AHRQ Safety Program for Improving Antibiotic Use

Slide Title and Commentary Slide Number and Slide

Title SlideAntibiotic Stewardship Program (ASP) DevelopmentAcute CareSAY: HostWelcome to the Antibiotic Stewardship Program Development within the acute care setting webinar.

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Presenter - Sara CosgroveSAY:

I’m Sara Cosgrove and I am the speaker for today’s call. I’m a Professor of Medicine at Johns Hopkins University School of Medicine and I have a joint appointment in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health and I direct the hospital’s Department of Antimicrobial Stewardship.…On the screen is contact information for the project. If you have any questions or need to reach me after this webex, please use this information.

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Antibiotic Stewardship Program (ASP) DevelopmentAcute Care

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HousekeepingSAY:

Let’s take a moment to go over housekeeping rules for this call.• Please mute your phone lines to avoid any distracting background noise.• If you have a question, please use the ‘chat’ feature to ask a question during the presentation.

• Question and answer time will be provided at the end of the presentation so if you have any questions, please make note of them and save them for the end. Please follow this structure unless I ask for any relevant questions during the presentation. In this case, please participate. Participation and active engagement is how you will get the most out of this presentation and out of this whole program.

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ObjectivesSAY:

By the end of this module you will be able to understand the key personnel for developing an antibiotic stewardship program, understand how to work with the senior executive to further the goals of the antibiotic stewardship program, discuss the pros and cons of common stewardship interventions, discuss evaluation metrics for stewardship programs and understand the steps involved in establishing a stewardship program.

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Key Personnel and Essential RelationshipsSAY:

First, we will discuss the key personnel that make up an antibiotic stewardship program and the essential relationships that a stewardship program must have with other departments.

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Essential Team Members SAY:

Ideally, all antibiotic stewardship programs should have both physician and pharmacist leadership.

Physician leadership is critical because interventions made by the stewardship program directly impact antibiotic prescribing decisions made by members of the medical staff, who should reasonably expect to have physician oversight of such recommendations. Other important roles of physician leaders of Antibiotic Stewardship Programs include determining program goals in conjunction with the pharmacist leader; settling differences of opinion between the stewardship team and prescribers; and functioning as a bridge to executive leadership in the institution.

The physician lead of stewardship is ideally trained in infectious diseases, as this specialty provides comprehensive knowledge regarding diagnosis, management, and treatment of infectious disease processes. This individual should have an interest in both optimal use of antibiotics as well as patient safety. Finally, to ensure maximum uptake of stewardship recommendations, the physician stewardship lead should be a diplomatic and collegial communicator.

Pharmacist leadership of stewardship programs is also essential. In most programs, pharmacists do the majority of interventions on a daily basis. In addition, pharmacists often lead efforts to coordinate data needs of the program such as data on antibiotic use. The pharmacist in the stewardship program also functions as a bridge to the department of pharmacy to ensure coordination of stewardship and pharmacy goals. The pharmacist lead of stewardship is also ideally trained in infectious diseases. If a pharmacist does not have formal infectious disease training he or she should pursue training courses in the area of antibiotic stewardship.

Finally, the pharmacist lead should be comfortable advising physicians and other providers in optimizing antibiotic use.

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Group and DepartmentsSAY:

This diagram shows other departments and groups in an institution with which the antibiotic stewardship program should form close relationships. In addition, representatives from these departments and groups should be members of the institutions antibiotic stewardship committee. The next slides will detail why these relationships are important.

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Essential Relationships: The Role of the Senior Executive in ASPsSAY:

All ASPs should strive to develop a close relationship with an executive to further the goals of the programs. Fortunately, leadership support of ASPs is a now highlighted in The Joint Commission Antimicrobial Stewardship Standard which provides justification for the ASP to work closely with a senior executive.

Ideally, the senior executive would be a physician, although this is not essential. The senior executive can help the ASP to align its goals with the organization’s strategic goals as well as identify financial resources for the ASP personnel and activities. The executive can connect the ASP to stakeholders across the institution who can help disseminate concepts of stewardship and engage their groups with the ASP. The executive can ensure that ASP leaders are included in high-level meetings such as board meetings. Finally, the executive can assist with other barriers to progress such as clinicians who do not wish to follow ASP guidelines and protocols.

