Antibiotic Stewardship-Key Clinical Strategies for ...
Transcript of Antibiotic Stewardship-Key Clinical Strategies for ...
4/6/2018
Pathway Health 1
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Antibiotic StewardshipKey Clinical Strategies for Successful Outcomes
Louann Lawson, BA, RN, RAC-CT, CIMTNurse ConsultantClinical Reimbursement Team Leader/Clinical Education ManagerPathway Health
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2018
Consulting | Talent | Training | Resources
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© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2018
Objectives
Upon completion of this presentation, attendees should be able to:
1. Understand the new Centers for Disease Control (CDC) requirements and expectations for an antibiotic stewardship program;
2. Identify the key expectations of the director of nursing and nursing home administrator for quality outcomes
3. Describe three essential leadership strategies for implementation and quality monitoring for successful outcomes
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2018
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Antibiotics - Are they OVERUSED?
4/6/2018
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Use of Antibiotics - CDC
Are overused
Are misused
Reactions and Side Effects
Can only work with infections=bacteria
Resistance is growing
Reactions and Side Effects
http://www.cdc.gov/getsmart/week/downloads/antibiotics-arent-always-the-answer-for-parents.pdf
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Definition of Antibiotic Stewardship
The CDC Defines Antibiotic Stewardship as:
“…a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse
events associated with antibiotic use”
The Core Elements of Antibiotic Stewardship for Nursing Homeshttps://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2018
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Antibiotic Stewardship - CDC
• Antibiotics are among the most frequently ordered drugs in nursing homes
• Up to 70% of residents in nursing homes receive 1 or more systemic antibiotics when they are followed for over a year
• 40-75% of antibiotics prescribed in Nursing Homes may be unnecessary or inappropriate
• Residents taking antibiotics are at risk for harm
o C-difficile
o Adverse drug events
o Drug interactions
o Colonization
o Antibiotic Resistant OrganismsThe Core Elements of Antibiotic Stewardship for Nursing Homeshttps://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html
4/6/2018
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INDUSTRY EXPERT RESOURCES
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Let’s Start with the
Regulatory Requirements!
CMS-State Operations ManualAppendix PP-Guidance to
Surveyors for Long Term Care Facilities
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
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CMS-State Operations ManualAppendix PP-Guidance to Surveyors for Long Term Care Facilities
F881 §483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
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F881: Antibiotic Stewardship
INTENT “The intent of this regulation is to ensure that the facility: • Develops and implements protocols to optimize the treatment of
infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic;
• Reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; and
• Develops, promotes, and implements a facility-wide system to monitor the use of antibiotics”. https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2018
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F881: Antibiotic Stewardship
Guidance:
• “As part of their IPCP programs, facilities must develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance”.
• “This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms”.https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2018
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F881: Antibiotic Stewardship
“The facility must develop an antibiotic stewardship program which includes the development of protocols and a system to monitor
antibiotic use. This development should include leadership support and accountability via the participation of the medical director, consulting
pharmacist, nursing and administrative leadership, and individual with designated responsibility for the infection control program if different”
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
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F881: Antibiotic Stewardship
The antibiotic stewardship program protocols shall describe how the program will be implemented and antibiotic use will be monitored, consequently protocols must:
• Be incorporated in the overall infection prevention and control program;
• Be reviewed on an annual basis and as needed;
• Contain a system of reports related to monitoring antibiotic usage and resistance data.
• Incorporate monitoring of antibiotic use, o including the frequency of monitoring/review.
o Monitor/review when the resident is new to the facility; when a prior resident returns or is transferred from a hospital or other facility
o during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic regimen review as requested by the QAAcommittee. https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2018
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F881: Antibiotic Stewardship
Continued:• In addition, establish the frequency and mode or mechanism of
feedback (e.g., verbal, written note in record) to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols.
