4/23/2012
1
Optimizing Antimicrobial StewardshipPutting Strategies into Action
A CDI A ti N t k W biA CDI Action Network Webinar
April 25, 2012
Tina Schwien, MPHP, MNQuality Improvement Consultant
CMS Innovation Advisor
Today
CDI Action Network
Featured Hospital
Panel Reaction
2
Discussion
4/23/2012
2
Qualis Health & You
HAI Action Networks
CAUTI CDI SSI
3
CAUTI CDI SSI
CDI Action Network Activities
2012
• Establish CDI baseline in NHSN
2013
• Where CDI baseline > 6/10,000 patient days, target assistance
4
• Share practical approaches to AMS in Webinar series
• Achieve 10% relative improvement 2014
4/23/2012
3
The Optimizing AMS Webinar Series
T d
Swedish
Jan 25
YVMH
Feb 22
Harborview
Mar 28
St. Mary
Apr 25
Today
5
Purpose: Create opportunity to share implementation stories, ask questions, discuss ideas for localization, connect “Silos”
Self Assessment Survey, Dec. ‘11
• 60% CDI Action Network has AMS program,
• Many– Monitor Rx and Appropriateness AFTER first dose
– Automatically adjust dose based on lab parameters
– Use at least 5 of the 7 supplemental strategies from IDSA/SHEA guidelines
Assess impact with
We will re-survey CDI Action Network Dec. ’12
6
– Assess impact with• Percentage of organisms sensitive to antimicrobials (outcome)
• Overall antimicrobial expenditures (financial)
– About half cited barriers ($ and personnel shortage)
4/23/2012
4
After Today…
• Join Antimicrobial Stewardship Committee of Seattle listserv – Contact John Lynch [email protected]
• For CDI Action Network Participants– Fall Qualis Health Webinar
– Winter Qualis Health Re-Survey
7
Today’s Guests
• Providence St. Mary Medical CenterMi h l B t i MD Mi h l B t i @ id– Michael Bernstein, MD [email protected]
– Peggy Yam, PharmD, [email protected]
• Reactor Panel*– Paul Pottinger, MD, [email protected]
– Scott Weismann MD Scott Weissman@seattlechildrens org
8
– Scott Weismann, MD, [email protected]
*Members of Antimicrobial Stewardship Committee of Seattle
4/23/2012
5
Approach at Providence St. Mary Medical Center
9
Field Trip #4
Stewardship through multidisciplinary practicesBreaking down silos &
Antimicrobial Stewardship
CDI Network—April 25th, 2012
Breaking down silos & thinking outside of the box
Providence Health & Services‐Providence St. Mary Medical Center
Michael Bernstein, MD, CMO, AMS Physician Champion
Peggy Yam, PharmD, BCPS, Clinical Supervisor, AMS Pharmacy Coordinator
4/23/2012
6
4/23/2012
7
Providence Core Values
Justice
Excellence
Compassion
Respect
Stewardship
4/23/2012
8
Case Report
65 M dialysis patient admitted with restlessness & muscle rigidity possible Baclofen toxicity mildlymuscle rigidity, possible Baclofen toxicity, mildly elevated WBC
Empiric Levaquin, ¼ blood cultures positive for Staph hemolyticus. Levaquin was continued. Discharged home.
2 days after discharge, developed abdominal pain and diarrhea
Case Report In outpatient dialysis, hypotensive, WBC elevated. Admitted with sepsis.
Stool positive for C diff Bedside sigmoidoscopy Stool positive for C. diff. Bedside sigmoidoscopy – pseudomembranous colitis.
Patient did not respond to IV/enteral Vancomycin. Toxic megacolon.
Urgent colectomy followed by multisystem f il d horgan failure, death.
