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PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
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Keeping up with the Joneses -Review and Recent Updates to Antimicrobial Stewardship Accreditation Requirements
Megan Patch, MS, PharmD, BCPS
November 2019
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Disclosures
The following planners, speakers, moderators, and/or panelists of this CE activity have no relevant financial relationships with commercial interests to disclose:
• Megan Patch, MS, PharmD, BCPS
1
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Objectives
• Understand the history and current role of hospital Antimicrobial Stewardship Programs (ASP)
• TJC/CDC/CMS/DNV – Breaking down the ingredients (requirements) of the alphabet soup for hospitals
• Changes and upcoming additions to accreditation for ASP
2
TJC = The joint Commission
CDC = Centers for Disease Control and Prevention
CMS = Centers for Medicare & Medicaid Services
DNV = Det Norske Veritas
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Antimicrobial Stewardship - Definition
Consensus definition from IDSA and SHEA guidelines for implementing an Antibiotic Stewardship Program:
“coordinated interventions designed to improve and measure
the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of
administration”
3Barlam, TF et al. 2016 Clinical Infectious Diseases
IDSA – Infectious Diseases Society of America
SHEA – Society for Healthcare Epidemiology of America
Fishman N. 2012 Infect Control Hosp Epidemiol
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Antimicrobial Stewardship - Beginnings
4
Dyar, OJ et al. 2017 Clinical Microbiology and Infection
First citation by John McGowen and Dale Gerding:
• Does antibiotic restriction prevent resistance?
PubMed citations on antimicrobial/antibiotic stewardship
McGowen et al. 1996 New Horizons
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Timeline of ASP Action1996-2000s - Antimicrobial stewardship gets its start
2014
• CDC releases core elements of an Antimicrobial Stewardship Program
2015
• U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria (National Action Plan)
2016
• CMS proposal for ASP as a condition of participation (CoP)
• IDSA and SHEA released guidelines for ASP Initiation
2017
• TJC requirement for ASP as Medication Management standard to hospitals and nursing care centers
• Baptist Health undergoes 3 TJC surveys throughout its hospitals
2019
• CMS confirms ASP as CoP September 30 (effective date 6 months later)
2020
• TJC expands ASP requirement to ambulatory centers prescribing antibiotics in January
• CMS ASP CoP effective around March 30
5Barlam, TF et al. 2016 Clinical Infectious Diseases
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
ASP Action – Where are we now?CDC reports from National Healthcare Safety Network (NHSN) survey in 2018 of ~4,900 acute care hospitals surveyed
• 76% stated they met all 7 of the CDC’s core elements for Antimicrobial Stewardship Programs
• Doubling response rate from 2014 survey
• 2015:
Hospitals with 50+ beds: >50% met requirements
Hospitals with <25 beds: 26% met requirements
Narrowing the gap
• About 25% of hospitals are not TJC surveyed, many of these being critical access hospitals
• How to provide ASP services to these institutions?
• CMS – allow for health system stewardship
• Example: Baptist Health
6https://www.cdc.gov/antibiotic-use/core-elements/small-critical.html
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC - The Joint Commission
Added Antimicrobial Stewardship to Medication Management Standards (MM.09.01.01)
• Requirement began January 1, 2017• Hospitals• Critical access hospitals• Nursing care centers
Eight “Elements of Performance”• Incorporates the CDC’s 7 core elements into element 5
WHY?
• CDC identified ~20-50% of antibiotic prescriptions in US acute care hospitals are unnecessary or inappropriate
• ~70% of nursing home (long-term care) residents receive antibiotics each year
7https://www.cdc.gov/antibiotic-use/healthcare/pdfs/core-elements.pdf
https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC – Elements of Performance
1. Leaders establish antimicrobial stewardship as an organizational priority(Leadership Commitment)
• Accountability documents
• Budget plans
• Infection prevention plans
• Performance improvement plans
• Strategic plans
• Using electronic health record to collect (and analyze) antimicrobial stewardship data
8https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC – Elements of Performance
2. Education of staff and licensed independent practitioners involved in antimicrobial:
• Ordering (providers, nurses)
• Dispensing (pharmacists)
• Administration (nurses)
• Monitoring (providers, pharmacists)
Education occurs upon hire and periodicallythereafter based on organizational need
9https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC – Elements of Performance
3. Education of patients, and families as needed, on appropriate use of antimicrobials including antibiotics
10https://www.cdc.gov/antibiotic-use/community/pdfs/Viruses-or-Bacteria-Factsheet-Eng.pdf
https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
This element has been
removed from the
requirements as of
October 2017
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC – Elements of Performance
4. Antimicrobial stewardship multidisciplinaryteam including the following members (when able):
• Infectious diseases physician
• Infection preventionist(s)
• Pharmacist(s)
• Practitioner
Each member plays an important role in the team
Ideally, team includes several members of each
11https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC – Elements of Performance
5. The antimicrobial stewardship program includes the following core elements:
• Leadership commitment
• Accountability
• Drug expertise
• Action
• Tracking
• Reporting
• Education
12https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
These are the CDC’s 7 Core Elements
https://www.cdc.gov/antibiotic-use/healthcare/pdfs/core-elements.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
