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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 1
CHSPSC, LLC Antimicrobial Stewardship Education Series
December 14, 2017Stewardship Assessment: A Multidisciplinary Approach
Faculty Speakers:
Kurt Bruckmeier, MDSandy Carson, RNKathryn DeSear, PharmD, BCPS, AAHIVP
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Submission of an online post‐test and evaluation is the only way to obtain CE/CME credit for this webinar
Go to www.ProCE.com/CHSRx Webinar attendees will also receive an email with a direct link to the
web page Print your CE/CME statement of completion online
– Credit for live or enduring (not both)
Deadline: January 12, 2018 CPE Monitor (applicable to pharmacists)
– CE credit automatically uploaded to NABP/CPE Monitor upon completion of post‐test and evaluation (user must complete the “claim credit” step)
Online Evaluation, Self-Assessmentand CE/CME Credit
Attendance Code
Code will be provided at the end of today’s activity
Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 2
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 3
2016 Pharmacy Education Series
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It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Dr. Bruckmeier does not have any relevant commercial and/or financial relationships to disclose. Ms. Carson does not have any relevant commercial and/or financial relationships to disclose. Dr. DeSear does not have any relevant commercial and/or financial relationships to disclose.
Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature.
December 14, 2017Stewardship Assessment: A Multidisciplinary Approach
Faculty Speakers:
Kurt Bruckmeier, MDSandy Carson, RNKathryn DeSear, PharmD, BCPS, AAHIVP
CE/CME Activity Information & AccreditationProCE, Inc. (Pharmacist CE)– 1.0 contact hour
Ultimate Medical Academy (Physician CME)– 1.0 contact hour
Wild Iris Medical Education, Inc. (Nurse CE)– 1.0 contact hour
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Funding:This activity is self‐funded through CHSPSC.
Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 4
Kate DeSear, PharmD, BCPS, AAHIVPSandy Carson, RNKurt Bruckmeier , MDDecember 14th, 2017
Assessment:Stewardship
A Multidisciplinary Approach
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Objectives
• Describe the regulatory requirements and measures for antimicrobial stewardship in acute care hospitals
• Discuss the core elements of antimicrobial stewardship as defined by CDC
• Discuss your role or responsibility in antimicrobial stewardship as part of the interdisciplinary team
• Explain how to apply principles of antimicrobial stewardship to promote incremental improvement at your facility or practice
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 5
Perspective
Simply asking clinicians to do a better job at prescribing antimicrobials has not and does not work. Unraveling years of overprescribing antimicrobials will require behavior change. TJC Standards will garner the attention of hospital administration, resulting in the formation of ASPs. However, these standards should not be implemented to simply “check the box” to fulfill having an ASP.
Goff DA, Kullar R, Bauer KA, et al. Eight habits of highly effective antimicrobial stewardship programs to meet the Joint Commission standards for hospitals. Clin Infect Dis 2017;64(8):1134-9.
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Background: AS Timeline
Early 2014
• CDCCore Elements for Hospital Antimicrobial Stewardship released 2014
• Later released supplements for LTAC, Outpatient, and small/critical access hospitals
Late 2014
• US GovernmentNational Strategy
• National Action Plan• Executive Order• Included goals and
timelines for various sectors of society contributing to antibiotic-resistance
2017
Regulatory Bodies• TJC Antimicrobial
Stewardship Standard• CMS Condition of
Participation
2020
National Reporting• Goal is to report
antimicrobial use and resistance metrics to NHSN by 2020
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 6
Background: Regulatory Intervention
Infection Control Model
• CMS designated infection control as a “Condition of Participation” for acute care hospitals in 1986
• Required trained staff in every hospital in USA
• Don’t have it don’t get paid
• Generally, private insurance companies follow same processes as CMS
• Inclusion in Value Based Purchasing requirements of Affordable Care Act
• Public reporting of infection data to get paid• Eventually, infection data will factor into payment
• C-suite now interested $$$ 11
https://www.cdc.gov/hai/pdfs/stateplans/factsheets/us.pdf 12
Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 7
Background: Regulatory Intervention
The CLABSI Approach
• Clearly defined goals • ALL hospitals engaged in CLABSI
prevention• CLABSI bundles/checklists made
it easy • Strong national measurement
system (NHSN)• C-suite involvement• National policies• Nation-wide education• Research
CLABSI = Central line-associated bloodstream infections
Vital Signs: Central Line-Associated Blood Stream Infections --- United States, 2001, 2008, and 2009. Published Mar 4, 2011, 60(08);243-8.
