Antibiotic Stewardship in the Long Term Care Setting Presented By Shelley Bhola RN BC, BSN, PHN, MSN RAC CT Nurse Consultant Senior Providers Resource, LLC Objectives Upon completion of this session, the attendee will be able to: 1. Review regulatory expectations in F441 2. Describe the role and need for an Infection Prevention and Control Officer 3. Demonstrate examples of Antibiotic Stewardship and how to incorporate them into every day practice From the White House Vision: The United States will work domestically and internationally to prevent, detect, and control illness and death related to infections caused by antibiotic resistant bacteria by implementing measures to mitigate the emergence and spread of antibiotic resistance and ensuring the continued availability of therapeutics for the treatment of bacterial infections. (National Strategy for Combating Antibiotic Resistant Bacteria, 2014) 1
History of Antibiotics The first U.S. civilian saved by antibiotics was in 1942 She was 33 years old and suffered with a life threatening streptococcal infection She was hospitalized for more than a month Treatments such as sulfa drugs, blood transfusions and surgery had no effect Her fever reached 107 F as a last resort, her doctors injected her with a tiny amount of an experimental drug That drug was penicillin (MMWR Weekly, 1999) The result? Not only did her temperature drop overnight, by the next day the delirium was gone She survived to marry, raise a family, & to meet Sir Alexander Fleming, the scientist who discovered penicillin She not only survived, she lived to be 90 years of age (MMRW Weekly, 1999) The Pre Antibiotic Era 1942 ended the pre antibiotic era Pneumonia, which was the leading cause of death, was treatable Life expectancy increased What has changed in the past 64 years? 2
Antibiotic Resistance Antibiotic Resistance According to the CDC Antibiotic/antimicrobial resistance is the ability of microbes to resist the effects of drugs the germs are not killed and their growth is not stopped. Antibiotic resistance has become one of the most important public health threats we face locally and globally spawning the vision set forth by the White House. Bacteria and Microbes Microbes are organisms too small for the eye to see and are found everywhere. Types of microbes include bacteria, viruses, fungi, and parasites. While most microbes are harmless and even beneficial some can cause disease among humans, other animals, and plants. Disease causing microbes are called pathogens or "bugs" or "germs". All types of microbes have the ability to develop resistance to the drugs created to destroy them, becoming drug resistant organisms. (CDC, 2016) 3
The Cause The World Health Organization (WHO) considers misuse and overuse of antimicrobials as one of the top three threats to human health. (Moody, 2012) Once antibiotic resistant organisms are present in an individual or a healthcare facility, they can spread easily via inadequate infection prevention and control measures primarily poor hand hygiene. Antibiotic IQ Question #1 True or False: Antibiotics do not help a chest cold, but if you have bronchitis, you will need them. Answer: False Acute bronchitis and chest cold are two different names for the same illness. The illness is almost always caused by a virus, so in general, antibiotics won t help. Rest, fluids and a cough expectorant will be more beneficial. The Reality in Long Term Care 4.1 million Americans are admitted to or live in a long term care setting during a year As many as 70% of these residents received antibiotics during a year Up to 75% of antibiotics are prescribed incorrectly 4
2015 The year of Change In March 2015 the 2014 National Action Plan for Combating Antimicrobial Resistance was released by the White House. In June 2015, the White House held a forum on Antibiotic Stewardship, which included many nursing home partner organizations. In July 2015, CMS proposed new Federal Regulations for Long Term Care facilities including new infection prevention and antibiotic stewardship activities. (Dow, 2016) It is time to act Antibiotic Stewardship has to be a focus. Challenges in Long Term Care Prescribers are often prescribing antibiotics over the phone Documentation is often missing key details regarding actual infection, and the patient symptoms that led to the call and request for antibiotics Laboratory and diagnostic data can be difficult to obtain, or results are not received timely (Dow, 2016) 5
Regulatory Guidance Currently the following exists to promote appropriate use of antibiotics: F 441 Infection Control F 329 Unnecessary Drugs F 332 & F 333 Medication Errors F 428 Drug Regimen Review (Dow, 2016) Proposed Rule of 2015 Addresses concerns about antibiotics, including expanding pharmacy medication reviews to include antibiotic use, improved antibiotic protocols, and integration of an Antibiotic Stewardship Program into existing QAPI activities. (Dow, 2016) Antibiotic IQ Question #2 True or False: Antibiotics are good for treating strep throat? Answer: True Most sore throats are caused by viruses, but strep throat is caused by a bacteria. If your doctor does a test, and you have strep, you will need to be on an antibiotic. 6
