Professional Nursing Solutions, LLC

Professional Nursing Solutions,

LLCParticipation in the National AHRQ Safety

Program for Antibiotic Stewardship

Presented by Carol Compas, PhD, BSN, RN

November 8, 2019

Introduction to the AHRQ Safety

Program for Improving Antibiotic UseLong-Term Care

AHRQ Safety Program for

Improving Antibiotic Use

Program Support and Target Audience

• Program Support –– This activity is supported by a contract from the

Agency for Healthcare Research and Quality –AHRQ

• Target Audience –– This activity is intended for physicians, physician

assistants, nurse practitioners, registered nurses

and certified nursing assistants.

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Objectives

1. List the goals of the AHRQ Safety Program for Improving Antibiotic Use

2. Apply the Four Moments of Antibiotic Decision Making

3. Recognize how to adapt the culture of a workplace to improve patient safety

4. Describe the Centers for Medicare and Medicaid Services (CMS) Condition of Participation related to antibiotic stewardship in the long-term care (LTC) setting

5. Describe the timeline of the AHRQ Safety Program

6. State the data requirements for the project and how to upload data on the AHRQ Safety Program website

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• A quality improvement

collaborative to improve

antibiotic use across

healthcare

• Program targets 3

settings:

– Acute Care

– Long-term Care

– Ambulatory Care

AHRQ Safety Program for Improving Antibiotic Use

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Integrating Two Important Concepts

• Program which focuses on appropriate use of antibiotics to improve patient outcomes and reduce the development of multi-drug resistant organisms

• Approach to make healthcare safer by improving teamwork and communication among physicians, pharmacists, nurses, and other team members using the science of safety

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Antibiotic

Stewardship

Culture of

Patient Safety

• Improved safety culture

• Enhanced teamwork and

communication

• Improved antibiotic decision

making

• Reduction in suboptimal

antibiotic usage

• Reduction in Clostridium difficile infections

• Improved compliance with CMS Condition of Participation

Expected Outcomes of Program

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• Technical assistance for implementing antibiotic stewardship

• Access to experts in patient safety and antibiotic stewardship

– Monthly Webinars

– Monthly office hours with the project team

– An Implementation Adviser for day-to-day troubleshooting

• Ability to network on the regional and national level

Benefits to Participants

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The Four Moments of Antibiotic Decision Making

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1. Does the resident have symptoms that

suggest an infection? Can we try

symptomatic treatment and active

monitoring?

2. What type of infection is it? Have we

collected appropriate cultures and diagnostic

tests before starting antibiotics? What

empiric therapy should we initiate?

3. What duration of antibiotic therapy is needed

for the resident’s diagnosis?

4. It’s been 2-3 days since we started

antibiotics. Re-evaluate the resident and

review results of diagnostic tests. Can we

stop antibiotics? Can we narrow therapy?

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monitoring?











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monitoring?











12





monitoring?











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Antibiotic Stewardship Involves Both Technical

& Adaptive Challenges

Technical Adaptive

Problems with a clear

technical solution

Problems that require changes in

priorities, beliefs, habits, loyalties,

role, way of thinking

Fix by providing resources to

complete the task

Fix by mobilizing people to tackle

challenges together

Example: Lack of awareness of

new guidelines

Example: Prescribers don’t believe the recommendations

Potential Solution: Develop a

method to get guidelines to

the point of care

Potential Solution: Discuss

concerns and different opinions

and work to achieve consensus

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5 Steps for Improving the Culture of Patient Safety

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1. Engage leadership for support and collaboration

2. Understanding the science of safety

3. Improve teamwork and communication

4. Recognize current practices that may lead to

patient harm

5. Develop system-based solutions to improve

patient safety

CMS Conditions of Participation

• CMS requires all long-term care facilities to have an Antimicrobial Stewardship Program (ASP)

• An ASP should include—– Written antibiotic use protocols

– A system to monitor antibiotic use with the goal of resident safety

– Measuring and reporting of antibiotic use and resistance data

– Feedback and education to individual prescribers

– Feedback and education to all facility staff

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2. Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. October 2016.

https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-

long-term-care-facilities. Accessed July 12, 2018.

https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities

CMS Conditions of Participation

• Each facility must designate at least one person as

an Infection Preventionist (IP) who is responsible

for the Infection Prevention and Control

Plan (IPCP).

• The Infection Preventionist must be a member of

the facility’s Quality Assessment and Assurance (QAA) committee and make regular reports.

• The Infection Preventionist must also conduct an

annual review of the Infection Prevention and

Control Plan and update as necessary.

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2. Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. October 2016.

https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-

long-term-care-facilities. Accessed July 12, 2018.


Participant Overview

• There will be two groups of participants within the AS program.

