Download Session 5 Slides - IHI Antibiotic Stewardship Expedition

8/9/2011
Session 5 – August 11, 2011
Christopher Ohl MD
Diane Jacobsen, MPH
Guest Presenters:
Brenda A. Egan, PharmD, BCPSS
Kristi Kuper, Pharm.D., BCPS
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8/9/2011
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Our Expedition Director
Diane Jacobsen, MPH, CPHQ, Director,
Institute for Healthcare Improvement (IHI), is
content director for Project JOINTS, directs
the CDC/IHI Antibiotic Stewardship Initiatives,
Expeditions on Antibiotic Stewardship and
Sepsis, and serves as IHI content lead and
improvement advisor for the California
Healthcare-Associated Infection Prevention
Initiative (CHAIPI). Ms. Jacobsen also
directed Expeditions on Preventing CA-UTIs,
Reducing C. difficile Infections, Improving
Flow in Key Areas and Improving Stoke Care.
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Christopher Ohl, MD
Christopher Ohl, MD, is the Medical
Director for Antimicrobial Utilization
Stewardship and Epidemiology at
Wake Forest University Baptist
Medical Center, and Infectious
Diseases Associate Professor at Wake
Forest University School of Medicine
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Kristi Kuper, PharmD, BCPS
Kristi Kuper, Pharm.D, BCPS is the Clinical Director
of Infectious Diseases for Cardinal Health and is based
in Houston,TX. Previously, she was a clinical pharmacy
coordinator at Olathe Medical Center, in Olathe, KS. To
date, she has worked in various capacities with over
160 hospitals nationwide. She is primarily responsible
for developing programs to assist hospitals with
antibiotic management, including antimicrobial
stewardship. Her expertise in stewardship is derived
from working directly with hospitals to implement on
site programs, typically in the community hospital
setting (i.e. “ID resource deficient”). She is a member
of ASM, IDSA, SHEA, and SIDP and several national
pharmacy organizations. Dr. Kuper received her Doctor
of Pharmacy from the University of Nebraska Medical
Center, completed a post graduate pharmacy practice
residency at the James A Haley Veterans Hospital in
Tampa, FL, and maintains Board Certification as a
Pharmacotherapy Specialist.
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Overall Program Aim
The Aim of this Expedition: To provide
hospitals with the most effective ideas and
practices in improving Antibiotic Stewardship
in their organization.
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Objectives
Upon completion of this expedition, participants will be able to:
•
Describe the impact of antibiotic overuse on complications, including
Clostridium difficile and adverse drug reactions, length of stay, costs,
and antimicrobial resistance
•
Establish or enhance a multidisciplinary focus to heighten awareness
of the challenges of antimicrobial resistance and support antibiotic
stewardship
•
Identify and begin improving at least one key process to optimize
antibiotic selection, dose, and duration of antimicrobial agents in their
hospital
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Expedition Focus
The expedition will focus on key “high leverage”
changes to ensure timely and appropriate antibiotic
utilization:
• Making antibiotics patient is receiving and start & stop
dates visible at point of care
• Reconciling and adjusting antibiotics – focused on care
transitions within the hospital
• Stopping or de-escalating therapy appropriately
• Monitoring and providing feedback on process measure to
assess progress over time
Agenda
•
Welcome and introductions
•
Follow-up from Session 4 – Stopping or de-escalating therapy
appropriately
- Review Assignment: what did you TEST? – Chris Ohl MD & Diane
Jacobsen
•
Session 5 Focus - Insights and challenges in community hospitals
- Bristol Hospital’s Journey Towards Antibiotic Stewardship
Brenda A. Egan, PharmD, BCPSClinical
- Implementing stewardship in an “ID resource challenged” environment
Kristi Kuper, Pharm.D., BCPS
•
Preparing for the Final Session – “all teach, all learn”
•
Final Questions & Close
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Session 4 – July 28th
•
High Leverage Change: Stopping or de-escalating therapy
appropriately
Key Change Concepts:
•
Establish process for prompt notification of culture and antibiotic
susceptibility results
•
Stop or de-escalate antibiotic based on culture result
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What did you TEST since the July 28th Session?
