Antibiotic Stewardship Upon completion of this program ...

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©Pathway Health 2015©Pathway Health 2015

Antibiotic Stewardship

Key Clinical Strategies for Successful Outcomes

Sue Lagrange, RN, BSN, NHA, CDONA, CIMTDirector of Education

Pathway Health


Upon completion of this program, attendees should be able to:

1. Understand the new requirements and expectations of an Antibiotic Stewardship Program;

2. Identify the key clinical processes requiring revision to align with the new requirements;

3. Describe three key leadership strategies

for implementation and quality monitoring for successful outcomes

Objectives

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©Pathway Health 2015©Pathway Health 2015 3

What EXACTLY IS Antibiotic Stewardship?


• The IDSA (Infectious Diseases Society of America):

• “Antimicrobial stewardship refers to coordinated

interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen,

dose, duration of therapy, and route of administration. Antimicrobial stewards seek to

achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections,

and limit the selection for antimicrobial resistant strains.”

• http://www.idsociety.org/Stewardship_Policy/#sthash.YJuwUaoI.dpuf

Definitions

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New Requirements and Expectations of an Antibiotic

Stewardship Program


Report

• Report to the President on Combating Antibiotic Resistance (September 2014):

http://www.whitehouse.gov/sites/default/files/micro

sites/ostp/PCAST/pcast_carb_report_sept2014.pdf

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http://www.idsociety.org/Stewardship_Policy/#sthash.YJuwUaoI.dpuf

http://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_carb_report_sept2014.pdf

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• The beginning of the 20th century, 9 our of every 1,000 women who gave birth

died—40% from Sepsis

• In some cities—up to 30% children died prior to their 1st birthday

• 1 out of 9 people who contracted a serious skin infection died (even scrapes and insect bites!)

• 30% of people with pneumonia died

• 70% of people with meningitis died

• Etc., etc.,

Report-Key Points

7©Pathway Health 2015©Pathway Health 2015

• What happened in the 20th century?

– Improvements in public health

– Vaccines

– Antibiotics

**Deaths from infections declined

**Millions of lives saved – primarily due to antibiotics!

Report

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We are losing progress!!!

• Antibiotic Resistance “is now occurring at an alarming rate and is outpacing the development of new countermeasures capable of thwarting infections in humans”

Report


Recommended focused efforts include:

1. Improving our surveillance of the rise of antibiotic‐resistant bacteria

2. Increasing longevity of current antibiotics

3. Increasing the rate at which new antibiotics and other interventions are discovered and developed

Report

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National Action Plan for Combating Antibiotic-Resistant Bacteria (March 2015):

https://www.whitehouse.gov/sites/default/files/docs/

national_action_plan_for_combating_antibotic-resistant_bacteria.pdf

Report


• “Antibiotics have been a critical public health tool since the discovery of penicillin in 1928, saving the lives of millions of people around the world. Today, however, the emergence of drug resistance in bacteria is reversing the miracles of the past eighty years, with drug choices for the treatment of many bacterial infections becoming increasingly limited, expensive, and, in some cases, nonexistent.”

Report

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https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf

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“The Centers for Disease Control and Prevention (CDC) estimates that drug-resistant bacteria cause two million illnesses and approximately 23,000 deaths each year in the United States alone”

Report

13http://www.cdc.gov/getsmart/week/downloads/antibiotics-arent-always-the-answer-for-parents.pdf©Pathway Health 2015©Pathway Health 2015

Resistance is due largely to extensive exposure of bacteria to antibiotics.

One of the recommendations for LTC includes Stewardship programs –by the end of 2017, CMS should have Federal regulations (Conditions of Participation) in place that will require LTC facilities to develop and implement robust antibiotic stewardship programs that adhere to best practices.

