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FHA Hospital Engagement NetworkInfection Prevention Roundtable
What’s New in Infection Prevention;What’s New in Infection Prevention;Updates, Challenges and Controversies
June 18, 2014
Agenda• Welcome• Key Points from the National APIC Conference:
What You Need to KnowWhat You Need to Know– Linda Greene, RN, MPS, CIC, Highland Hospital, NY
• Highlights from the Chasing Zero InfectionsHighlights from the Chasing Zero Infections Infections-Part 2 Meeting: Antibiotic Stewardship– Brian Mayhue, PharmD, Palm Beach Gardens Medical
Center– Suet-ping Lau, PharmD, Dr. Phillips Hospital
• Open Discussion / Q & A• Open Discussion / Q & A• Upcoming Events
2
Annual APIC Conference 2014Hi hli ht Highlights
Linda R. Greene, RN,MPS,CICManager of Infection Pre entionManager of Infection PreventionHighland Hospital Rochester, NY
University of Rochester Medical Centerlinda greene@urmc rochester [email protected]
3
Overview of SHEA CompendiumCAUTI – May publicationSSI‐ JuneC difficile‐ JuneCLABSI – JulyMDRO – JulyVAE‐ AugustHand Hygiene ‐ August
4
CLABSI Update• Majority of CLABSIs are outside ICU• New independent risk factor‐ femoral lines• Transfusion of blood products in children• New : Reduced Risk‐ Antibiotic administration‐ Minocycline impregnated cathetersy p g
*CLABSI Update‐ presented by Lynn HadawayCLABSI Update presented by Lynn Hadaway
5
Current BundlesSuccessful in patient safety culture
Adherence to individual measures
Recent data suggests that adherence to all bundle components is not necessary
6
Basic PracticesEvidence based indications for CVC USERe‐educate staff when infusion components changeRe educate staff when infusion components changeUse checklist by someone other than inserter in ICU and non‐ ICUAvoid femoral in obese patients
7
Other PracticesPICC use is not a strategy to reduce CLABSI
Use ultrasound for internal jugular insertion
Vigorously scrub injection ports no less than 5 seconds
IV SETS‐ replace at intervals no longer than 96 hours
U kl i h di l i hUse tpa weekly in hemodialysis catheters
8
Barriers
Lack of infusion specialist
Maintenance checklist – no singe episode to be witnesses‐ reliability of self reported data
9
ChallengesOther Departments‐ Radiology, OR
Patients transferred from other facilities
10
Abstract‐ CLABSIDanielson et al. – Texas Health68% decrease in CLABSI rates with use of alcohol i d impregnated port protector
Wawrzyniak et. al – Loyola U Medical Center b i l d D b 68% 2 year pre‐post observational study. Decrease by 68% overall with use of alcohol impregnated port prrotectorprrotector
11
Hand HygieneAlcohol vs. soap and water‐ stress glove use
Antimicrobial soap‐ invasive procedures(Either is OK as long as gloves are used)
UNRESOLVED Issue – Hand Hygiene before donning lgloves
* Presented by Janet Haas* Presented by Janet Haas
12
VAEVAE• The limitations of VAP surveillance definitions hinder
interpretation of the VAP prevention literature.
