MHA/OHA HIIN Antibiotic Stewardship/MDRO Collaborative Place picture here Nov. 14, 2017
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Housekeeping Education Credit Nursing Education Credit 1 hour Pharmacy Education Credit 0.1
Agenda Welcome Presentation: Sanford Bemidji Medical Center Antibiotic Stewardship Program Stefani Anderson, BSN, RN, PHN, CIC & Matt Webb, Pharm.D, BCPS Questions/discussion Resources & ASP 101 reminders Wrap-up
Sanford Bemidji Medical Center Antibiotic Stewardship Program (ASP) Stefani S. Anderson BSN, RN, PHN, CIC Matt Webb, Pharm.D., BCPS
Sanford Health of Northern Minnesota 118-bed regional medical center based in Bemidji, Minnesota. 78-bed skilled nursing home Home care and hospice 25-bed critical access hospital 37 Ambulatory clinics
Sanford Health of Northern Minnesota ASP Program and History Our program began in 2015 Team members include Pharmacy, Chief Medical Officer, Infectious Disease Physician, Infection Control Specialist, Quality, and Microbiology. Meet every other month Bemidji ASP reports to the Enterprise ASP committee as well as the local Pharmacy and Therapeutics (P&T) Early initiatives included Incorporation of antimicrobial review into clinical pharmacist workflow Training pharmacists Provider education about ASP Determining committee structure and reporting Garnering administrative support
ASP Regulatory Entities Joint Commission Centers for Medicare and Medicaid Services (CMS) NHSN Antimicrobial Usage (AU) and Antimicrobial Use and Resistance (AUR)
What is antimicrobial stewardship? Infectious Disease Society of America (IDSA) defines antimicrobial stewardship as coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. Can be practiced in all healthcare settings as well as on an individual and system wide level. Often a collaborative effort from providers, pharmacists, microbiologists, infection control, and information technologists.
Why is it important? Antibiotics are prescribed unnecessarily or inappropriately 20 50 % of the time in United States acute care hospitals. This can lead to antimicrobial resistance which is a growing problem and serious threat to our society s collective health. About 23,000 people die as a result of resistant organism each year.
IDSA Antimicrobial Stewardship Targets Discontinue antimicrobials when no clear evidence of infection Adjust antimicrobial regimens to account for community acquired vs healthcare associated infection Recommend guideline-based empiric therapy and definitive therapy when pathogen is known De-escalate treatment to the narrowest spectrum drug(s) they can give to accomplish the goal Set an appropriate duration (stop date) for antibiotics Transition from intravenous to oral therapy when able
Sanford Bemidji ASP
Data Definitions Days of Therapy (DOT)/1000 days present NHSN numerator: Inpatient locations, facility-wide inpatient, and specific outpatient acute care settings Standard Antibiotic Administration Ratio (SAAR) national benchmark not available until NHSN submission
Sanford Bemidji ASP Projects Establish local ASP committee with leadership support Educate pharmacists Educate providers Develop patient review plan with ID MD DUEs Vancomycin Fluoroquinolones for UTI
Daily Workflow Pharmacists Decentralized clinical pharmacists available Monday through Friday ASP is one of many responsibilities Review all patients on antimicrobials for appropriateness (drug, dose, route, duration) Infectious Disease Physician Communicates daily via inbox and detailed conversations regarding high-risk patients