CDC – 7 Core Elements of Hospital ASP
13https://www.cdc.gov/antibiotic-use/healthcare/pdfs/core-elements.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC – Elements of Performance
6. The antimicrobial stewardship program uses organizational-approved multidisciplinary protocols:
• Antibiotic formulary restrictions or preauthorization
• Assessment of appropriateness of antibiotics for
Community-acquired pneumonia
Skin and soft tissue infection
Urinary tract infection
• Care of patient with Clostridioides difficile
• Guidelines for antimicrobial use in pediatrics
• Parenteral to oral (IV to PO) conversion
• Use of prophylactic antibiotics
14https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC – Elements of Performance
7. Collection, analysis and reporting data on the antimicrobial stewardship program
• Antimicrobial prescribing patterns
• Antimicrobial usage reports Change over time
Restricted antimicrobials
High cost medications
• Antimicrobial resistance patterns Antibiograms
• Stewardship program interventions Acceptance/rejection rates
15
https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Ste
wardship_Standard.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
TJC – Elements of Performance
8. The hospital takes action on improvement opportunities identified in its antimicrobial stewardship program• Implementation of guidelines/protocols
Sepsis UTI Pneumonia
• Prospective audit and feedback on targeted antimicrobials or disease states Vancomycin Broad-spectrum antimicrobials Asymptomatic bacteriuria Bacteremia
• Restricted antimicrobials Broad-spectrum High cost
16
https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Ste
wardship_Standard.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Assessment Question
In a 2018 survey by the National Healthcare Safety Network (NHSN) including 4,900 acute care centers, how many stated they met all 7 of the CDC’s Core Elements? A. 50%
B. 65%
C. 76%
D. 88%
17
https://www.jointcommission.org/_prepublication_standards_%E2%80%93_new
_requirements_addressing_antimicrobial_stewardship_/
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Assessment Question
In a 2018 survey by the National Healthcare Safety Network (NHSN) including 4,900 acute care centers, how many stated they met all 7 of the CDC’s Core Elements? A. 50%
B. 65%
C. 76%
D. 88%
18
https://www.jointcommission.org/_prepublication_standards_%E2%80%93_new
_requirements_addressing_antimicrobial_stewardship_/
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Coming Soon – January 2020
• MM.09.01.03
• All Joint Commission-accredited ambulatory healthcare organizations that routinely prescribes antimicrobials will be subject to the implementation of this new standard
• Medical/dental services
• Episodic care
• Occupational/worksite health
• Urgent/immediate/convenient care
19
https://www.jointcommission.org/_prepublication_standards_%E2%80%93_new
_requirements_addressing_antimicrobial_stewardship_/
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
MM.09.01.03 - Ambulatory
Elements of Performance:
• Identifying an antimicrobial stewardship leader
• Establishing an annual antimicrobial stewardship goal
• Implementing evidence-based practice guidelines related to the antimicrobial stewardship goal
• Providing clinical staff with educational resources related to the antimicrobial stewardship goal
• Collecting, analyzing, and reporting data related to the antimicrobial stewardship goal
20
https://www.jointcommission.org/_prepublication_standards_%E2%80%93_new
_requirements_addressing_antimicrobial_stewardship_/
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
CMS – Centers for Medicare and Medicaid Services
Condition of Participation (CoP) proposed in June 2016 for antimicrobial stewardship
• Requires infection prevention/control and stewardship programs to receive CMS reimbursement
Focus on reducing the development and transmission of hospital-acquired infections and antimicrobial-resistant organisms
• Improve care of patients
• Improve safety
• Reduce costs
CMS confirms ASP as CoP September 30
• Effective date 6 months later ~ March 30
21https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-20736.pdf
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
DNV - Det Norske Veritas Healthcare
• Accreditation body – annual survey• Current surveyor of Lee Health
• Directly assess CMS requirements, including Antimicrobial Stewardship
22https://www.dnvgl.us/assurance/healthcare/standards/niaho-ac-dl.html
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Future of ASP AccreditationFocus of accreditation has traditionally been:
• Does your institution have an ASP?
• Are you doing something with it?
• Goal to increase the number of ASP programs
Future accreditation
• How has the quality of your program improved?
• What new, innovated ideas are you bringing to your institution to improve antimicrobial use and/or decrease antimicrobial resistance
23https://www.wsha.org/articles/cms-finalizes-the-conditions-of-participation-rule-antibiotic-stewardship-programs-required-for-hospitals/
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
Summary• In the past 20 years, antimicrobial stewardship has
been brought to the forefront of healthcare initiatives with concern for global health threat of antibiotic resistance
• Implementation of requirements from accreditation bodies has helped with developing stewardship programs across the country
• TJC/CDC/CMS/DNV all provide similar recommendations for Antimicrobial Stewardship Programs – and reference each other
• The future of accreditation will likely focus more on quality now that many programs have been established
24
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED
INFORMATION CREATED AS PART OF LPSES – LEE MEMORIAL HEALTH SYSTEM’S PATIENT SAFETY EVALUATION SYSTEM
#2
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ev. 0
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Keeping up with the Joneses -Review and Recent Updates to Antimicrobial Stewardship Accreditation Requirements
Megan Patch, MS, PharmD, BCPS
November 2019
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