2001, 43,000
2009, 18,000
2014, 8,247
R² = 0.9867
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
2000 2002 2004 2006 2008 2010 2012 2014 2016
Annual # CLABSI (ICU)
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Organizational and Individual Values• Safety• Cost• Effectiveness• Equity• Dignity
Patient Safety
Patient-Centered CareClinicians: • Duty to avoid unjustified risk or harm• Duty to produce an outcome• Duty to follow a procedural ruleQuality Professionals: • Ensure effective learning process• Provide tools to align managers• Help to redesign systemsHR: • Protect learning culture• Help with managerial competencies: consoling,
coaching, punishing
Marx D. Patient safety and the just culture. Available at: http://www.health.ny.gov/professionals/patients/patient_safety/conference/2007/docs/patient_safety_and_the_just_culture.pdf.
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 8
For Hospital Antimicrobial StewardshipElementsCore
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Best Practices• Dedicate human, financial, IT resources• Provide a written statement of support • Provide support for education and training• Include education in annual competencies• Establish hierarchy for reporting structure• Include AS outcomes in facility metrics and goals• Integrate ASP activities into quality/patient safety• Hold clinicians accountable for appropriate
antibiotic use
Leadership SupportOrganizational commitment is essential. Hospital leadership, the board, executive team MUST clearly support this commitment.
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 9
CMS Condition of Participation“…would promote better alignment of a hospital’s infection control and antibiotic stewardship efforts with nationally recognized guidelines and heighten the role and accountability of a hospital’s governing body in program implementation an oversight.”
Leadership Support 17
Executive LeadershipRecognition of PrestigeProfitabilityEmployee SatisfactionSurvey and Regulatory Compliance
PatientAccess to careAnswersImproved outcomes
Treating TeamAutonomy to PracticeAccess to ResourcesLeadership SupportInput on Facility Policies
Better Patient Outcomes↓ Length of Stay↓ Mortality↓ Cost of Care↑ Quality of Care
Healthcare Synergy
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 10
• Develop and implement an antibiotic stewardship strategy and action plan that cascades from the C-suite through individual department policies
• This action plan should be specific to the individual facility’s prioritized needs based on clinician input
Leadership Support
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AccountabilityA leader or co-leaders must be appointed and RESPONSIBLE for program outcomes. This leader should have expertise in antibiotic use and a good working relationship with the medical staff.
Best Practices• Accountable to hospital leadership for goals and
targets of ASP• Annual evaluation includes performance on AS
measures • Nurse practitioner leader in absence of physician
lead• Ensures collaboration between treatment care
team (nurses, physicians, pharmacists)• Actively engages in antibiotic use improvement
efforts 20
Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 11
ID Physician LeadIf no ID physician is available, a well-known and respected physician for on-site leadership can help to establish relationships and input from other clinicians and executive leadership leading to achievement of outcomes and success of the ASP.
Creative Solutions• Well-respected hospitalist or other non-ID
specialty• A Nurse Practitioner can make an excellent
lead in the absence of interested physicians• Telemedicine or regional collaboratives
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Responsibilities of ASP Leader
• Coordinate all service lines and clinicians• Engage stakeholders• Prospective review for potential opportunities for
improvement
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 12
Accountability
Facilities may have to be creative in establishing the “right fit” ASP lead and search for ways to fill identified gaps.
This person must act more as a quarterback rather than an antibiotic police officer.
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Drug ExpertiseA pharmacist with drug expertise can substantially contribute to an ASP’s success and accountability. This pharmacist must partner with other disciplines to fully understand and improve antimicrobial use at the facility. Drug expertise must be supplemented with training, specifically in infectious diseases for effectiveness.
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 13
A single pharmacist can NEVER accomplish the work of an entire facility’s ASP• Education• Order set development• Order review
The Pharmacists’ Role
Train the trainerBy training all pharmacists to take part in clinical review of antimicrobials, the burden is not left on a single “expert” and all clinicians can contribute to “appropriate use” of antimicrobials 25
Drug ExpertiseThe most important qualities in a pharmacist leader are a passion to improve patient outcomes and communication skills. The infectious diseases expertise can be learned through various training programs.
