Program Overview• Hosts:

– Jan Ratterree, RN, CIC, Georgia Hospital Association– Jesse Jacob, MD, MSc, Emory University Hospital Midtown– Jeanne Negley, MBA, HAI Surveillance Director, DPH

• Stewardship Story:– Lisa Ferraro, PharmD, Mountain Lakes Medical Center

• Advancing Antimicrobial Stewardship in Community Hospitals in Utah– Edward Stenehjem, MD, MSc, Intermountain Healthcare

Thank YouCalifornia Department of Public Health

Illinois Department of Public Health

Georgia AntimicrobialStewardship Story

Advancing Antimicrobial Stewardship in Community

Hospitals in Utah

May 6, 2015

Edward Stenehjem, MD, MScDivision of Infectious Diseases, Intermountain Healthcare

Medical Director of Antimicrobial Stewardship, IMC Co-Chair Intermountain Healthcare Antimicrobial Stewardship Committee

Advancing Antimicrobial Stewardship in Community Hospitals in Utah

Eddie Stenehjem, MD MSc

Infectious Diseases and Antimicrobial Stewardship

May 6th, 2015

Objectives

• Describe how antimicrobial usage in small, community hospitals compares to large urban centers

• Understand the basic concepts of Intermountain’s SCORE study and how it can apply to your hospital

What is Antibiotic Stewardship?

Systematic efforts to optimize the use of antibiotics to maximize

benefits, minimize resistance and decrease adverse events

Core ElementsAntibiotic Stewardship Program

• Leadership commitment from administration• Single leader responsible for outcomes• Single pharmacy leader• Antibiotic use tracking• Regular reporting on antibiotic use and

resistance• Educating providers on use and resistance• Specific improvement interventions

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Improvement Interventions

Antimicrobial Stewardship

Prospective Audit with Feedback

Formulary Restriction

Antimicrobial Indications

Guidelines and Clinical Pathways

EducationDose optimizationIV to PO conversionRapid Diagnostics

Decision Support

What is Antibiotic Stewardship?

Antimicrobial

Stewardship

Prospective Audit

Formulary Restriction

Antimicrobial Indications

Guidelines and Clinical Pathways

EducationDose optimizationIV to PO conversionRapid Diagnostics

Decision SupportStructured mechanism of optimizing antibiotic useThis isn’t a new topic

Sir Alexander Fleming June 26, 1945

• The public will demand [the drug and]…then will begin an era… of abuses….In such a case the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with penicillin-resistant organism.

Fleming A. Penicillin’s finder, assays its future. New York Times. 1945; 21

Why Stewardship?

1. All Antibiotics Fail2. Rising Resistance3. Dry (damp?) pipeline4. It is the right thing to do

Why Stewardship?

1. All Antibiotics Fail2. Rising Resistance3. Dry (damp?) pipeline4. We will have to

Presidential Report

National Action Plan

1. Slow the emergence of resistance bacteria

2. Strengthen National One-Health Surveillance

3. Advance development of rapid dx tests

4. Accelerate research and development of new abx

5. Improve international collaboration

Goal 1

• Within three years: – All hospitals that participate in Medicare and Medicaid

programs must comply with Conditions of Participation (COP). The Centers for Medicare Medicaid Services (CMS) will issue new COPs or revise current COP Interpretive Guidelines to advance compliance with recommendations in CDC’s Core Elements of Hospital Antibiotic Stewardship Programs.

• All acute care hospitals governed by the CMS COP will implement antibiotic stewardship programs.

