National Nursing Home Quality Care Collaborative … · · 2018-03-22The diagnosis of a UTI...

National Nursing Home Quality Care Collaborative (NHQCC)and the Clostridium difficile Infection (CDI) Initiative

Exploring Antibiotics and Their Role in Fighting Bacterial Infections

Health Services Advisory Group (HSAG)Thursday, March 22, 2018

Introduction and Overview

Rose Chen, MPH, RDAssociate Director, Nursing Homes

HSAG

Todays Webinar

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1Welcome and Overview

2Dr. James McKinnellExploring Antibiotics and Their Role in Fighting Bacterial Infections

3CDI Initiative and Nursing Home Online Training Sessions

4Question & Answers

Exploring Antibiotics and Their Role in Fighting (BUT ALSO SOMETIMES CAUSING) Bacterial Infections

James A. McKinnell, M.D.Los Angeles County Department of Public HealthAcute Communicable Disease Control Unit

Objectives Define infection, bacterial infection and antibiotics

Describe the different classes of antibiotics

Identify key factors when choosing an antibiotic

Explain why we need to be careful with antibiotics

Identify what the administrator, clinicians, and nurses MUST DO to maintain an antimicrobial stewardship program

What is an Infection? An infection occurs when a germ, bacteria or virus,

invades into the body and causes damage

Colonization Versus Infection Hands frequently get covered in bacteria -

COLONIZATION

Redness, warmth, and tenderness INFECTION

What is a Bacterial Infection? A bacterial infection is when a bacteria invades into the

body and causes infection

Bacterial infections usually differentiated from viral infections

E. Coli and MRSA are examples of bacteria

Bacterial infections typically require antibiotics

Definitions Colonization

Infection

Bacterial Infection Viral Infection

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What is an Antibiotic? An antibiotic is a medication given to a patient to treat a

bacterial infection

Antibiotics can be given through various routes, including oral, IV, and topical

Oral and IV antibiotics are used for the most severe infections

How do Antibiotics Work?

Antibiotics are designed to disrupt the vital mechanisms of life for bacteria

Beta-Lactam Antibiotics Cell Wall Penicillin Type Antibiotics

Penicillin, Ampicillin, Augmentin

Cephalosporin Type AntibioticsCefazolin (Keflex), Ceftriaxone (Rocephin),

Cefepime (Maxipime)

Carbapenem Type AntibioticsErtapenem, Meropenem, Imipenem

Fluroquinolones DNA Production Ciprofloxacin

Levofloxacin

Moxifloxacin

Aminoglycosides Protein Production Gentamicin

Tobramycin

Amikacin

Others

GlycopeptidesVancomycin

MacrolidesAzithromycin, Clarithromycin

MiscellaneousNitrofurantoin, Linezolid, Aztreonam

Examples of Antibiotic Side Effects

Beta-LactamsAllergy

FluroquinolonesSudden cardiac death (Particularly in the elderly)C. difficileAntibiotic resistance

AminoglycosidesKidney damage

What is Antibiotic Resistance? Changes how it performs vital functions

Cell Wall Beta-LactamsDNA production FluroquinolonesProtein production - Aminoglycosides

Destroys the antibiotic

Pumps the antibiotic out

Blocks entry of the antibiotic

How do we Test for Antibiotic Resistance?

Test antibiotics one-by-one to determine what will kill the bacteria

Sensitivity Testing: Dilution in Liquid Broth

Tubes containing increasing antibiotic concentration

0 0.25 0.50 1 2 4 8 mg/l

MICBacterial growth Inhibition

*

*Minimum Inhibitory Concentration (MIC)

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Ignore the MIC number!Pay attention to the

interpretation S or R.

Definitions Colonization Infection Bacterial infection Antibiotics with different mechanisms Antibiotics with different side effects How we test for antibiotic resistance How to interpret antibiotic susceptibility results

How do we use Antibiotics? Do we need to use antibiotics?

What antibiotic should we use?

How long should we treat?


RIGHT Diagnosis

What antibiotic should we use?RIGHT DrugRIGHT Dose

How long should we treat?RIGHT Duration

Nursing Evaluation of Patient Status

Signs and symptoms of infection

Is there invasion and damage

Colonization Versus Infection

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The most dangerous result in modern medicine is a positive urine culture.