• Assess residents for any infection using standardized tools and criteria
• Include the mode (e.g., verbal, written, online) and frequency (as determined by the facility) of education for prescribing practitioners and nursing staff on antibiotic use (stewardship) and the facility’s antibiotic use protocols.
https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
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CMS: LTC Survey Pathways
Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes:
• Written antibiotic use protocols on antibiotic prescribing, including the documentation of the indication, dosage, and duration of use of the antibiotics
• Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g. SBAR tool for urinary tract infection (UTI) assessment. Loeb minimum criteria for initiation of antibiotics).
CMS‐ Infection Prevention , Control & Immunizations, CMS‐20054 (5/2017):https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/GuidanceforLawsAndRegulations/Downloads/LTC‐Survey‐Pathways.zip
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CMS: LTC Survey Pathways-continued
Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes:
• A process for periodic review of antibiotic use by prescribing practitioners; for example, review of laboratory and medication orders, progress notes and medication administration records to determine whether or not an infection or communicable disease has been documented and whether an appropriate antibiotic has been prescribed for the recommended length of time. Determine whether the antibiotic use monitoring system is reviewed when the resident is new to the facility, when a prior resident returns or is transferred from a hospital or other facility, during each monthly drug regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic drug regimen review requested by the QAA committee
https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/GuidanceforLawsAndRegulations/Downloads/LTC‐Survey‐Pathways.zip
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
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CMS: LTC Survey Pathways-continued
Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes:
• Protocols to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotic;
• A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner
Did the facility conduct ongoing review for antibiotic stewardship
YES NO F881
https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/GuidanceforLawsAndRegulations/Downloads/LTC‐Survey‐Pathways.zip
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CDCCenters for Disease
Control and Prevention
https://www.cdc.gov/
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Best Practice Resources:
The Core Elements of Antibiotic Stewardship for Nursing Homes
https://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html
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CDC
http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
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CDC
http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
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Antibiograms
An antibiogram is a tool aimed at improving appropriate antibiotic prescribing.
• Report that displays the organisms present in diagnostic clinical specimens that nursing homes send for laboratory testing
• Referring to an antibiogram report helps the physician make prompt, empirically based decisions.
• Intended to improve the use of antibiotics in nursing homes by helping prescribing clinicians select the most appropriate therapies for residents with suspected infections
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https://www.ahrq.gov/nhguide/toolkits/help-clinicians-choose-the-right-antibiotic/toolkit2-concise-antibiogram-toolkit.html
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Example: AHRQ Tools for Infection Criteria
https://www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/index.html
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AHRQ - Another GREAT RESOURCE
Catheter – Associated UTI’s
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CAUTI-Catheter Associated Urinary Tract Infections
AHRQ toolkit
• Developed based upon 500 nursing homes across the country
• Was a 3-year implementation project
• Toolkit is organized in 3 main sections
o Implementation
o Sustainability
o Resources
https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/index.html?utm_source=ahrq&utm_medium=generic&utm_term=&utm_content=2&utm_campaign=AHRQ_cauti4ltc_2017
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Examples of Infection Control Risk Assessment Tools
http://community.apic.org/sierra/resources/overview
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CDC Toolkit for Influenza
https://www.cdc.gov/flu/professionals/index.htm
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CDC-Guidance on the Use of Antivirals
https://www.cdc.gov/flu/professionals/antivirals/antiviral-use-influenza.htm
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Minnesota Department of Health Long-Term Care: Influenza
http://www.health.state.mn.us/divs/idepc/diseases/flu/ltc/index.html
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C-Diff
CDC has developed a Toolkit
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http://www.cdc.gov/hai/pdfs/toolkits/CDI-Primer-2-2016.pdf
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User Friendly System Inclusions!
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Preadmission Assessment
Do you have a comprehensive Preadmission Screening Process?
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Preadmission Assessment
Review the Medical Record
• Diagnosis(es)
• Antibiotic Use
• Vital Signs
• Lab Work (Results or Pending Tests)
• Imaging
Ask the nursing staff at the hospital (or other entity) about infections or symptoms
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Admission Screening Risk Factors
• Antibiotic use past 30 days
• Current symptoms or diagnosis
• Cultures taken and results
• Immunization history
• Duration of indwelling catheter
• Presence of MDROs
• Prior infection
• 2-step Mantoux - history of positive reaction
• Vaccines
**Facilities will be required to incorporate any infection-related care needs on the initial 48 hour baseline care plan
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Do You Have User-Friendly Systems/Forms?