SCOPE

2005 United State Hospitals

4935 Registered Hospitals

72% have < 200 beds

Most of these are without antibiotic oversight

All will be included in National Action Plan

Very few studies of stewardship in these settingsAHA Statisticshttp://www.aha.org/research/rc/stat-studies/index.shtml

Since 1975• 22 hospitals• 2,784 licensed beds

Since 1983• Health plans• 700,000+ members

Since 1994• 1,200 employed physicians• 558 advanced practice clinicians

Since 1997• 10 key service lines

Intermountain HealthcareHighly-Integrated Health System

Hospitals

SelectHealth

Medical Group

Clinical Programs

Intermountain Antibiotic Stewardship

Increased emphasis in the past 5 years at our large facilities

• Corporate AS Committee– Subcommittee of Infection Control Guidance Council

• Corporate Outpatient AS Committee– Subcommittee of Primary Care Clinical Program

• Individual ASP Committees at our large sites

• NO FOCUS ON OUR SMALLER HOSPITALS

Hospital Staffed Bed CountIntermountain Medical Center 472Utah Valley 375McKay-Dee 300Primary Children's 289Dixie Regional 245LDS 243Logan Regional 128American Fork 89Riverton 88Alta View 66Valley View 48Park City Medical Center 30Cassia Regional 25Sevier Valley 24Orem Community 18Bear River Valley 16Heber Valley 16Delta Community 15Garfield Memorial 14Sanpete Valley 13Fillmore Community 7

Large Urban Hospitals-ASP focused-Formal ID consultation available

Small Community Hospitals-15 Hospitals-597 Beds-25% of IHC Beds-No formal ASPs-No Infectious Diseases MD support-All with full time pharmacy staff

Antimicrobial Use in Small Hospitals

• Antibiotic Usage Using NHSN AU Data

• How does usage differ across our system?– Small vs Large Hospitals– Usage and Case Mix Index (CMI)– Usage and Spectrum

Small vs. Large Hospitals3 year average

% of Total Antibiotic Use per

Category

27%

14%

24%

55%

20%29% 23%

14% 14%

34% 30% 28%21%

34%

65%19%

16%

24%

10%

22%13% 25%

26% 20%

15%13% 20%

19%

15%

11%

19%

35%

28%

23% 18%

24%29%

23%

13%12%

20%25%

18%

25% 35%16%

21%22% 27%

18% 22%

27%26%

31%

22%20%

24%

21%13% 14% 10% 10% 15% 12% 13%

8%

8%

9% 9%8% 9%

25%32% 31%

17%12% 18%

10%11%

15%

31% 27%

24%

17% 18%11%

0

200

400

600

Days of Therapy per 1000

Patient Days [Bars]

0.0

0.5

1.0

1.5

Average CMI

Drug CategoriesCategory 1 (narrow)Category 2Category 3Category 4Category 5 (broad)

Measure NamesCasemix IndexFacility AU Rate

Panel 2

SCHs LUHs

Panel 1

Panel 3

Hospitals

Figure 3. Description of Antimicrobial Use in 15 SCHs and 3 large, urban hospitals in Utah and IdahoPanel 1: Antimicrobial usage rates and case mix index. Panel 2: Distribution of antimicrobial use per category. Panel 3: Percentage of total use per unit type

Abbreviations: CMI - case mix index. AU - Antimicrobial Use. ICU - intensive care unit

15 Small IHC Hospitals 3 Large IHC Hospitals

Usage and Spectrum

Usage and Spectrum

% of Total Antibiotic Use per

Category

27%

14%

24%

55%

20%29% 23%

14% 14%

34% 30% 28%21%

34%

65%19%

16%

24%

10%

22%13% 25%

26% 20%

15%13% 20%

19%

15%

11%

19%

35%

28%

23% 18%

24%29%

23%

13%12%

20%25%

18%

25% 35%16%

21%22% 27%

18% 22%

27%26%

31%

22%20%

24%

21%13% 14% 10% 10% 15% 12% 13%

8%

8%

9% 9%8% 9%

25%32% 31%

17%12% 18%

10%11%

15%

31% 27%

24%

17% 18%11%

0

200

400

600

Days of Therapy per 1000

Patient Days [Bars]

0.0

0.5

1.0

1.5

Average CMI

Drug CategoriesCategory 1 (narrow)Category 2Category 3Category 4Category 5 (broad)

Measure NamesCasemix IndexFacility AU Rate

Panel 2

SCHs LUHs

Panel 1

Panel 3

Hospitals

Figure 3. Description of Antimicrobial Use in 15 SCHs and 3 large, urban hospitals in Utah and IdahoPanel 1: Antimicrobial usage rates and case mix index. Panel 2: Distribution of antimicrobial use per category. Panel 3: Percentage of total use per unit type

Abbreviations: CMI - case mix index. AU - Antimicrobial Use. ICU - intensive care unit

Need for Stewardship

63%

Usage Conclusions

• SCHs have similar antibiotic usage rates as large, urban hospitals.