– Antibiotic Stewardship team

• A physician

• Either an IP and control nurse OR a pharmacist

• Other members

– Make sure to designate team champions to motivate/encourage sustainable efforts

– Frontline staff

• People who prescribe antibiotics

• People who take care of residents daily

• Even without an AS program, people can use/view the educational material on the program’s website.

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Introduction and Antibiotic Stewardship Program

Development

December 2018

Antibiotic

Stewardship

Program

Development

Participants

Antimicrobial stewardship team

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November/

December 2018

Introduction to

the AHRQ Safety

Program for

Improving

Antibiotic Use

Overview of Adaptive Webinars

January 2019

Partnering With a

Senior Executive

January 2019

Improving

Antibiotic Use is a

Patient Safety

Issue

February 2019

Improving Teamwork

and Communication

February 2019

Identifying Targets to

Improve Antibiotic Use

March 2019

Changing the

System to Improve

Patient Safety

January – March 2019

Bi-monthly 25-minute Webinars about adaptive approaches for

cultural change

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Overview of Technical Webinars

April 2019

Appropriate

Collection of

Microbiological

Specimens

May 2019

Assessment of the

Resident With a

Suspected Urinary Tract

Infection

June 2019

Treatment and

Management of

Urinary Tract

Infections

July 2019

Assessment of the

Resident With a

Suspected Respiratory

Tract Infection

August 2019

Treatment and

Management of the

Resident With a

Suspected Respiratory

Tract Infection

Team approach to stewardship

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Additional Webinars

September 2019

Discussing Infectious

Concerns With Providers

October 2019

Discussing Infectious

Concerns With

Residents and

Caregivers

November 2019

Sustaining Antibiotic

Stewardship Efforts

Webinars about tools for frontline staff to discuss infectious concerns in long-

term care residents with prescribers and concerned family members.

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Data Collection

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Data To Be Submitted

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1. Monthly Dataa. Number of patient days of care

b. Number of days of antibiotic therapy (per 1,000 resident days) for antibiotics commonly used in the LTC setting

c. Number of antibiotic starts (per 1,000 resident days)

d. Number of C. diff LabID events (per 10,000 resident-days)

e. Number of urine cultures (per 1,000 resident days)

2. Team Antibiotic Review Forma. Data does not need to be submitted to the project website

b. Implementation information to be collected by your IA during the monthly check-in call

3. NHSOPS: pre- and post intervention survey on safety culture

Monthly: • Number of Patient Days of

Care

• Number of C. difficile LabID

events

• Number of Urine Cultures

collected

• Number of Days of

Antibiotic Therapy (DOT )

• Number of Antibiotic starts

Jan ‘19 Marc

hMay July Sept Dec ‘19Dec ‘18 Fe

b

April June Aug Oct Nov

Q1 (Baseline) Q2 (First Program Quarter) Q4 (Last Program Quarter)Q3 (Second Program

Quarter)

Collect monthly data for

Q1 (Jan, Feb, March

2019)

Q1 Benchmarking

Report received by

early June 2019

Submit

Feb 28


Q2 (April, May, June 2019)


Q3 (July, Aug, Sept 2019)


Q4 (Oct, Nov, Dec 2019)

Q2 Benchmarking

Report received by

early September

2019

Q3 Benchmarking

Report received

by early

December 2019

Q4 Benchmarking

Report received by

early March 2020

Submit

July 31

Submit

Oct 31

Submit

Jan 31

Jan ‘20

Submit

Mar 31

Submit

Apr 30Submit

Jun 30

Submit

May 31

Submit

Sept 30

Submit

Aug 31

Submit

Dec 31

Submit

Nov 30

Monthly Data Submission Timeline

Monthly Data Collection FormNPI [enter NPI here]

Long-Term Care Facility Name

Contact Name

Contact Email

Contact Telephone Number

Reporting Month

Number of Patient Days of Care

Number of C. difficile LabID events

Number of urine cultures collected

Days of Antibiotic Therapy (DOT)

[enter aggregate # of days residents were

administered each antibiotic below in the

reporting month. If no resident was administered a

particular antibiotic, enter "0" for that row]

# Antibiotic Starts

[enter # of antibiotic starts for each antibiotic below in the

reporting month. If there were no antibiotic starts for a particular

antibiotic, enter "0" for that row]

AMOXICILLIN (Amoxil)

AMOXICILLIN/CLAVULANATE

(Augmentin)

AMPICILLIN/SULBACTAM (Unasyn)

AZITHROMYCIN (Zithromax)

CEFADROXIL (Duricef)

CEFDINIR (Omnicef)

CEFIXIME (Suprax)

CEFPODOXIME (Vantin)

CEFTRIAXONE (Rocephin)

