Core Elements of Antibiotic Stewardship for Nursing Homes Nimalie D. Stone, MD, MS Medical Epidemiologist for LTC Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Antimicrobial Stewardship in Long-term Care March 23, 2016
Objectives Review current antibiotic use in nursing homes and opportunities for improvement Define antibiotic stewardship and the core elements for effective programs Discuss ways to introduce antibiotic stewardship activities to your facility
Call to action : Addressing antibiotic overuse and resistance in healthcare
Antibiotic use in NHs Antibiotics are frequently prescribed in NHs Comprise ~40% of all NH prescriptions Over the course of a year, 50-70% of residents will receive one or more courses of antibiotics Antibiotic use can cause harm to residents High risk of side effects and adverse events Major risk factor for C.difficile infection Driver of antibiotic resistance 25-75% of antimicrobial use in NHs may be inappropriate Daneman N et al. JAMAIntMed 2013; 173:673-82 Benoit et al. JAGS 2008; 56: 2039-2044 Nicolle LE et al. ICHE 2000; 21:537-545
Patterns of antibiotic use Antimicrobial use varies across facilities Pooled mean 4.8 courses/1,000 resident days, range 0.4-23.5) Primary indications are urinary and respiratory tract infections Fluoroquinolones are the most commonly used 38% of all prescriptions Benoit et al. JAGS 2008; 56: 2039-2044
Antibiotic use in post-acute care Review of antibiotic use among 221 post-acute care admissions in 7 nursing homes 48% of residents received at least one course of antibiotics Antibiotic use rate was 29 courses/1,000 resident days 50% of antibiotics were initiated by hospital Main indication was respiratory tract infections NH-initiated antibiotics most often for urinary tract infections Richards et al. JAMDA 2005; 6: 109 112
Antibiotic use in LTC, Ontario, 2010 Described antibiotic use patterns for LTC residents in Ontario over a single year 75% of the residents (~50,000) received an antibiotic course 44% of antibiotic courses exceeded 7 days in length (prolonged) In mixed logistic model of resident-level factors, only prescriber was associated with a resident receiving a prolonged treatment (P< 0.001) 2601 different physicians prescribed antibiotics 21% of prescribers were responsible for ~80% of the antibiotic courses A subset of providers (n=145) were identified as longduration prescribers (avg. treatment length 11.6 days) Prescribing tendencies were not driven by differences in patient demographic characteristics, comorbidities, or care needs Daneman N et al. JAMAIntMed 2013; 173:673-82
Antibiotic use challenges in nursing homes Prescribers rely on assessments made by someone else 67% of antibiotics were ordered over the phone Limited documentation of assessments and rationale when antibiotics are started 43% of NH-initiated antibiotic courses had no documentation of infection in medical record Difficulty obtaining and interpreting laboratory and diagnostic data to inform antibiotic use Influence of resident, family, and other NH staff on the decision to start antibiotics Richards et al. J Am Med Dir Assoc 2005;6(2): 109-12
Existing regulations promoting antibiotic stewardship in nursing homes Federal Tag 441: Infection Control Mentions performing antibiotic review Federal Tag 329: Unnecessary Drugs To optimize medication use and monitoring to appropriately minimize exposure and prevent consequences Federal Tag 332/333: Medication Errors To reduce preventable errors and adverse events Federal Tag 428: Drug Regimen Review Outlines role of pharmacist in scheduled reviews of medication use in high risk residents
CMS Proposed regulations for certified nursing homes, July 2015 Antibiotic stewardship integrated within pharmacy and infection prevention and control (IPC): Expanding pharmacy medication reviews to include antibiotics for monthly review; reviews also occur for all new admissions/readmissions, ( 483.45) Antibiotic use protocols and monitoring included in IPC ( 483.80) Integrating IPC and stewardship into QAPI activities ( 483.75) Richards et al. JAMDA 2005; 6: 109 112
CDC Core Elements of Antibiotic Stewardship Leadership commitment Accountability Drug expertise Action Tracking Reporting Education http://www.cdc.gov/longtermcare/ prevention/antibioticstewardship.html
Leadership commitment Demonstrate support and commitment to safe antibiotic use in your facility Who are the leaders in your facility? Facility administrators, owners, corporate managers What action can they take? Make stewardship part of position duties for the medical director and director of nursing services Set expectations that antibiotic prescribing and appropriateness of use will be tracked for all clinicians Create a culture, through messaging, education, and celebrating improvement, which promotes antibiotic stewardship