Example: Criteria for Infection Report Forms(UTI, Respiratory, Wound, Skin/Soft Tissue, etc.)
These forms assist the nurse in determining if the resident exhibits criteria for infection!
Great Resources include:Loeb M, Brazil K, Lohfeld L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomisedcontrolled trial. BMJ. 2005;331:669
Stone, N., Ashraf, M., Calder, J., Crnich, C., Crossley, K., Drinka, P., . . . For the Society for Healthcare Epidemiology Long-Term Care Special Interest Group. (2012). Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology, 33(10), 965-977. doi:10.1086/66774
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Tracking Log
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Infection Preventionist Tools
There is a requirement to…”establish the frequency and mode or mechanism of feedback (e.g., verbal, written note in record) to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols.”
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
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Audit Tools
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Leadership Strategies for Oversight of the Antibiotic Stewardship Program-Alignment with CDC Core Elements of
Antibiotic Stewardship in Nursing Homes
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Leadership Commitment
• Policies and Procedures
• Job Descriptions
• Identification of a solid communication system
• Culture Change
**All these efforts assist the facility with oversight of proper and safe antibiotic use
41
https://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html
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Policies and Procedures
Include policies for criteria for infection
• Use Evidence-Based Standards of Practice
• Professionally Accepted Resources
o CDC: Core Elements of Antibiotic Stewardship
o AHRQ: Nursing Home Antimicrobial Stewardship Guide
Loeb, M., Brazil, K., Lohfeld, L., McGeer, A., Simor, A., Stevenson, K., Zoutman, D…..Walter, S.D. (2005). Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial. BMJ, 331, 669 http://www.bmj.com/content/bmj/early/2004/12/31/bmj.38602.586343.55.full.pdf
“Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria” http://www.jstor.org/stable/10.1086/667743
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Policies and Procedures
Other Areas to Consider when drafting P&P’s:
Antibiotic Ordering and Use
• Drug, Dosage, Duration, etc.
• Prophylactic Antibiotic Ordering
Diagnostic Testing and Reporting
Medical Director Involvement
Pharmacy Consultant Involvement
Communication and Education
• Staff
• Residents
• Families 43
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Job Descriptions
Antibiotic Stewardship Responsibilities should be included in the job descriptions of:
• Infection Preventionist
• Director of Nursing
• Licensed Nurses
• Medical Director
• Pharmacy Consultant
44
https://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html
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Communication: Do You Have a Good System?
• Nurse to Practitioner
• Nurse to DON
• Medical Director
• Families
• Residents
• Pharmacy Consultant
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Culture
46
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Accountability
Medical Director
DON
Infection Preventionist
Consultant Pharmacist
Lab
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https://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html
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Drug Expertise
Pharmacist
• Identify what specific training does the consultant pharmacist (and pharmacists at the contracted pharmacy)
• **You can work with your Pharmacy Consultant on attending a course
Physicians
• Enlist Medical Director
Hospital Partners
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https://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html
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Action
**Identify ONE area that can improve antibiotic use practices for care improvement—Put into QAPI Process!
• One example is an Antibiotic “Time-Out”
o After culture results obtained (24-48 hours) talk to physician and re-evaluate the therapy
− Still necessary
− Appropriate (based on lab results)
− Can even assist in plan (i.e. duration)
49
https://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html
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QAPI Action Plan
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Tracking and Reporting
In order for organizations to be able to appropriately monitor success of the antibiotic stewardship program, organizations will need to have a solid system to be able to track data. CMS has outlined information on how to track process measures, antibiotic use measures and antibiotic outcome measures as well as costs at: http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
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Auditing
Example: Appropriate Antibiotic Use
Diagnosis
Practitioner Order
Site of Infection
Start/Stop Date of Medication
Resident presents with signs/symptoms of infection (using evidence based definitions of infection)
Organism identified through laboratory testing (i.e. C&S)
Care Planning 52
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Reporting
• Nursing Staff
o Appropriate Use
o Prescribing Practices
• Pharmacy Consultant
• Leadership Team
• Medical Director
53
https://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html
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Facility Staff Education
• CDC Core Elements of Antibiotic Stewardship for LTCFacilities
• Infection Criteria (McGeer’s Criteria, Loeb, AHRQ, etc.)