Antibiotic Stewardship Antibiotic Stewardship Programs (ASPs) promote the appropriate use of antibiotics by selecting the appropriate dose, duration and route of administration. The appropriate use of antibiotics has the potential to: Improve efficacy, Reduce treatment related costs, Minimize drug related adverse events, and Limit the potential for emergence of antibiotic resistance. (Drew, 2009) CDC Program for Long Term Care The CDC defines antibiotic stewardship as A set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Core Elements for Antibiotic Stewardship in Nursing Homes 1. Leadership commitment 2. Accountability 3. Drug expertise 4. Action 5. Tracking 6. Reporting 7. Education 7
Leadership Commitment Write statements in support of improving antibiotic use Include stewardship related duties in position descriptions for the medical director, clinical nurse leads, and consultant pharmacists Communicate with the nursing staff and prescribing clinicians about the facility expectations regarding the use of antibiotics, the monitoring and enforcement of stewardship policies Create a culture, through messaging, education, and celebrating improvement, which promotes antibiotic stewardship Accountability Medical Director sets standards for antibiotic prescribing practices that are followed by all clinical providers. Director of Nursing set the practice standards for assessing, monitoring and communicating changes in resident s condition by the front line staff. The knowledge, perceptions and attitudes among the nursing staff will influence how information is communicated to the clinicians who decide on use of antibiotics. Consultant Pharmacist quality assurance activities such as medication regimen review and reporting of antibiotic use data. Accountability Infection Prevention and Control Preventionalist must have expertise to improve antibiotic use. This includes tracking, monitoring adherence to evidence based published criteria and evaluation and management of treated infections to review patterns or trends. Consultant Laboratory develop a process for alerting the facility if certain antibiotic resistant organisms are identified, providing education for nursing staff on the differences in diagnostic tests available, etc. 8
Drug Expertise Work with a consultant pharmacist who has received specialized infectious disease or antibiotic stewardship training. Partner with antibiotic stewardship program leads a the hospitals in your referral network. Develop relationships with infectious disease consultants in your community interested in supporting your facility s stewardship goals. Antibiotic IQ Question #3 True or False: It does no harm to take an antibiotic even if you have a virus it will make you feel better sooner Answer: False By misusing antibiotics, you could also be helping to create superbugs resistant bacteria that are not killed by antibiotics. Antibiotics are one of our most important weapons in the fight against disease. We can t afford to misuse them. Action Provide policies that support optimal antibiotic use Broad interventions to improve antibiotic use (will discuss later) Pharmacy interventions that improve antibiotic use Infection and syndrome specific interventions looking at those on prophylaxis antibiotics for history of UTI s 9
Tracking and Reporting Usually are done simultaneously. Track how and why antibiotics are prescribed. Track how often and how many antibiotics are prescribed. Antibiotic use data from nursing homes to improve antibiotic stewardship efforts is important for individual facility improvements and for public health action. Antibiotic outcome measures: Tracking the adverse outcomes and costs of antibiotics New QA data Antibiotic days of Therapy (DOT) An antibiotic day each day the resident receives a single antibiotic If a resident is prescribed a 7 day course of amoxicillin, that course equals 7 antibiotic days. However, if a resident is prescribed a 7 day course of amoxicillin plus azithromycin, then the course equals 14 antibiotic days. Antibiotic DOT the sum of all antibiotic days for all residents in the facility during a given time frame (a month or a quarter) Rate of antibiotic DOT (per 1,000 resident days): (Total monthly DOT/total monthly resident days x 1000) Antibiotic utilization ratio: Total monthly DOT/total monthly resident days Example A facility has 10 residents that received a 7 day course of single antibiotics. The facility has an average of 50 residents in the facility with a total resident days for a 30 day month being 1500. 70 x 1000 = 46% 1500 10
Education, Education, Education It s more than simply staff antibiotic stewardship education needs to go out to the clinicians, residents and their families/rp s. Flyers, pocket guides, newsletters, emails whatever way works best for your facility you need to get your goals out there. The strongest evidence for improving medication prescribing practices is to have everyone looking at the same goal. Infection Preventionalist & Control Officer (IPCO) The proposed changes to F 441 require a RN staff member who is employed by the facility at least ½ time. This RN needs to receive education above and beyond the education received in nursing school. The primary focus of the IPCO is that of infection prevention. Surveillance As discussed, tracking and reporting will be imperative to this position. However, surveillance requires that the information tracked is analyzed and appropriate measures are then taken. The regulation currently defines surveillance as the ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks, to try to reduce morbidity and mortality, and to improve resident health status. (SOM, 2015) 11