Phil Robinson, MDExpert Stewardship

A positive culture is not the same as an infection

The diagnosis of a UTI requires DIS-EASE Symptoms

McGeer Criteria to the rescue!

Updated 2012 McGeers Criteria

removed Worsening of

mental or functional status from the UTI surveillance

definition.

Reference: Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeerCriteria. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/ Last accessed 3/22/2018.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/




What happens if we use antibiotics too much?

Antibiotics Before Culture Result The physician must guess what the best antibiotic

should be

Antibiotic resistance rates change and differ by facility

Annual Antibiogram

Antibiotic Stewardship Committee

Interpretation of antibiogram

Recommendations for empiric treatment for common infections in the nursing home

Antibiotics After Culture Result The physician must choose the most effective and safest

drug for the patient

Make a list of the S antibiotics that can get to the site of infection

Choose the safest agent from the list

Antibiotic Stewardship Committee Preferred agents for use in the facility

How Long Should we Give Antibiotics? Depends on the type of infection

Ideally give antibiotics for as short a period as possible

Dr. McKinnells Duration Notes

Disease State Duration (days) Community Associated Pneumonia 710 HAP/VAP* 1014 Pyelonephritis 1014 Cellulitis 710 Bacteremia 1442

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*Hospital-Acquired Pneumonia/Ventilator-Associated Pneumonia

Dr. McKinnells Duration Notes

Disease State Duration (days) Community Associated Pneumonia 710 HAP/VAP* 1014 Pyelonephritis 1014 Cellulitis 710 Bacteremia 1442

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*Hospital-Acquired Pneumonia/Ventilator-Associated Pneumonia

HCAP/VAP7 DAYS

Several RCTs* 78 days equal to 1015 days

Reduced emergence of resistance

MRSA** and Pseudomonas infections may require longer therapy

*Randomized Controlled Trials**Methicillin-resistant Staphylococcus aureus

Capellier et al. PLoS One 2012:7:e41290; Chastre et al. JAMA 2003 290:2588-98; Kalil et al. CID 2016 63:e61-e111

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Antibiotic Stewardship Committee Target for duration of therapy for common infections

Overuse of Antibiotics is Bad Unacceptable Clostridium difficile rates

Alarming antibiotic resistance

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LTC Antibiotic cost estimates:

$38137 million per year in US

CDC. Get smart for healthcare: Antibiotic use in nursing homes. http://www.cdc.gov/getsmart/healthcare/learn-from-others/factsheets/nursing-homes.htmlLast accessed 8/15/2016.

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

Antibiotics and CDI

Risk of CDI compared to resident on 1 antibiotic

Number of ATBs

2 ATBs 34 ATBs 5+ ATBs

2.5 times higher

3.3 times higher

9.6 times higher

Risk of CDI compared to resident on ATBs for 18 days1.4 times higher

3 times higher

7.8 times higher

15. Epson,E. Orange County CDI Prevention Collaborative: Antimicrobial Stewardship. CDPH. November 5, 2015. Permission granted for use of this slide by Dr. Erin Epson. Original slide reference: Stevens,et al. Clin Infect Dis. 2011;53(1):42-48

C. Difficile Associated Deaths

Number of annual cases

Cost Number of annual deaths

Hospital-onset, hospital-acquired (HO-HA) 165,000 $ 1.3 B 9,000

Community-onset, hospital-acquired (CO-HA)[4 weeks of hospitalization]

50,000 $ 0.3 B 3,000

Nursing home-onset 263,000 $ 2.2 B 16,500

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New Conditions of Participation (COP) Requirements

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CMS COP

CMS requires that the Governing Body ensure that systems are in place and operational for infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities

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Steps to Stewardship1. Get Leadership Support2. Form a Multi-Disciplinary Team with Expertise3. Define the Stewardship Opportunities for Improvement

a. Tracking4. Develop an Action Plan and Educate

a. Action and Educate5. Report on Results

a. Reporting

Repeat Steps 35

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CMS COP ASP Leader1. Develop and Implement antibiotic stewardship program2. Document, written or electronic, all antibiotic

stewardship program activities3. Communicate and collaboration with medical staff,

nursing, and pharmacy leadership4. Communication and collaborate with Infection

Preventionist (IP) and Quality Assurance & Performance Improvement (QAPI)