Report

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An antibiotic stewardship program will include a system in which the use of antibiotics is only to maximize the benefit to the resident while minimizing the rise in antibiotic resistance and includes:

• Identification of the microbe responsible for the disease

• Selection of the appropriate antibiotic including dose, route, duration and d/c when no longer needed

Report


Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities; Proposed Rule

http://www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf

Proposed Rule

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• Will need written standards, P&P’s to include

– Surveillance

– Reporting

– Standard and transmission based precautions

– Isolation

– When to prohibit employees with communicable diseases or infected skin lesions may work

– Hand Hygiene

Proposed Rule


• The facility must establish an IPCP that includes:

– A system for prevention, identification, reporting, investigating and controlling infections and communicable diseases for residents, staff, volunteers, visitors and others – based upon the facility assessment

Proposed Rule

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http://www.cdc.gov/getsmart/week/downloads/antibiotics-arent-always-the-answer-for-parents.pdf

http://www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf

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• Antibiotic Stewardship Program

• System to record incidents under your IPCP along with corrective actions

Proposed Rule

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• Infection Prevention and Control Officer (IPCO):

– Facility must designate

– IPCP is a major responsibility

– A clinician who works at least part-time at the facility

– Must have specialized training in Infection

Prevention and Control “beyond their initial professional degree”

– Must participate and be a member of the QA&A committee

• Influenza and pneumococcal information

Proposed Rule

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“These six bacteria are among the most deadly antibiotic-resistant bacteria, identified as urgent or serious threats by CDC”:

• CRE (carbapenem-resistant Entrobacteriaceae)

• MRSA (Methicillin-resistant Staphylococcus aureus)

• ESBL-producing Enterobacteriaceae (extended-spectrum ß-lactamases

• VRE (vancomycin-resistant enterococci)

• Multi-Drug resistant pseudomonas

• Multi-Drug resistant Acinetobacter

http://www.cdc.gov/vitalsigns/protect-patients/index.html

CDC


Still Current

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http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf


Multidrug-Resistant Organisms (MDROs):

• Microorganisms (primarily bacteria)

• Resistant to one or more classes of antimicrobial agents– (MRSA)Methicillin-resistant Staphylococcus aureus

– (VRE) Vancomycin-resistant-enterococci

– (ESBL) Extended spectrum beta-lactamase

– Acinetobacter baumannii

– (CRE) Carbapenem-resistant enterobacteriaceae

– (KPC) Klebsiella pneumoniae carbapenemase

– Etc.


MDRO’s


C. difficile:

“Most C. difficile is not resistant to the antibiotics used to treat it, but antibiotic use puts patients at high risk for deadly diarrhea”


CDC

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CDC has developed a Toolkit

C-Diff

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http://www.cdc.gov/hai/pdfs/toolkits/CDItoolkit2-29-12.pdf


Antibiograms:

• Microbiology lab tests (tests sensitivity of a bacteria strain to a variety of antibiotics)

• Determine how specific antibiotics will treat a certain infection

• Intended to improve antibiotic prescribing

Agency for Healthcare Research and Quality:

Module 2: Antibiograms: Choosing an Appropriate Antibiotichttp://www.ahrq.gov/professionals/quality-patient-safety/patient-

safety-resources/resources/nh-aspguide/module2/index.html

Antibiograms

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ANTIBIOTICS


• Are overused

• Are misused

• Reactions and Side Effects

• Can only work with infections=bacteria

• Resistance is growing

• Reactions and Side Effects


Use of Antibiotics-CDC

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“An estimated 2 million illnesses and 23,000 deaths occur each year in the United States due to antibiotic-resistant infections.2 Overuse and misuse of antibiotics are main drivers of resistance.”

• http://www.cdc.gov/getsmart/week/downloads/antibiotics-arent-always-the-answer-for-parents.pdf

CDC


CDC

30http://www.cdc.gov/getsmart/healthcare/learn-from-others/factsheets/nursing-homes.html

http://www.cdc.gov/hai/pdfs/toolkits/CDItoolkit2-29-12.pdf

http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module2/index.html



http://www.cdc.gov/getsmart/healthcare/learn-from-others/factsheets/nursing-homes.html

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**”Antibiotic resistance is one of the biggest threats to global health today.”

Recommendations for Health Care Workers:

• Infection prevention with proper hand hygiene and clean instruments and environment

• Keep residents vaccinations up to date

• If you suspect a bacterial infection, test to confirm

with bacterial cultures

• Antibiotic administration only when truly

necessary

• Antibiotics: Right dose and right duration!

