The Core Elements of Antibiotic Stewardship with CMS and QAPI Updates

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1 The Core Elements of Antibiotic Stewardship with CMS and QAPI Updates Emily Lutterloh, MD, MPH Director, Bureau of Healthcare Associated Infections New York State Department of Health February 8, 2017

2 March 6, Outline Antibiotic stewardship (ASP) in nursing homes Core elements for ASP CMS and ASP QAPI and ASP

3 March 6, Antimicrobial Stewardship

4 March 6,

5 March 6, Stewardship for Nursing Homes

6 March 6, Core Elements Leadership commitment Accountability Drug expertise Action Tracking Reporting Education

7 March 6, Leadership Commitment Statements supporting improved antibiotic use shared with staff, residents, families Stewardship duties included in position descriptions for medical director, nurse leads, consultant pharmacists Communicate expectations and enforcement regarding antibiotic use Create a culture promoting stewardship

8 March 6, Accountability Medical director sets prescribing standards for credentialed staff Accountable for adherence Reviews antibiotic use data Director of nursing sets standards for communicating a resident s condition Role in decision-making Knowledge of guidelines

9 March 6, Drug Expertise Consultant pharmacist with training in infectious disease or antibiotic stewardship Infectious disease consultants Partner with hospital stewardship leads

10 March 6, Action: Policy and practice change to improve antibiotic use Medication regimen review applied to antibiotics Standardization of antibiotic start process Communication Diagnostic testing Antibiotic time-out Pharmacist integration Interventions to improve use in specific clinical situations

11 March 6, Action

12 March 6, Action Documentation of dose, duration, indication Best practices for microbiology testing Treatment recommendations based on national guidelines and local susceptibilities Review accessibility of drugs off hours Develop and disseminate antibiograms Reduce prolonged courses of antibiotics Specific interventions Asymptomatic bacteriuria, prevention of UTI Pneumonia Superficial wound cultures

13 March 6, Tracking How and why antibiotics are prescribed How often and how many antibiotics are prescribed Starts, DOT Adverse outcomes and costs C. difficile, antibiotic resistance, adverse drug events

14 March 6, Tracking

15 March 6, Tracking Completeness of documentation Clinical assessment, prescribing Point prevalence survey of antibiotic use

16 March 6, Reporting Share data with prescribers and nurses Future: NHSN reporting? Summary data National benchmarking

17 March 6, Education Clinicians, nursing staff, residents, families Academic detailing Feedback to clinicians

18 March 6, Partners Infection preventionists Tracking antibiotic starts Monitoring adherence to guidelines Reviewing resistance patterns Consultant pharmacist Medication review Reporting antibiotic use data Consultant laboratory Alerts for resistant organisms Antibiograms

19 March 6, Resources

20 March 6, Antimicrobial Stewardship SHEA, IDSA, and PIDS recommend that the Centers for Medicare and Medicaid Services (CMS) require participating healthcare institutions to develop and implement antimicrobial stewardship programs. This can be achieved by incorporating the requirement into existing regulations via expansion of interpretive guidelines of the relevant regulation(s). All healthcare facilities, including hospitals, long-term care facilities, long-term acute care facilities, ambulatory surgical centers, and dialysis centers should develop and implement an antimicrobial stewardship plan that is modeled after the IDSA and SHEA Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. * *Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hospital Epidemiol. 2012;33:322-7.

21 March 6, CMS CFR

22 March 6, Timeline Nov Phase 1 (existing, straightforward, minor changes) Nov Phase 2 (more time to develop) Antibiotic stewardship Nov Phase 3 (more time to develop and/or implement, personnel/training requirements) Infection preventionist

23 March 6,

24 March 6, Surveys and Worksheets

25 March 6, Infection Control Worksheets

26 March 6, Infection Control Worksheets Antibiotic Stewardship Has stewardship program approved by governing body Accountable clinical leader(s) per their position description Written protocols on antibiotic prescribing

27 March 6, Infection Control Worksheets Antibiotic Stewardship Infection assessment tools/management algorithms for at least one infection Ex. SBAR for UTI assessment, Loeb minimum criteria for initiation of antibiotics Report summarizing antibiotic use from pharmacy data within last 6 months

28 March 6, Infection Control Worksheets Antibiotic Stewardship Antibiogram created within past 24 months Clinical leadership provides prescribers with feedback about antibiotic prescribing Clinical leadership has provided training on antibiotic use to nursing staff and prescribers within last 12 months Educational materials on stewardship for residents and families

29 March 6,

30 March 6, Infection Control Worksheets QAPI Infection preventionists provides documentation of infections to QAA Committee QAA Committee plan includes oversite of infection control program

31 March 6, Infection Control Worksheets QAPI QAA Committee develops plans of action to address infection prevention issues Infection prevention related adverse events analyzed using root cause analysis

32 March 6, Infection Control Worksheets Care Transitions (selected) Documentation of infection, colonization, h/o MDRO, C. difficile, etc. Communication about antibiotic dose, route, indication, start/stop date, last administered

33 March 6, Thank you!