program overview hosts: – jan ratterree, rn, cic, georgia hospital association – jesse jacob,...
TRANSCRIPT
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Program Overview• Hosts:
– Jan Ratterree, RN, CIC, Georgia Hospital Association– Jesse Jacob, MD, MSc, Emory University Hospital Midtown– Jeanne Negley, MBA, HAI Surveillance Director, DPH
• Stewardship Story:– Lisa Ferraro, PharmD, Mountain Lakes Medical Center
• Advancing Antimicrobial Stewardship in Community Hospitals in Utah– Edward Stenehjem, MD, MSc, Intermountain Healthcare
Thank YouCalifornia Department of Public Health
Illinois Department of Public Health
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Georgia AntimicrobialStewardship Story
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Advancing Antimicrobial Stewardship in Community
Hospitals in Utah
May 6, 2015
Edward Stenehjem, MD, MScDivision of Infectious Diseases, Intermountain Healthcare
Medical Director of Antimicrobial Stewardship, IMC Co-Chair Intermountain Healthcare Antimicrobial Stewardship Committee
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Advancing Antimicrobial Stewardship in Community Hospitals in Utah
Eddie Stenehjem, MD MSc
Infectious Diseases and Antimicrobial Stewardship
May 6th, 2015
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Objectives
• Describe how antimicrobial usage in small, community hospitals compares to large urban centers
• Understand the basic concepts of Intermountain’s SCORE study and how it can apply to your hospital
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What is Antibiotic Stewardship?
Systematic efforts to optimize the use of antibiotics to maximize
benefits, minimize resistance and decrease adverse events
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Core ElementsAntibiotic Stewardship Program
• Leadership commitment from administration• Single leader responsible for outcomes• Single pharmacy leader• Antibiotic use tracking• Regular reporting on antibiotic use and
resistance• Educating providers on use and resistance• Specific improvement interventions
http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
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Improvement Interventions
Antimicrobial Stewardship
Prospective Audit with Feedback
Formulary Restriction
Antimicrobial Indications
Guidelines and Clinical Pathways
EducationDose optimizationIV to PO conversionRapid Diagnostics
Decision Support
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What is Antibiotic Stewardship?
Antimicrobial
Stewardship
Prospective Audit
Formulary Restriction
Antimicrobial Indications
Guidelines and Clinical Pathways
EducationDose optimizationIV to PO conversionRapid Diagnostics
Decision SupportStructured mechanism of optimizing antibiotic useThis isn’t a new topic
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Sir Alexander Fleming June 26, 1945
• The public will demand [the drug and]…then will begin an era… of abuses….In such a case the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with penicillin-resistant organism.
Fleming A. Penicillin’s finder, assays its future. New York Times. 1945; 21
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Why Stewardship?
1. All Antibiotics Fail2. Rising Resistance3. Dry (damp?) pipeline4. It is the right thing to do
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Why Stewardship?
1. All Antibiotics Fail2. Rising Resistance3. Dry (damp?) pipeline4. We will have to
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Presidential Report
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National Action Plan
1. Slow the emergence of resistance bacteria
2. Strengthen National One-Health Surveillance
3. Advance development of rapid dx tests
4. Accelerate research and development of new abx
5. Improve international collaboration
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Goal 1
• Within three years: – All hospitals that participate in Medicare and Medicaid
programs must comply with Conditions of Participation (COP). The Centers for Medicare Medicaid Services (CMS) will issue new COPs or revise current COP Interpretive Guidelines to advance compliance with recommendations in CDC’s Core Elements of Hospital Antibiotic Stewardship Programs.
• All acute care hospitals governed by the CMS COP will implement antibiotic stewardship programs.