Accountability Identify physician and nursing leads responsible antibiotic stewardship activities Who is empowered to set the practice standards? The medical director? The director of nursing? What action can they take? Educate clinical providers and nursing staff about stewardship policies and practices Explore knowledge, perceptions and attitudes about antibiotic use stewardship among staff Establish best practices and management algorithms for evaluating and managing residents with infections Monitor and report antibiotic prescribing and use data to staff and providers
Partner with consultant pharmacists The consultant pharmacists are key partners in guiding antibiotic stewardship activities by: Establishing standards on laboratory testing to monitor for adverse events and drug interactions Ensuring appropriate medication selection Reviewing antibiotic prescriptions for appropriate dosing, duration, indication and match with culture results Providing summary reports on antibiotic use New antibiotic starts and/or days of therapy Provider-specific reports for feedback and education
Drug Expertise Establish access to individuals with experience or training in antibiotic stewardship for your facility. Request a consultant pharmacist who has training/experience in antibiotic stewardship Partner with stewardship program leads at hospitals within your referral network Develop relationships with infectious disease providers interested in providing consultation to support stewardship Ask state and local health departments to connect you with other facilities working on stewardship within your community
Actions Add stewardship activities in a step-wise fashion Implement policies on antibiotic prescribing and use Develop communication protocols for relaying information to providers when an infection is suspected Establish best practices for use of microbiology and diagnostic testing Work with your consultant pharmacist to monitor antibiotic prescribing and use Establish facility-specific management and treatment algorithms
Nursing Home Core Elements: Appendix A Provides evidencebased examples of policy and practice interventions including pharmacy-driven actions
Examples of antibiotic prescribing policies Documenting the elements of an antibiotic prescribing bundle Dose and route Duration (start date/end date/planned days of therapy) Indication Treatment rationale (prophylaxis vs. therapeutic) Treatment site (e.g., urinary tract, wound, etc.) Performing an antibiotic time-out Assessing a resident 2-3 days after an antibiotic start to determine ongoing need and appropriateness of antibiotic selection Changes to antibiotic selection may be based on resident s clinical status, new laboratory or diagnostic data
Improve assessments and communication for suspected infections Examine your process for assessing, documenting and communicating suspected infection Assess the quality of interactions between front-line staff and clinical providers Consider asking providers and nurses for barriers or opportunities for improvement Review the information being communicated when residents are suspected of infection Identify relevant history, vital signs, appropriate physical exam, medication hx, allergies, etc. Ensure all staff are communicating the key pieces of data Consider using a standard assessment/communication tool (e.g., SBAR)
Example of tools for documenting and communicating new signs/symptoms IP Form courtesy of Ellen Bartlett, Houlton Regional Hospital, Maine AHRQ: http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/nh-aspguide/module1/toolkit1/utisbar-form.html
Set standards for use of diagnostic tests Examine the ways laboratory tests are used in your facility Assess the rationale for submitting a urinalysis or urine culture Are non-specific changes driving urine testing? If a urine culture is positive, has the resident been reassessed for symptoms before treatment is started? Ensure good quality specimen for culture prior to antibiotic start Poor specimen collection and handling leads to false positive results Do not send urine cultures or C. difficile tests following a course of therapy Diagnostic tests were not designed to show cure Positive results frequently reflect colonization but drive additional antibiotic treatment
Use evidence-based practice guidelines to create management algorithms Clin Infect Dis 2009; 48:149-171 Infect Control Hosp Epidemiol 2001; 22:120-124
Urine culture algorithm based on Loeb minimum criteria Loeb M, et al. Br Med J. 2005; 331: 669
Tracking Monitor antibiotic prescribing patterns and outcomes from antibiotic use in your facility Prescribing process measures Adherence to documenting prescribing elements Completeness of resident assessment documentation Appropriateness of antibiotic selection Antibiotic use measures Point prevalence of antibiotic use New antibiotic starts Days of antibiotic therapy Outcome measures C.difficile and multidrug-resistant organisms Adverse events and/or costs related to antibiotic use