What is expected Currently, these are items that the surveyor can ask for: 1. Monitoring and documenting of infections this includes tracking and analyzing outbreaks of infection, as well as implementing and documenting actions to resolve related problems. 2. Surveillance, including process and outcome surveillance, monitoring, data analysis, documentation and communicable disease reporting. 3. Documented data analysis to help detect unusual or unexpected outcomes that will determine the effectiveness of infection prevention and control practices 4. Use of records to improve infection control processes and outcomes by taking corrective actions (SOM, 2016) Current expectations 5. Perform surveillance and investigation to prevent the onset and spread of infection. 6. Facilities may use various approaches to gathering, documenting, and listing surveillance data; but it needs to describe the types of infections and needs to be able to identify trends and patterns. (SOM, 2016) Current Expectations There needs to be statistical analysis of the data that is found and then there needs to be feedback of results to the primary caregivers so that they can assess the residents for signs of infection and use the correct precautions. 12
What's to come? The IPCO will need to coordinate all efforts in the facility to assure timeliness of surveillance. Month end reports will do nothing to stop the immediate spread of an infection. Real time prevention will be required. Real time data analysis with prevention strategies firmly in place. Antibiotic usage will need to be stopped the day an infection is found not to meet criteria. Education, Education, Education Antibiotic IQ Question #4 True or False: Clostridium Difficile is the most common MDRO we currently have. Answer: False C Diff is one of our most pressing adverse reactions to the use of antibiotics, but it is not considered to be a MDRO. It is however, a major threat to our residents and is caused by; overprescribing of antibiotics, improper cleaning of surrounding environment, and improper infection prevention precautions of staff. What to do? Infections are a common problem among residents in a long term care facility. They are at risk due to: 1. Resident factors including chronic illness, age, functional impairment 2. Close living conditions 3. Low influenza vaccination rates among healthcare staff 4. Transfer between acute and long term care settings 5. High rates of antibiotic usage 13
What is seen The most common infections seen in long term care residents are: 1. Urinary tract infections (UTI) 2. Lower respiratory tract infections such as influenza or pneumonia 3. Skin and soft tissue infections 4. Gastroenteritis Where to start? An example given on a recent MLN Connects webinar Performance Improvement Project Subject Urinary Tract Infections Root Cause Analysis: Criteria for utilization of antibiotics has changed Family insistence Adequate hydration Physicians/Nurses/Families require education on new criteria Objectives Reduce urinalysis obtained by 25% Reduce culture and sensitivity of those by 25% Reduce antibiotic usage for asymptomatic bacteria by 25% 14
Action Plan Educational topics needing to be presented: McGeer criteria Colonization Reading and understanding culture and sensitivity reports Asymptomatic bacteriuria Appropriate peri care Risk for C Diff and adverse events Action Plan Education presented to: Nurses Therapists Senior leaders Nursing assistants Residents/Families Ancillary staff Antibiotic IQ Question #5 True or False Being colonized with a bacteria does not make a person feel sick, however, they should receive treatment for the colonization so that the bacteria does not remain in their system. Answer: False Colonization is when bacteria is present in your body or on your skin, but does not cause infection. Caring for colonized residents can result in contamination of healthcare workers hands, however, that resident does not need to be treated unless it turns into an infection. 15
Challenges with Residents with Dementia Residents with dementia are not able to voice their signs and symptoms so you will hear: "They are acting funny, let's get a UA to be safe" Families will say, "I know when Mom gets a UTI, you need to get a UA" Educate, Educate, Educate Have staff watch for changes in behavior, including: 1. Increase in agitation/anxiety 2. Decrease in ADL ability, mood, and/or lethargy Share information on multi drug resistant organisms and antibiotic stewardship Non pharmacological interventions specific to each resident Always, always start pushing fluids and cranberry juice (unless on a fluid restriction) The Results??? 16