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SCOPE
2005 United State Hospitals
4935 Registered Hospitals
72% have < 200 beds
Most of these are without antibiotic oversight
All will be included in National Action Plan
Very few studies of stewardship in these settingsAHA Statisticshttp://www.aha.org/research/rc/stat-studies/index.shtml
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Since 1975• 22 hospitals• 2,784 licensed beds
Since 1983• Health plans• 700,000+ members
Since 1994• 1,200 employed physicians• 558 advanced practice clinicians
Since 1997• 10 key service lines
Intermountain HealthcareHighly-Integrated Health System
Hospitals
SelectHealth
Medical Group
Clinical Programs
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Intermountain Antibiotic Stewardship
Increased emphasis in the past 5 years at our large facilities
• Corporate AS Committee– Subcommittee of Infection Control Guidance Council
• Corporate Outpatient AS Committee– Subcommittee of Primary Care Clinical Program
• Individual ASP Committees at our large sites
• NO FOCUS ON OUR SMALLER HOSPITALS
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Hospital Staffed Bed CountIntermountain Medical Center 472Utah Valley 375McKay-Dee 300Primary Children's 289Dixie Regional 245LDS 243Logan Regional 128American Fork 89Riverton 88Alta View 66Valley View 48Park City Medical Center 30Cassia Regional 25Sevier Valley 24Orem Community 18Bear River Valley 16Heber Valley 16Delta Community 15Garfield Memorial 14Sanpete Valley 13Fillmore Community 7
Large Urban Hospitals-ASP focused-Formal ID consultation available
Small Community Hospitals-15 Hospitals-597 Beds-25% of IHC Beds-No formal ASPs-No Infectious Diseases MD support-All with full time pharmacy staff
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Antimicrobial Use in Small Hospitals
• Antibiotic Usage Using NHSN AU Data
• How does usage differ across our system?– Small vs Large Hospitals– Usage and Case Mix Index (CMI)– Usage and Spectrum
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Small vs. Large Hospitals3 year average
% of Total Antibiotic Use per
Category
27%
14%
24%
55%
20%29% 23%
14% 14%
34% 30% 28%21%
34%
65%19%
16%
24%
10%
22%13% 25%
26% 20%
15%13% 20%
19%
15%
11%
19%
35%
28%
23% 18%
24%29%
23%
13%12%
20%25%
18%
25% 35%16%
21%22% 27%
18% 22%
27%26%
31%
22%20%
24%
21%13% 14% 10% 10% 15% 12% 13%
8%
8%
9% 9%8% 9%
25%32% 31%
17%12% 18%
10%11%
15%
31% 27%
24%
17% 18%11%
0
200
400
600
Days of Therapy per 1000
Patient Days [Bars]
0.0
0.5
1.0
1.5
Average CMI
Drug CategoriesCategory 1 (narrow)Category 2Category 3Category 4Category 5 (broad)
Measure NamesCasemix IndexFacility AU Rate
Panel 2
SCHs LUHs
Panel 1
Panel 3
Hospitals
Figure 3. Description of Antimicrobial Use in 15 SCHs and 3 large, urban hospitals in Utah and IdahoPanel 1: Antimicrobial usage rates and case mix index. Panel 2: Distribution of antimicrobial use per category. Panel 3: Percentage of total use per unit type
Abbreviations: CMI - case mix index. AU - Antimicrobial Use. ICU - intensive care unit
15 Small IHC Hospitals 3 Large IHC Hospitals
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Usage and Spectrum
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Usage and Spectrum
% of Total Antibiotic Use per
Category
27%
14%
24%
55%
20%29% 23%
14% 14%
34% 30% 28%21%
34%
65%19%
16%
24%
10%
22%13% 25%
26% 20%
15%13% 20%
19%
15%
11%
19%
35%
28%
23% 18%
24%29%
23%
13%12%
20%25%
18%
25% 35%16%
21%22% 27%
18% 22%
27%26%
31%
22%20%
24%
21%13% 14% 10% 10% 15% 12% 13%
8%
8%
9% 9%8% 9%
25%32% 31%
17%12% 18%
10%11%
15%
31% 27%
24%
17% 18%11%
0
200
400
600
Days of Therapy per 1000
Patient Days [Bars]
0.0
0.5
1.0
1.5
Average CMI
Drug CategoriesCategory 1 (narrow)Category 2Category 3Category 4Category 5 (broad)
Measure NamesCasemix IndexFacility AU Rate
Panel 2
SCHs LUHs
Panel 1
Panel 3
Hospitals
Figure 3. Description of Antimicrobial Use in 15 SCHs and 3 large, urban hospitals in Utah and IdahoPanel 1: Antimicrobial usage rates and case mix index. Panel 2: Distribution of antimicrobial use per category. Panel 3: Percentage of total use per unit type
Abbreviations: CMI - case mix index. AU - Antimicrobial Use. ICU - intensive care unit
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Need for Stewardship
63%
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Usage Conclusions
• SCHs have similar antibiotic usage rates as large, urban hospitals.