WHO-World Health Organization

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http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/


CDCCenters for Disease Control and

Prevention


• Core Elements for Antibiotic Stewardship

– Leadership Commitment

– Accountability

– Drug Expertise

– Action

– Tracking

– Reporting

– Education

http://www.cdc.gov/media/releases/2015/p0915-nursing-home-antibiotics.html

CDC

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Steps to Institute an Antibiotic Stewardship Program


Antibiotic stewardship involves a system that will lead staff and practitioners to:

• Follow a process to identify the microbe

responsible for disease, based on evidence based definitions;

• Selection of the appropriate antibiotic with documentation to indicate the indication for use

and rationale as well as to include the appropriate dose, duration and route of medication; and

• To ensure that the antibiotic is discontinued when no longer needed.

Antibiotic Stewardship


CDC

36http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html


http://www.cdc.gov/media/releases/2015/p0915-nursing-home-antibiotics.html

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

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CDC


CDC

38http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf


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

Leadership Commitment

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• Include policies for criteria for infection

– Use Evidence-Based Standards of Practice

– Professionally Accepted Resources

“Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria”

http://www.jstor.org/stable/10.1086/667743

Policies and Procedures


• Definitions for Criteria (Infections)

– Fever

– Respiratory Tract Infections

– Urinary Tract Infections

– Skin, Soft Tissue and Mucosal Infections

– Gastrointestinal Tract Infections

“Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer

Criteria”



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



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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



Antibiotic Stewardship Responsibilities should be included in the job descriptions of:

• Infection Preventionist

• Director of Nursing

• Licensed Nurses

• Medical Director

• Pharmacy Consultant

Job Descriptions

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• Nurse to Practitioner

• Nurse to DON


• Families

• Residents


Communication


Culture

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Culture Change for Quality!

• Facility

• Practitioners

• Nurses

• Families

• Residents

Culture

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Accountability

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• DON


• Consultant Pharmacist

• Lab

Accountability

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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

Drug Expertise

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ACTION


• Leaders of the organization will determine necessary system updates

– Policy and Procedural changes

– Collaboration with Medical Director

– Collaboration with Pharmacy Consultant

– Staff Education

Action


• **Identify ONE area that can improve antibiotic use practices for care improvement—Put into QAPI Process!

• One example is an Antibiotic “Time-

Out”

– 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)

Action

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QAPI Action Plan

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Tracking


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

Tracking and Reporting



– Antibiotic Use

• Symptoms/Infection Criteria

• Diagnostics

• Dose, Duration

• Follow up

Tracking

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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

Auditing

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Reporting

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

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• Nursing Staff

– Appropriate Use

– Prescribing Practices


• Leadership Team


Reporting

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Education


• Facility Staff

• Clinicians

• Residents

• Families/Responsible Party

Education


• Review the reports from the President

• CDC Core Elements of Antibiotic Stewardship for LTC Facilities

• McGeers Criteria

• Facility Policy and Procedures

• Multidrug Resistant Organisms

– Prevention

– Treatment

Facility Staff Education

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• Determine practitioner need

• Develop an action plan in association with:

– Pharmacy Consultant

– Medical Director

• Determine opportunities for improvement

• Utilize evidence-based best practice

• Determine method of delivery

Clinician Education


Resident/Family Education-CDC

66

http://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-what-to-ask.pdf

http://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-what-to-ask.pdf

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Resident/Family Education-CDC

67http://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-what-you-need-to-know.pdf


CDC Resources


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

Checklist


CDC

70http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf


CDC

71http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf


Key Clinical Processes Requiring Revision to Align with the New

Requirements

http://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-what-you-need-to-know.pdf




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1. Ongoing analysis that includes:1. Auditing all antibiotic use in the facility

1. Review nurse assessment information

2. Root cause analysis: what information was discussed with the physician? (Criteria for Infection?)

3. Documentation

2. Ensure that the resident is taking the right

antibiotic for the right amount of time

3. Appropriate discussion with practitioner regarding antibiotic use—may need to involve the Medical Director and the Pharmacy

Consultant

Key Clinical Processes


2. Look at Regulatory Requirements

• F441: Infection Control

• F329: Unnecessary Medications

• F428: Drug Regimen Review

Key Areas to Look at

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3. Review Your ENTIRE Infection Prevention and Control Program!