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Engaging Senior ExecutivesSAY:

The stewardship team should work to engage the senior executive. This can be challenging because senior executives often lack sufficient time to dedicate to the stewardship team. On occasion, they might also show a lack of interest.

There are several approaches to engage the senior executive. These include inviting the executive to join your AS Committee to understand institutional issues around antibiotic prescribing and inviting them to the unit CUSP meetings to hear about challenges and successes from the front line staff. In addition, developing brief and regular executive summaries of work done by the ASP can keep the topic at the forefront of the executive’s mind and highlight the important work of the ASP. Consider including high level talking points for the executive in these reports to make it easy for the executive to share the work of the ASP with others.

If persistent problems with senior executive engagement occur, consider approaching a different executive.

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Essential RelationshipsSAY:

A strong relationship with the pharmacy is critical to the success of an ASP because the pharmacy dispenses all antibiotics that are prescribed. Thus, they are often in the position of enforcing prescribing policies developed by the ASP.

In addition, they can be the source of antibiotic use data as well as more general data on prescribing trends such as sudden increases in carbapenem use. There may be pharmacists who are not core members of the ASP who can lead stewardship interventions such as IV to PO conversion protocols and therapeutic antibiotic monitoring protocols as well as other AS activities. Finally, the pharmacy can monitor antibiotic shortages and work with the ASP to provide treatment alternatives.

The Pharmacy and Therapeutics Committee (or its Antibiotic Sub-Committee) generally makes formulary and restriction decisions regarding antibiotics and thus should have ample ASP representation. In some institutions, the P&T Committee may endorse guidelines, order sets and restriction policies. Finally, some ASPs may elect to report formally to the P&T Committee.

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Essential RelationshipsSAY:

ASPs must form relationships with the medical staff who do the bulk of antibiotic prescribing. Optimally, the ASP works with clinical champions with whom they collaborate on development of guidelines and policies that are relevant to their practices. Clinical champions may also be able to assist with management of outlier prescribers in their group by modeling good prescribing behavior or having non-confrontational one-on-one conversations to understand concerns about guidelines.

Similarly, the ASP must work closely with other ID physicians who not only should function as collaborators on guidelines and policies but also are often called upon by the ASP to perform formal consultation on more challenging cases or on patient receiving restricted antibiotics. It is important to strive for the buy-in of other ID physicians so recommendations made by the ASP are not undermined.

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Essential RelationshipsSAY:

Antibiotic Stewardship Programs must have access to Information Technology resources to identify targets for AS interventions and to evaluate outcomes. IT can assist with collating antimicrobial, microbiology and clinical data from several sources. They can also assist with providing antibiotic use data for the institution and for reporting to the CDC NHSN AUR module. In addition, the ASP should engage with IT when decisions about EHRs and other relevant software are made.

Most ASPs work closely with the microbiology lab because the ASP is able to provide information about how clinicians interpret microbiology reports and assist with improving reports when needed. The microbiology lab should develop antibiograms in consultation with the ASP. The groups should work together in making decisions about selective reporting of susceptibility testing and selection and implementation of rapid diagnostic tests.

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Essential RelationshipsSAY:

ASPs should align their work with that of the infection control department. Infection control departments often have existing access to data of importance to the ASP such as rates of resistant organisms and C. difficile. The infection control department also has familiarity with acquiring, tabulating, and disseminating data across the institution. Finally, the infection control department is very familiar with preparation for The Joint Commission surveys and can provide advice for ASPs on essential elements of this preparation. Increasingly, the role of nursing in ASP efforts is being recognized. ASPs should identify champions in the nursing department and educate nurses about their potential role in stewardship. Examples include nurses assisting teams by prompting on rounds regarding the type and day of antibiotic therapy; detection of adverse events such as rash; obtaining microbiology specimens in optimal ways; and assisting with correct timing of antibiotic drug level collection.

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Essential RelationshipsSAY:

In light of the new Joint Commission requirement, ASP partnership with regulatory affairs has increased in importance to ensure compliance and preparation for surveys. ASPs should also collaborate with quality improvement to ensure that compliance with quality metrics involving antibiotics are implemented in a rational way within the institution. Finally, some institutions have patient safety groups that may be able to assist with ASP interventions to improve antibiotic use or laboratory testing.