• There is significant variation in antibiotic selection in SCHs.
• Antibiotic Stewardship in SCHs is critical
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SCORE
Stewardship in Community Hospitals: Optimizing Outcomes and Resources (SCORE)
Funded by:
Pfizer Independent Grants for Learning and Change
The Joint Commission
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Project Aim: SCOREStewardship in Community Hospitals Optimizing Outcomes and Resources
Define an antibiotic stewardship strategy for Intermountain’s smaller hospitals that
optimizes outcomes while maximizing resources
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Study Design: Cluster Randomized Clinical Trial
Study sites: 15 small hospitals
Intervention: • Low Resource Utilization – 5 hospitals• Medium Resource Utilization – 5 hospitals• High Resource Utilization – 5 hospitals
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ALL Sites – Antibiotic Best PracticesIV to PO Conversion
Antibiotic Indications48 hour Antibiotic “Timeout”
Access to: ID clinicians and pharmacistsMonthly Hospital Antibiotic Utilization Report
Low Resource Medium Resource High ResourceEducation Initiative - PharmacyTopics Covered: Stewardship Basics Antibiotic Time Out IV to PO Antibiotic Indications Bug-Drug mismatch When to call ID
KAP Survey
Education Initiative - PharmacyTopics covered (in addition to low group): De-escalation - mylearning Anaerobes - mylearning Restrictions - mylearning Allergy Verification Stewardship Pearls / Q and A
KAP survey
Education Initiative - PharmacyTopics covered (in addition to low group): De-escalation - mylearning Anaerobes - mylearning Restrictions - mylearning Allergy Verification Stewardship Pearls / Q and A
KAP survey
PAF – lite: Audit a limited number of antimicrobial agents* and provide feedback Restriction (local pharmacy review) of selected antimicrobials***
* Vancomycin, carbapenems, piperacillin/tazobactam, and cefepime
PAF: Audit an expanded list of antimicrobial agents** and provide feedback Restriction (Infectious Diseases review) of selected antimicrobials*** ID study staff to review positive blood culture results and all cultures with MDROs.
** Vancomycin, carbapenems, piperacillin/tazobactam, cefepime, aminoglycosides, ciprofloxacin, levofloxacin, ceftriaxone, and ampicillin/sulbactam*** Restricted agents: Meropenem, linezolid, daptomycin, ceftaroline, tigecycline, antifungals.
