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What Does Antibiotic Stewardship Mean? As it Relates to the Clostridium difficile Infection (CDI) Initiative
Tuesday, November 7, 2017
National Nursing Home Quality Care Collaborative (NNHQCC)
Health Services Advisory Group (HSAG)
Need Help? Have Questions?
2
Jim Barnhart, LNHA
Quality Improvement (QI)
Project Lead
614.307.5475
Eli DeLille, RN, BSN, CIC
QI Specialist
216.644.3998
Angila Anderson, BSHA, LPN
QI Specialist
614.704.1216
Ohio Contacts
What is a QIN-QIO?
• Funded by the Centers for Medicare & Medicaid Services (CMS)
– QIN-QIO in each state
– Dedicated to improving health quality at the community level
– Ensures people with Medicare get the care they deserve, and improves care for everyone
Department of Health & Human
Services
Centers for Medicare &
Medicaid Services
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HSAG’s QIN-QIO Responsibility
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QIO Work
Patient is at the center of care
Cardiac
HealthDisparities in
Diabetes
Transforming Clinical Practice
Antibiotic Stewardship in Communities
Coordination of Care
Behavioral Health
Healthcare-Acquired
Conditions in Nursing Homes
Support of Clinicians in the
Quality Payment Program
Adult Immunizations
Improve Hand Hygiene and
Injection Practices in
ASCs*
*ASCs=Ambulatory Surgical Centers5
QIO Work
Patient is at the center of care
Cardiac
HealthDisparities in
Diabetes
Transforming Clinical Practice
Antibiotic Stewardship in Communities
Coordination of Care
Behavioral Health
Healthcare-Acquired
Conditions in Nursing Homes
Support of Clinicians in the
Quality Payment Program
Adult Immunizations
Improve Hand Hygiene and
Injection Practices in
ASCs
6
Objectives
• Understand the importance of an ASP in long-term care facilities (LTCFs).
• Learn about regulatory requirements for an LTCF ASP.
• Identify tools, key members, infrastructure, and activities necessary to implement an ASP in your facility.
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Antibiotic Resistance: How It Works
8Source: Centers for Disease Control and Prevention. https://goo.gl/1F4AYG
Antibiotic Use in Nursing Homes
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Source: Centers for Disease Control and Prevention. https://goo.gl/F6xoiq
HAI and ASP in LTCF
• Between 1.6 and 3.8 million healthcare-associated infections (HAIs) occur in LTCFs annually.– Result in
• 150,000 hospitalizations• 388,000 deaths • Healthcare costs ranging between $673 million to $2 billion
– 1 in 5 of all adverse drug events (ADEs) in nursing homes (NHs) are the result of antibiotic medications.
• Patients in LTCFs may be more susceptible to infection.– Malnutrition, dehydration, comorbidities, or functional
impairment (incontinence, medications, and mobility)
10Source: Centers for Medicare and Medicaid Services. https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf
Most Common Infections Treated With Antibiotics in NHs
11Source: Adapted from: Benoit et all. J am Geriatr Soc. 2008 Nov;56(11):2039-44
President’s Advisory Council For Combating Antibiotic-Resistant Bacteria (PACCARB)
12Source: The Centers for Disease Control and Prevention. https://www.cdc.gov/drugresistance/federal-engagement-in-ar/national-strategy/index.html
Leading to…Regulatory Requirements
CMS 81 FR68688:• proposed that the facility’s infection prevention and
control plan (IPCP) must also include an ASP that includes antibiotic use protocols and systems for monitoring antibiotic use and recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility.
• to require that the facility designate an infection prevention and control officer (IPCO) who is responsible for the IPCP and who has received specialized training in infection prevention and control.
13Source: Centers for Medicare and Medicaid Services. https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf
Regulatory Requirements (cont.)
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Infection Control 483.80—An ASP that includes antibiotic use protocols and a system to monitor antibiotic use.
Source: Centers for Medicare & Medicaid Services. https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf
Basics of Antibiotic Stewardship
Multiple definitions exist, so keep it simple.
Ensure that every resident gets:– An antibiotic (ATB) only when one is needed.
– The right antibiotic.• At the right dose
• Via the correct route
• For the right duration
ATB use correlated to clinical signs and symptoms is crucial!
Source: Centers for Disease Control and Prevention. https://www.cdc.gov/hicpac/pdf/Antibiotic-Stewardship-Statement.pdf15
Challenges to ASP Implementation
• Lack of administrative support
• Full-time employee (FTE) allocation
• Lack clear ATB guidelines for LTCF residents
• No institutional prescribing oversight
• Lack access to infectious disease (ID) specialists/specialized diagnostic testing
• Knowledge gaps around culture reports (ATB sensitivity, bug-drug mismatch)
• Influence of resident, family, and other NH staff of the decision to start antibiotics
16 Source: Centers for Disease Control and Prevention. https://www.ndhealth.gov/disease/hai/Docs/Stone_AntibioticUseinNH_NDWebinar_v1%20LTC%20[Compatibility%20Mode].pdf
What Are We Going To Do?
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Call to Action
• Reference the key facts contained in this presentation to raise the level of awareness
• Additional facts:– In LTC, 20 percent of prescribers account for
80 percent of antibiotics prescribed– Almost 50 percent of antibiotics are given longer
than necessary– Residents with high ATB use have 24 percent
higher risk of harm– All residents are at increased risk due to ATB resistant
bacteria or Clostridium difficile infection (CDI) from other residents
18 Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
Put a Strong ASP Team in Place
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Infection Prevention Nurse
Administrator
QAA Nurse
Consultant Pharmacist
Director of Nursing
Physician/ Medical Director
Can you name any other positions that should
be included?
