Antibiotic Stewardship Core Elements for LTC Part I

May 18, 2017

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Objectives

• Outline the threat of antibiotic resistance

• Review the definition of antibiotic stewardship and discuss why is it important

• Review CDC Antibiotic Stewardship for Nursing Homes Core Elements Checklist

• Review resources for increasing antibiotic stewardship knowledge

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• Antibiotic resistance occurs when an antibiotic has lost its ability to effectively control or kill bacterial growth; in other words, the bacteria are "resistant" and continue to multiply in the presence of an antibiotic.

What is Antibiotic Resistance?

http://emerald.tufts.edu/med/apua/about_issue/antibiotic_res.shtml

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Antibiotic Pipeline Drying Up

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• Antibiotics are frequently prescribed in NHs – Comprise ~40% of all NH prescriptions

– Over the course of a year, 50-70% of residents will receive one or more courses of antibiotics

• Antibiotic use can cause harm to residents – High risk of side effects and adverse events

– Major risk factor for C.difficile infection (CDI)

– Driver of antibiotic resistance

• 25-75% of antimicrobial use in NHs may be inappropriate

Antibiotic Use in Nursing Homes

Daneman N et al. JAMAIntMed 2013; 173:673-82 Benoit et al. JAGS 2008; 56: 2039-2044 Nicolle LE et al. ICHE 2000; 21:537-545

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What is Antibiotic Stewardship?

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Where Do We Want to Be?

• Every resident gets optimal antibiotic treatment

– Antibiotics given only when they are needed

Right antibiotic

Right dose

Right duration

• Ensure antibiotic stewardship policies and practices are in place to protect residents and improve clinical care in nursing homes.

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Have We Made Any Progress?

2000-10 Antibiotic Prescribing

Pediatric: Decreased 18% Adults: No Change Older Adults: Increased 30%

CDC.MMWR. 2011;60:1153-6; Lee BMC Med2014 Jun11;12:96

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• The Skilled Nursing Facility (SNF) Value-Based Purchasing (VBP) Program/FY 2019 with Performance Period CY 2017 – 30-Day All-Cause Readmission Measure (NQF #2510)

– CDI doubles chances of readmission. Sepsis is a leading cause of unplanned readmissions

• Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Infection Control (§483.80) – Infection Prevention and Control Program & Infection Preventionist

• Bundled Payments, including the Comprehensive Care for Joint Replacement Model

– Incentivizes Readmission Reduction and Decreased Length of Stay

• CMS Accountable Care Organizations (ACOs) – Readmissions is a Quality Measure

The National Landscape: Antibiotic Stewardship and Readmission Reduction in Nursing Homes

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Review the New Rules and Regulations for Infection Prevention and Control Program (IPCP) in LTC

• Phase I: November 28, 2016 – Review IPCP and policies/procedures to determine if all newly

required elements are addressed

– A system for recording incidents (communicable diseases and infections) and corrective action taken by facility

– Annual review of program and update when necessary

• Phase II: November 28, 2017 – Telligen can help! – Implement an antibiotic stewardship program: Core Elements of

Antibiotic Stewardship in Long Term Care

– Use facility assessment to re-evaluate the system

• Phase III: November 28, 2019 – Designate Infection Preventionist

Specialized training

Must be quality committee member and report on IPCP regularly

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Core Elements of Antibiotic Stewardship in Long Term Care

https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

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https://www.cdc.gov/longtermcare/pdfs/

core-elements-antibiotic-stewardship-

checklist.pdf

Available on the

CDC Core

Elements of

Antibiotic

Stewardship for

Nursing Homes

website

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Checklist uses:

As a baseline assessment of antibiotic stewardship policies and practices in place in your nursing home.

As a companion to the Core Elements of Antibiotic Stewardship in Nursing Homes.

As a regular review of progress in expanding stewardship activities.

As a guide to implement activities for each element in a step-wise fashion.

Checklist for Core Elements of Antibiotic

Stewardship in Nursing Homes

https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-

stewardship-checklist.pdf

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Leadership Support

• Can your facility demonstrate leadership support for antibiotic stewardship through one or more of the following actions?