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Antibiotic Best Practices
• IV to PO Conversion• Antibiotic Indications• 48 Hour Antibiotic “Timeout”• Monthly Antibiotic Report• Access to ID Consultation
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Antibiotic Time-Out
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Usage Reports
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Usage Reports
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Access to ID Clinicians
• Adults and Pediatrics• One number: 1-801-50-SCORE
• Call: Anytime– Adults: Stenehjem– Pediatrics: Attending on call at PCMC
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https://my.intermountain.net/qpsafety/Pages/SCORE.aspx
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ALL Sites – Antibiotic Best PracticesIV to PO Conversion
Antibiotic Indications48 hour Antibiotic “Timeout”
Access to: ID clinicians and pharmacistsMonthly Hospital Antibiotic Utilization Report
Low Resource Medium Resource High ResourceEducation Initiative - PharmacyKAP surveyTopics Covered: Stewardship Basics Antibiotic Time Out IV to PO Antibiotic Indications Bug-Drug mismatch When to call ID
Education Initiative - PharmacyKAP surveyStewardship Basics – all of those in Low, plus De-escalation - mylearning Anaerobes - mylearning Restrictions - mylearning Allergy Verification Stewardship Pearls / Q and A
Education Initiative - PharmacyKAP surveyStewardship Basics – all of those in Low, plus De-escalation - mylearning Anaerobes - mylearning Restrictions - mylearning Allergy Verification Stewardship Pearls / Q and A
PAF – lite: Audit a limited number of antimicrobial agents* and provide feedback Restriction (local pharmacy review) of selected antimicrobials***
* Vancomycin, carbapenems, piperacillin/tazobactam, and cefepime
PAF: Audit an expanded list of antimicrobial agents** and provide feedback Restriction (Infectious Diseases review) of selected antimicrobials*** ID study staff to review positive blood culture results and all cultures with MDROs.
** Vancomycin, carbapenems, piperacillin/tazobactam, cefepime, aminoglycosides, ciprofloxacin, levofloxacin, ceftriaxone, and ampicillin/sulbactam*** Restricted agents: Meropenem, linezolid, daptomycin, ceftaroline, tigecycline, antifungals.
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Prospective Audit and Feedback
Pharmacy will review the following medications after 48 hours of administration• Vancomycin• Carbapenems• Piperacillin/tazobactam• Cefepime• Fluoroquinolones• Aminoglycosides• Ceftriaxone• Ampicillin/sulbactam
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Restrictions
• The following drugs are restricted – Daptomycin, linezolid, ceftaroline– Imipenem/meropenem, tigecycline– Amphotericin, vori/posaconazole, micafungin
• Medium group – local pharmacy control• High group – ID pharmacist control
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High Group
• Infectious diseases involvement– Positive blood cultures– S. aureus bacteremia– CNS infections– MDRO– Home IV antibiotic therapy
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SCORE Outcomes
• Primary Outcome: – Antimicrobial use
• Secondary Outcomes: – Stratified antimicrobial use– Incidence of C. difficile infection– Incidence of MDRO infections
• (VRE, ESBL, CRE, MRSA, FQ R E.coli)
– Feasibility– Cost
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Significance
• One of the largest AS studies ever done
• First AS study to evaluate effectiveness of different intervention levels
• First randomized AS study done in small, community hospitals
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Timeline
Jan/Feb 2014: Education
March 2014 – June 2015: Intervention
July 2015 – Aug 2015: Analyze Data
Sept 2015: Present Intermountain Plan
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Conclusions
• 70% of US hospitals have < 200 beds, most don’t have ID specialists/pharmacists
• SCHs use antibiotics at a similar rate compared to larger facilities
• Stewardship is feasible in SCHs, hopefully SCORE will tell us more
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Webinar Contact:Jeanne Negley ([email protected])
Questions?
Advancing Antimicrobial Stewardship in Community Hospitals in Utah
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Upcoming Best Practice Power Hour Webinar’s:
• Wednesday, May 13th at 11:00 a.m.– Redmond Regional Medical Center
• “Improving Patient Flow in an Emergency Department, a Hospital-wide Initiative”
• Wednesday, May 20th at 11:00 a.m.– Grady Health System/Grady Memorial Hospital
• “Heading Toward Zero: Falls Reduction Patient Safety Program”
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Angelina Davis, PharmD, MS, BCPS (AQ-ID) and Daniel Sexton, MD
Duke Antimicrobial Stewardship Outreach Network
Next Antimicrobial Stewardship Series Webinar:
June 3, 2015, 12 – 1 pm (ET)Webinar: https://gharef.webex.com
Webinar Password: Gha060315Teleconference: 877-443-9072
Effective Communication between Physicians and Pharmacist for
Stewardship
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THANK YOU!
• Thank you Dr. Stenehjem, Lisa Ferraro, and all of our participates from Georgia, California, Illinois.
• Copy of the slides and webinar recording will be available within one week.