• Many interventions have been shown to reduce VAP rates but few interventions have been shown to improve objective p joutcomes such as average duration of mechanical ventilation or mortality
13
UpdatesUpdatesBasic PracticesBasic Practices: Interventions with little risk of harm that decrease duration of mechanical ventilation, length of stay, mortality, and/or costs.•Use non‐invasive positive pressure ventilation (NIPPV) whenever feasible• Minimize the use of sedation when possible.p• Interrupt sedation daily (spontaneous awakening trials) for patients without contraindications•Assess readiness to extubate daily (spontaneous breathing trials) in patients y ( p g ) pwithout contraindications•Maintain and improve physical conditioning•Minimize pooling of secretions above the endotracheal tube cuff ( Subglottic p g ( gsuctioning)•Elevate the head of the bed to 30‐45°•Change the ventilator circuit only if visibly soiled or malfunctioningg y y g
14
U dUpdatesSpecial Practices: Interventions that decrease duration of mechanical ventilation length of stay and/or mortality but insufficient data available on ventilation, length of stay, and/or mortality but insufficient data available on possible risks.• Decrease the microbial burden of the aerodigestive tractSpecial Practices: Interventions that may lower VAP rates but for which there are Special Practices: Interventions that may lower VAP rates but for which there are insufficient data at present to determine their impact on duration of mechanical ventilation, length of stay, and mortality.• Oral care with chlorhexidine• Prophylactic probiotics• Ultrathin polyurethane endotracheal tube cuffs• Automated control of endotracheal tube cuff pressureAutomated control of endotracheal tube cuff pressure• Saline instillation before tracheal suctioning
15
Future Bundle Process Measure Date Y/N CommentsContinuous Subglottic Suctioning
Assess readiness to extubate ( Spontaneous breathing trials)
Paired SBT’s and SATs. Standardized process measures in development.
Interrupt sedation daily( S k i i l )
If contraindications – note here( Spontaneous awakening trials)
Ambulate according to protocol* Note level
Regular Mouth care (without chlorhexidine )* chlorhexidine )
Elevate HOB 35‐4000
Low Tidal Volume Identify:
16
Focus on MobilityFocus on Mobility
17
MRSAHorizontal vs. Vertical approach to MDROsIsolation still recommended for colonized and infected
ipatientsPerform a MRSA Risk assessmentU i l d l i i f d l ICU i i h Universal decolonization of adult ICU patients with daily chlorhexidine bathingMupirocin ointmentMupirocin ointmentActive surveillance and targeted decolonization
* Presented by Julia Moody18
I t d d d i t d d Intended and non intended consequences of public reportingPublic attentionAdministration attentionAdministration attentionTransparencyThe Truth:e ut :Protect patientsKnow when something is wrong‐ interveneg gGet the help we need
* Susan Huang19
Response to GamingValidationIncreased visibility for IPs
What can we do:BelieveBe a voiceBe proactiveProve
20
Trial to eliminate MRSA
• Chlorhexidine Matters:• Method• Method• ConcentrationC i• Consistency
• Safety
21
DecolonizationMassage into skin for sustained 24 hour activityNo rinse
P lProtocol:Attention to high risk skin areasClean over non gauze dressingsClean over non gauze dressingsProximal 6 inches of lines catheters, etcPerineum and woundsPerineum and woundsMany soaps and shampoos inactivate
22
Chlorhexidine
• 2% non rinse cloth most widely studied• 4% ‐ no rinse more adverse skin events• 4% rinse‐ shower or bath‐ lower concentrations• 2 min contact time before rinse• Mesh sponge works well for liquide application
23
Consistency24 Hour Effect‐
Daily application
Assure all staff are trained
Night and weekends
C li h kCompliance checks
24
ANTIBIOTIC STEWARDSHIPSTEWARDSHIP
Brian Mayhue, Pharm D, CGPDirector of PharmacyDirector of Pharmacy
Palm Beach Gardens Medical Center
25
Magnitude of Antimicrobial Use• Antibiotics are the second most commonly used class of
drugs in the United States• More than 8 5 billion dollars are spent on anti infectives• More than 8.5 billion dollars are spent on anti -infectives
annually200-300 million antimicrobials prescribed annuallyp y53% for outpatient use
• 30-50% of all hospitalized patients receive antibiotics• Studies estimate up to 50% of antibiotic use is either
unnecessary or inappropriate across all type of health care settingssettings
26
Unnecessary Use of Antimicrobials in HospitalizedUnnecessary Use of Antimicrobials in Hospitalized Patients
• Prospective observational study in ICU• 576 (30%) of 1941 antimicrobial days of therapy deemed
unnecessaryy
Most Common Reasons for Unnecessary Days of Therapy
192 187
94100
150
200
250
ys o
f The
rapy
Hecker MT et al Arch Intern Med
0
50
Duration of TherapyLonger than Necessary
Noninfectious orNonbacterial Syndrome
Treatment ofColonization orContamination
Day
Hecker MT et al. Arch Intern Med. 2003;163:972-978.
