Download STRATEGIC INFORMATION SYSTEMS PLAN

Pharmacist Monitoring Tools
for Antimicrobial
Stewardship
Dianna Gatto, Pharm.D., BCPS
Pharmacy Clinical Manager
Chris Beuning, Pharm.D., BCPS
Pharmacy Clinical Analyst
MultiCare Health System
September 10, 2012
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MultiCare Health System
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MultiCare Health System
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Not for profit organization in
the greater Tacoma, East
Pierce and South King
County regions in
Washington state
879 licensed beds
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Tacoma General – 402 beds
Good Samaritan – 275 beds
Allenmore – 130 beds
Mary Bridge Children’s –
72 beds
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Specialized Services
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Level II trauma at TGH and
Mary Bridge Children’s
Level III NICU at TGH
Rehabilitation program at Good
Samaritan
Primary Care Clinics
Urgent Care Centers
Free standing Emergency
Department
Employed Providers
HIMSS Davies Award winner
2009
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Objectives
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Be familiar with antimicrobial stewardship
Understand key pharmacist workflows
Identify tools for patient monitoring
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Outline
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Overview of MultiCare Health System
What is Antimicrobial Stewardship
Pharmacist tools
Key pharmacist workflows
Challenges
Future directions
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Outline
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Overview of MultiCare Health System
What is Antimicrobial Stewardship
Pharmacist tools
Key pharmacist workflows
Challenges
Future directions
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What is Antimicrobial Stewardship
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Antimicrobial Stewardship (AMS)
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Systematic, multi-faceted approach to the use of
antimicrobial agents, to optimize clinical outcomes while
minimizing unintended consequences
Goals of programs
Achieve the best clinical outcomes
 Reduce emergence of resistant organisms
 Decrease costs
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Antimicrobial Stewardship at MHS
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Specialized ID pharmacist
 Prospective
audit of targeted hospitalized patients
receiving antimicrobial agents and/or diagnosis of
infection
 Patient identification based on the following:
 Selected
antimicrobials
 Bug-drug mismatches
 Inappropriate durations of therapy
 De-escalation opportunities
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Role of Decision Support in AMS
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Efficiently identify patients who need to be reviewed
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Pharmacists spend time assessing patient therapy versus
report generation and data mining
Easily generate daily reports in a timely manner that
pharmacists can utilize
Target patients by running reports based on flexible
criteria
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Outline
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Overview of MultiCare Health System
What is Antimicrobial Stewardship
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Key Pharmacist Workflows
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Order entry and order verification
Prescriptive authority (dosing) protocols
Pharmacist Inbasket message review
Consults
 Medication messages
 Best practice alerts
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Intervention documentation
Ongoing drug monitoring
Microbiology results
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Outline
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Overview of MultiCare Health System
What is Antimicrobial Stewardship
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Tools
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Need specialized tools that drill down to
increase the number of patients served,
focusing on outcomes and decreasing costs
Selected antimicrobials
 Bug-drug mismatches
 Inappropriate durations of therapy
 De-escalation opportunities
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Tools – Order Entry/Verification
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Order sets
 Appropriate
agents and doses
 Links to guidelines from order sets
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Targeted medication build
 Appropriate
defaults
 Linked
labs
 Order instructions
 Reference Links
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Tools – Microbiology Results
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Best Practice Advisories - General
New properties allow creative rules based on culture results
 Rules can be used in BPA criteria
 Do not fire to end user
 Trigger Inbasket message to pharmacists or pools
 Pharmacists can monitor messages based on workflows and
time
 Custom Inbasket message created to provide patient
specific information within message
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Tools – Microbiology Results
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Best Practice Advisories – Applications
 Updated
micro results available
 Positive blood culture and no antimicrobial
 Resistant culture
 Duplicate anaerobic coverage
 Duplicate C. difficile coverage
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Tools – Microbiology Results
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Best Practice Advisories – Properties
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(Vendor specific screen capture removed)
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Tools – Pharmacist/Physician Rounding
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Accordion Reports
 General
 Medication
administration visual
 Culture information
 Lab data, Vital information
 Pertinent drug levels
 Allow changes to time view
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Tools – Pharmacist/Physician Rounding
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Antimicrobial Accordion
Challenge – complicated patients, multiple antimicrobial
orders, changes in regimen over time
 Visual timeline of all antimicrobial administrations
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Vancomycin Accordion
Challenge – vancomycin often non-continuous therapy with
stops, starts and dosing changes
 Visual timeline of vancomycin administrations
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Accordion Reports - Antimicrobial
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(Vendor specific screen capture removed)
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Accordion Reports – Vancomycin
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(Vendor specific screen capture removed)
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Tools - Pharmacist Rounding: Scoring
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System Lists and Patient Scoring Tools
 Utilize
same BPA properties to create rules
 Ability to sort columns and relative overall score to
identify key patients
 Rules/Columns in Antimicrobial Stewardship Scoring
 Patient
specific information: location, name, age, primary
problem, weight, height and creatinine clearance
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Tools - System Lists and Patient Scoring
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Rule based columns
Score
Creatinine clearance (CrCl)
Value of 0 to 1 based on
level of renal dysfunction
(0 = >70 mL/min; 1 = < 10 mL/min)
On antimicrobial
AMS target medications
Aminoglycoside/Vancomycin
Value of 1 for each
antimicrobial
Value of 1 for each target
antimicrobial
Value of 1 if on either
On 3 or more antimicrobials for 2 Value of 1 if true
or more days
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Tools - System Lists and Patient Scoring
Rule based columns
Score
On quinolone, vanco or imipenem
Value of 1 if true
for 3 or more days
On ceftriaxone and azithromycin IV Value of 1 if true
for 5 or more days
On nitrofurantoin and
CrCl < 60 mL/min
Open I-Vents
Value of 1 if true
Rx Protocol
Value of 1 for each open
protocol
Value of 1 for each open
I-Vent
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Tools - System Lists and Patient Scoring
(Vendor specific screen capture removed)
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Tools - Surveillance/Effectiveness Reports
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Drug Usage
 By
patient, location, physician and drug
 Days of therapy
 Individual
drug per 1000 patient days
 Entire patient hospitalization per 1000 patient days
 IV compared to PO
 Track
antibiotic use and days of therapy by
provider and specialty groups
 Antimicrobial cost per patient day
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Tools - Surveillance/Effectiveness Reports
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Process/Outcome Measurements
 Antimicrobial
use and impact on Clostridium difficile
infection rates
 Intervention
acceptance rate by physicians
Direct antimicrobial expenditures
 Track discharge antibiotic trends
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Outline
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Overview of MultiCare Health System
What is Antimicrobial Stewardship
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Challenges
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Identifying specific interventions
Incorporating tools into pharmacist workflows
Quirky BPA behavior based on free text
Lacking interfaced lab system
Free text data sent for microbiology results from lab
system
Competing requests for reporting resources
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Mitigating Challenges
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Creative use of BPA’s and searching for free text
strings
Use of reports with data already in the Enterprise
Data Warehouse (EDW) for other initiatives (sepsis
metrics)
Leverage expertise from outside the pharmacy team
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Outline
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Overview of MultiCare Health System
What is Antimicrobial Stewardship
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Future Directions
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Introduction of QlikView for reporting from Epic
 AMS program outcomes
 Antimicrobial
usage trends
 Drug use patterns related to infection control data
 Comparative reports by drug, facility and prescriber to
identify improvement areas
 Financial impact
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Expand AMS to all hospitals in system
Consideration of changes to lab system
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Conclusion
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What is Antimicrobial Stewardship
Pharmacist tools
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Questions
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[email protected]
[email protected]
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