Antibiotic Stewardship: Changing Culture & Making It Work in South Dakota

Alyssa Osborn Howard, Pharm.D. Director of Pharmacy/Clinical Pharmacist Community Memorial Hospital-Avera Marshall County Healthcare Center-Avera

Financial Disclosure Statement

I have had no financial relationship over the past 12 months with any commercial

sponsor with a vested interest in this presentation

Objectives—Pharmacist ¡  Identify current publications, guidelines and

initiatives regarding antimicrobial stewardship

¡  Summarize the CDC’s “Core Elements of Hospital Antibiotic Stewardship Programs” document

¡  Evaluate different tactics for implementing antimicrobial stewardship principles in various practice settings

¡  Identify current models of antimicrobial stewardship throughout the state of South Dakota

Objectives—Pharmacy Technician ¡  Recognize the overuse of antibiotics and the

danger this presents

¡  Identify important publications regarding antibiotic stewardship

¡ Describe ways pharmacy technicians could promote stewardship in both the community and hospital setting

¡  Recognize current models of antimicrobial stewardship throughout the state of South Dakota

What’s so Threatening?

Urgent Threats ¡  Clostridium Difficile (CDIFF)

¡  Carbapenem Resistant Enterobacteriaceae (CRE)

¡  Neisseria gonorrhoeae

Serious Threats ¡  Multidrug-resistant Acinetobacter

¡  Drug-resistant Campylobacter

¡  Fluconazole-resistant Candida

¡  Multidrug-resistant Pseudomonas Aeruginosa

¡  Vancomycin-resistant Enterococcus (VRE)

¡  Extended Spectrum Enterobacteriacae (ESBL)

http://www.cdc.gov/drugresistance/biggest_threats.html

Quick Facts ¡ Annually: 23,000 deaths, 2 million illnesses1

¡  ~50% of antibiotics prescribed are inappropriate

¡  Few drugs targeting “ESKAPE” pathogens2

¡ Antibiotic development has drastically slowed ¡  The 10 x ’20 Initiative2

¡  GAIN act (Generating Antibiotic Incentives Now)3

CDC “Get Smart” campaign; cdc.gov The 10 x ’20 Initiative: Pursuing a Global Commitment to Develop 10 New Antibacterial Drugs by 2020. Clin Infect Dis.(2010) 50 (8) Woodcock, J. Three encouraging steps towards new antibiotics. http://blogs.fda.gov/fdavoice/index.php/tag/gain-act/. Accessed July 17, 2016.

Antibiotic Stewardship ¡ “…an inter-professional effort and

involves optimal, prudent antimicrobial use for patients across the continuum of care: acute, inpatient, long-term care, and outpatient settings.”10

¡ “…the single greatest challenge in infectious diseases today...”

Programs, Papers & Guidelines ¡  Presidential Initiative: “National Action Plan for

Combating Antibiotic-Resistant Bacteria”4

¡  CDC’s “Core Elements of Hospital Antibiotic Stewardship Programs”5

¡  CDC program “Get Smart”1

¡  Infections Disease Society of America Guidelines7

¡  “ASHP Statement on the Pharmacist’s Role in Antimicrobial Stewardship and Infection Prevention Control”8

¡  Joint Commission Prepublication Requirements6

¡  January 1, 2017

¡  CMS Conditions of Participation in Hospitals/CAH9

Collaboration: Where Stewardship Starts ¡ Alex Middendorf

¡  Brad Liable

¡ Veronica Lesselyoung & Joe Strain

¡  Beth Loecker

¡  Justin Manning

¡  South Dakota Department of Health

¡  Redfield Community Antibiotic Stewardship Program

General Approaches to Antibiotic Stewardship

Preprescription/Front-End

¡  Formulary restrictions ¡  Force clinician collaboration

¡  Antibiogram Use ¡  Tailor antibiotics to location—

guides restriction

¡  Guideline Development

¡  Required information on medication orders

¡  Education

¡  Vaccine administration

Postprescription/Back-End

¡  Prospective Audit and Feedback (PAF)

¡  Antibiotic “time-outs” and stops

¡  Physician/Pharmacist rounding

¡  De-escalation ¡  IV:PO

¡  Education

¡  Infection Control Education

Inpatient Approaches to

Antibiotic Stewardship

CDC Core Elements of Hospital Antibiotic Stewardship Programs

Risks of Inappropriate Use ¡ Organ system damage/toxicity ¡  Due to wrong dose

¡  Ex: vancomycin, gentamycin

¡  Formation of “super bugs” ¡  E.g. increasing occurrence of C. Diff

¡  Increase in patient costs

¡  Increase in length of stay

CDC’s: Core Elements of Hospital Antibiotic Stewardship Programs

¡ Elements of Success: ¡ Leadership Commitment ¡ Accountability ¡ Drug Expertise ¡ Action ¡ Tracking ¡ Reporting ¡ Education

Leadership Commitment: Culture Change ¡ “Whole Facility/System” Approach ¡ Administration

¡ Medical Staff personnel

¡  Pharmacy staff

¡  Lab personnel

¡ Nursing personnel

¡  Locums participation

¡ Quality Improvement/Infection Control Staff

¡  IT staff participation

Accountability and Drug Expertise: ID physician + Pharmacist

¡ Stewardship Program Leader ¡  ID physician ideal ¡  Can telehealth be utilized?