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Establishing an AS CommitteeSAY:

All Antibiotic Stewardship Programs should establish an AS Committee. This committee is a multidisciplinary group consisting of the ASP, representatives from the groups just described as being essential relationships, including a senior executive, and medical staff from different departments.

Meetings can be monthly or quarterly.

Minutes should be taken and distributed.

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Establishing an AS Committee: ActivitiesSAY:

The Antibiotic Stewardship Program should present the activities of the committee. These might include

Evaluate antibiotic use data and CDI rates and recommend areas for improvement interventions;

Evaluate antibiogram changes over time Review guidelines and practices developed to

optimize antibiotic prescribing in the facility; Review materials for patient and healthcare

worker education regarding optimal antibiotic prescribing;

Review ASP responses to antibiotic shortages; Assure ASP and its procedures and policies

meet relevant regulations and guidelines; and Review approaches for reporting culture and

susceptibility data.

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Development of Institutional Guidelines for Antibiotic UseSAY:

All ASPs should develop institution guidelines for antibiotic use. Guidelines are important because they provide evidence-based and standardized recommendations based on local data. They promote adherence to the use of formulary drugs. In addition, they provide intellectual back up for the ASP. They can be made available at the point of care; and as previously noted, they offer the opportunity to engage though leaders from specific departments and groups during the development process.

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Approach to Development of GuidelinesSAY:

The next two slides outline an approach to developing guidelines. Since the primary target of guidelines are clinicians who prescribe antibiotics, we recommend selecting a reasonable number of common conditions that contribute significantly to antibiotic prescribing in your institution. These might include community acquired pneumonia, urinary tract infection, asymptomatic bacteriuria, hospital and ventilator-associated pneumonia, skin and soft tissue infection, and intra-abdominal infections.

You may also consider developing recommendations for clinicians regarding interpretation of rapid diagnostic tests. We suggest prioritizing syndrome-based over antibiotic-based guidelines because the goals of stewardship are to get clinicians to think about what the right antibiotics are for the syndrome they suspect rather than to decide they want to use a certain antibiotic and come up with a justification to use it.

It is, however, reasonable to consider guidelines for use of select antibiotics that are expensive or used for specific indications.

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Approach to Development of GuidelinesSAY:

Next, the ASP should identify relevant collaborators who are subject matter experts. They should review national guidelines and guidelines from other institutions, when available, in order to come to consensus on what local guidelines should be.

We recommend organizing recommendations based on the Four Moments of Antibiotic Decision-Making: using appropriate diagnostic criteria to determine if a patient has an infection, obtaining relevant cultures and initiating appropriate empiric therapy, narrowing, stopping, or changing from IV to oral therapy as soon as appropriate, and selecting the appropriate duration of therapy.

Guidelines should be short and to-the-point. Remember that clinicians are busy and often don’t have the time or interest to read through too much information.

Finally, consider how to make guidelines available at the point of care. This may be via web site, app, handbook, pocket card, or available in the electronic health record.

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Options for InventionsSAY:

An ASP must decide what approaches to use to intervene to improve antibiotic use.

Direct interaction with clinicians, whether by phone or in person, to discuss recommendations are perhaps the most important part of stewardship as they allow the ASP and clinicians to build a trusting relationship. Although some stewardship interventions might be accomplished with prompts in the EHR, we believe that such “electronic stewardship” will never fully substitute for human interactions to promote rational antibiotic use.

Stewardship programs generally choose to perform pre-prescription approval of antibiotics or post-prescription review and feedback of antibiotic therapy. In pre-prescription approval, prescribers must place a phone call or fill out a form justifying use before the pharmacy dispenses an antibiotic. The advantage of this approach is that unnecessary antibiotic starts can be avoided and empiric selection of antibiotics optimized. The ASP can also advise about obtaining the correct cultures. The disadvantage of this approach is that it impacts only the agents that are restricted, does not address downstream antibiotic use and requires resources to field requests in real time. Post-prescription review and feedback generally occurs 48 to 72 hours after antibiotics are started when more clinical data are available to make recommendations.