• Facility Policy and Procedures
• Multidrug Resistant Organisms
o Prevention
o Treatment
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Clinician Education
Required!
“Include the mode (e.g., verbal, written, online) and frequency (as determined by the facility) of education for prescribing practitioners and nursing staff on antibiotic use (stewardship) and the facility’s antibiotic use protocols”• Develop an action plan in association with:
o Pharmacy Consultant
o Medical Director
• Determine opportunities for improvement
• Utilize evidence-based best practice
• Determine method of delivery55
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Resident/Family Education-CDC
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http://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-what-to-ask.pdf
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Additional Clinical Processes
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Key Clinical Processes
Ongoing analysis that includes:• Auditing all antibiotic use in the facility
o Review nurse assessment information
o Root cause analysis: what information was discussed with the physician? (Criteria for Infection?)
o Documentation
• Ensure that the resident is taking the right antibiotic for the right amount of time
• Appropriate discussion with practitioner regarding antibiotic use -may need to involve the Medical Director and the Pharmacy Consultant
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Facility Assessment
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.
• Must be reviewed/revised annually
• Must be reviewed/revised when any change would require a substantial modification to the assessment
• Assessment must address a facility-based and community-based risk assessment using an all-hazards approach
• The results of the facility assessment must be used to establish and update the Infection Prevention and Control Program, including policies and procedures
• TB screening per State requirements
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Facility Assessment
• Administrative Measures
• Risk Assessment
• Education
• Antibiotic Use Evaluation and Antibiotic Stewardship
• Surveillance
• Hand Hygiene
• Standard and Transmission Based Precautions
• Environmental Measures60
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Leadership Strategies
Stay up to date with the most current recommendations, guidelines, evidence based standards of practice and regulatory requirements.
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Summary
1. Become familiar with the regulatory requirements (F881) for Antibiotic Stewardship
2. Understand best practices for infection criteria
3. Work with the IDT, Medical Director, Pharmacy Consultant and hospital partners to ensure a solid system (Policies, Procedures, Preadmission Process, etc.)
4. Education!
5. Surveillance, tracking, data analysis, audits
6. QAA involvement
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Resources
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CDC Education
https://www.train.org/cdctrain/course/1075730
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References and Resources
CMS State Operations Manual, Appendix PP –Guidance to Surveyors for Long Term Care Facilities:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
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References and Resources
CDC - Core Elements of Antibiotic Stewardship for Nursing Homes
http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
U.S. Department of Health & Human Services: AHRQ: Nursing Home Antimicrobial Stewardshiphttp://www.ahrq.gov/nhguide/index.html
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Resources
National Healthcare Safety Network (NHSN) LTC facilities
Tracking Infections
• Training
• Protocols
• Forms
• Support Materials
• And More!
https://www.cdc.gov/nhsn/ltc/index.html67
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Resources
“Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/
http://www.annalsoflongtermcare.com/article/antibiotic-stewardship-programs-long-term-care-facilities
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References and Resources
AHRQ: CAUTI - Catheter Associated Urinary Tract Infections
https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/index.html?utm_source=ahrq&utm_medium=generic&utm_term=&utm_content=2&utm_campaign=AHRQ_cauti4ltc_2017
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Resources and References
World Health Organization
Antibiotic Resistance
http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/
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References and Resources
Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases Advance Access published April 13, 2016http://cid.oxfordjournals.org/content/early/2016/04/11/cid.ciw118.full.pdf+html
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Resources
CDC: Antibiotic Stewardship Statement for Antibiotic Guidelines – Recommendations of the Healthcare Infection Control Practices Advisory Committee
http://www.cdc.gov/hicpac/Pubs/Antibiotic-Stewardship-Statement.html
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Questions?
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Disclaimer
“This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health.”
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