¡ Pharmacy Leader ¡  ASP/Infectious disease training ideal

¡  SIDP ¡  MAD-ID

¡  Pharmacy and Therapeutics Committee is “not enough”

¡ Accountability of other departments

Action: Implement Policies and Interventions to Improve Antibiotic Use

¡ Implement policies that support studious antibiotic use ¡  Restricted formulary ¡  Antibiotic “time outs” & automatic stops ¡  3 D’s when prescribing

¡  Optimization here ¡  Prescribing pathways

¡ Prospective audit & feedback ¡  External party

¡ Disease-specific focus ¡  PCN skin testing

Tracking and Reporting Antibiotic Use and Outcomes

¡ Usage trends

¡ Pharmacy interventions

¡ Inventory value

¡ DOT (days of therapy)

¡ Clinical outcomes

Education

¡ In house training sessions ¡  Didactic

¡  Articles/guidelines

¡ Follow up on facility specific results ¡ Antibiogram

¡  Infection prevention interventions

¡ Infection Control

¡ Don’t forget your community!

Steps to Forming Stewardship ¡ Gain physician championship

¡  Establish pharmacy leadership

¡ Outline facility-specific goals

¡ Discuss prescribing pathways

¡ Develop data capturing

¡ Continuous provider/patient education

¡  Focused diligence

Inpatient/Acute Care Action Items ¡  IV:PO standing policy

¡  Appropriate antibiotic choice—multidisciplinary approach

¡  Appropriate pharmacokinetic dosing (ex: vancomycin)

¡  PCN allergy testing—ensure “hard PCN stops”

¡  Infection control committee

¡  Order set management—EHR embedment

¡  “Off limits” list/pre-authorization list

¡  Working with lab—forming facility antibiogram

Success Story: Avera Antimicrobial Stewardship

Program

Avera ASP Call •  Daily antimicrobial stewardship

calls system-wide •  ID physician

•  Pharmacist from different regions

•  Ability to include rural sites

•  Interventions recorded (tracking started 10/16/15) •  293 cases viewed

•  98.23% completion

•  ~92% acceptance rate

•  Implementation of prospective audit and feedback for multiple facilities

Contact: Brad Liable

Success Story: Rapid City Regional Antimicrobial Stewardship

Program

Rapid City Regional

•  Initiated program in ~2000 •  In response to growing resistance

•  Removed Levofloxacin from formulary except in specific circumstances

•  Initiated infection control practices •  Vaccination of employees

•  Removal of catheters

•  VRE work group •  Say “no” to vanco

•  Specific focus on infection control

•  Both within RCRH, and other facilities

•  PCN allergy testing

Contacts: Veronica Lesselyoung, Joe Strain

Community Setting

Approaches to Antibiotic

Stewardship

Community Setting Antibiotic Stewardship ¡ Compliance counseling

¡  Unnecessary prescribing

¡ OTC counseling

¡  Infection Control

¡ Consultation with other facilities

¡ Who are the champions in your community? ¡  Is there a healthcare system that manages/owns

your clinic?

https://consumer.healthday.com/infectious-disease-information-21/antibiotics-news-30/many-adults-use-antibiotics-without-consulting-doctor-survey-finds-712717.html

Vaccination ¡  Educate patients and providers

¡ Vaccination collaborative agreements ¡  New SDBOP statement

¡ Documentation key!

CDC http://doh.sd.gov/boards/pharmacy/assets/Policy-Immunizations.pdf

Success Story: Sanford

Sanford •  Working on enterprise-wide ASP

standardization •  ASP software •  Clinic prescribing pathways—

shared with SD DOH •  Adult bronchitis

•  Adult acute exacerbation of chronic bronchitis

•  Adult pharyngitis

•  Adult rhinosinusitis

•  Pediatric sinusitis

•  Pediatric otitis media

•  Skin and soft tissue MRSA infection

•  Adult female UTI

•  Pediatric UTI

•  Community Acquired Pneumonia

Contact: Beth Loecker

Success Story: Hy-Vee

Hy-Vee •  Program created in 2015

•  Signed protocol by one physician

•  Addresses Prevnar, Pneumovax, Zostavax, flu vaccine among others

•  Reminders to patients in daily workflow

•  Patients are screened, then given vaccination in the pharmacy

Contact: Justin Manning

Community-Wide

Approaches to Antibiotic

Stewardship

Community-Wide Stewardship ¡  Form a stewardship group with healthcare

facilities

¡  Pharmacist/provider on point for consults

¡  Education throughout community

¡ Community-wide antibiogram ¡  Data reporting

Antibiotic Stewardship in Long-Term Care Facilities ¡  4 million Americans reside in LTCF