Other advantages to this approach include greater flexibility in the timing of interventions and the ability to address downstream therapy and duration. The primary disadvantage of this approach is that recommendations are generally optional and may not be followed.

A third category of interventions are known as syndrome-specific interventions in which a stewardship “bundle” is developed and implemented for a specific disease process such as community acquired pneumonia, urinary tract infection, or asymptomatic bacteriuria. In this project, we will be assisting ASPs and frontline teams with syndrome specific interventions. The advantages of these interventions are that they can

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address empiric and downstream therapy and are more engaging for clinicians which can facilitate sustained learning. The primary disadvantage is that it can be difficult for the ASP to identify cases of syndromes in which cultures are often not sent to trigger a review such as community-acquired pneumonia.

Specific Examples of InterventionsSAY:

The next two slides provide some examples of specific stewardship interventions. ASPs could target use of a costly or salvage drug (e.g., daptomycin, meropenem, ceftolozane/tazobactam) using either prior approval or post-prescription review and feedback approaches. The advantages are that it is generally easy to find patients who are on these antibiotics; however, targeting only these agents does not address the majority of antibiotic use in the hospital. ASPs may elect to focus on IV to PO conversion with the goals of avoiding IV lines and perhaps reducing length of stay. If the conversion involves the same agent, a protocol can be developed and the work executed by staff pharmacists independent of direct ASP involvement. However, if the ASP is targeting IV to PO conversion of different agents, such as piperacillin-tazobactam to levofloxacin, more direct ASP involvement will be needed to ensure that the oral regimen covers the desired spectrum of activity.

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Specific Examples of InterventionsSAY:

ASPs may consider working with providers and/or teams to implement an antibiotic time out tool. This gives clinicians or teams of clinicians designated time each day during which they review their patients on antibiotics to determine if the antibiotics are truly needed or if they could be modified.

The advantage of this approach is that it engages frontline clinicians/teams to think about optimizing prescribing; however, it can be challenging to implement. Teams have to buy-in to the process—and sometimes clinicians think their prescribing is correct; when in reality there might be room for improvement.

Finally, if microbiology labs implement rapid diagnostic tests, it is critical that the ASP be involved, particularly when the tests are first made available. ASPs can call prescribers with results of rapid tests to assist with optimal antibiotic choices. This may be viewed as quite helpful by the clinician. Disadvantages of implementation of rapid diagnostic tests includes impact on a limited number of patients (often just patients with bacteremia) and the need to ensure the test is highly accurate for prescriber “buy-in.”

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MetricsSAY:

Over the next few slides we will discuss the metrics within the Antibiotic Stewardship Program.

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What to Measure and ReportSAY:

ASPs should plan to collect data to demonstrate the activities and success of their programs. When presenting data, it is important to consider who the audience is. Clinicians want to know their patients won’t be harmed and that ASP interventions will improve their patient’s outcomes.

Administrators care about this too of course, but also like to see cost-savings. If you focus on cost-savings with clinicians, they can get turned off by the ASP and think they are “only focused on saving money.”

ASPs may report the number and type of interventions they perform. This is useful for demonstrating how their work benefits patient care. They may report results of a specific initiative such as improvement in peri-operative antibiotic use (percent of cases where an antibiotic is given correctly, improvement in not treating asymptomatic bacteriuria (percent of patients treated inappropriately before and after an intervention, reduction in antibiotic use), or reduction in daptomycin use and associated cost after an intervention.

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What to Measure and ReportSAY:

ASPs should plan to report antibiotic use data both for internal purposes and to demonstrate a decrease in use. It is important to understand and let administrators know that antibiotic use will eventually plateau as the program progresses over time.

Use should be evaluated quarterly and stratified by unit or service and agent (or group of agents). Antibiotic use data should be normalized (e.g. per 1000 patient-days present). The CDC NHSN Antimicrobial Use and Resistance Module uses antimicrobial days/days present by month by patient location and total admissions and reports observed antibiotic use vs expected antibiotic use, a metric known as the Standardized Antibiotic Administration Ratio (SAAR). If your EHR has the infrastructure, you should plan to use the CDC NHSN AUR definitions and methodology.

