How we Got Here: Implementing Stewardship in Rochester Nursing Homes

Transcription

1 How we Got Here: Implementing Stewardship in Rochester Nursing Homes Ghinwa Dumyati, MD Professor of Medicine Center for Community Health University of Rochester Medical Center February 28, 2018

2 Outline Describe how we assisted several Rochester nursing homes in implementing the CDC core elements of antimicrobial stewardship Discuss our successes and challenges Review options to sustain a successful program

3 The Objectives of the Rochester Nursing Home Collaboration 1. Implement antibiotic stewardship programs in Nursing Homes (NH) 2. Reduce the use of quinolones for the treatment of urinary tract infections (UTI) and pneumonia 3. Reduce the overall incidence of C. difficile infections (CDI)

4 Setting ASP Implementation Dissemination Project Implementation Rochester, NY 33 nursing homes (NH) Initially recruited 6 NH-expanded to 10 Size: beds ASP implemented successively moving from one NH to another Tools and approach tailored depending on NH context and needs Through a Medical Directors Advisory Group Regional workshops Website * Project started in 2014 *

5 CDC Core Elements of Antibiotic Stewardship Provide a framework to improve antibiotic prescribing 1. Leadership support 2. Accountability 3. Drug expertise 4. Actions to improve use 5. Tracking 6. Reporting info to staff 7. Education

6 I. Leadership, Accountability, Expertise

7 Hospital and NH Teams Collaboration Advisory Group Hospital Expert Team NH Leadership NH Stakeholders Several NH Medical Directors Hospital Infectious Diseases physician Hospital Antimicrobial Stewardship Pharmacist Project Infection Preventionist and coordinator Nursing Home Administrator Medical Director Director of Nursing Director of Quality Infection Preventionist Nursing Educator Nurse practitioner/physician Assistant In house Dispensing Pharmacist Consultant Pharmacist

8 Implementation Strategy Data Collection by Hospital Team Antibiogram collection and interpretation Urine culture data Antibiotic use data Education and Tools by Hospital Team with input from Medical Directors Advisory team Feedback of data Testing and treatment guidelines Education Pocket cards, posters, pamphlets NH Implementation of antimicrobial stewardship Implementation of tools and guidelines Antibiotic reviews and feedback Review of urine culture testing and UTI treatment Education

9 II. Tracking Data for Action

10 Understanding the Data 8 most common antibiotic indications by days of therapy (DOT) 8 most common indications by number of residents HEAD AND ENT 178 UTI PROPHYLAXIS 12 BONE/JOINT 284 HEENT 12 C. DIFFICILE 435 C. DIFFICILE 13 PNEUMONIA 531 BRONCHITIS 13 SKIN AND SOFT TISSUE 562 DENTAL PROPHYLAXIS 19 PENPHIGOID 689 PNEUMONIA 48 UTI PROPHYLAXIS 878 SKIN AND SOFT TISSUE 62 UTI 980 UTI

11 Improving Your Knowledge Linezolid Fluconazole Doxycycline Cefpodoxime Trimethoprim Amox/K Clav Ceftriaxone Ampicillin Amoxicillin SMZ-TMP Cephalexin Nitrofurantoin Levofloxacin Ciprofloxacin Treatment for UTI Number of Patients

12 Ampicillin Amoxicillin/Clav Ampicillin/sulbactam Cefazolin Ceftazidime Ceftriaxone Cefepime Ciprofloxacin Gentamicin Imipenem Levofloxacin Piperacillin/tazobactam Tobramycin Trimethoprim/sulfa Nitrofurantoin Linezolid Daptomycin Vancomycin Doxycycline Tetracycline Improving Your Knowledge Organism # of Isola tes Gram Negative Organisms Escherichia coli Klebsiella pneumonia * 0 0 Proteus mirabilis * Gram Positive Organisms Enterococcus faecalis * *Differences in the % susceptible for an organism represented by <30 isolates may not be statistically significant from year to year.

13 III.Action Improve Antibiotic Use for UTI

14 More Data: Understanding the prescribing process through antibiotic use review Clinical Situation Diagnostic Process and Decision Makings Decision to treat or active monitoring Monitor Clinical situation and Lab results Reassessment at hours: Stop, or change antibiotic, decide on duration

15 Appropriateness of UTI Testing and Treatment: Symptoms Breakdown (n=42) New onset confusion Dysuria Nausea/Vomitting/Diarrhea Frequency Other Fever Urgency New Onset Retention Incontinence & Bladder Spasm Hematuria Elevated WBC Flank Pain None Suprapubic Pain * Number of Patients

16 Appropriateness of UTI Testing and Treatment: Symptoms Breakdown (n=42) New onset confusion 15* Dysuria 11 Nausea/Vomitting/Diarrhea 5 Frequency 4 Other 3 Fever Urgency New Onset Retention Incontinence & Bladder Spasm Hematuria *12 patients, confusion delirium was the only symptom that triggered a urine culture Elevated WBC 2 Flank Pain 1 None 1 Suprapubic Pain Number of Patients

17 Appropriateness of UTI Testing and Treatment: Symptoms Breakdown (n=42) New onset confusion 15* Dysuria 11 Nausea/Vomitting/Diarrhea 5 Frequency 4 Other 3 Fever 3 Urgency New Onset Retention Incontinence & Bladder Spasm Hematuria Elevated WBC Flank Pain Most of the patients were treated for asymptomatic bacteriuria A positive Urine Culture Triggers Treatment None 1 Suprapubic Pain Number of Patients

18 IV. Development of Guidelines and Tools Nursing Staff Medical Staff Residents and Families Poster Testing and treatment Guidelines Pamphlet

19 V. Face to Face Education Nursing Staff Medical Staff Residents and Families

20 VI. Feedback-Regular and Face to Face Review progress toward completing all the ASP core elements Review processes Communication (use of SBAR) Documentation Follow up on culture results Additional educational needs Next intervention Sustaining progress- who will collect data and give feedback?

