antimicrobial stewardship, pharmacy and standard 3.14……. matthew rawlins id pharmacist royal...
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antimicrobial stewardship,pharmacy
and standard 3.14……. Matthew Rawlins
ID pharmacistRoyal Perth Hospital
June 2014matthew.rawlins@health.wa.gov.au
plan
• definition
• why is there a need for stewardship?
• pharmacy and implementation of an ASP (antimicrobial stewardship program)
• getting started and ASP components
• pharmacy resources
• where to find help
definition
• optimising the selection, dosage and duration of an antimicrobial treatment in order to achieve the best clinical outcome whilst minimising toxicity, antimicrobial resistance selection and cost
Paskovaty et al. Int J Antimicrob Agents 2005 MacDougall and Polk. Clin Microbiol Rev 2005
Paterson D. Clin Infect Dis 2006 (Suppl)
Dellit et al. Clin infect Dis 2007
TG: antibiotic v14 (2010)
ACSQHC 2011
international benchmarking
NAUSP Annual Report 2012-2013
stewardship – where to start?• ACSHC publication and executive support
• “pink book” (TG: antibiotic)– local guidelines where necessary
• antimicrobial formulary and restriction
• measuring use (before you start and as you go)– NAPS– NAUSP
• antibiograms
• rounds
Australia - ACSQHC publication• Duguid and Cruickshank (Eds). Antimicrobial Stewardship
in Australian Hospitals. Australian Commission on Safety and Quality in Healthcare January 2011
• Dellit et al. IDSA guidelines CID 2007
– implementation
– strategies
– resources
recommendations for implementation of an ASP (ACSQHC 2011)
• includes an antimicrobial prescribing and management policy, plan and implementation strategy
• antimicrobial formulary, guidelines for treatment and prophylaxis according to TG: antibiotic
• multidisciplinary AST (AS team)» ID physician, clinical microbiologist or lead clinician» pharmacist
• ASP resides in quality improvement and patient safety structure
• ASTs links to DTC, IPCC, clinical governance or safety and quality units
• support and training for AST member roles• process and outcome indicators are measured
ASP structure
antimicrobial stewardship committee (ASC)
• multidisciplinary membership– ID pharmacist
• DUE, QUM, “interested” pharmacist(s)
• role• directing appropriate antimicrobial use at institution
level
• TOR• chair/membership/reporting• aims and objectives
executive support (ACSQHC 2011)
VRE outbreak RPH 2001
provision of resources (esp. personnel time)
• accreditation!• ACSQHC National Safety and Quality Health Service
(NSQHS) Standards. Standard 3: Preventing and controlling healthcare associated infections – Antimicrobial Stewardship “3.14”
• EQuIP 5
strategies (ACSQHC 2011)
• front end– formulary and approval systems
• all institution except possibly ICU
• back end – review and prescriber feedback– point of care interventions
• all of institution including ICU
• outcome measures and education• measuring performance• addressing prescriber education and competency
formulary and antimicrobial approval systems (ACSQHC 2011)
– restricted list and criteria for use (TG: antibiotic)
• use by ID/Micro only or clinical specialties with suitable experience
• traffic light system
– antimicrobial approval system• telephone/verbal• computerised (eDSS)
– rapid and targeted review facilitated
– expert advice is available• 24 hours (on call service A/H)
measuring antimicrobial use(ACSQHC 2011)
• continuous or point-prevalence surveys– before you start and as you go– benchmarking
• international data• national (NAUSP, NAPS)• locally
– trends• within hospital
– can they be linked to particular events?» eg. increased ESBL rates
– clinical audit of particular units/guidelines
NAPS – resultsNational Antimicrobial Prescribing Survey
(www.naps.vicniss.org.au)
NAPS - resultsBENCHMARKING DATA
NAPS - results
antimicrobial use
• National Antimicrobial Use Surveillance Program (NAUSP)
vicki.mcneil@health.sa.gov.au
– Business Unit for OBDs– InfoHealth for iPharm reports
NAUSP total hospital use
NAUSP Annual Report 2012-2013
back end review of therapy - RPH
• stewardship rounds– IV to PO switch– empirical to directed therapy– cessation of therapy– duration of therapy– management advice
• assessment of clinician acceptance
• cost savings
RAD
stewardship rounds
measuring the performance of ASP’s(ACSQHC 2011)
ASR - all advice
ASA Abstracts 2014
ASR – cost savings
Cost Savings for Rounds
0
50
100
150
200
250
300
2004 2005 2011 2013
Year
Co
st S
avin
g $
Per
Pat
ien
t
ASA Abstracts 2014
antimicrobial use – cost savings
– institution (formulary decisions)– unit (guidelines containing antimicrobials)– patient level (rounds)
• compare what was done to what would have been done
– approximately $120-240 per patient (ASA Abstracts 2014)
– institution unit costs and DDD’s/patient days can be significantly reduced by an ASP (Standiford et al. Infect Control Hosp Epidemiol. 2012)
antimicrobial usemeasuring the impact
antimicrobial use time-series analysis• compare rate of increase before and after the
stewardship intervention(s)• ratio of narrow-spectrum to broad-spectrum agents
(eg. 1st/2nd versus 3rd/4th generation cephalosporins)
David Andresen ASA 2013
Ratio of Narrow Spectrum to Broad Spectrum Cephalosporins (outside ICU)
0
2
4
6
8
10
12
14
Jul-04 Jul-05 Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jul-11 Jul-12 Jul-13
Date
Rati
o
education and competency of prescribers (ACSQHC 2011)
antimicrobial resistanceIbrahim and Polk Expert Rev Anti-infect Ther. 2012 Davis et al. ASA Abstracts 2012
Patel et al. Exp Rev Anti-infect Ther. 2008
• can antimicrobial use be linked to clinical outcomes? (“do no harm!”)
– mortality– readmission rates– LOS
• reality is more complex– association between use and resistance can be
shown but causality is more difficult to prove
• decreased resistance and amount of CDI have been proposed
role of pharmacy service(ACSQHC 2011)
• admin/management support critical
• ID pharmacist• co-leader of ASP and activities
» education, promotion guideline development, implementation and audit, rounds, formulary, research
• liaison between ID/micro and pharmacy• expert advice
• (clinical) pharmacist participation• point-of-care review and interventions• knowledge and enforcement of restrictions• referral of cases for ASR review• advice and education at patient level
IT support(ACSQHC 2011)
• measuring performance of stewardship programme» development of databases» Smart-phone/tablet applications» electronic prescribing, medical records
• eDSS– address organisational, social and cultural issues relating to
prescribing behaviour during implementation– pharmacist/AST maintenance and support
audit support– DUAG or similar– pharmacist rotations, interns, students?
smaller hospitalsSeptimus and Owens CID 2011 (Suppl)
conclusions
– antimicrobial stewardship is here• ACSQHC and accreditation
– comprehensive ASPs contain many different strategies and require multidisciplinary input
• determined by institutional size (resources)• support from administration is critical
– use your (pharmacy) networks
assistance• ID pharmacy COSP (SHPA)
– email discussion group
• ACSQHC (“the commission”)• ASA (Australian Society for Antimicrobials)
• annual pharmacist workshop
• NPS (National Prescribing Service)• NAUSP, NAPS (usage data)
• international guidelines and literature– US: IDSA/SHEA/CDC– UK: Antimicrobial Stewardship: Start Smart then Focus: ARHAI
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