From Resident to Ready: Expanding Clinical Services in a Community Hospital through Antimicrobial Stewardship Rebecca Swierz, PharmD Southwest General Cleveland, Ohio
Pharmacist Objectives Explain the need for a Pharmacist-Driven Antimicrobial Stewardship in a Community Hospital Setting Describe the Process of Position Approval at the Executive Level Discuss a New Stewardship Program's Successes and Mishaps
Technician Objective Recognize the Ability of a Certified Pharmacy Technician to Impact Antimicrobial Stewardship
I have no disclosures or conflicts of interest
From Resident to Ready PharmD 2013 PGY-1 SWG ED Discharge Order Entry Begin Abx Stewardship Certification Antimicrobial Stewardship Pharmacist
Explain the need for a Pharmacist-Driven Antimicrobial Stewardship in a Community Hospital Setting
Southwest General Non-profit community hospital No medical residents 350-bed Average census of 250 patients 6.1 FTE Clinical Pharmacists (3.0 ICU, 2.1 ED, 1.0 ID) 2 PGY-1 Residents Decentralized model Cerner EHR
Antimicrobial Stewardship Prior to a dedicated Abx Stewardship Pharmacist, Pharmacist responsibilities IV to PO Automatic stop orders Aminoglycoside dosing Vancomycin dosing for non-id physicians Renal adjustments at point of order entry Restricted antibiotic list (minimally enforced) Minimal surveillance of house wide antimicrobials Minimal interaction with infection control
Why Do We Need Stewardship? Rising antimicrobial resistance and multi-drug resistant organisms (MDRO) Reduced drug therapy options Bad bugs no drugs Increased health care cost and length of stay Risk of adverse drug reactions Joint Commission National Patient Safety Goal 7
Why Do We Need Stewardship? How is your facility promoting antimicrobial stewardship? CMS, CDC draft worksheet for accreditation by JC Quality measures C.2.a Facility has a multidisciplinary process in place to review antimicrobial utilization, local susceptibility patterns, and antimicrobial agents in the formulary and there is evidence that the process is followed. C.2.b Systems are in place to prompt clinicians to use appropriate antimicrobial agents (e.g., computerized physician order entry, comments in microbiology susceptibility reports, notifications from clinical pharmacist, formulary restrictions, evidenced based guidelines and recommendations) C.2.c Antibiotic orders include an indication for use. C.2.d There is a mechanism in place to prompt clinicians to review antibiotic courses of therapy after 72 hours of treatment. C.2.e The facility has a system in place to identify patients currently receiving intravenous antibiotics who might be eligible to receive oral treatment. We must be proactive!
Barriers to Stewardship Physician participation and cooperation No formal mechanism of data collection Lack of resources Insufficient funds Not a priority
Pharmacist-Driven Stewardship is considered a medical staff function Community setting No formal rounds 3 ID groups Pharmacist able to be a part of all ID services which allows for all hospitalized patients to be monitored In a teaching center, may have ID team for patient instead of 1 physician More eyes on the patient! Link between infection control, physician, quality Pharmacist satisfies all quality measures of JC accreditation Experts in medication therapy and kinetics Ten by 2020
Describe the Process of Position Approval at the Executive Level
Research, education, and professional development for ID PharmD Step 1 Step 2 Leadership support Examine your facilities antimicrobial use Business proposal Step 3 Step 3 Step 4 Step 5 Form the team! Advertise service Expand stewardship scope Incorporate all pharmacists into antimicrobial stewardship Incorporate all health care professionals into antimicrobial stewardship
Research, education, and professional development for ID PharmD Developing the ASP Pharmacist Site visits to local established programs Contact CDC program ID pharmacists See Appendix 1 Time with microbiology lab Antimicrobial Stewardship certification Subscription to Clinical Infectious Diseases or other pertinent ID journals Electronic Table of Contents Take on residents and students ACCP ID Prn Resources See Appendix 2
Leadership support Stewardship Mission Improve patient safety Optimize clinical outcomes Reduce inappropriate and excessive use of antimicrobials at Southwest General Reduce hospital-acquired infections Reduce health-care costs
Antimicrobial Use Examine antimicrobial use in your hospital Data extrapolated from 3 months of antimicrobial stewardship interventions Found that up to 43% of antimicrobials associated with hospital-acquired infections were inappropriate Length of therapy Missed opportunities for testing Spectrum not narrowed with culture results and/or clinical improvements Multiple antibiotics No indication stated or noninfectious Antibiotics prior to admission not taken into account
Business proposal The Proposal Budgeted replacement request for 1.0 FTE Focus on antimicrobial stewardship measures while expanding clinical services Promote the appropriate selection, dosing, route, and duration of therapy of antimicrobials in the most effective and cost conscious fashion Cost savings