FY17 Goals Improve patient outcomes Reduce resistance Healthcare-associated Clostridium difficile Hospital survival Length of stay Reduce 30-day readmission incidence Pneumonia Sepsis Reduce carbapenem use Reduce quinolone use
Data Collection
Statistics 450 400 350 300 250 200 150 100 50 0 # of ASP ivents By Month = Bemidji 427 415 416 392 396 427 383 381 362 173 163 177 175 105 1 2 4 22 23 30 31 57 48 44 47 56 Total Month
Required Indications Within Drug Order Carbapenems/ Meropenem Piperacillin/ Tazobactam Quinolones/ Levofloxacin
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 DOT/1000 Pt Days 600 a Facility-Wide Antibiotic DOT/1000 Patient Days = Bemidji 574 550 500 450 446 440 494 422 433 468 519 447 533 465 481 487 492 456 434 459 492 523 551 523 512 456 437 423 400 386 390 350 300 Month
Outcomes Pneumonia and Sepsis
PNEUMONIA
Hospital Encounters - Pneumonia as Principal Diagnosis at Discharge
30-day Readmission- Pneumonia
% Hospital Mortality 10% Pneumonia - Hospital Mortality 9% 8% 7% 6% Pneumonia - SANFORD BEMIDJI MEDICAL CENTER - N 5% 5% Pneumonia - SANFORD BISMARCK MEDICAL CTR - N 4% 3% 2% 4% 3% 3% 3% 3% 2% 4% 4% 3% 4% 3% Pneumonia - SANFORD MEDICAL CENTER FARGO - N Pneumonia - SANFORD USD MEDICAL CENTER - N 1% 1% 1% 0% 2014 2015 2016 2017 Fiscal Year
Avg LOS 10.00 9.00 Pneumonia - Avg LOS 8.00 7.00 6.00 5.00 4.00 3.00 5.84 5.31 5.19 4.52 5.78 5.62 4.64 4.08 5.25 5.28 3.37 5.14 5.61 4.88 4.90 3.91 Pneumonia - SANFORD BEMIDJI MEDICAL CENTER Pneumonia - SANFORD BISMARCK MEDICAL CTR Pneumonia - SANFORD MEDICAL CENTER FARGO Pneumonia - SANFORD USD MEDICAL CENTER 2.00 1.00 0.00 2014 2015 2016 2017 Fiscal Year
SEPSIS
# of Hospital Encounters 900 800 # Hospital Encounters - Sepsis as Principal Diagnosis at Discharge 849 818 787 700 600 668 Sepsis - SANFORD BEMIDJI MEDICAL CENTER 500 400 449 415 501 434 Sepsis - SANFORD BISMARCK MEDICAL CTR 300 Sepsis - SANFORD MEDICAL CENTER FARGO 200 Sepsis - SANFORD USD MEDICAL CENTER 100 0 2016 2017 Fiscal Year
30d Readmit % 50.0% 45.0% 30-day Readmission- Sepsis 40.0% 35.0% 30.0% 25.0% 20.0% SANFORD BEMIDJI MEDICAL CENTER - N SANFORD BISMARCK MEDICAL CTR - N SANFORD MEDICAL CENTER FARGO - Y 15.0% 10.0% 5.0% 0.0% 7.6% 5.3% 5.9% 4.3% 5.3% 3.6% 3.4% 4.2% 2016 2017 Fiscal Year SANFORD USD MEDICAL CENTER - Y
% Hospital Mortality 20% Sepsis - Hospital Mortality 18% 16% 15% 14% 13% 14% 12% 12% Sepsis - SANFORD BEMIDJI MEDICAL CENTER - N 10% 10% 10% Sepsis - SANFORD BISMARCK MEDICAL CTR - N 8% 6% 6% Sepsis - SANFORD MEDICAL CENTER FARGO - N 4% 4% Sepsis - SANFORD USD MEDICAL CENTER - N 2% 0% 2016 2017 Fiscal Year
Avg LOS 12.00 Sepsis - Avg LOS 10.00 10.01 8.00 6.00 4.00 8.65 7.48 5.25 8.53 7.48 6.94 5.63 Sepsis - SANFORD BEMIDJI MEDICAL CENTER Sepsis - SANFORD BISMARCK MEDICAL CTR Sepsis - SANFORD MEDICAL CENTER FARGO 2.00 Sepsis - SANFORD USD MEDICAL CENTER 0.00 2016 2017 Fiscal Year
Ordersets and Protocols
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Cost Analysis
Year-end total coming to July meeting as of March 2017 High cost antibiotic targets next year Zosyn Daptomycin Micafungin