Amazing January June the prior year 79 UA's were obtained, 60 C&S, 42 were treated with antibiotics January June during the PIP 47 UA's were obtained, 39 with C&S, 21 treated with antibiotics July December the prior year 71 UA's obtained, 57 C&S, 37 treated with antibiotics July December during the PIP 13 UA's obtained, 10 C&S, 12 were treated with antibiotics The reality is "I did then what I knew then, when I knew better, I did better." (Maya Angelou) Incorporation Remembering the CDC's Core Elements for Antibiotic Stewardship, incorporating each step should occur in a systematic fashion that will guarantee continued adherence and success. Start small begin with the education for all staff, residents, clinicians and families. Don't expect immediate "buy in" but don't settle for less. 17
Incorporation It takes 30 days to create a habit. Monitor infections on a daily basis. Meet with the laboratory to assure timeliness of information. Assure nursing staff understand how to read the results and report to the clinicians. Incorporation Have the pharmacist do an antibiotic review on a weekly basis in the beginning Standardize practices that should be applied during the care of any resident suspected of having the start of an infection e.g. push fluids, cranberry juice with each meal. Identify clinical situations that could be driving inappropriate antibiotics e.g. knowledge deficit dealing with difficult behaviors or not understanding lab results when returned. Top 10 Questions to Ask a Nursing Home Leader 1. What infections commonly occur among the residents in this facility? 2. When was the last outbreak in this facility? What was the cause? 3. How does the facility communicate with residents, family and visitors when an outbreak occurs? 4. Is the flu vaccine mandatory for all staffing working in this facility? If a staff member is sick, is he/she allowed to stay home without losing pay or time off? 18
Top 10 Questions 6. How are facility staff trained to respond to questions about hand hygiene from residents and family? 7. Are residents with new diarrhea given separate toilet facilities until the cause of their diarrhea is determined or resolved? 8. How is shared equipment managed to prevent the spread of germs? (think common areas and therapy as well) 9. Does the facility have private rooms for those who develop signs or symptoms of potentially contagious infection? 10. Does the facility provide educational materials for residents and families on infection control issues? As a leader what can you do? Share formal statements in support of improving antibiotic use with staff, residents, and families. Commit resources for monitoring antibiotic use and providing feedback to staff. Identify and empower the medical director, director of nursing, and/or consultant pharmacist to lead stewardship activities. As a leader Have clear policies for staff to assure antibiotics are not started unless needed: Establish minimum criteria for prescribing antibiotics Develop facility specific standards for empiric antibiotic use Review antibiotic appropriateness and resistance patterns Meet monthly with IPCO to assure processes are in place Provide access to individuals with antibiotic expertise for staff support, e.g. infectious disease clinicians Partner with the ABS leaders in referral hospitals 19
The Urgency Antibiotics are a precious resource, it takes years for an antibiotic to be developed. Antibiotics have increased life expectancy for all. Modern medical advances such as surgery, transplants, and chemotherapy may no longer be viable due to the threat of infection. (White House, 2014) The Post Antibiotic Era This is an era we have the power to change we need to begin. Questions? 20
References CDC. (2015) The Core Elements of Antibiotic Stewardship for Nursing Homes. Atlanta, GA; US Department of Health and Human Services. Retrieved from http://www.cdc.gov/longtermcare/index.html Dow, B. (2016). Antibiotic Stewardship in America's Nursing Homes. Harmony Healthcare Blog. http://www.harmonyhealth.com/blog/antibiotic stewardship in americas nursing homes Drew, R. (2009). Antimicrobial Stewardship Programs: How to Start and Steer a Successful Program. Supplement to Journal of Managed Care Pharmacy, 15(2). S18 S23. www.amcp.org References MMRW Weekly. (1999). Achievements in Public Health, 1900 1999: Control of Infectious Diseases. Morbidity and Mortality Weekly Report 48(29). 621 629. www.cdc.gov Moody, J. (2012). Infection prevention + antimicrobial stewardship. Prevention strategist. Summer 2012. 52 56. References State Operations Manual Appendix PP Guidance to Surveyors for Long Term Care Facilities. (Rev. 133, 02 06 15). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/regulations and Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines _ltcf.pdf White House. (2014). National Strategy for Combating Antibiotic Resistant Bacteria. 1 34. www.cdc.gov/drugresistance/federalengagement in ar/national strategy/index.html. 21
Thanks for your participation!!! Shelley Bhola RN BC, BSN, PHN, MSN, RAC CT Nurse Consultant Senior Providers Resource, LLC shelley@seniorprovidersresource.com Cell: 952 270 3160 22