21 Start Rate Per 1,000 Resident Days Culture Rate per 1,000 Resident Days Measuring Progress 3 Urine Cultre Rate and Antibiotic Start Rate for UTI: Q Q Start of the ASP Q Q Q Q Q Q Q Q Q Q Q Q Q Q Median Length of Treatment (LOT) for UTI = 5 days 94% of UTI treatments were for 7 days or less Start Rate Culture Rate

22 DOT Rate (per 1000 Resident Days) Comparative Feedback-Reporting Antibiotic Use DOT: days of therapy Nursing Home 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4 2017Q1 2017Q2 2017Q3 Data unpublished

23 DOT Rater (per 1000 resident days) Ciprofloxacin Use Q4 2016Q1 2016Q2 2016Q3 2016Q4 2017Q1 2017Q2 2017Q3

24 Incidence (per 10,000 Resident Days) CDI Incidence- NH Collaborative Start of the antimicrobial stewardship project Data from Rochester/NYS EIP

25 Successes Antibiotic Data Microbiology Lab Collaboration NH team collaboration Obtained data from in-house and a large dispensing pharmacy Summarized data to be actionable Provided monthly or quarterly urine culture data Citywide antibiogram for smaller NH Sensitivity testing for fosfomycin Medical directors advisory group Intra-facility communication across facilities (e.g. IP team meetings and assistance for new IP)

26 Successes Citywide treatment guidelines Citywide recognition of ASP effort Provision of expertise beyond ASP Provision of educational opportunities Implementation of the guidelines in nursing homes not involved in the project Nursing Homes are asking to be part of our initiative Infectious diseases Infection control Pharmacy Support for national conference attendance Webinars and educational talks by national speakers

27 Challenges-Nursing Homes Lack of infrastructure to independently implement an ASP Dedicated personnel, expertise, easily retrievable data Interest does not always translate into action Competing priorities, high staff turnover, lack of dedicated time, unavailability of key personnel to form an ASP team Difficult to adapt to new systems (e.g. NHSN reporting, use of Excel program) Pressure to avoid re-hospitalization

28 Challenges-Hospital Antimicrobial Stewardship Team Inability to obtain antibiotic data from all nursing homes and a large commercial dispensing pharmacy Inability to provide education to covering medical providers and all nursing staff Limited capacity to perform antibiotic use evaluations No capacity to provide prospective antibiotic audit and feedback

29 Solutions and Sustainability Need a NH champion (physician, nurse, IP, NP) with dedicated time to lead/ assist with the AS program Requires leadership buy-in and a job description that includes antimicrobial stewardship Involve multiple team members to provide resilience and flexibility in case of personnel change Antimicrobial stewardship works needs to be integrated into the daily work flow and NH quality and performance improvement (QAPI)

30 Solutions and Sustainability Involve the consultant pharmacists through a change in their scope of work We provided an educational workshop Training of nursing leadership and IP in data collection and ownership We provided an educational workshop and a tool for tracking antibiotic and infection data Assistance from hospital AS experts can facilitate the implementation and sustainability of the program

31 Additional Resources Our website: Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings. Jump LR. et al. JADMA 2017 Nursing Home Antimicrobial Stewardship Guide: Do Bugs Need Drugs, Antimicrobial Stewardship in Long Term Care Facilities: Improving Evaluation of Urinary Tract Infections in the Elderly: Massachusetts coalition: Promoting Wise Antibiotic Use In Nursing Homes: Nebraska Antimicrobial Stewardship Assessment and Promotion Program: Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities: Washington State Department of Health: Jump start antimicrobial stewardship:

32 BIG THANKS! Christina Felsen, MPH Grant Barney Gail Quinlan Elizabeth Dodds Ashley PharmD

33 More Acknowledgments Medical Director Advisory Group Alexandra Yamshchikov, MD Dallas Nelson, MD Joseph Nicholas, MD Timothy Holahan, MD Annette Medina Walpole, MD Scott Schabel, MD Diane Kane, MD Pharmacy All the Nursing Homes Dispensing Thomas Pingree, MD Pharmacists Mary Aydelotte, MD Vince Galetta, Pharm D, Buffalo Rena Pine, MD Pharmacies Kim Petrone, MD Brandi Van Valkenburg, Pharm D, Brian Heppard, MD Health Direct Pharmacy Nirmala Nicholas, MD Alexander Karlic, MD All the nursing Homes IPs All the Nursing Home Staff Microbiology Labs

34 Acknowledgments