4/23/2012
9
Objectives
Utilize adapted and creative strategies in the creation of an AMS program, addressing lack of resources
Choose most appropriate team members for concept building and program leadership, design, and execution
Develop explicit metrics and/or goals to be Develop explicit metrics and/or goals to be completed between disciplines
Antimicrobial Stewardship
Preserve antibiotic effectiveness in population
Marked reduction in antibiotic pipeline development by pharmaceutical industry
Reduce complications of antibiotic therapy resistant infections MRSA
GNB‐ESBLGNB ESBL
C. difficile
4/23/2012
10
Goals of an AMS program
Optimize appropriate antimicrobial use Selection, duration, dose, route of administration
Improve patient outcomes Reduce adverse events Reduce morbidity and mortality Reduce length of stay
Ensure cost‐effective therapy Reduce direct costs of antimicrobial agents Reduce direct costs of antimicrobial agents Reduce healthcare costs associated with suboptimal antimicrobial use
Lessen/control incidence of antimicrobial resistance
Reality of Stewardship in the community setting
2004 survey of community hospitals by Stevenson et al5% h 24 h h i 5% have 24 hours pharmacy services
70% of some “element” of antimicrobial stewardship Less than 30% of these have method to track their stewardship practices
Less than 30% have capability to recommend changes in antimicrobial therapy based on culturechanges in antimicrobial therapy based on culture and sensitivity results
4/23/2012
11
Reality of Stewardship in the community setting
Survey through American College of Clinical Pharmacy, March 201226 it ( d i ) h it l d d 26 community (non‐academic) hospitals responded (250‐500 beds) 3/26 (11.5%): 0 dedicated pharmacy FTE’s to AMS
4/26 (15.3): <1 dedicated FTE
16/26 (61.5%): 1 dedicated FTE
2/26 (7.7%): 2 dedicated FTE’s2/26 (7.7%): 2 dedicated FTE s
1/26 (3.8%): 3 dedicated FTE’s
Challenges of AMS in small, rural institutions
Frequently, no infectious diseases physician on site
Antimicrobial stewardship may be a novel idea to Antimicrobial stewardship may be a novel idea to rural hospitals as they are typically associated with larger tertiary or academic institutions
Most AMS programs are driven by infectious diseases physicians and infectious diseases fellowship trained pharmacists the latter being infellowship‐ trained pharmacists, the latter being in short supply
Physician culture historically not accustomed to regulation of antibiotic choice
4/23/2012
12
Providence ACT grant PSMMC was awarded an ACT grant to develop an antimicrobial stewardship (AMS) program
Multidisciplinary AMS team to increaseMultidisciplinary AMS team to increase knowledge sharing between departments & hospitalsDr. Collins, Dr. Sarah Beaty‐Vandermark, Molly Angel
Model for Antimicrobial Stewardship in a rural facility without Infectious Disease practitionersfacility without Infectious Disease practitioners
Export learning to other similar facilities to improve overall system quality performance
PSMMC General Process Timeline
GAP Analysis, l i2009‐
Rx Resident gathers b liSpring Program Mayplanning,
ACT Grant application submitted
2009‐2010
baseline data, ACT Grant
approved
Spring 2010
gbegins,
prelim data
May 2010
Gaps in
New rx personnel
July 2010
Gaps in metric & data
capture & reporting identified & addressed
Nov 2010
Results captured, plans for future
directions
June 2011
4/23/2012
13
SMMC’s AMS Practice Model
Daily review of patients receiving targeted antibiotics by clinical pharmacist or pharmacy
idresidentAdditional review by pharmacy resident during Infectious Diseases rotation Review of patients receiving any antibiotic
Review of all patients with any culture
l d Review includes:Appropriate indication, dosing, duration of therapy
Culture and sensitivity data
Vital signs, other laboratory data, patient progress
KEY to SMMC’s AMS Practice Model Tele‐medicine Off site infectious diseases physician
Educationd f l Attendance of annual IDSA meeting
Hospital‐wide physician CME AMS Newsletter (quarterly) & Case PresentationsMAD‐ID Advanced and Basic Training Certificate programs Attendance of SHEA/IDSA ID Week meeting Competencies—annual monitoring of patient cases Infectious diseases physician feedback Infectious diseases physician feedback Contribution to literature
Multidisciplinary, non‐restrictive approach Information technology
4/23/2012
14
KEY to SMMC’s AMS Practice Model
Multidisciplinary, non‐restrictive approach Preserve close and collaborative relationship
Positive reinforcement versus restrictive prescribing Positive reinforcement versus restrictive prescribing authority
Information technology Tailor information technology to accurately and easily track the metrics you are following
Current program structureExecutive SponsorSteve BurdickChief Executive
Officer
Physician Infectious
Program oversightPharmacy
Program Lead & Coordinator
MicrobiologyInfection Control
Program oversightQuality
Physician champion
Michael Bernstein, MDChief Medical Officer