27
Antibiotic Misuse• Given when they are not needed• Continued when they are no longer necessary-
duration• Given at the wrong dose-renal and weight-based
dosing• Broad spectrum agents are used to treat very
ibl b isusceptible bacteria• The wrong antibiotic is given to treat an infection
28
Guidelines to develop an institutionalGuidelines to develop an institutional Antimicrobial Stewardship Program (ASP)
• Antimicrobial Stewardship committee• Computer surveillance and decision support
software• Proactive microbiology lab• Monitoring of process and outcomes
measures• Elements of an ASP
– Active Strategiesg– Supportive Strategies
29
Goals of AntimicrobialGoals of Antimicrobial Stewardship Programs
Optimize Patient Safety
Decrease or Control Costs
Reduce Resistance
30
Antimicrobial StewardshipAntimicrobial StewardshipGoals
• Improve patient outcomes• Optimize selection, dose and duration of Rx
R d d d i l di d i f i• Reduce adverse drug events including secondary infection (e.g. C. difficile infection)
• Reduce morbidity and mortalityReduce morbidity and mortality• Limit emergence of antimicrobial resistance• Reduce length of stay• Reduce health care expenditures
MacDougall CM and Polk RE. Clin Micro Rev 2005;18(4):638-56.MacDougall CM and Polk RE. Clin Micro Rev 2005;18(4):638 56.Ohl CA. J. Hosp Med. In press.
Dellit TH, et. al. Clin Infect Dis. 2007;4
31
PBGMC C. Diff Rate
• Rate based on cases per 10000 admissions
4 55
33.5
44.5
22.5
320122013
0.51
1.5
0Rate
32
Challenges• Literature often not clear in Infectious Diseases• Everyone thinks they know how to use antibiotics
P id i i l• Providers perceive autonomy is lost• Difficulty proving impact (no national measures)• Financial pressures dictating decisions• Financial pressures dictating decisions
– Pharmaceutical manufacturers– Hospitals p– Insurance companies– Patients
33
Getting StartedMultidisciplinary team
– Physician champion– Clinical pharmacist (with ID training)
Decentralized (on the units)Additi l– Additional
– clinical microbiology– Information systems specialist– Infection prevention professional/ hospital
epidemiologist
34
Multidisciplinary TeamMultidisciplinary Team Approach
*HospitalHospitalEpidemiologistEpidemiologistHospitalHospitalEpidemiologistEpidemiologist
I f tiI f ti
InfectiousInfectiousInfectiousInfectiousDiseases Diseases
DirectorDirectorDirectorDirector
Hospital and NurseHospital and NurseAdministrationAdministrationHospital and NurseHospital and NurseAdministrationAdministration
InfectionInfectionPreventionPrevention
MedicalMedicalMedicalMedicalInformationInformation
Director,Director,QualityQuality
Chairman,Chairman,Chairman,Chairman,P&TP&T
AMP Directors•• Cl. PharmacistCl. Pharmacist•• Physician ChampionPhysician Champion
SystemsSystemsSystemsSystems
MicrobiologyMicrobiologyMicrobiologyMicrobiologyLaboratoryLaboratory
CommitteeCommitteeCommitteeCommitteePartners in Partners in OptimizingOptimizingPartners in Partners in OptimizingOptimizingAntimicrobial Use such asAntimicrobial Use such asED, hospitalists, ED, hospitalists, intensivistsintensivists
y py p
ClinicalClinical
SpecialistsSpecialists
ClinicalClinicalPharmacyPharmacySpecialistsSpecialists , p ,, p ,
and surgeonsand surgeons, p ,, p ,
and surgeonsand surgeonsDecentralizedDecentralized
SpecialistSpecialist
DecentralizedDecentralizedPharmacyPharmacySpecialistSpecialist *based on local resources
Modified: Dellit et al. ClD 2007;44:159-177.
