on the front lines of antimicrobial stewardship (marci drees)
TRANSCRIPT
On the Front Lines of Antimicrobial Stewardship
Marci Drees, MD, MS, FACP
Hospital Epidemiologist
Hospital of Tomorrow Summit
19. October 2015
Disclosures: None to report.
Setting
Two-hospital, 1100-bed private not-for-profit community-based academic health care system
>50,000 admissions, 185,000 emergency visits annually 21st in U.S. for admissions and ED visits
Level 1 trauma, level 3 NICU
> 11,000 employees
~1600 Medical-Dental staff (400 employed)
Largest teaching affiliate of Sidney Kimmel Medical College at Thomas Jefferson University
~450 employed or rotating residents/fellows (No ID)
~12,000 rotating students annually
Evolution of Stewardship at CCHS
Pre-2009: 1 ID-trained PharmD, working with 1 private ID physician
~2009-10: different ID-trained PharmD hired, stewardship “committee” formed
2011: current ID-trained PharmD hired
2013: 2nd ID-trained PharmD hired
2014: Revamped ASP committee launched
Co-chaired by ID PharmD and private ID physician
3rd ID-trained PharmD hired (left after 6 mo.)
2015: replacement 3rd PharmD hired
Early Accomplishments
Series of guidelines developed for front-line staff
Pneumonia, skin/soft tissue infections, sepsis, UTI
Duration of therapy
Vancomycin dosing by pharmacy protocol
Procalcitonin guidelines
Working with microbiology lab to adopt and implement Verigene® as a stewardship tool
Identification of blood culture organism within hours
Engagement ASP committee revamped early 2014
Co-chaired by David Cohen, MD
Private practice (inpt/outpt)
Chair of ID Division
Force of personality
Membership expanded
Pharmacy, ID docs, microbiology, infection prevention
Hospitalists, residents, surgery PAs, students, ED, family practitioners, critical care PAs
Strong educational/outreach component
“Staphylococcupalooza”
Culture/Testing Stewardship
Recognition that positive cultures/tests very difficult NOT to treat C. difficile colonization Asymptomatic bacteruria
Interventions Laxative alert Previous C. difficile alert
Future: Urinalysis with reflex to urine
culture Requirement for symptom
documentation when ordering urine cultures
Culture/Testing Stewardship
Recognition that positive cultures/tests very difficult NOT to treat C. difficile colonization Asymptomatic bacteruria
Interventions Laxative alert Previous C. difficile alert
Future: Urinalysis with reflex to urine
culture Requirement for symptom
documentation when ordering urine cultures
Clinical Decision Support
“Forcing function”
Or, making the right thing to do the EASIEST thing to do
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Metrics
Intra-facility Internal benchmarking for
targeted antibiotics
Evaluate effect of interventions
Compare antibiotic use between similar units
Compare individual providers
Inter-facility Benchmarking to similar
institutions
What is the “right” amount of antibiotic use?
Possible metrics Resistance rates:
Annual antibiogram
Pharmacy interventions
ASP pharmacist
Unit-based pharmacists
Utilization (DOT)
Safety Surveillor® (Premier)
Power Insight (Cerner®)
University Health System Consortium (UHC)
Outcomes (?)
Measuring Utilization
Data mining program (SafetySurveillor®)
Pro: pulls in micro and pharmacy data (bug/drug mismatch)
Con: orders, not actual administration; labor intensive
SAP Business Objects software (Power Insight)
Pro: anything in PowerChart available for query (barcode)
Con: labor-intensive, slow
UHC
Pro: ability to benchmark nationally to similar institutions
Con: based on charges; 3-month delay
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On the Front Lines…
Engagement is key…
Private ID docs
Employed and private hospitalists
Many, many others who prescribe antibiotics (or obtain the tests that prompt antibiotics)
Measurement is hard…
Interventions should make less work, not more, for frontline providers.
Acknowledgments
Nicole Harrington, PharmD
David Cohen, MD
Jennifer Lukaszewicz, PharmD
Julianne Gardner, PharmD
Donna Walsh, PharmD
Kim Taylor, BSN, RN
Sharon Kleban, MA
Steve Eppes, MD
Paul Sierzenski, MD, MS-HQS