC Meropenem Yearly Susceptibility Test Information Collection (Astra Zeneca) TRUST - Tracking Resistance in the US Today Isolates are collected from 130 global centers. Micro testing performed on site and then info entered into a proprietary database JMI Labs Central Data Repository JMI Labs Central Data Repository Focus Technologies Central Data Repository http://testsurveillance.com/in dex.php?view=welcome&te mplate=main http://www.gppathogens.com/data/default. cfm Not available Not available Susceptibility data limited to drugs that have similar spectrum of activity to tigecycline. Access is free but must register. Data is independently maintained by JMI Labs, one of the leaders in antibiotic susceptibility testing. Site only has gram positive info. Data can only be found in published articles. Not searchable. Website only contains info on S. pneumoniae resistance patterns but TRUST surveillance tracks Gram negative also. May be able to access more info through Ortho McNeil. 53 Sources of Comparison Data Non-Pharma Name (Sponsor) Website Comments ABC - Active Bacterial Core Surveillance CDC CDC Antimicrobial Resistance homepage (CDC) http://www.cdc.gov/abcs/reportsfindings/surv-reports.html http://www.cdc.gov/drugresistance/inde x.html Contains annual susceptibility reports for Group A and B Strep, MRSA, N. meningitidis, and S. pneumoniae, and H. influenzae (through 2009). Cannot query. Real time data not available. JMI Laboratories http://jmilabs.com/default.cfm One of the leaders in antimicrobial testing. Posters and abstracts that they have presented are on this website under the Scientific presentations website but are difficult to search for a particular resistance pattern. National Healthcare Safety Network http://www.cdc.gov/nhsn/ Cannot query. Real time data not available. 54 27
Closing Thoughts 55 Don t let the better get in the way of the good (Voltaire) Don t let perfection stand in the way of progress Questions and Discussion 56 28
What You Should Do Over the Next 14 Days Community Hospitals Identify one key idea from today s session to test in your hospital *consider the steps to implementing stewardship in a resource challenged setting 10 steps to implementing stewardship in a resource challenged sett Review and/or expand - a small test of change your team has focused on related to: visibility of start & stop dates at the point of care process for reconciling and adjusting antibiotics at all care transitions stopping or de-escalating antibiotics. 57 What You Should Do Over the Next 14 Days Huddle with your team to come to the final session prepared to discuss: - role(s) in your organization that you recruited to the unit-based multidisciplinary team to actively test changes, identifying key roles in your organization that may not currently be involved in the process *did you engage roles that had not been involved in ABS? 58 29
What You Should Do Over the Next 14 Days Come to the final session prepared to discuss: Tests of change you ve focused on related to: visibility of start & stop dates at the point of care process for reconciling and adjusting antibiotics at all care transitions stopping or de-escalating antibiotics Approaches used (or tested) in your hospital to monitor and provide feedback on process measure to assess progress 59 Final Session 1-2pm ET Aug 25 th Brief report outs from participating hospitals: progress and challenges 60 30