•
Design a small test of change to ensure
prompt notification of culture and antibiotic
susceptibility results
Ideas to consider………….
1. Set a time frame within which culture results
must be reported and to whom.
2. Develop a list of “critical results” to report to the
physician via page or automated means, such as
a text message (e.g., MDRO)
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- Ensure that the reporting system includes
mechanisms to alert responsible clinical staff when the
attending physician is unavailable
- Develop and monitor a standard timeframe for
reporting and receiving critical results.
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What did you TEST since the July 28th Session?
•
Design a small test of change to
Stop or de-escalate antibiotic based on culture
result
Ideas to consider………….
1.
Develop a process to discontinue antibiotics
- When positive cultures most likely represent colonization rather than infection.
- If cultures are negative or alternative non-infectious agent is diagnosed in 48 to 72
hours.
- Permit physicians to opt out of automatically discontinuing antibiotics based on
negative culture results, but require documentation of the rationale.
2.
3.
If indication for antibiotics is clearly identified, deescalate therapy to target the susceptibilities of the
pathogen.
Standardize all hand offs to include review of culture
results or pending culture results, antibiotic duration,
and current plans for antibiotic discontinuation.
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Today’s Focus
Insights and challenges in community hospitals
considerations in:
• Making antibiotics patient is receiving and start & stop dates visible at point
of care
• Reconciling and adjusting antibiotics – focused on care transitions within
the hospital
• Stopping or de-escalating therapy appropriately
• Monitoring and providing feedback on process measure to assess progress
over time
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One Community Hospital’s
Experience
Brenda A. Egan, PharmD, BCPS
Pharmacy Clinical Manager
Bristol Hospital
Bristol, CT
Bristol Hospital’s Journey
Towards Antimicrobial
Stewardship
Brenda A. Egan, PharmD, BCPS
Clinical Manager Bristol Hospital, CT
August 11, 2011
© Copyright 2010,1Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
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About Bristol Hospital
•
•
134 bed community care hospital
Services lines:
–
–
–
–
–
–
•
Inpatient acute care medicine
Medical/surgical
ICU
Labor and delivery
Same day admissions/peri-op center
Outpatient Cancer Care Center
Pharmacy staff:
– Current hybrid of decentralized and centralized where an ICU pharmacist
attends M-F rounds on the unit.
– 5.6 pharmacist FTEs and all perform clinical activities with varying strengths.
•
Prescribers of antibiotics:
– ID physicians
– Hospitalists
– Intensivists
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Pharmacy
Antimicrobial Stewardship Activities
• Conducted staff training in Fall 2010
– Completed a 4 hour proprietary antibiotic stewardship
workshop
– ASHP JCAHO competency assessment
• Participated in a live webinar on antimicrobial
stewardship
– Speaker from Cardinal Health
– Infection Preventionist in attendance
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© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
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Pharmacy
Antimicrobial Stewardship Activities
• New class of pharmacist interventions created entitled,
“MDRO Prevention Interventions”, to better track the
work done towards NPSG 07.03.01
– Later re-titled to “Antimicrobial Stewardship Interventions”
• Dramatic improvement in interventions as evidenced
by increased documentation
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© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
External to Pharmacy
Antimicrobial Stewardship Activities
• Integrated stewardship into Infection Control
Committee
• One clinical staff pharmacist greatly involved in the
monthly Infectious Disease Committee where she
provides quarterly Antibiotic Stewardship activity
reports from the pharmacy
• Interactions with members of the microbiology team to
streamline reporting in terms of hiding non-formulary
agents
• Coordination with nurses for timely blood draws to
obtain vancomycin or aminoglycoside levels
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© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
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External to Pharmacy
Antimicrobial Stewardship Activities
• Interactions with intensivists and/or ID physicians at
daily rounds in the ICU
• Daily length of stay huddles (LOSH)
– Attended by nursing, social work, case managers and unit
clinical coordinators
– PRN attendance by Medical Director
– Pharmacy focus
• IV to PO conversion opportunities
• Identify opportunities for de-escalation if not already picked up on