35
Physician Champion• Basic knowledge of antibiotics*(does not have to
be an infectious disease MD but helps)M t h i t t i t ki l d hi l i• Must show interest in taking a leadership role in the hospital
• Respected by his or her peers• Respected by his or her peers• Good interpersonal skills• Good team playerp y• Basic understanding of human factors and culture
transformation
36
PBGMC Antibiotic StewardshipPBGMC Antibiotic Stewardship Program
• Prospective audit with intervention and feedback
• Streamlining or de-escalation of therapy• Dose optimization• Dose optimization• Formulary restriction and pre-authorization
l l i• Parenteral to oral conversion
37
Prospective Audit and FeedbackProspective Audit and FeedbackBack-end Approach
Physician writes order
Antibiotic DispensedAntibiotic Dispensed
At a later date, time antibiotics reviewed
Prescribing physician contacted and recommendations maderecommendations made
38
Prospective Audit and FeedbackProspective Audit and Feedback
• Advantages– Prescriber autonomy maintainedy– Educational opportunity provided– Patient information can be reviewed before
interaction– Inappropriate antibiotic use decreasedpp p– De-escalation
39
Prospective Audit and Feedback
• Disadvantages– Voluntary compliancey p– Identification of patients require computer
support (IT pharmacist helpful)– Prescribers reluctant to change if patient is
doing well– Some inappropriate antibiotic use permitted
40
Dose Optimization• New evidence for duration of therapy
– Uncomplicated urinary tract infection: 3-5 days1
– Community-acquired pneumonia: 3-7 days2
– Ventilator-associated pneumonia: 8 days3
– CR-BSI Coagulase-negative staphylococci: 5-7 days4
– Acute Hem Osteomyelitis in children-21 days5
i l i i i d 6– Meningococcal meningitis-7 days6
– Uncomplicated secondary peritonitis with source control: 4-7 days7
• Avoid 10-14 day course of antibioticAvoid 10 14 day course of antibiotic therapy
41
Dose Optimization
• Other steps taken at PBGMC– Implementation of extended infusion of p
Pip/Tazo (started in Feb 2013)• Dosing based on renal function (either Pip/Tazo
3 375 IV 12h 8h 4 h i d)3.375g IV q12hrs or q8hrs over 4 hr period)
Renal Dosing Policy– Renal Dosing Policy• Allows pharmacist to change dose/ frequency based
on renal function
42
Pip/Tazo purchases
100000
120000
60000
80000
2012
20000
400002013
0
20000
Pip/TazoPip/Tazo
43
Formulary Restriction
• Restrict high cost antibiotics to infectious disease physicians– Examples: daptomycin, linezolid, tigecycline
44
IV to PO Conversion
• Develop a policy specifically targeting antibiotics which have same bioavailability to change to oral if certain criteria are met.– Azithromycin
Fluconazole– Fluconazole– Fluoroquinolones (ciprofloxacin, levofloxacin)– Metronidazole
Li lid– Linezolid– Clindamycin– Doxycycline
45
IV to PO Conversion
• Inclusion Criteria (must meet one)– Tolerating a regular or modified diet for at least g g
24 hours– Tolerating enteral nutrition for at least 24 hours– Receiving other scheduled medications by the
oral route– Signs and symptoms of infection have resolved
or are improving
46
IV to PO Conversion
• Exclusion criteria (must have none)– Unable to swallow, NPO, high risk for aspiration
A ti N/V/D GI b t ti IBS l b ti il– Active N/V/D, GI obstruction, IBS, malabsorption, or ileus– Signs and symptoms of infection have not improved– Experienced severe trauma within last 72 hrs
A ti GI bl d– Active GI bleed– Neutropenia (ANC<5000– Documented CNS infection or endocarditis
P i ith AIDS l i i d– Pneumonia with AIDS or severely immunocompromised– Pseudomonas infection and on antibiotics <24 hrs– Candidemia treated <7 days