• There is significant variation in antibiotic selection in SCHs.

• Antibiotic Stewardship in SCHs is critical

SCORE

Stewardship in Community Hospitals: Optimizing Outcomes and Resources (SCORE)

Funded by:

Pfizer Independent Grants for Learning and Change

The Joint Commission

Project Aim: SCOREStewardship in Community Hospitals Optimizing Outcomes and Resources

Define an antibiotic stewardship strategy for Intermountain’s smaller hospitals that

optimizes outcomes while maximizing resources

Study Design: Cluster Randomized Clinical Trial

Study sites: 15 small hospitals

Intervention: • Low Resource Utilization – 5 hospitals• Medium Resource Utilization – 5 hospitals• High Resource Utilization – 5 hospitals

ALL Sites – Antibiotic Best PracticesIV to PO Conversion

Antibiotic Indications48 hour Antibiotic “Timeout”

Access to: ID clinicians and pharmacistsMonthly Hospital Antibiotic Utilization Report

Low Resource Medium Resource High ResourceEducation Initiative - PharmacyTopics Covered: Stewardship Basics Antibiotic Time Out IV to PO Antibiotic Indications Bug-Drug mismatch When to call ID

KAP Survey

Education Initiative - PharmacyTopics covered (in addition to low group): De-escalation - mylearning Anaerobes - mylearning Restrictions - mylearning Allergy Verification Stewardship Pearls / Q and A

KAP survey

Education Initiative - PharmacyTopics covered (in addition to low group): De-escalation - mylearning Anaerobes - mylearning Restrictions - mylearning Allergy Verification Stewardship Pearls / Q and A

KAP survey

PAF – lite: Audit a limited number of antimicrobial agents* and provide feedback Restriction (local pharmacy review) of selected antimicrobials***

* Vancomycin, carbapenems, piperacillin/tazobactam, and cefepime

PAF: Audit an expanded list of antimicrobial agents** and provide feedback Restriction (Infectious Diseases review) of selected antimicrobials*** ID study staff to review positive blood culture results and all cultures with MDROs.

** Vancomycin, carbapenems, piperacillin/tazobactam, cefepime, aminoglycosides, ciprofloxacin, levofloxacin, ceftriaxone, and ampicillin/sulbactam*** Restricted agents: Meropenem, linezolid, daptomycin, ceftaroline, tigecycline, antifungals.

Antibiotic Best Practices

• IV to PO Conversion• Antibiotic Indications• 48 Hour Antibiotic “Timeout”• Monthly Antibiotic Report• Access to ID Consultation

Antibiotic Time-Out

Usage Reports

Usage Reports

Access to ID Clinicians

• Adults and Pediatrics• One number: 1-801-50-SCORE

• Call: Anytime– Adults: Stenehjem– Pediatrics: Attending on call at PCMC

https://my.intermountain.net/qpsafety/Pages/SCORE.aspx

ALL Sites – Antibiotic Best PracticesIV to PO Conversion

Antibiotic Indications48 hour Antibiotic “Timeout”

Access to: ID clinicians and pharmacistsMonthly Hospital Antibiotic Utilization Report

Low Resource Medium Resource High ResourceEducation Initiative - PharmacyKAP surveyTopics Covered: Stewardship Basics Antibiotic Time Out IV to PO Antibiotic Indications Bug-Drug mismatch When to call ID