daily review of target drug reports
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© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Pharmacy MDRO Interventions
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
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New Policies and Education
•
Antimicrobial Stewardship Policy and Procedure
– Defines an antimicrobial stewardship program (ASP)
– Outlines the procedure of the pharmacist’s ASP activities that involves
a multidisciplinary effort
•
Formulary Restriction Policy
– Formulary restrictions for antibiotics requiring an Infectious Diseases
consultation in the effort to control usage, decrease resistance and
control overall costs
•
IV to PO Policy –Auto-Conversions
– 13 out of 17 medications are antibiotics
– Passed by the ID and P&T Committee
•
•
Featured articles in the medical staff & pharmacy newsletters
P&T Committee requested an early report of physician acceptance
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Stewardship Interventions
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
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IV to PO Conversions
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Breakdown of Interventions
1st Quarter 2011
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
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Antibiotic Purchases Nov 2009 thru Oct 2010
Benchmark
ct
O
ug
Se
p
Ju
l
A
M
ar
A
pr
M
ay
Ju
n
Fe
b
ec
Ja
n
N
ov
$20.00
$18.00
$16.00
$14.00
$12.00
$10.00
$8.00
$6.00
$4.00
$2.00
$0.00
D
$/APD
12-month Antibiotic Trend
Prior Year
Antibiotic Stewardship activities have resulted in proper utilization of antibiotics and
favorable resistance trends
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
An Estimated Cost Value Placed on ASP
Intervention
Class
Quantity
Estimated Cost
Avoidance
Antibiotic
Recommendations
16
$3,210.00
Antibiotic Renal Dosing
50
$12,998.00
Antibiotic/Microbiology
Assessment
315
$83,348.00
PK EvaluationAminoglycoside
3
$600.00
PK Evaluation-Vancomycin
52
$6,834.00
436
$106,990.00
Total
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© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
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Lessons Learned
• Empower staff to get involved in stewardship
– May not necessarily be an “ID trained pharmacist”
– Look to engage staff that have a passion or interest in ID
• Staff education is key
– Serves to increase the knowledge base and allow for
increased confidence during prescriber interactions
• Integrate into your hospital culture
– Don’t just put the whole burden on pharmacy
– “If all eyes are on the target, we’ll achieve much more”
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Lessons Learned
• Document, document, document
– Once you’ve gathered enough data to see a difference,
brag about it to everyone that will listen
• Lastly, attitude is everything! Rome wasn’t built in
a day and being a smaller community hospital
shouldn’t stop you from thinking big.
– Grabbing pieces and owning parts of an antibiotic
stewardship program is better than doing nothing at all
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
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Take Home Points
• “We were doing great work, but we didn’t know it”
• Creation of a stewardship specific intervention in
electronic intervention program helped to quantify
number of interventions
– Allowed us to better measure the program’s performance
through objective data
– Provided great information to share with those outside of
Pharmacy
• Multi-disciplinary involvement was key
• Next steps:
– External marketing campaign to “drum up” excitement
– Posters in elevators and bulletin board throughout facility
© Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Questions and Discussion
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Implementing Stewardship in
an ID Resource Challenged
Environment
Kristi Kuper, PharmD, BCPS
Clinical Director, Inf. Diseases
Cardinal Health Pharmacy Solutions
[email protected]
Analogy Quiz
• Implementing stewardship in an ID
resource challenged hospital can be like:
A. Making ice in the desert
B. Trying to start a fire in a blizzard
C. Driving a car from Texas to
California with only two tires
D. All of the above
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What is “ID Resource
Challenged”?
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• No Infectious Diseases physician on staff
─ Based on a 2009 survey of 97 hospitals, 42% did not
have an ID physician on staff
• ID physicians not engaged
• ID physician engaged, but not full time
• No pharmacist on staff with formal ID training
Data on file: Cardinal Health
Getting Started
• It is an exciting time for stewardship
─Excess excitement often leads to wanting to
do something right away
─ We are going to have a meeting!
─Ready , Fire, Aim!