– Policies and Procedures

– Surveillance Activities

– Tracking and Data Management

– IDT Involvement

– Medical Director Involvement

– Pharmacy Consultant Involvement

– Lab and X-Ray



• Enhance Clinical Skills of Nursing Staff

– Assessment skills

– Early identification of changes of condition

• INTERACT™ Quality Improvement Program

– Communication

– Notifications

– Prompt Action


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Leadership Strategies for Implementation and Quality

Monitoring for Successful Outcomes


• Administrative Measures

• Risk Assessment

• Education

• Antibiotic Use Evaluation and Antibiotic Stewardship

• Surveillance

• Hand Hygiene

• Standard and Transmission Based Precautions

• Environmental Measures

Facility Assessment

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• Ensure all policies and procedures are updated to include new requirements, recommendations and evidence-based standards of practice

• Meet with Medical Director to discuss changes necessary and include in policy and procedure changes as well

• Include the Pharmacy Consultant in the process of system update and implementation

Leadership Strategies


• Ensure a solid, preadmission process to identify potential resident’s with MDRO’sand/or antibiotic use

• Include antibiotic stewardship in your QAPI process and report all status updates and practice outcomes to the quarterly QA Committee meeting


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• Ensure ongoing communication with the Infection Preventionist

– Daily stand-up meeting

– Direct contact with concerns

– During Quality Assurance Committee meetings



• Stay up to date with the most current recommendations, guidelines, evidence based standards of practice and regulatory requirements.


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CDC: The Core Elements of Antibiotic Stewardship for Nursing Homes

Key Resource Locations

83http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html


• https://www.dhs.wisconsin.gov/regulations/nh/hai-resources.htm

• https://www.dhs.wisconsin.gov/publications/p0/p00319.pdf

• https://www.dhs.wisconsin.gov/publication/p00886.pdf

Resources-Wisconsin DHS

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https://www.dhs.wisconsin.gov/publication/p00886.pdf



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• https://www.dhs.wisconsin.gov/publication/p00886.pdf

• https://www.dhs.wisconsin.gov/regulations/listserv-2015-09-15.pdf

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579247/

Resources and References


• http://blogs.cdc.gov/safehealthcare/2010/11/16/let%E2%80%99s-take-an-antibiotic-time-out/

• http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module2/index.html

Resources

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• http://www.annalsoflongtermcare.com/article/antibiotic-stewardship-programs-long-term-care-facilities

CDC Vital Signs: Making Health Care Safer (March 2016)

• http://www.cdc.gov/vitalsigns/protect-patients/index.html

Resources


Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006:



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Infections

• Information

• Helpful Websites

• Infections Tracking Tool

• Assessment Checklists

• Fact Sheets

• Ability to submit data and view your trend graphs for infections

https://www.nhqualitycampaign.org/goalDetail.aspx?g=inf

Advancing Excellence


Furuno, J.P., Comer, A.C., Johnson, J.K., Rosenberg, J.H., Moore, s.L., MacKenzie, T.D., Hall, K.K., Hirshon, J.M. (2014) Using Antibiograms to Improve Antibiotic Prescribing in Skilled Nursing Facilities. Retrieved from: http://www.jstor.org/stable/10.1086/677818

Resources

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https://www.dhs.wisconsin.gov/regulations/listserv-2015-09-15.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579247/

http://blogs.cdc.gov/safehealthcare/2010/11/16/let%E2%80%99s-take-an-antibiotic-time-out/

http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module2/index.html

http://www.annalsoflongtermcare.com/article/antibiotic-stewardship-programs-long-term-care-facilities



https://www.nhqualitycampaign.org/goalDetail.aspx?g=inf


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World Health Organization

• Antibiotic Resistance




Questions

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Thank You For Attending Today’s Presentation!

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This presentation is copyrighted information of Pathway Health. This presentation is not to be sold or reused without written

authorization of Pathway Health.

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