Core Elements of Antibiotic Stewardship for Nursing Homes

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1 Core Elements of Antibiotic Stewardship for Nursing Homes Welcome! Holly Harmon, RN, MBA, LNHA Senior Director Clinical Services 1

2 Leonard Russ Immediate Past Chair AHCA Board of Governors Antibiotic Stewardship A set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Source: CDC Core Elements 2

3 Why is Antibiotic Stewardship Important? National Issue & Priority Multiple Implications: Quality of Care Quality of Life Regulatory Cost More. Call to Action White House Forum Collaboration with CDC Proposed Reform of Requirements of Participation AHCA/NCAL Quality Initiative A Solution:Core Elements of Antibiotic Stewardship for Nursing Homes 3

4 Call to Action Commit now to ensure antibiotic stewardship policies and practices are in place to protect patients and residents and improve clinical care in nursing centers. Select one or two activities from the Core Elements to start with and over time, as improvements are implemented, expand efforts to add new strategies to continue improving antibiotic use. Dr. Nimalie Stone Medical Epidemiologist for LTC, CDC Board-certified infectious disease physician with research and clinical background Prior experience in Long Term Care Acute Hospitals and Nursing Homes Strong advocate for inclusion of LTC in programs and policies on infection prevention in healthcare 4

5 Core Elements of Antibiotic Stewardship for Nursing Homes Nimalie D. Stone, MD, MS Medical Epidemiologist for LTC Division of Healthcare Quality Promotion Centers for Disease Control and Prevention AHCA Webinar February 2, 2016 Objectives Review the harms from antibiotic misuse and the importance antibiotic stewardship in nursing homes Describe the seven Core Elements of antibiotic stewardship Provide examples of actions leadership can take to support antibiotic stewardship in their facilities 5

6 Call to action : Addressing antibiotic overuse and resistance in healthcare Spotlight on antibiotic stewardship in NHs March 2015 The White House releases the National Action Plan for Combating Antimicrobial Resistance Call to action for implementing antibiotic stewardship programs and activities in all healthcare settings, including long-term care June 2015 The White House hosts a forum on Antibiotic Stewardship to highlight healthcare partner commitments included several NH partner organizations July 2015 CMS proposes new Federal Regulations for Long-term care facilities including new infection prevention and antibiotic stewardship activities September 2015 CDC releases the Core Elements of Antibiotic Stewardship for Nursing Homes 6

7 Antimicrobial use in Nursing Homes Over 4 million individuals receive care in nursing homes/skilled nursing facilities (NH/SNF) every year The majority are coming directly from hospitals to receive skilled nursing care/rehabilitation Antimicrobials are frequently prescribed in NHs Over the course of a year, 50-70% of residents will receive a systemic antimicrobial 25-75% of antimicrobial use in NHs may be inappropriate Daneman N et al. JAMAIntMed 2013; 173: Benoit et al. JAGS 2008; 56: Nicolle LE et al. ICHE 2000; 21: Case Example 99 year old with urinary catheter placed in hospital for urinary obstruction transferred to SNF on 7/7 Recommended follow-up in 2 weeks with urology On 7/20, patient afebrile, no documented complaints, but urine culture submitted Culture revealed many bacteria, white cells on urinalysis Started Augmentin and Rocephin on 7/20; Rocephin stopped on 7/23; Augmentin changed to Ertapenem 7/27 for 2nd culture No documentation of signs/symptoms except urine results Sent to hospital 8/3 for antibiotic management; no documented follow-up with urology Evidence of harm -- Inappropriate antibiotic use and poor device management leading to progressive resistance and re-hospitalization Courtesy of J Moore, Office of Inspector General 7

8 Harms from antibiotic use in nursing homes Antibiotic use and misuse can lead to harm Side effects, drug interactions and adverse events Major risk factor for C. difficile infection Acquisition and infection from antibiotic resistant bacteria Residents in high antibiotic use in NHs have a 24% increased risk of antibiotic-related complications Range of use per facility (n=607): antibiotic-days/1,000 resident days High use: >62 antibiotic-days/1,000 resident days Other predictors of experiencing antibiotic harms: Recent hospitalization or ED visit, indwelling medical device, incontinence, functional dependence Daneman N et al. JAMAIntMed 2013; 173: Antibiotic use challenges in nursing homes Prescribers rely on assessments made by someone else 67% of antibiotics were ordered over the phone Limited documentation of assessments and rationale when antibiotics are started 43% of NH-initiated antibiotic courses had no documentation of infection in medical record Difficulty obtaining and interpreting laboratory and diagnostic data to inform antibiotic use Influence of resident, family, and other NH staff on the decision to start antibiotics Richards et al. J Am Med Dir Assoc 2005;6(2):