Oth i f ti h IV th i th f d t d d f– Other infections where IV therapy is the preferred standard of care (osteomyelitis)
47
Other Interventions
• Post antibiogram on line through our physician portal
• Work with Pharmacy Informatics to get computer generated reports to help clinical p g p ppharmacists identify opportunities
• Future opportunities (procalcitonin) toFuture opportunities (procalcitonin) to identify sepsis
48
PBGMC Antibiotic Spending
80000
100000
120000
40000
60000
80000
2012
0
20000 2013
49
Lessons Learned
• Physician push back was a huge problem– Education does not always work- because they y y
“know” better– A peer (trusted colleague/ physician champion)
is the key to success– Showing physicians financial data vs their peers
does work
50
Lessons Learned
• One ID physician changing prescribing habits can make all the difference
• Getting simple policy and procedures thru P&T is not always simpley p
• Whatever is the driving force for starting an ASP it can be successful and can helpASP it can be successful and can help substantially cut medication costs
51
Conclusion
• Effective empiric antimicrobial selection based on your particular hospital (antibiogram)
• Optimize dose and route of administrationp• Administer for the shortest duration
possiblepossible• De-escalate once susceptibility known
S if i f i id ifi d• Stop if no infection identified52
Overview: A ti i bi lAntimicrobial Stewardship Program at DPH
S t i L Ph DSuet-ping Lau, Pharm.D. Infectious Diseases Clinical PharmacistDr P Phillips HospitalOrlando Health
53
Before ASP ……• The highest utilization of broad & costly abx at OH:
• Meropenem, linezolid, daptomycin… etc
• The highest abx Cost / PDE at OH:• $33.6 at DPH vs. $22.9 at OLM
• The usage of meropenem was above the national average• The usage of meropenem was above the national average
DPHDPH
OLMSSHSSH
54
Overview Antimicrobial Stewardship Program (ASP)• Daily antimicrobial agents monitoring & surveillance:
• IV to PO switch • Bug-drug Mismatch• Possibility de-escalation per culture resultsPossibility de escalation per culture results • Decrease the duration of antimicrobials• Formulary alternatives per culture results, allergies, pharmacotherapy
D i i i l / h i f i• Dose optimization per renal / hepatic function• Discontinue surgical prophylaxis antimicrobial agent(s)• Allergies investigation (Antimicrobial Allergy Team)• Monitor high cost / broad spectrum / high toxicity / national shortage
agents: • Meropenem, tigecycline, linezolid, daptomycin, colistin, aminoglycosides, ampho-B,
IV acyclovir
55
Meropenem Utilization at DPH vs. ORMC
Use of Meropenem DPH vs. ORMC in 2010-2011
2500
3000
1500
2000
500m
g vi
als
500
1000# of
5
0 Jan-10
Mar-10
May-10
Jul-10
Sep-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Sep-11
Nov-11
ORMC
DPH
56
Antimicrobial Agent Cost Saving at DPH (Before vs After ASP):DPH (Before vs. After ASP):
Antimicrobialagents yearly
Cost reductionfrom year of
Cost Reduction
Cost Reduction from the
Year
agents yearly expenditure
from year of 2009 without ASP (baseline)
Reduction from the previous year
from the previous year (%)
20092009$1,630,546
2010$1,374,318 $256,228 $256,228 -16.0%
2011$863,932 $766,614 $510,386 -37.0%
2012$788,461 $842,085 $75,471 -9%
2013$550,106 $1,080,440 $238,355 -30%
Potential Cost Saving in 4 years: $2,945,36557
Overall Intervention Acceptance Rate
Therapy recd accepted
Type of Interventions in 2013 (N=1217)
96%
Formulary Alt Accepted
Therapy recd accepted
96%
96%
Dose Optimization Accepted
Cut Duration of abx Accepted 95%
IV to PO Accepted
Dose Optimization Accepted98%