Ideally, ASPs would report on how their work leads to decreased CDI rates or length of stay across the institution. Many factors are related to patient outcomes and it can be difficult, however, to know whether ASP interventions are directly correlated with them. If a specific ASP intervention targets CDI or LOS reduction, then these are important outcomes to collect for that intervention.

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How Do I Get Started?SAY:

Many ASPs find that it can be difficult to introduce the concepts of AS in an institution that is not used to AS activities. The final section of this webinar will discuss an approach to lead change within your institution.

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Change According to John KotterSAY:

John Kotter has published widely in the area of leadership and change in the business world. He has developed an eight step model to facilitate change in an institution.

Andrew Morris, who directs an ASP in Toronto, at the Sinai Hospital-University Health Network, has applied this change model to implementation of AS. We will discuss this next and you can access the paper via the citation.

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Leading Change StepsSAY:

The first step is to create a sense of urgency within the institution. This inspires people to care about a problem in a more immediate way. This can be referred to as creating a ‘burning platform’.

ASPs can elect to focus on patient safety, regulatory requirements, and/or drug costs with hospital leaders as potential topics requiring urgent attention. Some examples include: “Our CDI rates are too high and we are hurting patients” and “We are not compliant with The Joint Commission Antimicrobial Stewardship Standard and run the risk of a citation at our next visit.”

The second step is to form a powerful guiding coalition. This is a team of leaders who represent key stakeholders and should have characteristics such as position power, expertise, credibility, and leadership skills. You should think about who these individuals might be in your hospital.

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Leading Change StepsSAY:

The third step is to create a compelling vision for change. You can consider this to be a vision statement. An example might be, “Helping patients receive the right antibiotics when they need them.” The goal is to make a clear and succinct statement that people can remember and rally around.

The fourth step is to communicate the vision effectively. ASPs should think carefully about communication to all levels such as senior leadership, boards, department heads, unit directors, physicians and other prescribers. Regular communication is recommended to keep interest and enthusiasm. You may consider developing an elevator speech about what you do, what you are trying to accomplish and why it is important. Valuing input from all team members is an important component of the Comprehensive Unit-Based Safety Program as you will learn in future webinars.

The fifth step is to empower others to act on the vision. This can be viewed as spreading your passion and enthusiasm effectively by working with teams to develop buy-in, and mutually acceptable approaches to antibiotic use, and to empower non-traditional decision makers such as nurses and non-ASP pharmacists to engage in AS work.

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Leading Change StepsSAY:

The sixth step is to plan for and create short term wins. This step emphasizes the importance of demonstrating that your ASP can improve antibiotic use and that the improvement can be observed by relevant stakeholders. ASPs should engage in projects in which rapid improvement can be seen such as non-treatment of asymptomatic bacteriuria or reduction in the duration of therapy for a specific syndrome. They should provide feedback about these successes and emphasize the importance of the team that participated in the work.

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Leading Change StepsSAY:

The seventh step is to consolidate improvements and create still more change. ASPs should learn from successes and strive to spread successful interventions to other clinicians and units.

The eighth step is to institutionalize new approaches. This includes ensuring that the positive results of an intervention are recognized by the institution. This is used to establish the importance of the ASP and its relevance to improving the safety of patients receiving antibiotics. At the same time, work should continue to have prescribers themselves be stewards of antibiotics.

One of the primary goals of this project is to assist ASPs in working with frontline teams to permanently change how they think about antibiotic prescribing.

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Program Website AccessSAY:

You have been sent login credentials to the AHRQ Safety Program for Improving Antibiotic Use website. Please log in to the website to access project resources such as the project schedule, recorded webinars, and slide decks with scripts. The website is updated routinely with new resources. Please note that recorded webinars may take up to 5 days after the presentation date to be posted on this website. The AHRQ Safety Program for Improving Antibiotic Use has not yet started data collection for the pilot project. You will be notified when data collection begins. If you have any questions about login credentials or website content please email AHRQ-AS-SUPPORT@NORC.OR G

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Questions SAY:

Thank you for participating in this webinar about developing an antibiotic stewardship program. We will now open the line for questions.

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Next StepsSAY:

The next webinar is on Improving Antibiotic Use is a Patient Safety Issue or the first step of CUSP. We hope to see you there.

If you have questions or concerns, please don’t hesitate to contact us at: antibioticsafety@jhmi.edu.

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