5. Competency-based training and education of personnel and staff, including medical staff, and contracted services

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a. Reporting

Repeat Steps 35

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Antimicrobial Stewardship Team1. Administrator2. Stewardship Expert/ASP Leader3. Facility Medical Director4. Infection Preventionist/Director of Staff Development5. Pharmacist (May only provide data)6. Laboratory (May only provide data)

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Expertise in Stewardship Formal Training by Infectious Disease (ID) Fellowship or

ID Pharmacist Fellowship

Coursework with the Society for Healthcare Epidemiology of America

Coursework from the Society of Infectious Disease Pharmacists (SIDP)

Infectious Disease Association of California




a. Reporting

Repeat Steps 35

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0

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10

15

20

25

30

35

40

45

50

Ord

ers

Number of Unique Antibiotic Orders by Class




a. Reporting

Repeat Steps 35

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Action and Education Indirect Methods of Education

Posters, Treatment Guidelines

Direct MethodsNursing In-ServicePhysician Lectures

Antibiotic Time OutsASP led review of antibiotic orders




a. Reporting

Repeat Steps 35

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0

10

20

30

40

50

60

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Number of Orders by Class

Chart1

00

00

00

00

00

00

00

00

00

00

00

00

#REF!

#REF!

C-DIFF RATES 2016

Why do we Need to do Antibiotic Stewardship? Mandated by CMS

Avoid Deficiencies

Better Treatment of Infections

Avoid C. difficile

Save Lives

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Thank you for Your Attention

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CDI Initiative

Quality Innovation Network-Quality Improvement Organization (QIN-QIO) Program

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Funded by the Centers for Medicare & Medicaid Services (CMS), the QIN-QIO program is the largest federal program dedicated to: Improving individual patient care Improving health for populations

and communities Integrating care for populations

and communities Delivering beneficiary and

family-centered care

NNHQCC Aims

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Ensure every nursing home (NH) resident receives the highest quality of care.

Implement Quality Assurance & Performance Improvement (QAPI).

Eliminate healthcare-acquired conditions (HACs). Eliminate healthcare-associated infections (HAIs). Improve resident satisfaction. Reduce use of unnecessary antipsychotic

medications in residents with dementia. Achieve score of 6.0 or lower on the NH quality

measure composite score by January 2019.

CDI Initiative in AZ, CA, FL, and OH

Baseline MarchDecember 2017

Cohort NHs Consistent monthly data

submission HSAG

Support, educate, and monitor data submission into NHSN

Goal: Identify a national baseline for CDI in nursing homes

Post-BaselineJanuaryDecember 2018

Cohort NHs Consistent monthly data

submission Implement interventions to

reduce CDI HSAG

Support, educate, and monitor data submission into NHSN

Provide education and outreachGoal: Achieve a measurable CDI aim

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2018 Post-Baseline Education and Outreach

HSAG Website Monthly Quality Care

Connection Email Nursing Home Training

Program Certificates Red/Yellow/Green

Reminders Performance

Improvement Project (PIP) Assistance

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2018 Education and Outreach

Monthly Educational Webinars

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Date Topic

January, 17, 2018 CDI Intervention Kick-Off

February 22, 2018 Antibiotic Stewardship

March 22, 2018 Exploring the Role of Antibiotics

April 19, 2018 Case Study: CDI Reduction and QAPI

May 31, 2018 Strategies to Decrease Antibiotic Resistance

June 21, 2018 CDI Part 1: Clinical Overview

July 19, 2018 CDI Intervention PIP Progress Report

August 16, 2018 CDI Part 2: Prevent, Track, and Monitor

September 13, 2018 TeamSTEPPS Communication

Registration Information to Follow.Check www.hsag.com/events often for upcoming webinars and events.

Webinar Recordings

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Date Topic

January, 17, 2018 CDI Intervention Kick-Off

February 22, 2018 Antibiotic Stewardship

Go to www.hsag.com/eventsand search by event date

to locate past event recordings and materials.

Accessing Your Facility-level CDI Rates

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NH Online Training Sessions

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http://qioprogram.org/nursing-home-training-sessions

Earn 11.3 Nursing

CEs

Online NH Training Session: Topics Covered

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1. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in Long-Term Care (LTC): Communication Strategies to Promote Quality and Safety

2. Exploring Antibiotics and Their Role in Fighting Bacterial Infections

3. Antibiotic Resistance: How it Happens and Strategies to Decrease the Spread of Resistance

4. Antibiotic Stewardship 5. Clostridium difficile Part One: Clinical Overview 6. Clostridium difficile Part Two: Strategies to Prevent,

Track, and Monitor C. difficile

Online NH Training Sessions: Purpose

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Enhance understanding of important concepts and practices that promote effective communication, antibiotic stewardship and C. difficile prevention, and to provide information, tools, and resources to take action to improve practices.