Nursing Home Core Elements: Appendix B Provides detailed examples for monitoring antibiotic use process and outcome measures Includes information about reporting antibiotic resistance and C. difficile using the CDC s National Healthcare Safety Network
Process measure: Prescription auditing tool
Antibiotic use measure: Point prevalence Point prevalence surveys of antibiotic use describe the percent of residents receiving an antibiotic during a specified time frame (e.g., single day) Provides a snap-shot of use Calculating prevalence Antibiotic prevalence: # of residents on an antibiotic/total residents in the facility X100 Antibiotic prevalence on admission: # residents admitted on antibiotics/ total new admissions X100 You can compare antibiotic prevalence in different populations, (e.g., short-stay vs. long-stay) or by provider
Antibiotic use measure: Antibiotic starts Rate of new antibiotic prescriptions each month; usually only count nursing home initiated courses Trended over time, usually by month or quarter Calculating rates of antibiotic starts Number of new antibiotic prescriptions/ residentdays X1,000 You can calculate antibiotic starts by provider but the denominator has to be adjusted by the number of residents cared for by each clinician Number of new antibiotic starts by Dr. S/ (total resident-days * % of residents cared for by Dr. S) If Dr. S cares for 25% of patients in the facility, then adjustment is total resident days*0.25
Antibiotic use measure: Days of therapy Describes the total amount of antibiotic days during a specific time period, usually a month or quarter Each day a resident receives a single antibiotic = 1 antibiotic day. A 7-day course of amoxicillin = 7 antibiotic days A 7-day course of ceftriaxone plus azithromycin = 14 antibiotic days Antibiotic days of therapy (DOT) calculations Antibiotic utilization ratio: Total monthly antibiotic DOT/ total monthly resident-days *1,000
Outcome measures Antibiotic stewardship can have impact on important resident outcomes Reduced rate of adverse events from antibiotics Reduced rate of C.difficile infection Improvements in the antibiotic susceptibility profile of common organisms identified in cultures A tool for monitoring susceptibility in your facility is known as an antibiogram a report which summarized the percent of isolates susceptible to various antibiotics Work with your clinical laboratory to see if an antibiogram can be developed for your facility
NHSN Long-term Care Facility Component: Data for Action NHSN infection reporting tailored for LTCF providers, released in September 2012: ~295 NHs currently enrolled Offers standardized event criteria and data analysis across facilities Reporting options Urinary tract infections, Multidrug-resistant organisms and C.difficile Adherence to hand hygiene and gown/glove use www.cdc.gov/nhsn/ltc
Reporting Provide regular feedback to providers and frontline staff about antibiotic use and resistance data The most effective antibiotic stewardship interventions have combined education with provider-specific feedback Feedback on performance makes a provider aware of his/her practices and how that compares to their peers Data is most powerful when it is shared try to make sure everyone in your facility is aware of important resident outcomes related to antibiotic use (e.g., C. difficile infections) Showing providers and staff the impact of their efforts is critical to sustaining change
Education Educate clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use Perhaps the most important first step in implementing antibiotic stewardship Change doesn t happen without education Use educational events as an opportunity to engage providers and staff in identifying ways to improve current practices Include residents and family materials in your educational efforts -- remember their beliefs about antibiotics are based on what we teach them.
CDC antibiotic stewardship campaign: Get Smart Utilize existing campaigns, resources, to make facility staff, and residents more aware of safe antibiotic use http://www.cdc.gov/getsmart/healthcare/
CDC resources for clinician education www.cdc.gov/longtermcare/
CDC resources for consumer education http://www.cdc.gov/longtermcare/pdfs/factsheet-coreelements-what-you-need-to-know.pdf
Resources for consumer education www.choosingwisely.org/doctor-patient-lists/
Core Elements of Antibiotic Stewardship for Nursing Homes Summarized as 2-page checklist http://www.cdc.gov/longtermcare/pdfs/core-elementsantibiotic-stewardship-checklist.pdf
Take away points Antibiotic stewardship is a national priority for all healthcare settings, including nursing homes Creative solutions and partnerships can overcome resource limitations Engaging in activities now will prepare nursing homes for the future Facilities actively developing antibiotic stewardship programs will be identified as community leaders by hospital partners Programs will be in place to meet regulations for improving antibiotic use
Thank you!! Email: nstone@cdc.gov with questions/comments For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion