Antimicrobial Stewardship: Size Doesn’t … Stewardship: Size Doesn’t Necessarily Matter Alice...

Antimicrobial Stewardship: Size Doesn’t Necessarily Matter Alice Hogg RPh, ACPR Pharmacist Consultant, Public Health Ontario Clinical Pharmacist, Markham Stouffville Hospital

PublicHealthOntario.ca

Background • 2 sites, Markham (200 beds)

and Uxbridge (20 beds)

• Services provided onsite in Markham and remotely to Uxbridge

• ASP started in late 2008, 0.5 FTE pharmacist

• Computer system: Meditech

• Successful ASPs require an inter-disciplinary team approach (frontline staff and senior administrators)

• Team members should include but are not limited to: • Physician champion • Pharmacist • Microbiology laboratory services • Infection Prevention and Control professional

Consider Membership of the ASP Team

Additional Resource ASP 101 Presentation

Dellit T et al. Clin Infect Dis 2007;44:159-177

SHEA, IDSA and PIDS. ICHE 2012;33:322-327

ASP Training Opportunities

• Conferences and Education Opportunities • Certificate/Training opportunities

• MAD-ID – Basic & Advanced Training program (US) • Society of Infectious Diseases Pharmacists (US) • U of T Faculty of Pharmacy – Antimicrobial Stewardship

(Canada) • Antimicrobial Stewardship - Optimization of Antibiotic

Practices (https://www.coursera.org/#course/antimicrobial) (US Stanford ID)

• Antimicrobial Stewardship in Practice: An Online Educational Series for Healthcare Practitioners (US SHEA)

ASP Support & Structure

• Administrative/upper management buy-in is important • Easier now that ROP

• Alignment with institutional priorities • Patient Quality and Safety Focus • Excellent Care for All Act – Quality Improvement Plan (QIP)

• Safety indicators: C. diff and VAP rates • ASP Metrics: DDD, susceptibility data

• Quality Based Procedures • COPD • Pneumonia

Program Development

• IHI/CDC ASP Driver Diagram

• CDC Get Smart for Healthcare: Implementing and Improving Stewardship Efforts. (http://www.cdc.gov/getsmart/healthcare/improve-efforts/index.html)

• ASHP Implementing Antimicrobial Stewardship Programs in Health Systems: An Interprofessional Team Approach. (http://www.leadstewardship.org).

• Joint Commission International Antibiotic Stewardship Toolkit (http://store.jcrinc.com/antimicrobial-stewardship-toolkit/)

ASP Gap Analysis Checklist

Source: PHO Antimicrobial Stewardship Program

NYG-ASP Logic Model

North York General Hospital Antimicrobial Stewardship Program

NYG-ASP Logic Model Program

Components Targeted Antibiotic Review

Activities

Target population

Indicators

Short-term Objectives

Long-term Objectives

Weekly review of restricted antimicrobials and those requiring therapeutic drug monitoring

Patients on restricted antimicrobials or requiring therapeutic drug monitoring

No. of patients reviewed No. of patients reviewed with clinical pharmacist

No. & type of recommendations made No. of recommendations accepted

No. of recommendations resulting in ID consult

Optimize antimicrobial use through appropriate selection, dose, and duration of therapy

Decrease or delay the emergence of antibiotic resistant organisms Decrease the morbidity or mortality associated with antibiotic resistant

organisms and the selection of pathogenic organisms (eg C difficile)

Markham Stouffville Hospital ASP

Early Program (2008-2010)

• Pharmacist driven

• Limited audit and feedback

• Dose optimization, streamlining, IV to PO

• ASP policies

Mid Program (2010-2012)

• Initial ID physician involvement

• Data collection improvements

• Focus on education to Medicine and Surgery

Current Program (2012-2014)

• ASP pharmacist and ID physician commitment formalized

• Expanded metrics collection

• Feedback to frontlines

Identify the Problem(s)

• IV antibiotic overuse

• Fluroquinolone overuse • Ciprofloxacin, Moxifloxacin

• Duration of Therapy

Each hospital to define how their facility can best meet the objectives of an ASP

Examples of ASP Elements • Prospective audit with intervention and feedback • Formulary restriction and preauthorization • Education • Guidelines and clinical pathways • Antimicrobial order forms • Streamlining and de-escalation of therapy • Dose optimization • Parenteral to oral conversion

Dellit T et al. Clin Infect Dis 2007;44:159-177

SHEA, IDSA and PIDS. ICHE 2012;33:322-327 Additional Resource How to Build Business Case

IV to PO Stepdown Policy • Shown to lead to a decreased hospital length of stay, decease

workload (Nursing, Pharmacy) and reduction in health care costs

• Could be a shared responsibility amongst all the pharmacists (not just an “ASP Pharmacist” responsibility)

• Relatively easy to create a policy and implement • Set criteria for inclusion/exclusion, table of stepdown options and doses • Became part of the pharmacists workload (already printing off a daily

list of antibiotics for renal dose adjustment, now would also use this list to assess if patients could be switched from IV to PO therapy)

PublicHealthOntario.ca 14

Method • Chart audit conducted over 6-week period

Results • 43.8% (n=112) were eligible for conversion. • 22% patients were switched to PO antibiotics prior to

discharge. • Average time to switch = 3 days

Cost implications

• Increasing to 45% conversion rate, 2.5 x increase in annual cost-savings

Future directions

• Amend current policy to better align with current practice and workflow • Educate/increase awareness among pharmacists and prescribers regarding

IV-to-PO switch policy • Utilize clinical decision support tools

Modified with permission: Tiffany Kan, PharmD, NYG Pharmacy Services

NYG-ASP Oral Switch Policy

Allied Health Involvement • Bluewater Health – pharmacy student reviews IV

metronidazole: 2 criteria (>48 hours of therapy and patient on diet other that NPO) then communicates to physician / pharmacist that patient may be eligible for PO step-down

• Fergus Hospital (no pharmacist on site) - pharmacy tech runs list of IV abx and weeds out based on criteria then communicates to remote pharmacist. Pharmacist follows up with physician.