Business proposal Project Scope Review house wide antimicrobial use daily Assume responsibility for all automatic stop orders Develop/Update criteria for use of all restricted antimicrobials Review requests for additions to formulary Recommend prescription filling of antimicrobials at SWG Community Pharmacy Staff education
Business proposal Other Responsibilities Lead Antimicrobial Stewardship Committee Report to P&T Committee Monthly review of hospital-acquired infection cases Publish annual antibiogram ED culture review Expand clinic services
Business proposal Tracking Interventions De-escalation Discontinue Dose optimization Formulary substitution Monitoring Renal dosing Rx filled in community pharmacy Culture/sensitivity substitution Drug therapy initiated Drug information provided IV to PO conversion Drug level ordered Contraindication Automatic stop order change Other metrics Interventions reported as cost avoidance Physician acceptance rate Antibiotic purchases cumulative report Days of therapy or total daily dose Restricted antimicrobial usage per physician Revenue to community pharmacy
Form the team! Stewardship Team ID physician Clinical pharmacist with ID training Clinical microbiologist IT specialist Infection control professional Hospital epidemiologist
Advertise service Getting the Word Out Area of improvement Word of mouth Column in pharmacy newsletter Physician grand rounds Start interventions with I am the Antimicrobial Stewardship Pharmacist or the Antimicrobial Stewardship Team
Expansion Expand stewardship scope Education without intervention only marginally effective Developed an Antimicrobial Stewardship Intervention electronic power form Patient education Letter to physicians Persistence
Incorporating Pharmacists Incorporate all pharmacists into antimicrobial stewardship Guidelines and pathways Evidence based treatment guidelines Local resistance patterns Restricted antibiotics and approved indications Renal dosing with specifics for dialysis Alternate recommendations in shortage Spectrum covered by antibiotics Basic bugs and drugs Surgical prophylaxis Alerts/Popups CrCl Length of therapy Restricted Communication Feedback
House-wide ASP Nurses play an important role in stewardship Intercept or question restricted antibiotics ordered by non-id physician Communicate days of therapy to physician Interpret cultures and sensitivities Evaluate discharge antibiotics Communicate goals of therapy Incorporate all health care professionals into antimicrobial stewardship Long-term goal ASP pocket guide Antibiogram Antimicrobial classes and spectrum of coverage Clinical guidelines and pathways Renal adjustments
Discuss a New Stewardship Program's Successes and Mishaps
Daily Tasks and Reports Print/Review necessary reports Restricted* Automatic Stop Order (ASO) House-wide Amikacin Amphotericin B Colistin Daptomycin Ertapenem Linezolid Meropenem Micafungin Tigecycline Duration of therapy > 3 Antimicrobial agents IV to PO Fast movers Zosyn Vancomycin *24 hours of therapy is approved without ID consult
Daily Tasks and Reports Daily check in Review Infection Control All interventions Drug-bug mismatches are logged daily as Cultures Accepted, Modified, Denied, Urine or Other Blood Wound Sputum Vancomycin monitoring and dosing
Expansion Plans Retrospective Prospective Reports Renal dosing Sepsis alerts Length of stay Surveillance Prescriber habits ASO to 72 hours IC Nurse/floor Order sets CDAD Endo procedures Further advertising position Pharmacy newsletter Grand rounds Develop computer-based training for pharmacists and hospital staff
Incorporating Residents into ASP Currently a longitudinal rotation 4 hours/week of antimicrobial stewardship Patient discussions weekly Topic discussion with case presentation bimonthly Interesting cases are sent to residents to review for weekly stewardship discussion Resident responsibilities Antimicrobial MUE Evaluate current drug literature Answer drug information questions related to ID Case report prepared for publication Assist in pharmacy to dose vancomycin and aminoglycosies See Appendix 3 for discussion topics
Challenges Electronic records New program Training Prescriber resistance Baseline for comparison Tracking usage Discharge antibiotics
Recognize the Ability of a Certified Pharmacy Technician to Impact Antimicrobial Stewardship
Importance of Pharmacy Technicians Medication history Allergies Front lines of drug requests, IV room, phone calls Experts of compounding Frequencies Dosage forms Purchase data from buyer Shortages Price changes Total expenditure
Potential Problems Lack of knowledge with restricted antibiotics IV batch for 0900 is made by third shift which allows for restricted doses to be sent to the floor Possible Solutions List restricted antibiotics in easy access area Most restricted abx must be activated or opened at SWG Ensure abx are not activated until dose is needed Where is my patient s IV? Provide a refrigerated vs unrefrigerated abx list for CPhT and nurses on the floor COMMUNICATION!