9 Existing regulations promoting antibiotic stewardship in nursing homes Federal Tag 441: Infection Control Mentions performing antibiotic review Federal Tag 329: Unnecessary Drugs To optimize medication use and monitoring to appropriately minimize exposure and prevent consequences Federal Tag 332/333: Medication Errors To reduce preventable errors and adverse events Federal Tag 428: Drug Regimen Review Outlines role of pharmacist in scheduled reviews of medication use in high risk residents CMS Proposed regulations for certified nursing homes, July 2015 Antibiotic stewardship integrated within pharmacy and infection prevention and control (IPC): Expanding pharmacy medication reviews to include antibiotics for monthly review; reviews also occur for all new admissions/readmissions, ( ) Antibiotic use protocols and monitoring included in IPC ( ) Integrating stewardship into QAPI activities ( ) 9

10 CDC Core Elements of Antibiotic Stewardship Leadership commitment Accountability Drug expertise Action Tracking Reporting Education Practical strategies for applying the core elements in nursing homes Leadership commitment Demonstrate support and commitment to safe and appropriate antibiotic use in your facility Identify the leaders in your facility Facility administrators, owners, corporate managers What action can they take? Share formal statements in support of improving antibiotic use with staff, residents and families. Commit resources for monitoring antibiotic use and providing feedback to staff. Identify and empower the medical director, director of nursing, and/or consultant pharmacist to lead stewardship activities. Have clear policies to improve prescribing practices for staff to ensure patients are not started on antibiotics unless needed. Print and distribute materials to educate staff, residents and families 10

11 Accountability Identify physician, nursing and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities: Medical Directors: Set standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics. Oversee adherence to antibiotic prescribing practices. Review antibiotic use data and ensure best practices (e.g., the right drug at the right dose for the right amount of time) are followed. Directors of Nursing: Establish standards for nursing staff to assess, monitor and communicate changes in a resident s condition that could impact the need for antibiotics. Use their influence as nurse leaders to help ensure antibiotics are prescribed only when appropriate. Educate front line nursing staff about the importance of antibiotic stewardship and explain policies in place to improve antibiotic use. Accountability (cont.) Consultant pharmacists working in partnership with the medical director and DON to support antibiotic stewardship: Provide education to staff about the different types of antibiotics and their uses. Review antibiotic prescriptions as part of the medication regimen review and ensure they are ordered appropriately Create treatment protocols for common infections Reviewing antibiotic prescriptions for appropriate dosing, duration, and match with culture results Establish standards on laboratory testing to monitor for adverse events and drug interactions Providing summary reports on antibiotic use New antibiotic starts and/or days of therapy Provider specific use reports for feedback and education 11

12 Other partners who support stewardship Infection prevention and control coordinator: Tracking antibiotic starts as part of infection surveillance Monitoring adherence to evidence-based published criteria on evaluation and management of infections Reviewing antibiotic resistance and CDI as part of surveillance Consultant laboratory: Developing a process of notifying the facility if certain AR organisms are identified Providing education for NH staff on use of diagnostic tests Creating a summary report of antibiotic susceptibility patters (i.e., antibiogram) State and local health departments: Proving educational support and resources Engaging facilities in coordinated activities (e.g., stewardship collaboratives) to promote shared learning Drug expertise Establishing access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship for your facility. Work with consultant pharmacy provider to identify staff with specialized ID or stewardship training (e.g., certificate course) Partner with stewardship program leads at hospitals within your referral network Develop relationships with infectious disease consultants in your community interested in supporting your facility s stewardship efforts 12