Leadership can:
• Raise the importance of antibiotic stewardship
– Provide a written statement of support
• Allocate resources
– Embed ASP duties in job descriptions to clearly set expectations
• Oversee compliance
• Ensure antibiotic use and resistance data is regularly reviewed in quality assurance meetings
– Expect action when an issue is identified
20Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
Medical Directors can:
• Set standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics
• Oversee adherence to antibiotic prescribing practices
• Review antibiotic use data and ensure best practices (e.g., the right drug at the right dose for the right amount of time) are followed
21 Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
Directors of Nursing can:
• Establish standards for nursing staff to assess, monitor, and communicate changes in a resident’s condition that could impact the need for ATBs.
• Use their influence as nurse leaders to help ensure ATBs are prescribed only when appropriate.
• Educate front line nursing staff about the importance of Antibiotic Stewardship and explain policies in place to improve ATB use.
22 Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
Pharmacist Consultants can:
• Provide education to staff about the different types of ATBs and their uses.
• Review ATB prescription as part of the drug regimen review for new medication and ensure they are ordered appropriately.
• Establish laboratory testing protocols to monitor for adverse events and drug interactions related to use of ATBs and other high risk medications (HRMs).
• Review microbiology culture results and provide feedback to prescribers on initial ATB selection to let them know if it is the right drug to treat the infection or if the bacteria may be resistant to the ATB.
23Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
Select an Approach
• Agency for Healthcare Research and Quality NH Antimicrobial Stewardship Guide
– https://www.ahrq.gov/nhguide/index.html
• CDC Core Elements of ATB Stewardship for NHs
– https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
• The Core Elements of ATB Stewardship for NHs Checklist
– https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf
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Select and Approach (cont.)
• QIO NCC NH Training Sessions: ATB Stewardship
– http://qioprogram.org/antibiotic-stewardship
• Minnesota ASP Toolkit for LTCFs
– http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/
• CDC GetSmart Campaign
– https://www.cdc.gov/getsmart/healthcare/index.html
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Perform a Baseline Assessment
26 Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
Core Elements for ASP in NHs
27Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
Core Elements for ASP in NHs (cont.)
28Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
Core Element Checklist
29Source: Centers for Disease Control and Preventionhttps://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
Core Element Checklist
• Intended to be both a baseline assessment and action plan for your facility
– Create a binder
– Update regularly
– Be prepared to share
– Don’t expect to be perfect
• Prioritize interventions on those that have the most impact on patient care
• Correlate improvement activities to metrics and share successes!
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QI Programs that Support Antibiotic Stewardship
• National Nursing Home Quality Improvement Campaign (Formerly Advancing Excellence)
• The HSAG CDI Initiative
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Advancing Excellence is now the National Nursing Home Quality Improvement Campaign
Same goals.
New resources!
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Advancing Excellence is now the National Nursing Home Quality Improvement Campaign
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National Nursing Home Quality Improvement Campaign
• Online education– C. difficile and
ATB Stewardship
• Tools and resources• Benchmarking• No-cost
HSAG’s CDI Initiative
CDI Initiative in AZ, CA, FL, and OH
• National Healthcare Safety Network (NHSN) enrollment
• 10-month data collection for baseline
• Quality improvement
– Starting in early 2018
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CDI Initiative Education Opportunities
• NHSN
• TeamSTEPPS®=Team Strategies and Tools to Enhance Performance and Patient Safety
• Infection Control
• Antibiotic Stewardship
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What is NHSN?
• National Healthcare Safety Network (NHSN)
• Operated by the Centers for Disease Control and Prevention (CDC)
• Currently utilized by hospitals
• Secure federal mainframe
– Need for Secure Access Management Services (SAMS) card
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How Do I Get a SAMS Card?
• At least two SAMS card holders per NH
• SAMS card is proof of your identity
• SAMS card stays with you, not the facility
• Steps to receiving your SAMS card:
– Watch training/prep videos
– Register facility with NHSN
– Register w/SAMS (identity verification)
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Frequently Asked Questions (FAQs) re NHSN
• New to nursing homes
• Learning curve
• HSAG is here to help
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NHSN FAQs
Question 1: How do I calculate the Total Resident Days for summary data?
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Answer: It’s the sum of each day’s facility census for the reporting month.
Remember: You do not include bed-hold days.
NHSN FAQs (cont.)
Question 2: How do I know if the resident type for an event is Long-stay or Short-stay?
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Answer:Short-stay: Resident has been in facility for less than or equal to 100 days from date of first admission. Long-stay: Resident has been in facility greater than 100 days from date of firstadmission.
NHSN FAQs (cont.)
Question 3: We have reported our summary data but did not have any cases of in-house CDI for the month. How do we report this?
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Answer: For the given month check the “Report No Events” box in NHSN.
NHSN FAQs (cont.)
Question 4: How do I report a resident who was admitted with C. difficile?
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Answer: A resident who is admitted with C. difficile is only counted in your summary data.
Remember: If the resident came from a hospital, they would report the event on their end.
NHSN FAQs (cont.)
Question 5: The NHSN Facility Administrator will be leaving the facility. How does someone else take over reporting CDI events?
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Answer: Another person must go through the process of acquiring a SAMS card, and then gain rights.
Remember: HSAG and the CDC recommend all homes have at least 2 individuals within your facility have a SAMS card.
HSAG NHSN Resources
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www.hsag.com/nh-nhsn-resources
Are You Receiving Monthly Email Updates?
Email us to be added!
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Contact Us!
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Questions? Comments? Assistance?
Reach out to your state Quality Improvement Organization (QIO).
Click to edit Master title style
Questions?
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Ohio, Florida, and the
U.S Virgin Islands under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Publication No. QN-11SOW-C.2-11012017-01