Closing Thoughts Assess hospital needs Start small, plan big Track all interventions Use your resources
Questions?
Appendix 1 - Questions for ASP What are you daily reports? How did you advertise your service? How many days and where do you round? With who? Do you rotate floors? What do you do on weekends? Would you classify your program as prospective or retrospective? What metrics do you report to P&T, Abx committee? What 3 areas should I focus on starting the program? How do you train your residents/appe/ippe students prior to taking on an Infectious Disease rotation? Do you require them to read any specific articles/guidelines? If so, what? What conferences are do you think are beneficial for me to attend as an ASP? How long has it taken to develop your program into what it is today?
Appendix 2 - Helpful Websites CDC Stewardship Program examples http://www.cdc.gov/getsmart/healthcare/programs.html Antimicrobial Stewardship Certifications SIDP: http://www.sidp.org/page-1442823 MAD-ID: http://mad-id.org/antimicrobial-stewardship-programs/ SHEA website http://www.shea-online.org/news/stewardship.cfm
Appendix 3 - Discussion Topics Required Topics Pneumonia Ventilator Associated Community Acquired Nosocomial Aspiration Urinary Tract Infections C.difficile-associate Diarrhea Cellulitis and Soft Tissue Infections Endocarditis Resistant Pathogens MRSA VRE CRE Pseudomonas Acinetobacter Sepsis Antimicrobial Use during Pregnancy & Lactation Elective Topics HIV Infection Human and Animal Bite Wounds Febrile Neutropenia Antibiotics in Specific Populations Pelvic Infections Meningitis Osteomyelitis Fungal Infections Hepatitis B, C Seldom Used Antibiotics STIs
References Dellit TH, Owens RC, McGowan JE, Jr., et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Jan 15 2007;44(2):159-177. Manning ML, Giannuzzi D. Antibiotic resistance and the role of nurse executives in antibiotic stewardship. JONA 2015;45(2);67-69. "Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship ; Clinical Infectious Diseases 2007; 44: 159-77 Antimicrobial Stewardship Policy Statement of the IDSA, SHEA and PIDS. IDSA, SHEA, PIDS, Infection Control and Hospital Epidemiology. 2012;33:322-327. ASHP Statement on the Pharmacist s Role in Antimicrobial Stewardship and Infection Prevention and Control. Am J Health- Syst Pharm 2010; 67:575-7. Beardsley JR, Williamson JC, Johnson JW, et al. Show me the money: long-term financial impact of an antimicrobial stewardship program. Infect. Control Hosp. Epidemiol. 2012;33(4):398-400. Carling P, Fung T, Killion A, Terrin N, and Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infection Control and Hospital Epidemiology. 2003;24(9): 699-706. Drew RH, White R, MacDougall C, et al. Insights from the Society of Infectious Diseases Pharmacists on Antimicrobial Stewardship Guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Pharmacotherapy 2009;29(5):593-607. Fowler S, Webber A, Cooper BS, Phimister A, Price K, Carter Y, Kibbler CC, Simpson AJH, Stone SP. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. Journal of Antimicrobial Chemotherapy (2007), 59: 990-995 Haley RW, Schaberg DR, Crossley KB, et al. Extra charges and prolongation of stay attributable to nosocomial infections: a prospective interhospital comparison. Am J Med 1981 Jan;70(1):51-8. Harbarth S, Nobre V, Pittet D. Does antibiotic selection impact patient outcome? Clin. Infect. Dis. 2007; 44:87 93. John JF, Fishman NO. Programmatic role of the infectious diseases physician in controlling antimicrobial costs in the hospital. Clin. Infect. Dis. 1997;24:471-485. Abhijit BM, Gould IM. Antibiotic stewardship: overcoming implementation barriers.curr Opin Infect Dis. 2011 August; 24(4): 357 362