diseases physician Michael Gillum, MD
Providence Sacred Heart
Anita Treis, RPHDirector of Pharmacy
Peggy Yam, PharmDClinical Pharmacy
Supervisor
Clinical pharmacist
One from 0630‐1700
Pharmacy residents
When on clinical rotation
Ronda ReisdorphMicrobiology lead
Sharie Ledford, RNInfection Preventionist
Yvonne Strader, RNChief Nursing
Officer
4/23/2012
15
SMMC’s AMS Practice Model Daily communication with prescribers regarding any potential changes Initially used “AMS Communication Form” cosigned Initially used AMS Communication Form cosigned by physician champion
As needed communication between pharmacist & ID expert (phone or email)
As needed communication between prescriber & ID expert (through pharmacist or directly by& ID expert (through pharmacist or directly by phone)
As needed communication between pharmacist & physician champion
Identify Patients
Sentri7 Tool used to identify target patients
R l t d t id tif ti t b d t Rule created to identify patients on broad spectrum antibiotics and flag for review
Imipenem/cilastatin, piperacillin/tazobactam, vancomycin, linezolid, ertapenem, daptomycin
4/23/2012
16
Wednesday/Thursday RoutineWednesdayWork up patients on target antibiotics using formMeet with Dr. Bernstein Wednesday evening to review
ti t d d d tipatient cases and proposed recommendations E‐mail the cases to Dr. Gillum; patient identifiers removed
Thursday 8 am conference call with Dr. Gillum in Spokane Discuss patient cases and Dr. Gillum’s recommendationsMicrobiologist and Infection Preventionist attendMicrobiologist and Infection Preventionist attend Present our recommendations and receive his inputMake follow up recommendations to physicians as necessary
SMMC’s AMS Practice Model
Thursday morning AMS rounds with ID expert Initially, all patients receiving any of the targeted
tibi ti di dantibiotics were discussed
As patient volume increased dramatically, only discussed remaining cases
4/23/2012
17
Multidisciplinary approach Improve sharing of information previously limited to isolated departments
Multidisciplinary AMS team:Multidisciplinary AMS team: Clinical Pharmacy Infectious disease physician Physician championMicrobiology Infection PreventionInfection PreventionQualityAdministration
Choosing your team members
Physician champion + Administrative influence
+ Leader amongst peers
+ Infectious diseases or related experience
+ Existing relationship with pharmacy leaders
Infectious disease physicianOn‐site or off‐site
Existing relationship with pharmacy leaders
Influence amongst peers
4/23/2012
18
Choosing your team members
Hospital administration Chief executive officer or Chief financial officer
Quality improvement leaders
Infection control Infection prevention lead for institution
LaboratoryMicrobiology lead supervisorMicrobiology, lead supervisor
Laboratory director and medical director
Choosing your team members
PharmacyDirector of pharmacy
Clinical pharmacy supervisor “AMS Coordinator”
Clinical pharmacists
Pharmacy residents
4/23/2012
19
Member responsibilities
Physician champion Introduction of program to peers
Representation at medical executive committee
Representation within administration
Representation at Providence t l lsystem level
Close relationship & communication with infectious diseases physician
Member responsibilities
Physician champion Program oversight and direction
Management of “outlaw prescribers”
Participation in educational opportunities
Daily support of clinical pharmacist
4/23/2012
20
Member responsibilities
Infectious disease physician Provide daily support and expert opinion for
h i t d ibpharmacists and prescribers
Provide weekly review of AMS cases
Participate in educational activities for institution
Provide education and feedback for clinical pharmacist as they present patient cases
Member responsibilities
Hospital administration Program appraisal
Representation throughout hospital
Representation at Providence system level
Quality officers—process change and facilitation Program oversight
Infection control Participation in weekly rounds
Surveillance of MDR organisms, C. diff, hospital acquired pneumonia, VAP
4/23/2012
21
Member responsibilitiesMicrobiologyAttendance of Thursday morning rounds to provide knowledge and information regarding patient casesknowledge and information regarding patient cases
Availability to clinical pharmacist on a daily basis to discuss patient cultures and sensitivities
Increase awareness between microbiology & pharmacy’s daily routine and expectations
Develop joint goals and projects with AMS team Clinical pharmacy team
Increase communication with providers regarding culture data
Member responsibilities Director of pharmacy Program oversight Budget
Clinical supervisor Program oversight Administer education & training Quality assurance, program tracking, data mining, report generation
Increase awareness, presence, and communication with ibprescribers
Lead and promote
Clinical pharmacists/pharmacy residents Daily clinical review & weekly rounds Education & Training!