$17,936, 3% $28,831, 6% $62,523, 12% $117,658, 23% Daptomycin $516K $7,500, 1% $417, 0% $281,376, 55% Jul 2016 May 2017 PHARMACEUTICAL SERVICES SMC PHARMACY FGO PHARMACEUTICAL SERVICES SBK PHARMACEUTICAL SERVICES SMB PHARMACY FGO SU $4,89 2, 3% $3,159, 2% Ertapenem $164K $4,876, 3% $2,291, 1% $19,17 5, $16,596 12%, 10% $113,309, 69% PHARMACEUTICAL SERVICES SMC PHARMACY FGO PHARMACEUTICAL SERVICES SBK PHARMACEUTICAL SERVICES SMB PHARMACY FGO SU $7,855, 1% $9,881, 2% $38,518, 6% $63,388, 10% $289,535, 45% Zosyn $647K $2,619, 0% $235,205, 36% PHARMACY ADN PHARMACEUTICAL SERVICES SMC PHARMACY FGO PHARMACEUTICAL SERVICES SBK PHARMACEUTICAL SERVICES SMB a PHARMACY FGO SU PHARMACY ADN $415, 0% $367, 0% $19,039, 19% $26,585, 26% Micafungin $102K $123, 0% $56,267, 55% PHARMACY ADN PHARMACEUTICAL SERVICES SMC PHARMACY FGO PHARMACEUTICAL SERVICES SBK PHARMACEUTICAL SERVICES SMB PHARMACY FGO SU PHARMACY ADN
ASP Response
Engagement Sanford-wide ASP participation Leadership support throughout Sanford Local executive leadership support Financial support
Successes Decreased carbapenem use Allocated ID MD time to ASP ASP tool in Epic ASP related data / reports
Barriers Antibiotic-related order set uptake Expanding ASP to ambulatory clinics
Additional Projects Procalcitonin (PCT) Lower respiratory tract infections ICU patients with sepsis/severe sepsis Ambulatory ASP DUEs Collaboration with Long-term Care facilities
Recommendation ID involvement and accountability ASP data presented to relevant committees Dedicated time for program Data collection to support program
FY18 Goals Reducing Zosyn by 15% Continue expanding required indications for antibiotics Complete UTI fluoroquinolone DUE for select ambulatory clinics
References Barlam, T, et al. (2016). Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Disease Society for Healthcare Epidemiology of America. Clinical Infectious Disease, 62(10), e51-77. Centers for Disease Control and Prevention. (2017). Checklist for Core Elements of Hospital Antibiotic Stewardship Programs. Retrieved from https://www.cdc.gov/antibiotic-use/healthcare/implementation/checklist.html National Quality Form. (2016). National Quality Partners Playbook: Antibiotic Stewardship in Acute Care. Retrieved from http://www.qualityforum.org/publications/2016/05/national_quality_partners_playb ook Antibiotic_Stewardship_in_Acute_Care.aspx The Joint Commission. (2016). Joint Commission Perspectives, 36(7), 1-8.
Resources & ASP 101 Reminders Place picture here
U.S. Antibiotic Awareness Week Nov. 13-19 #BeAntibioticsAware Stakeholder toolkit now available! Thursday, Nov. 16 - CDC & Federal Office of Rural Health Policy webinar on ASP in CAH
ASP 101 Reminders
ASP 101 Resources CDC Core Elements 5 & 6 Homework Review ASP Toolkit for Rural and Critical Access Hospitals, pages 28-29 Action Item: create an antibiotic use report or scorecard on at least one antibiotic that is being tracked in the facility. Action Item: Determine to how and with what frequency the antibiogram will be shared with all prescribers in the facility Action item: Determine how and with what frequency prescribers will receive direct, personalized communication about how they can improve their antibiotic prescribing. Supplemental Resources Sample Antibiotic Stewardship Scorecard http://www.ihi.org/engage/members hips/passport/documents/ihi%20anti biotic%20stewardship%20expedition %20- %20Session%205%20Handouts.pdf NQF Core Elements Playbook: pages 19-20 http://www.qualityforum.org/publicat ions/2016/05/national_quality_partn ers_playbook Antibiotic_Stewardshi p_in_acute_care.aspx CDC Strategies to Assess Antibiotic Use in Hospitals: https://www.cdc.gov/getsmart/health care/pdfs/strategies-to-assessantibiotic-use-in-hospitals-508.pdf
Thank you for joining us! Next Webinar: ASP Education Strategies: Challenges & Successes Tuesday, Dec. 12 at 11:30am CST/ 12:30pm EST Register online: https://zoom.us/j/874320868