2/17/2012

1

Antimicrobial Stewardship at

Yakima Valley Memorial Hospital

Gregory Matsuura, PharmD, BCPS

Antibiotic Review Team Coordinator

Yakima Valley Memorial Hospital

• 225 bed acute care community hospital

• Community & hospitalist providers

• 3 independent ID specialists

• AMS Team:

– 0.5 FTE pharmacist (AMS/clinical informatics)

– ≈1 hour/week ID physician

• Infection control

• Microbiology

• Clinical Floor pharmacists (5 teams)

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2

If At First You Don't

Succeed, Try, Try

Again…

A bit of history

• 1999 start of antibiotic review team (ART)

– Interested staff pharmacists + ID physician

– Wide variation of interest/skill set

• 2001 Pharmacy residency project

– staff pharmacists + ID physician + pharm resident

– Wide variation of interest/skill set

• 2002-2006

– PRN stewardship

• 2007- present

– Building up interest/impact

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3

Clinical floor

pharmacist

Infectious

diseases

physician

Stewardship

Coordinator

Microbiology

Infection control

Development of computerized

resources (shoestring budget)

2004Year 2006 2008 2010 2012

Search by drug

mining tool

Culture results;

renal fx added

Service Flags

added

EMR bug drug

Bar code

admin Abx

use data

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4

PDF report of patients on Abxtherapy, “Follow-up” notes by pharmacists

EMR reviewed → Additional sources (RNs, Floor pharmacists, Micro lab)

Discussion with ID physician

Direct case discussion with physician

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5

Targeted review

• Patients with initial diagnosis-therapy

mismatch

• Isolate resistant/not covered by current abx

• Potential IV – PO switch

• Broad spectrum abx >3 days

• Duration >7 days

• Targeted antimicrobials

Antimicrobials of interest

Targeted - Unrestricted Restricted

Piperacillin-Tazobactam Linezolid

Cefepime Daptomycin

Vancomycin Tigecycline

Imipenem

Aztreonam

3rd generation cephalosporins

Antifungals

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6

Documented Antibiotic Review Team

Interventions

• 1/1/2010-12/31/11 (n=645)

– Streamline/de-escalate coverage 27% (n=174)

– Dosing change 29.7% (n=191)

– Antibiotic mis-match 13% (n=84)

– IV to PO 10.2% (n=66)

A minor example: Aztreonam

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2008 2009 2010 2011

DDD/1000

Aztreonam

DOT/1000

Aztreonam

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Target antibiotic example: Pip-Tazo

DDD/

1000 pt days

DOT/

1000 pt days

2009 75.6 105.1

2010 73.4 98.6

2011 74.8 96.2

Building Drug-bug system from

(almost) scratch

• Alerts generated in real time

– Triggered by updates in micro reports only

• Not able to scale to clinical relevance

– Needs clinical review

• Needs preliminary pathogen descriptions

trigger

– Fungus

– “Non-lactose fermenter”

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Antibiotic Stewardship and CDI

• Continued to limit broad spectrum abx

• All cases of nosocomial CDI

– Reviewed by infection control

– Reviewed by stewardship team for trends/

association

• Trend towards ↓ nosocomial abx CDI from 2009

– Low rate prevents meaningful cause-effect

• Association of PPI use and CDI?

Future steps

• Improving Drug-bug match alert system

• Improve feedback to prescribing house-staff

– Increased patient proportion seen by hospitalists

• Antibiotic use data for March meeting

– Implementation of CPOE

• Electronic data available at the provider level

• Bar coding medication record (BCMA)

– Monthly Clinical Vignette with FP inpatient service

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9

AMS experience at YVMH

• It’s a team approach– Floor pharmacists are an extension of the service

• No centralized method of contacting physicians

– Coordination with other departments• Infection control

• Microbiology

• Information is key– Prospective data mining is invaluable

– Knowing more faster

• Drug-bug match alert system

• Further evaluate potential 3rd party vendor systems

Acknowledgements

• Infectious diseases/epidemiology – Neil Barg

• All the YVMH clinical pharmacists– Angela Stewart (Assist Mgr Adv Pharmacy Services)

• Microbiology– Maria Clark

• Infection Control – Jaala Langley

• VP Patient Care Services– Sandy Dahl