4/23/2012
22
Goals and metrics in ACT grant Objective “Improve relations in areas of communication, collaboration and integration of services betweencollaboration and integration of services between Pharmacy, Laboratory and infection preventionists”
Metric description Increase Pharmacy / Microbiology / Infection Control interactive reviews on a periodic basis to look at:I di id l P ti t C C Individual Patient Care or Cases
Population Based Care
4/23/2012
23
Goals and metrics in ACT grantMetric goals 2 cases per week or 10 cases per month
R i d t t th PSMMC I f ti C t l d Review data at the PSMMC Infection Control and Pharmacy and Therapeutics Committees: Annual review of the facility antibiogram and the antibiotic resistance patterns of multi‐drug resistant organisms.
Twice yearly review of facility Hospital‐associated Clostridium difficile enterocolitis disease rates
Twice yearly review of facility quantitative trends in utilization of targeted antibiotics, regarding volume of use and cost.
Specific goals between disciplines
Lab/Pharmacy subgroup charter
Composition Lead microbiologist, Clinical pharmacy supervisor, Director of Pharmacy
Sponsor & oversight: Chief medical officer
Coordinator: Clinical pharmacy supervisor
Key initiative & expected outcome:y p Increase pharmacy and microbiology interactive reviews of individual patient cases as well as population based care
4/23/2012
24
Specific goals between disciplines
ReportingAMS Committee
h h Pharmacy & Therapeutics committee
Infection control committee
Develop major projects or goals Pharmacy and microbiology annual review and selection of VITEK cards Formulary, antibiogram, MUE’s, prescribing patterns
Pharmacy and microbiology review and selection of culture and sensitivity reporting suppression model
4/23/2012
25
Results Did not track in numbers specific cases or positive changes—Lesson Learned!
Examples: Fluoroquinolone sensitivities reporting out for Enterococcus faecalis on all culture sources
Change in manual reporting, double‐check system Enterococcus faecalis “R” to Ampicillin in Urine, but “S” to ampicillin in Blood culture, same MIC
Piperacillin‐tazobactam FDA recall on VITEK cardsPiperacillin tazobactam FDA recall on VITEK cards Automatic E‐test on pseudomonas
Gram negative slow growing Lab performed different test to result more quickly Clinical difference
Results
4/23/2012
26
Results
Results 2008 purchase data: $144,605
2009 purchase data: $167,970 ($13,521/1000 PD)
2010 estimated budget: $179,728, projected 7% savings with AMS program ($167,147)p g ($ , )
2010 actual budget: $140,445.70 ($9,756.56/1000 PD)
2011 actual budget: $74,673.34 ($6,583.52/1000 PD)
4/23/2012
27
Results
14.00
16.00
Hospital acquired C. diff per 10,000 patient days
6.00
8.00
10.00
12.00
0.00
2.00
4.00
1st Qrt 2008
2nd Qrt 2008
3rd Qrt 2008
4th Qrt 2008
1st Qrt 2009
2nd Qrt 2009
3rd Qrt 2009
4th Qrt 2009
1st Qrt 2010
2nd Qrt 2010
3rd Qrt 2010
4th Qrt 2010
1st Qrt 2011
2nd Qrt 2011
3rd Qrt 2011
4th Qrt 2011
Future directions Based on: Lessons learned
Pearls from other groups: MAD‐ID, IDSA/SHEAg p
Bedside medication verification to track actual antimicrobial use
Patient outcome focus Timing of first antimicrobial
b l (b d h )Appropriate antimicrobial (bug‐drug mismatches)
Duration of therapy
Length of stay (total, ICU)
Mortality
4/23/2012
28
Future directions Prescriber behavioral patterns Track de‐escalation prior to AMS team intervention Track appropriate empiric antimicrobial choices
MetricsMetricsMake them visible and transparent
Benchmark with NHSN Data source choice
Cycle 2.5% of antibiotic purchase savings back into programEd i Education
Weekly attendance of microbiology
Community stewardship practices Outpatient infusion antibiotics
4/23/2012
29
Reaction/Discussion
• What excited you?What excited you?
• What could you adapt/adopt?
• What barriers exist for you?
57
Thank You
Sharon Eloranta, MD
sharone@qualishealth [email protected]
Tina Schwien, MN, MPH
58
For more information: www.QualisHealthMedicare.org
This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a 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. ID/WA-C7-QH-793-04-12