Prospective Audit and Feedback Communication Tool

• Implemented to make communication more efficient

• Physician signs and recommendations become orders

16 Markham Stouffville Hospital Preprinted Order

Targeted Audit and Feedback

• Manual/Report driven process • Set criteria for review

• Computerized targeting • set criteria or change in baseline results in a flag for

review • Clinical decision support

• At the time of order entry or automatic message to prescribers at some threshold (culture result, length of therapy etc)

* = automated

Education • Presentations to Surgery, Medicine and ED physicians

• Presented the issues (FQ, Cefoxitin overuse; DOT)

• Supported with data from chart review

• Presented the literature

• Shared Markham Stouffville Hospital Antibiogram

• Feedback from Physicians about logistics of ASP and expectations from team members • What tools would be useful in practice • Best communication strategy

Surgery: Ciprofloxacin and Cefoxitin Use • Obvious from pharmacist order entry

• Retrospective Chart Review • Pharmacy student project

• Motivation: C. diff outbreak

Antibiotic Regimens Ordered by Surgery Service (March - May 2011, n = 70)

TOTAL ABX

Ciprofloxacin/Metronidazole

Cefazolin

Cefoxitin

Ceftriaxone/Metronidazole

Ciprofloxacin

Meropenem

Cefazolin/Metronidazole

Ertapenem

Ceftazidime/Metronidazole

Ciprofloxacin/Metronidazole/Cefazolin

Markham Stouffville Hospital, Internal Data

Antibiotic Regimen Usage by Surgeon(March - May 2011, n = 70)

MD 1 MD 2 MD 3 MD 4 MD 5

Ciprofloxacin/Metronidazole/CefazolinCeftazidime/Metronidazole

Ertapenem

Cefazolin/Metronidazole

Meropenem

Ciprofloxacin

Ceftriaxone/Metronidazole

Cefoxitin

Cefazolin

Ciprofloxacin/Metronidazole

Guidelines and Clinical Pathways

Metrics: How can we measure success?

Additional Resource Metrics Chart

Metrics: Days of Therapy

24 Markham Stouffville Hospital, Internal Data

IT solutions for Data Collection

• Custom Reports

• Homegrown Database Program • Royal Victoria Hospital – clinical decision making and

data collection (outcome data focus) • www.otn.ca (35997028) Dr. Gulio DiDiodato

• Credit Valley – intervention flag (targeted audit and feedback) and data collection. • www.publichealthontario.ca Dr. Lorne Small

• Commercially available

Susceptibility Data

P. aeruginosa % susceptible to 2008 2009 2010 2011 2012 2013 Ciprofloxacin 65 72 71 78 82 88 Gentamicin 80 79 74 80 92 92 Piperacillin-Tazobactam 99 91 88 90 90 81 Meropenem 81 82 90 93 91 90 Ceftazidime 98 82 84 91 90 87 E.coli % susceptible to 2008 2009 2010 2011 2012 2013 Ampicillin 63 59 58 58 55 56 Cefazolin 92 87 89 87 87 87 Septra 80 79 78 76 76 75 Ciprofloxacin 85 80 83 82 82 80

Markham Stouffville Hospital Internal Data

Microbiology • Antibiogram

• “Sneak peek” at culture results

• Input into susceptibility panel

• Collaboration on process measures to help change practice • Asymptomatic bacteriuria

Microbiology Leis J et al. Clin Infect Dis. (2014) 58 (7): 980-983. www.otn.ca (33044222)

• “no longer routinely reporting urine culture results from noncatheterized medical and surgical inpatients can greatly reduce unnecessary antimicrobial therapy for asymptomatic bacteriuria”

• New report for all positive inpatient non-catheterized urine specimens

“The majority of positive urine cultures from inpatients without an indwelling urinary catheter represent asymptomatic bacteriuria. If you

strongly suspect that your patient has developed a urinary tract infection, please call the Microbiologist on call.”

Leis J et al. Clin Infect Dis. (2014) 58 (7): 980-983.

Nursing Engagement • Review of practices and implementation of process changes

• IV Abx reviewed on bullet rounds

• DOT on quality boards

• Foley Campaign

• Time to first dose audit

• Education sessions on ID topics

• Front line ownership

Communication to Front Line Staff • Quarterly Newsletter

• Monthly Metrics posted on units quality boards

• Presentations to physician groups as needed • Share antibiogram • Change in practice • Update to guidelines or Preprinted Orders

• Antibiotic Awareness Week • Banner, posters • Info on Intranet

Take Home Points • Identify problems and address them one at a time

• measure and refine processes

• Use students/nursing/pharmacy techs for data collections and to help facilitate ASP

• Know the needs of your prescribers • Education, Tools, Communication preferences

• Implement strategies that will improve efficiencies • IV to PO step down • Communication tool for audit and feedback • IT solutions for clinical decision making and data collection

• Keep frontline staff engaged

PHO ASP Website

“Can you afford to do it? No!” “Can you afford not to do it? No!”

Neil Walker, Chief Operations Officer

Markham Stouffville Hospital

Thank-you!

Alice Hogg alice.hogg@oahpp.ca

Antimicrobial Stewardship: Size Doesn’t … Stewardship: Size Doesn’t Necessarily Matter Alice...

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