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Before You Have a Meeting
• Stop and take an inventory of what you
are currently doing related to stewardship
─Many hospitals are doing stewardship, they
just don’t define it as such
─ Pharmacy specific
─Organizational activities
 Four IHI high leverage changes
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Before You Have a Meeting
• Gather Pharmacy metrics
─ Drug costs (per census metric)
─ Utilization
─ Antibiotic intervention data
De-escalation
─ Staff resources – current and proposed
• Gather data from other departments
─ Infection Control reports
─ Microbiology/Laboratory
─ Quality
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Before You Have a Meeting
• Find a physician champion
─ May be ID, may not be
─ Engage CMO or Administrative support
• Give specific thought to key participants
• Clearly outline the first meeting
─ Send out agenda ahead of time
─ Tell the story with the data
─ Set goals or define specific actions
─ Set frequency to meet back
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Ask Yourself These 3 Basic
Questions
40
• What objective (not subjective) data do you have
that shows that there is an issue with
inappropriate antibiotic use in your institution?
• How will you know (again objectively) if your
program is successful?
• What personnel will comprise your team?
─Do not make your program an island of 1
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Assessing Program Motivators
• “Not so good” answers
─To only save money
─My CFO requested it
─I enter a lot of orders for antibiotics
─Antibiotic resistance is bad
─There just seems to be a lot of antibiotic
overruse
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Good Answers
To employ cost effective, quality care in our institution.
To create a multi-disciplinary program that will encourage
appropriate antimicrobial use in our institution.
Antibiotic utilization has increased by 17% in the last year.
• Our goal is to reduce this number to 5% growth for FY11
Based on a review of 100 general medical and surgical
patients who received > 3 antibiotics, only 30% of
patients had therapy de-escalated after culture and
susceptibility reports were returned.
• Our goal is to improve this number to 60% by year end
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Other Suggestions
• Identify which of the defined problems or
issues you plan to address with your
stewardship program?
─ Rome wasn’t built in a day
─ Please don’t make the blanket statement that you are
going to decrease ALL antibiotic resistance
http://www.idsociety.org/Content.aspx?id=11840
Emerg Inf Dis 2007;13(6):838-46
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Other Suggestions
• Formalize stewardship policy
• Set up a stewardship scorecard
─ Antibiotic utilization by month
─ Antibiotic cost per month (e.g. $/APD)
─ Select resistance: Carbapenem resistant
Pseudomonas
─ Intervention rates
─ Quality metrics (CMS)
─ HAI rates
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Sample Scorecard
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Define Implementation
• 1. How will the day to day activities of the ASP
be set up?
• 2. Who will perform the streamlining functions?
• 3. Which personnel are assigned to the program
(based on hours per week)?
• 4. Most hospitals are more successful in
implementing the stewardship program in stages
vs. all at once
• Use "culture of the month" principles
• First month only do bug-drug matching
on urine cultures, then blood cultures, etc.
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Identify Additional Resources
• Assess resources that are available (personnel and
tools)
• Personnel
• The most successful programs are inter-disciplinary
• Look for program “extenders”
• Nursing, Case Management, technicians
• Maximize technology if you can
• Make friends with your hospital IT department
• Network with others that have the same IT system
• Tools
 Intervention tracking
 Other systems within the hospital
 For example, look at Infection Control tools available
 Build your own!!
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Identify Additional Resources
• Education
─ Home grown
─ Commercial products
─ State and national societies
• Basic bugs and drugs
─ Nursing
─ Microbiology (obviously more drugs than bugs)
• Grand rounds
• Pocket cards and “5 minute consult” in-services
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Market the Program
• Advertise the program before it starts and clearly
communicate that this is not just a cost issue
• Continue to advertise or communicate the results
in newsletters or unique communiqués
• Recognize the successes and acknowledge those
individuals who contributed to the success of the
program
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Stewardship Resources
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On the Web
•
Society of Infectious Diseases Pharmacists
•
Johns Hopkins Antibiotic Guide
•
Nebraska Medical Center ASP Homepage
•
University of Kentucky – Chandler Medical Center
•
KU Medical Center Antibiotic Homepage
─ www.sidp.org
─ http://www.hopkinsguides.com/hopkins/ub
─ http://www.nebraskamed.com/careers/education/asp/
─ http://www.hosp.uky.edu/pharmacy/amt/default.html
─ http://www2.kumc.edu/pharmacy/AbxUseGuide/Table%20of%20Conten
ts.htm
•
WHO DDD
─ http://www.whocc.no/atc_ddd_index/
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In Print
• Septimus EJ, Owens RC. Need and potential of
antimicrobial stewardship in community hospitals. Clin
Infect Dis 2011;53(S1):S8-S14
• Antimicrobial Stewardship Programs: Interventions and
Associated Outcomes. Expert Rev Anti Infect Ther.
