CHSPSC, LLC Antimicrobial Stewardship Education Seriess3.proce.com/res/pdf/CHS2017Dec14Handout.pdf · Webinar attendees will also receive an email with a direct link to the web page

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



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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.



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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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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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



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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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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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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• 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



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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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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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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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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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 Score Calculation

0

1

3

5Points

0% 20% 40% 60% 80% 100

2016Q4 Stewardship Score

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Stewardship Score Progress Report32



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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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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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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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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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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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



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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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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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

Documents

CHSPSC, LLC Antimicrobial Stewardship Education Seriess3.proce.com/res/pdf/CHS2017Dec14Handout.pdf · Webinar attendees will also receive an email with a direct link to the web page