Education Initiative - PharmacyKAP surveyStewardship Basics – all of those in Low, plus De-escalation - mylearning Anaerobes - mylearning Restrictions - mylearning Allergy Verification Stewardship Pearls / Q and A

Education Initiative - PharmacyKAP surveyStewardship Basics – all of those in Low, plus De-escalation - mylearning Anaerobes - mylearning Restrictions - mylearning Allergy Verification Stewardship Pearls / Q and A

PAF – lite: Audit a limited number of antimicrobial agents* and provide feedback Restriction (local pharmacy review) of selected antimicrobials***

* Vancomycin, carbapenems, piperacillin/tazobactam, and cefepime

PAF: Audit an expanded list of antimicrobial agents** and provide feedback Restriction (Infectious Diseases review) of selected antimicrobials*** ID study staff to review positive blood culture results and all cultures with MDROs.

** Vancomycin, carbapenems, piperacillin/tazobactam, cefepime, aminoglycosides, ciprofloxacin, levofloxacin, ceftriaxone, and ampicillin/sulbactam*** Restricted agents: Meropenem, linezolid, daptomycin, ceftaroline, tigecycline, antifungals.

Prospective Audit and Feedback

Pharmacy will review the following medications after 48 hours of administration• Vancomycin• Carbapenems• Piperacillin/tazobactam• Cefepime• Fluoroquinolones• Aminoglycosides• Ceftriaxone• Ampicillin/sulbactam

Restrictions

• The following drugs are restricted – Daptomycin, linezolid, ceftaroline– Imipenem/meropenem, tigecycline– Amphotericin, vori/posaconazole, micafungin

• Medium group – local pharmacy control• High group – ID pharmacist control

High Group

• Infectious diseases involvement– Positive blood cultures– S. aureus bacteremia– CNS infections– MDRO– Home IV antibiotic therapy

SCORE Outcomes

• Primary Outcome: – Antimicrobial use

• Secondary Outcomes: – Stratified antimicrobial use– Incidence of C. difficile infection– Incidence of MDRO infections

• (VRE, ESBL, CRE, MRSA, FQ R E.coli)

– Feasibility– Cost

Significance

• One of the largest AS studies ever done

• First AS study to evaluate effectiveness of different intervention levels

• First randomized AS study done in small, community hospitals

Timeline

Jan/Feb 2014: Education

March 2014 – June 2015: Intervention

July 2015 – Aug 2015: Analyze Data

Sept 2015: Present Intermountain Plan

Conclusions

• 70% of US hospitals have < 200 beds, most don’t have ID specialists/pharmacists

• SCHs use antibiotics at a similar rate compared to larger facilities

• Stewardship is feasible in SCHs, hopefully SCORE will tell us more

Thank You

• eddie.stenehjem@imail.org

Webinar Contact:Jeanne Negley (Jeanne.Negley@dph.ga.gov)

Questions?

Advancing Antimicrobial Stewardship in Community Hospitals in Utah

Upcoming Best Practice Power Hour Webinar’s:

• Wednesday, May 13th at 11:00 a.m.– Redmond Regional Medical Center

• “Improving Patient Flow in an Emergency Department, a Hospital-wide Initiative”

• Wednesday, May 20th at 11:00 a.m.– Grady Health System/Grady Memorial Hospital

• “Heading Toward Zero: Falls Reduction Patient Safety Program”

Angelina Davis, PharmD, MS, BCPS (AQ-ID) and Daniel Sexton, MD

Duke Antimicrobial Stewardship Outreach Network

Next Antimicrobial Stewardship Series Webinar:

June 3, 2015, 12 – 1 pm (ET)Webinar: https://gharef.webex.com

Webinar Password: Gha060315Teleconference: 877-443-9072

Effective Communication between Physicians and Pharmacist for

Stewardship

THANK YOU!

• Thank you Dr. Stenehjem, Lisa Ferraro, and all of our participates from Georgia, California, Illinois.

• Copy of the slides and webinar recording will be available within one week.