2008;6(2):209-222.
• Antimicrobial Resistance – Problem Pathogens and
Clinical Countermeasures (Owens RC, Lautenbach E,
editors)
• Antibiotics Simplified. (Gallagher JC, MacDougall C,
editors)
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Sources of Comparison Data
Pharma Sponsored
Name (Sponsor)
Data Source
Website
T.E.S.T – Tigecycline
Evaluation and Surveillance
Trial (Pfizer, Formerly
Wyeth)
Isolates are collected from
130 global centers. Micro
testing performed on site and
then info entered into a
proprietary database
http://testsurveillance.com/in
dex.php?view=welcome&te
mplate=main
Susceptibility data limited to
drugs that have similar
spectrum of activity to
tigecycline. Access is free
but must register.
Comments
Susceptibility of Gram
Positive Pathogens
(Cubist)
JMI Labs Central Data
Repository
http://www.gppathogens.com/data/default.
cfm
Data is independently
maintained by JMI Labs, one
of the leaders in antibiotic
susceptibility testing. Site
only has gram positive info.
MYSTIC –Meropenem
Yearly Susceptibility Test
Information Collection (Astra
Zeneca)
JMI Labs Central Data
Repository
Not available
Data can only be found in
published articles. Not
searchable.
TRUST - Tracking
Resistance in the US Today
Focus Technologies Central
Data Repository
Not available
Website only contains info
on S. pneumoniae resistance
patterns but TRUST
surveillance tracks Gram
negative also. May be able
to access more info through
Ortho McNeil.
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Sources of Comparison Data
Non-Pharma
Name (Sponsor)
Website
Comments
ABC - Active Bacterial Core
Surveillance – CDC
http://www.cdc.gov/abcs/reportsfindings/surv-reports.html
Contains annual susceptibility reports
for Group A and B Strep, MRSA, N.
meningitidis, and S. pneumoniae, and
H. influenzae (through 2009).
CDC Antimicrobial Resistance
homepage (CDC)
http://www.cdc.gov/drugresistance/inde
x.html
Cannot query. Real time data not
available.
JMI Laboratories
National Healthcare Safety Network
http://jmilabs.com/default.cfm
http://www.cdc.gov/nhsn/
One of the leaders in antimicrobial
testing. Posters and abstracts that they
have presented are on this website
under the Scientific presentations
website but are difficult to search for a
particular resistance pattern.
Cannot query. Real time data not
available.
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Closing Thoughts
• “Don’t let the better get in the way of
the good” (Voltaire)
• “Don’t let perfection stand in the way
of progress”
Questions and Discussion
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What You Should Do Over the Next 14 Days
•
Community Hospitals
─ Identify one key idea from today’s session to “test” in
your hospital
*consider the steps to implementing stewardship in a
resource challenged setting
10 steps to implementing stewardship in a resource
challenged sett
•
Review and/or expand - a small test of change your
team has focused on related to:
─ visibility of start & stop dates at the point of care
─ process for reconciling and adjusting antibiotics at all
care transitions
─ stopping or de-escalating antibiotics.
57
What You Should Do Over the Next 14 Days
• Huddle with your team to come to
the final session prepared to
discuss:
- role(s) in your organization that you recruited to
the unit-based multidisciplinary team to actively test
changes, identifying key roles in your organization
that may not currently be involved in the process
*did you engage roles that had not been involved in
ABS?
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What You Should Do Over the Next 14 Days
• Come to the final session prepared
to discuss:
Tests of change you’ve focused on related to:
─ visibility of start & stop dates at the point of care
─ process for reconciling and adjusting antibiotics at all
care transitions
─ stopping or de-escalating antibiotics
Approaches used (or tested) in your hospital to
monitor and provide feedback on process measure
to assess progress
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Final Session 1-2pm ET
• Aug 25th – Brief report outs from participating hospitals:
progress and challenges
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