100%
0 50 100 150 200 250 300 350 400 450 500
De-Escalation Accepted94%
Overall Acceptance Rate: 96%0 50 100 150 200 250 300 350 400 450 500
58
1st CAUTI Rounds at DPH• Established the FIRST CAUTI prevention Rounds at DPH
with the Infectious Diseases Physician • Weekly rounds with ID physician• Educated Staff and family member to remove unnecessary Foley
catheter
• Developed electronic CAUTI Progress Note • Assisted other OH sites to establish site wide CAUTI rounds• Successfully reduced the CAUTI rate at DPH since 2012
Fiscal Year # of CAUTI2010 262011 252012 152013 112014 0 (till April)
59
C.diff PreventionD l d C diff I f i Q li M i i F• Developed C.diff Infection Quality Monitoring Form • Review each HACDI with the attending• Review all HACDI cases monthly (CQO, ID physicians, Infection y ( Q , p y ,
Preventionist)• C.diff task force: launched hand-washing Champaign
• Reduced unnecessary antimicrobial usage• Reduced unnecessary antimicrobial usage• Floroquinolones restriction at Orlando Health
• Reduced proton pump inhibitor (PPI) usage
Fiscal Year # of HACDI
2010 53
2011 82
2012 64
2013 752013 75
2014 22 (Till April)
60
DPH Antibiogram (2009-2013)
Pseudomonas aeruginosa
2009 2011 2012 2013aeruginosa
Amikacin 95 95 96 96Cefepime 64 83 85 90Ciprofloxacin 57 71 75 8857 71 75 88Pipercillin-Tazobactam
75 89 92 92Meropenem 64 79 86 89
61
DPH AntibiogramsComparison DPH antibiogram (2009 – 2013)
MDR Rate 2009 2010 2011 2011 2012 2012 2013MDR Rate 2009 2010 – 2011 2011 – 2012 2012 – 2013
MRSA 55% 55% 50% 50%
VRE 17% 13% 19% 17%VRE 17% 13% 19% 17%
ESBL:• E. Coli 8% 5% 6.6% 4.4%•K. pneumoniae 15% 12% 9% 8.1%
CRE:• KPC 2.4% 1.8% 1.6% 0.6%
(No other CRE cases!!)
•MRSA i
No reported 2.5% (N=6) 4.5% (N=9) 0% (N=0)!!! vancomycin MIC ≥ 2
62
Sharing ASP Experience
• It was tough to start but it is rewarding with the accomplishments!accomplishments!
• NEVER EVER give up!• Remember: we are the physicians’ teammates NOTRemember: we are the physicians teammates NOT
enemies! • We can be a “police” but we have to be friendly!We can be a police but we have to be friendly!• Be SMART and SWEET!• Find out what are the problems then tackle each one!Find out what are the problems then tackle each one!
63
Questions?Questions?Preguntas?
Th k !Thank you! 64
Open Discussion / Questions?
65
Upcoming EventsJune 19 VAE Office Hours (12-1pm)June 19 Role of Pharmacists in Transitions of Care Services (1-2pm)June 20 Data Coordinator Webinar – Live Encore (11:30am-2pm)June 23 OB & Failure to Rescue Webinar (11:30am-2:30pm)June 23 Patient & Family Engagement Master Class (3-4pm)June 24 Junior Fellows Open Office Hours (11am-12pm)June 24 Patient & Family Engagement Office Hours (12-12:30pm)June 24 Care of Children in General Hospitals (3-4pm)June 25 Florida CAUTI Coaching Call (11am-12pm)June 25 Monthly OB Coaching Webinar (1-2pm)June 25 HAI Affinity Group Meeting (1-2pm)June 25 ILF Virtual Meeting (2-4pm)June 26 Falls & Procedural Harm Webinar (11:30am-2:30pm)June 26 NPLH Readmissions Office Hours (12:15-1pm)Sept 16-17 TeamSTEPPS Master Trainer Class (Deerfield Beach, FL)
HEN Education & Event Details are posted at www.fha.org/hen as they are available(To receive the Weekly “FHA HEN Events” via E-mail, send a request to [email protected] to be added)
66
We are here to help!FHA ContactsFHA Contacts
Sally Forsberg RN Director of Quality & Patient Safety
(407) 841-6230, [email protected]
Kim StreitVP/Healthcare Research & Information Services
(407) 841-6230, [email protected]( ) @ g
Phyllis Byles RNQuality Coordinatory
(407) 841-6230, [email protected]
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