¡  $38-137 million spent on antibiotics in LTCF ¡  25-75% antibiotics misused

¡  Education ¡  Improved communication

¡  Staff

¡  Family/caregiver

¡  Prescribing protocols

McKesson

Success Story: Redfield Community-Wide Antimicrobial Stewardship

Program

Redfield project implemented July 2014

•  Unified approach •  Hospital •  Clinic •  Retail Pharmacy •  2 Nursing Homes •  South Dakota Developmental

Center

•  Pharmacy Champion

•  ID Consult •  Dr. James Keegan—PYA Consulting

•  Culture Change •  Medical Staff/Locum Education

•  Community Education

•  Improved Communication = Culture Change

•  Results

Did things really change?

All facilities saw a decrease in antibiotic prescribing

Staph. Aureus Susceptibility 2013 SD Antibiogram vs. CMH baseline year vs. CMH project year vs. CMH final project quarter

Statewide Approaches to

Antibiotic Stewardship

Statewide Stewardship: South Dakota Department of Heatlh

South Dakota: Statewide Stewardship ¡  South Dakota Antibiotic Stewardship Workgroup ¡  March, 2013 è response to CRE outbreak

¡  Bring systems across the state together in stewardship

¡  State Antibiogram ¡  Regional data

¡  SDSU College of Pharmacy involvement

¡ Working on statewide culture of stewardship

Conclusion Let’s wrap it up!

Antibiotic Stewardship: Take Away Points ¡  Know your local contacts for stewardship ¡  Providers? System?

¡  Understand key components of program implementation

¡  Extend program to all areas ¡  Community ¡  Community wide

¡  Focus on changing culture ¡  Education ¡  Partnership ¡  Communication

Thank You!! Questions?

alyssa.howard@redfieldcmh.org

Go BIG! Go BLUE!

Go JACKS!

References 1.  CDC “Get Smart” campaign; cdc.gov

2.  The 10 x ’20 Initiative: Pursuing a Global Commitment to Develop 10 New Antibacterial Drugs by 2020. Clin Infect Dis.(2010) 50 (8)

3.  Woodcock, J. Three encouraging steps towards new antibiotics. http://blogs.fda.gov/fdavoice/index.php/tag/gain-act/. Accessed July 17, 2016.

4.  White Paper: National Action Plan for Combating Antibiotic-Resistant Bacteria. 2015.

5.  Frieden, T, Bell, B. Core Elements of Hospital Antibiotic Stewardship Programs. 2014. CDC, US Department of Health and Human Services.

6.  Joint Commission Prepublication Requirement; New Antimicrobial Stewardship Standard. 2016.

7.  Barlam, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Disease Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. (2016)

8.  ASHP Statement on the Pharmacist’s Role in Antimicrobial Stewardship and Infection Prevention and Control. Medication Therapy and Patient Care: Specific Practice Areas—Statements. 291-293.

9.  CMS Issues Proprosed Rule that Prohibits Discrimination, Reduces Hospital-Acquired Conditions, and Promotes Antibiotic Stewarship in Hospitals. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-13.html. 2016

10.  Gerding DN. The search for good antimicrobial stewardship. JT Comm J Qual Improv. 2001;27(8):403-404.

Pharmacist Post-Test Questions Antibiotic resistance has:

a.  Gained attention through healthcare association based organizations (e.g. ASHP)

b.  Influenced certification agencies like JNC and CMS

c.  Gained attention at a White House level

d.  All of the above

Pharmacist Post-Test Questions Prospective audit and feedback requires input and review from a member who is on the care team.

True False

Pharmacist Post-Test Questions Select potential antimicrobial stewardship tactics: a.  Educating patients regarding infection

prevention at home b.  Mandating vaccination during inpatient stays c.  Requiring pre-authorization of high risk

formulary items d.  All of the above e.  A & C only

Pharmacist Post-Test Questions Vaccination collaborative agreements, structured prescribing protocols, antimicrobial prospective audit and feedback phone calls, and community-wide stewardship activities have all been implemented in South Dakota.

True False

Technician Post-Test Questions Antibiotic stewardship can help lessen: a.  Deaths due to multi drug resistant bacteria b.  C. Diff infections in hospitals c.  UTI super bugs in nursing homes d.  All of the above

Technician Post-Test Questions CMS and Joint Commission have both recently changed, or started the process of changing their requirements for hospitals in regards to antibiotic stewardship program implementation.

True False

Technician Post-Test Questions A pharmacy technician could promote stewardship by: a.  Screening patients for eligibility for pneumonia

vaccination in a community setting b.  Administer appropriate vaccinations c.  Clarify patient’s antibiotic allergies for chart

completeness d.  Practice appropriate sterile technique while

compounding medications e.  A, C & D

Technician Post-Test Questions Vaccination collaborative agreements, structured prescribing protocols, antimicrobial prospective audit and feedback phone calls, and community-wide stewardship activities have all been implemented in South Dakota.

True False