Certificates of participation or 11.3 nursing continuing education credits at no cost.

Online NH Training Sessions: Use

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NH leaders can decide: Which modules would be helpful. The appropriate staff member to include for

each module. How to use the materials during education

sessions or self study. How to best provide this training over time.

Online NH Training Sessions: Whats Included?

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Welcome and overview Objectives How you can use this session Orientation (list of sections and content) Topic information presented via text/narrative, video, PowerPoint

presentations with notes, or links to website pages Interactive activities and scenarios, including discussion questions Informational handouts Take home messages Links to additional optional resources Opportunity to apply for a certificate of participation or nursing

CE credits

How to Access NNHQCC Resources

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1

2

3

4

Click For Medicare Providers

Click Your State

Click Nursing Homes

https://www.hsag.com/

Click National Tools and

Resources

What Should You Do Next? Continue to submit monthly CDI data

through 2018. Check your CDI rate. Register for CDI Initiative April webinar. Check out the online NH training sessions. Add another NHSN user to your account.

Contact us!

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Questions? Comments? Assistance?Reach out to your state QIN-QIO.

State Name Email Phone Number

Arizona Buffy Lloyd-Krejci [email protected] 602.801.6878

California Rose ChenEzrah [email protected]

[email protected] 818.636.8242

Florida Gazelle Zeya [email protected] 813.865.3188

Ohio Angila Anderson [email protected] 614.704.1216

Questions?

Thank you!

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the

U.S. Virgin Islands, 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.

Publication No. QN-11SOW-C.2-03192018-01

CMS DisclaimerSlides 13 and 6583

National Nursing Home Quality Care Collaborative (NHQCC)and the Clostridium difficile Infection (CDI) InitiativeExploring Antibiotics and Their Role in Fighting Bacterial InfectionsIntroduction and OverviewTodays WebinarExploring Antibiotics and Their Role in Fighting (BUT ALSO SOMETIMES CAUSING) Bacterial InfectionsObjectivesWhat is an Infection?Colonization Versus InfectionWhat is a Bacterial Infection?DefinitionsWhat is an Antibiotic?How do Antibiotics Work?Beta-Lactam Antibiotics Cell WallFluroquinolones DNA ProductionAminoglycosides Protein ProductionOthersExamples of Antibiotic Side EffectsWhat is Antibiotic Resistance?How do we Test for Antibiotic Resistance?Sensitivity Testing: Dilution in Liquid Broth DefinitionsHow do we use Antibiotics?How do we use Antibiotics?How do we use Antibiotics?Nursing Evaluation of Patient Status How do we use Antibiotics?Antibiotics Before Culture ResultAnnual AntibiogramAntibiotic Stewardship CommitteeAntibiotics After Culture Result Antibiotic Stewardship CommitteeHow do we use Antibiotics?How Long Should we Give Antibiotics?Dr. McKinnells Duration NotesDr. McKinnells Duration Notes Antibiotic Stewardship CommitteeOveruse of Antibiotics is Bad Antibiotics and CDIC. Difficile Associated DeathsNew Conditions of Participation (COP) RequirementsCMS COPSteps to StewardshipCMS COP ASP LeaderSteps to StewardshipAntimicrobial Stewardship TeamExpertise in StewardshipSteps to Stewardship Steps to StewardshipAction and EducationSteps to Stewardship Why do we Need to do Antibiotic Stewardship?Thank you for Your AttentionCDI InitiativeQuality Innovation Network-Quality Improvement Organization (QIN-QIO) Program NNHQCC AimsCDI Initiative in AZ, CA, FL, and OH2018 Post-Baseline Education and Outreach2018 Education and OutreachWebinar RecordingsAccessing Your Facility-level CDI RatesNH Online Training SessionsOnline NH Training Session: Topics CoveredOnline NH Training Sessions: PurposeOnline NH Training Sessions: UseOnline NH Training Sessions: Whats Included?How to Access NNHQCC ResourcesWhat Should You Do Next?Contact us!Questions?Thank you!CMS DisclaimerSlides 13 and 6583

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