13 Actions Implement at least one policy or practice to improve antibiotic use: Policy Documentation of prescribing elements Developing evidence-based management algorithms for common infections Medication regimen review Broad practice improvements Improving assessments / documentation and communication between front-line nursing staff and off-site clinical providers Standardizing use of laboratory testing to reduce inappropriate testing (e.g., stool for C.diff at end of therapy) Performing an antibiotic time-out Infection-specific practice improvements Reducing antibiotic use for UTI prophylaxis Improving documentation of signs/symptoms to decrease antibiotic use in asymptomatic bacteriuria Reducing prolonged duration of therapy for common infections Nursing Home Core Elements: Appendix A Provides evidence-based examples of policy and practice interventions including pharmacy-driven actions 13

14 Tracking Monitor at least one process measure and at least one outcome measure from antibiotic use in your facility Prescribing process measures Adherence to documenting prescribing elements Completeness of resident assessment documentation Appropriateness of antibiotic selection (based on facility guidelines) Antibiotic use measures Point prevalence of antibiotic use Antibiotic starts/ 1,000 resident days Days of antibiotic therapy/ 1,000 resident days Outcome measures C.difficile and multidrug-resistant organisms Adverse events and/or costs related to antibiotic use Nursing Home Core Elements: Appendix B Provides detailed examples for monitoring antibiotic use process and outcome measures Includes information about reporting antibiotic resistance and C. difficile using the CDC s National Healthcare Safety Network 14

15 Reporting Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff Monitoring and feedback to providers and staff on the impact of their efforts is critical to sustaining improvements Provider specific feedback is one of the most effective ways to change prescribing behaviors Any measure being tracked as part of monitoring antibiotic use should have a mechanism for reporting the results back to appropriate staff in the facility Having antibiotic use data to share with staff, residents and families especially improvement in clinical outcomes (e. g., decreased CDI) can increase support of stewardship activities Education Provide educational resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use Education may be one of the first elements implemented to establish support among facility providers and staff Effective and sustained change doesn t happen without education Use educational events as an opportunity to engage providers and staff in identifying ways to improve current practices Understand and address staff concerns and barriers to changing antibiotic use in your facility Work with facility staff to develop resources/tools to educate residents/families on stewardship efforts in your facility 15

16 CDC antibiotic stewardship campaign: Get Smart Utilize existing campaigns, resources, to make facility staff, and residents more aware of safe antibiotic use Resources for clinician education 16

17 Resources for consumer education Resources for consumer education 17

18 Core Elements of Antibiotic Stewardship for Nursing Homes Summarized as 2-page checklist to assess current practice Scenarios to consider A new administrator has joined Committed to Quality Nursing Home how would she know whether this facility made antibiotic stewardship a priority area? Nursing staff have structured assessment tools to document and report signs/symptoms to providers when a resident is suspected of infection The consultant pharmacist presents a monthly report of antibiotic use by provider during Quality Assurance/Performance Improvement committee The laboratory provides a summary report of antibiotic resistance (antibiogram) to the facility every year which is shared with front-line nursing staff and providers Pamphlets and information about antibiotic stewardship and the harms from antibiotic overuse were discuss with new residents and their families 18

19 Scenarios to consider How would staff and providers know this new administrator thought antibiotic stewardship should be a priority? She asks what the monthly rate of antibiotic starts/1,000 resident days has been for the past quarter during the first QAPI committee meeting She provides funding and time for the Director of Nursing to attend a course on antibiotic stewardship being provided during a national conference She requests the Medical Director provides feedback to prescribing clinicians about their antibiotic use practices each quarter and hosts meetings with the Medical Director and the clinicians who have unusually high prescribing rates She arranges for the local hospital s stewardship pharmacist to share strategies with the facility nursing staff about performing an antibiotic review Take away points Antibiotic stewardship is a national priority Nursing homes are expected to take action in preventing the spread of resistance by improving antibiotic use Leadership serves a critical role in supporting antibiotic stewardship efforts Discussing current practices can engage staff and providers Giving your time and support to improving antibiotic use shows your commitment Engaging in activities now will prepare nursing homes for the future Facilities developing antibiotic stewardship programs will be identified as community leaders by hospital partners Practices will be in place to meet regulations or future incentives for improving antibiotic use 19

20 Thank you!! with questions/comments For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion ahcancal ahcancal 20