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 14
Tracking & ReportingMonitoring antimicrobial use, resistance, and related stewardship activities is essential to identify areas of opportunity and assess the impact of efforts. Reporting that information back to the stakeholders (nurses, physicians, practitioners) is essential to close the loop and ensure future buy-in and success.
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Provider-specific trendingBenchmarking physicians can be a powerful means to shed light on outliers. Careful consideration must be paid to specialties or practice areas that would portend to increased, but appropriate, antimicrobial use (ID specialists, ICU physicians, etc.).
This data should be blinded to avoid embarrassment for outlying providers.
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 15
Management of Outlier Providers
• Outlier physicians require dialogue & education• Increased complexity when physician is ID specialist• Administrative support is crucial• Peer review if recalcitrance continues
• Noncompliant behavior• Failure to reach consensus• Academic arrogance• Persistent noncompliance
• Strategies to avoid noncompliance• Outreach prior to implementation
• Listen to fears and opinions of affected stakeholders in discussion and decision-making
• Discuss benefits to patients with each department
Goldstein E. Approaches to modifying behavior of clinicians who are noncompliant with antimicrobial stewardship program guidelines. Clin Infect Dis. 2016:63(4):532-8.
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Quantifiable ProgressEach CDC Core
Element assigned weighted scale of
implementation based on survey response
The Stewardship Score =
Total Points Scored--------------------------
Total Points PossibleDownloadable Key Located
within TSS Toolkit: http://tinyurl.com/TSSToolkit
Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 16
Stewardship Score Calculation
0
1
3
5Points
0% 20% 40% 60% 80% 100
2016Q4 Stewardship Score
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Stewardship Score Progress Report32
Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 17
Stewardship Score Calculation
Quartile Legend:
Bottom Quartile
Top Quartile
Middle Quartiles
CHS Average
CDC Core Element
Enterprise Average Score
Distribution of Scores by Division
0%10%20%30%40%50%60%70%80%90%
100%
1 2 3 4
Tota
l Sco
re
Division
Stewardship Score Toolkit
Click image to launch Toolkit
Toolkit available to help
implement suggested
actions
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 18
Antimicrobial Use Reporting• NHSN submission of Antimicrobial Use (AU)
through Sentri-7• Days on Therapy per Days Present
Tracking & ReportingThere are many ways to track antimicrobial use, resistance, and related activities. These reports can come from the clinical decision support system, corporate leadership, or individual facility-kept record systems. Action should always be based on real data.
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 19
ActionThe ASP should take action on identified needs. This includes implementing interventions aimed at improving antimicrobial use with measurable outcomes.
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Examples of Action
• Prospective review of select antimicrobials (Ex. Tigecycline, daptomycin, ceftazidime/avibactam, etc.)
• Required documentation of indication and duration for antibiotics
• Development of facility-specific order sets
• Antibiotic time out
• Protocol-based adjustment of antimicrobials (Ex. renal dysfunction or IV to PO)
• Rapid diagnostics and microbiologic stewardship
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 20
Clinical Decision Support Software
Alert identifies patients with pending blood cultures that have either a negative PCR (rapid)
test for MRSA or a negative final culture for MRSA who are receiving anti-MRSA agents (eg,
daptomycin, vancomycin, linezolid).
Shows preliminary results and confirms negative
MRSA PCR
Treatment Recommendations from UpToDate and aligned with organizational policies, formulary, etc.
PharmD makes treatment
recommendations to responsible MD
Informs on specific MRSA agent and dose
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Order Set Development
• Incorporate stewardship principles and antibiogram
From This…
To That…
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 21
Microbiologic Stewardship
Ordering Tests (Preanalytic)
Pay attention to symptoms & pretest probability of infection
Ex. Urine cultures only if symptomatic or positive urinalysis
Ex. C. difficile testing only if diarrhea
Collection (Preanalytic)
Pay attention to sample collection/transport to reduce contamination
Ex. Properly swab collection site prior to blood draw
Ex. Midstream catch of urine
Processing (Analytic)
Use the laboratory to distinguish colonization from contamination
Ex. Cascade tests after initial positive result
Ex. Utilize a testing algorithm for CDI
Reporting (Postanalytic)
Make sure reporting guides appropriate practice
Ex. “Multiple organisms indicating likely contamination”
Ex. “Procalcitonin is low which indicates a low likelihood of infection. Consider de‐escalation of antibiotic therapy.”
Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship – Leveraging the Laboratory to Improve Antimicrobial Use. JAMA 2017; published online.
“Give it a name and they will treat it as a
pathogen”
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ActionThe actions taken at the facility should be carefully prioritized with all stakeholders. Focus should be on achievable interventions that are mutually agreed upon by ASP.
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 22
EducationGeneral PublicPatientPhysicianPharmacistNurseLaboratory Technician
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Protocol DevelopmentQuality, Pharmacy, Physicians,
Lab, IT
Sepsis AlertsEMS
Order EntryPhysician/Practitioner
Order Verification and Dispensation
Pharmacist & Pharm. Tech.
Medication Administration & MonitoringPatient, Nurse
Lab Results & Microbiologic Stewardship
Lab
Surveillance & InterventionIT, Pharmacist, Physician
OutcomesInfection Prevention/Quality
Transmission AvoidanceInfection Prevention & Housekeeping
& Nursing & all Personnel 44
Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 23
Patient EducationAlthough TJC EP3 mandating patient education on antibiotics prior to discharge has been removed, patient education should still always be a part of the discharge process.
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Accurate Allergy History, Medication Reconcilliation
Early & Appropriate cultures and antibiotic initiation
Progress Monitoring/Reporting
Transitions of Care
Triage and Isolation Designation
Culture results, adverse events, change in patient status
IV to PO, patient education, transition to outpatient
Critical role of Nursing Staff in Antimicrobial Stewardship
Admission to floor or unit, isolation precautions
Severity of allergy and cross-reactivity, accurate antibiotic history
Microbiologic stewardship, follow through on physician orders
Olans RN, Olans RD, DeMaria Jr., A. The Critical Role of the Staff Nurse in Antimicrobial Stewardship – Unrecognized, but Already There. Clinical Infectious Diseases 2016;62(1):84-9.
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 24
Integrating Nursing into Stewardship• 3.6 million nurses in US in hospital, home health,
and assisted living• Perfectly suited to advocate for antibiotic
stewardship at patient and facility level• Educational gap regarding antibiotic use and
stewardship• The nurse executive should fully support and
engage bedside nurses in ASP activities
CDC/ANA White Paper. Redefining ther Antibiotic Stewardship Team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the Role of Registered Nurses in Hospital Antibiotic Stewardship Practices, 2017. White Paper http://www.nursingworld.org/ANA-CDC-AntibioticStewardship-WhitePaper
Olans, RD, Nicholas, P, Hanley, D, & DeMaria, A Jr. (2015). Defining a role for nursing education for staff nurse participation in antimicrobial stewardship. Journal of Continuing Education in Nursing, 46, 318-321. 47
Clinician Education• Physicians
• Interpreting antibiogram & resistance trends• Comfort with evidence-based order sets• Distinguishing
• Test results from disease• Colonization vs. contamination vs. infection
• Pharmacists• Utilization of clinical decision support to make meaningful
interventions based on incoming data
• Nurses• Interpretation of true antibiotic allergies• Translating microbiology, epidemiology, and antimicrobial
pharmacology from “pure” science to “applied” science• Antibiotic timeouts• IV to PO
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Stewardship Assessment: A Multidisciplinary ApproachCHSPSC, LLC Antimicrobial Stewardship Education Series
ProCE, Inc.www.ProCE.com 25
EducationEducation does not have to be overly complex. A pamphlet, newsletter article, or poster can serve as an excellent educational tool. The goal is outreach and improvement of antimicrobial use.
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Antimicrobial Stewardship Programs should have multidisciplinary involvement, be centered around measurable outcomes, and focus on incremental improvements over time. All clinicians in the hospital should be involved and engaged.
Concluding Point
Take Home Points• Find out who leads/co-leads your facility ASP• What metrics they are using to assess?• Is your discipline is adequately represented?• Ask to attend a meeting 50