Written statement of leadership support to improve antibiotic use

Antibiotic stewardship duties included in medical director position description

Antibiotic stewardship duties included in director of nursing position description

Leadership monitors whether antibiotic stewardship policies are followed

Antibiotic use and resistance data is reviewed in quality assurance meetings

15 https://www.cdc.gov/getsmart/community/materia

ls-references/print-materials/hcp/index.html

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Accountability

• Has your facility identified a lead(s) for antibiotic stewardship activities?

Medical director

Director or assistant director of nursing services

Consultant pharmacist

Other

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Infection Prevention Program

Coordinator

Infection prevention coordinators have key

expertise and data to inform strategies to

improve antibiotic use.

Consultant Laboratory Nursing homes contracting laboratory

services can request reports and services

to support antibiotic stewardship activities.

State and Local Health

Departments

Nursing homes benefit from the

educational support and resources on

antibiotic stewardship and infection

prevention which are provided by the

Healthcare-Associated Infection (HAI)

Prevention programs at state and local

health departments.

Utilize Existing Resources

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Drug Expertise

• Does your facility have access to individual(s) with antibiotic stewardship expertise?

Consultant pharmacy has staff trained/is experienced in antibiotic stewardship

Partnering with stewardship team at referral hospital

External infectious disease/stewardship consultant

Other

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Actions to Improve Use

• Does your facility have policies to improve antibiotic prescribing/use?

Requires prescribers to document a dose, duration, and indication for all antibiotic prescriptions

Developed facility-specific algorithm for assessing residents

Developed facility-specific algorithms for appropriate diagnostic testing (e.g., obtaining cultures) for specific infections

Developed facility-specific treatment recommendations for infections

Reviews antibiotic agents listed on the medication formulary

Other

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Tracking: Monitoring Antibiotic Prescribing, Use and Resistance

• Does your facility monitor one or more measures of antibiotic use?

Adherence to clinical assessment documentation (signs/symptoms, vital signs, physical exam findings)

Adherence to prescribing documentation (dose, duration, indication)

Adherence to facility-specific treatment recommendations

Performs point prevalence surveys of antibiotic use

Monitors rates of new antibiotic starts/1,000 resident-days

Monitors antibiotic days of therapy/1,000 resident-days

Other

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https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-

stewardship-appendix-b.pdf

• Point prevalence of antibiotic use

• Antibiotic starts per 1,000 resident-

days

• Antibiotic days of therapy (DOT)

• Track CDI and antibiotic

resistance

• Track adverse drug events related

to antibiotic use

• Track costs related to antibiotic

use

Learn more about tracking

antibiotic data using

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Reporting Information on Improving Antibiotic Use and Resistance

• Does your facility provide facility-specific reports on antibiotic use and outcomes with clinical providers and nursing staff?

Measures of antibiotic use at the facility

Measures of outcomes related to antibiotic use (i.e., C. difficile rates)

Report of facility antibiotic susceptibility patterns (within last 18 months)

Personalized feedback on antibiotic prescribing practices (to clinical providers)

Other

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Education

• Does your facility provide educational resources and materials about antibiotic resistance and opportunity for improving antibiotic use?

Clinical providers (e.g., MDs, NPs, PAs, PharmDs)

Nursing staff (e.g., RNs, LPNs, CNAs)

Residents and families

Other

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Exploring Antibiotics

and their Role in Fighting Bacterial

Infections

Optional Tools and

Resources Section

https://telligenqinqio.com

/resource/exploring-

antibiotics-role-fighting-

bacterial-infections/

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https://www.cdc.gov/getsmart/community/mater

ials-references/print-materials/adults/b-general-

color.pdf

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Exploring Antibiotics and their Role in Fighting Bacterial Infections

This primer on antibiotics provides a helpful foundation to understand the relationships between infections, antibiotics, antibiotic resistance and antibiotic stewardship.

Available on the Telligen Nursing Home website https://telligenqinqio.com/resource/exploring-antibiotics-role-fighting-bacterial-infections/

Exploring Antibiotics Educational Resources

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Antibiotic Resistance: How it Happens and Strategies to Decrease the Spread of Resistance In this training session learn about antibiotic resistance and how it develops, existing threats from antibiotic resistant organisms, the opportunities that exist for improving the judicious use of antibiotics, and strategies and resources to decrease the development of antibiotic resistance and prevent the spread of antibiotic resistant bacteria in long-term care organizations.

Available on the Telligen Nursing Home website https://telligenqinqio.com/resource/antibiotic-resistance-happens-strategies-decrease-spread-resistance/

Antibiotic Resistance Educational Resources

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Antibiotic Stewardship

In this training session about antibiotic stewardship in nursing homes, learn about antibiotic stewardship and how it helps to prevent antibiotic resistance and problems associated with antibiotic use. You will learn to identify the core elements of an antibiotic stewardship program and understand the need for community-wide antibiotic stewardship efforts.

Available on the Telligen website https://telligenqinqio.com/resource/antibiotic-stewardship/

Antibiotic Stewardship Educational Resources

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TeamSTEPPS® in LTC: Communication Strategies to Promote Quality and Safety This session features communication strategies to promote quality and safety. It is designed to help train nursing home staff in teamwork and communication using specific evidence-based tools and strategies which are a part of TeamSTEPPS® 2.0. This session incorporates specific strategies and principles tailored to the long-term care (LTC) environment.

http://qioprogram.org/teamstepps%C2%AE-ltc-communication-strategies-promote-quality-and-safety

TeamSTEPPS Communication Resources

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• Select one or two activities to start with and over time, as improvements are implemented, expand efforts to add new strategies to continue improving antibiotic use

• Ensure antibiotic stewardship policies and practices are in placed to protect residents and improve clinical care in nursing homes

Next Steps

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Antibiotic Stewardship Core Elements for LTC Part II

• June 22, 2017 / 1-2 pm MT/2-3 pm CT

Antibiotic Stewardship Core Elements for LTC Part III

• July 27, 2017 / 1-2 pm MT/2-3 pm CT

See our weekly Telligen Digest to learn more

Register here to receive the weekly Digest

https://telligenqinqio.com/newsletters/newsletter-sign-up/

Telligen Upcoming Events

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Questions

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Resources

CDC Core Elements of Antibiotic Stewardship for Nursing Homes https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

CDC Core Elements of Antibiotic Stewardship for Nursing Homes CHECKLIST

https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf

CDC Core Elements of Antibiotic Stewardship Appendix B: Measures of antibiotic prescribing use and outcomes

https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-b.pdf

CDC Get Smart Cold or Flu Antibiotics Don’t Work for You brochures and posters

https://www.cdc.gov/getsmart/community/materials-references/print-materials/adults/index.html

CDC Get Smart Antibiotic Stewardship Commitment Posters

https://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/index.html

AHRQ Nursing Home Antimicrobial Stewardship Guide https://www.ahrq.gov/nhguide/about/index.html

National Nursing Home Quality Improvement Campaign C. difficile & Antibiotic Stewardship

https://www.nhqualitycampaign.org/cdifficileAntibioticStewardship.aspx

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Please Contact any of our Quality Innovation Network Representatives to Learn More

Lisa Bridwell

lisa.bridwell@area-d.hcqis.org

630-928-5831

Nell Griffin

nell.griffin@area-d.hcqis.org

630-928-5813

Larpie Castro larpie.castro@area-D.hcqis.org 630-928-5812

This material was prepared by Telligen, the Medicare Quality Improvement

Organization for Colorado, under 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. 11SOW-

QIN-C2-05/02/17-2105

Linda Savage linda.savage@area-d.hcqis.org 303-513-2323

Deanna Curry

deanna.curry@area-d.hcqis.org

720-554-1479 Kristen Ives – NHSN support kristen.ives@area-d.hcqis.org 720-554-1695