CEFUROXIME (Ceftin)

CEPHALEXIN (Keflex)

CIPROFLOXACIN (Cipro)

CLINDAMYCIN (Cleocin)

DOXYCYCLINE (Vibramycin)

ERTAPENEM (Invanz)

FOSFOMYCIN (Monurol)

LEVOFLOXACIN (Levaquin)

LINEZOLID (Zyvox)

MEROPENEM (Merrem)

METRONIDAZOLE (Flagyl)

MOXIFLOXACIN (Avelox)

NITROFURANTOIN (Macrobid)

PIPERACILLIN/TAZOBACTAM (Zosyn)

SULFAMETHOXAZOLE/TRIMETHOPRIM

(Bactrim, Septra)

VANCOMYCIN Intravenous (Vancocin)

VANCOMYCIN Oral (Vancocin)

[enter # urine cultures collected in the reporting month]

[the sum of each daily census (number residents in the facility each day) for the entire reporting month]

[enter facility name here]

[enter telephone number here]

[enter # C. difficile LabID events for the reporting month]

[enter email here]

[enter name here]

[enter reporting month]

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Facility Information

• Facility information – 10-digit NPI number

– Facility name (same as used during registration)

– Contact name, email, and telephone number

• Reporting month and days of care– Reporting month (drop down menu)

– Number of patient days of care

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NPI [enter NPI here]

Long-Term Care Facility Name

Contact Name

Contact Email

Contact Telephone Number

Reporting Month

Number of Patient Days of Care [the sum of each daily census (number residents in the facility each day) for the entire reporting month]

[enter facility name here]

[enter telephone number here]

[enter email here]

[enter name here]

[enter reporting month]

C. difficile Lab Events and Urine Cultures

• Record any positive C. difficile LabID events

• Contact contracted microbiology lab for this information- usually easily accessible.

• Data is concordant with current NHSN requirements.– If you are already working with a QIN/QIO on collecting this data, consider

asking them to help navigate

• Monthly number of urine cultures collected

• Record all urine cultures collected, not simply positive urine cultures

• This information can often be obtained from your contracted microbiology lab or can be a part of monthly QA review.

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Number of C. difficile LabID events

Number of urine cultures collected [enter # urine cultures collected in the reporting month]

[enter # C. difficile LabID events for the reporting month]

Antibiotic Use

1. Days of antibiotic therapy

2. Antibiotic starts

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Two measures of

monthly antibiotic use

(by antibiotic)

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Antibiotic Days of Therapy

• Measures the total number of days residents

received a particular antibiotic

Monday Tuesday Wednesday Thursday Friday

Morning

dose

X X X X

Afternoon

dose

X X X X

Evening

dose

X X X X

• In this example, the resident received 5 days

of therapy

Antibiotic Days of TherapyDays of Antibiotic Therapy (DOT)

[enter aggregate # of days residents were

administered each antibiotic below in the

reporting month. If no resident was administered a

particular antibiotic, enter "0" for that row]



(Augmentin)




CEFDINIR (Omnicef)

CEFIXIME (Suprax)



CEFUROXIME (Ceftin)

CEPHALEXIN (Keflex)




ERTAPENEM (Invanz)



LINEZOLID (Zyvox)

MEROPENEM (Merrem)






(Bactrim, Septra)



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Antibiotic Starts

• Count number of new antibiotics courses

started in the facility in each month

• New admissions on antibiotics should be

included as a new antibiotic start

– This is to capture total antibiotic usage,

including what is prescribed from

surrounding acute care facilities

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Antibiotic Starts# Antibiotic Starts

[enter # of antibiotic starts for each antibiotic below in the

reporting month. If there were no antibiotic starts for a particular

antibiotic, enter "0" for that row]



(Augmentin)




CEFDINIR (Omnicef)

CEFIXIME (Suprax)



CEFUROXIME (Ceftin)

CEPHALEXIN (Keflex)




ERTAPENEM (Invanz)



LINEZOLID (Zyvox)

MEROPENEM (Merrem)






(Bactrim, Septra)



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References

1. Heifetz R, Grashow A, Linsky M. The practice of adaptive leadership: tools and

tactics for changing your organization and the world, 1st ed. Boston, MA:

Harvard Business Review Press; 2009.

2. Medicare and Medicaid Programs; Reform of Requirements for Long-Term

Care Facilities. October 2016.

https://www.federalregister.gov/documents/2016/10/04/2016-

23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-

term-care-facilities. Accessed July 12, 2018.


Thank You for Your Time

• Please collaborate with your long term care

providers on all things quality

• There is untapped talent in Nursing Homes

• Contact Information:

• [email protected]

• Cell (501) 520-5244

mailto:[email protected]

Professional Nursing Solutions, LLC

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