Antimicrobial Stewardship Program in the Nursing Home CAHF San Bernardino/Riverside Chapter May 19 th, 2016 Presented by Robert Jackson, Pharm.D. Pharmaceutical Consultant II, Specialist CDPH Licensing & Certification
Learning Objectives Review public health impetus and regulatory framework for LTC antibiotic stewardship programs Discuss the CDC s core elements of antibiotic stewardship in nursing homes Identify potential strategies for implementing an antibiotic stewardship program
Why are we concerned? 4.1 million Americans admitted to or reside in nursing homes annually Approximately 77% to 88% of all potential infectious episodes are treated with antimicrobials Numerous reviews have concluded that a high percentage ( 75%) may be unnecessary or inappropriate For comparison, 50% in hospitals
Actions at the National Level September 2013 CDC report: Antibiotic Resistance Threats in the United States September 2014 Executive Order: Combating Antibiotic-Resistance Bacteria March 2015 - National Action Plan for Combating Antibiotic-Resistant Bacteria June 2015 - White House Forum on Antibiotic Stewardship
CMS Proposed Reform of LTC Requirements Published in the Federal Register in July 2015 Includes proposed revisions to 42 CFR 483.80 (Infection Control) Infection Prevention & Control Program Develop antimicrobial stewardship program which includes antibiotic use protocols and antibiotic monitoring Recording incidents/corrective action taken Infection Control Program Officer (ICPO)
CA Senate Bill 361 Licensing requirements chaptered October 2015 Adds Section 1275.4 to Health and Safety Code SNFs shall adopt and implement an antimicrobial stewardship policy by 01/01/2017 Consistent with guidelines developed by CDC, CMS, SHEA or similar recognized organizations
CDPH-CHCQ Program Healthcare Associated Infections (HAI) Program created by mandate to oversee the prevention, surveillance and reporting of healthcare-associated infections in California's general acute care hospitals. Useful resources and links to nationally recognized infection control organizations HAI webpage: https://www.cdph.ca.gov/programs/hai/pages/default.aspx ASP initiative: https://www.cdph.ca.gov/programs/hai/pages/antimicrobialstewardshipp rograminitiative.aspx ASP toolkit: https://www.cdph.ca.gov/programs/hai/documents/asptoolkitreviewedl C042815FINAL.pdf
What is Antibiotic Stewardship? A set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.
The Core Elements of Antibiotic Stewardship for Nursing Homes Leadership commitment Accountability Drug Expertise Action Tracking Reporting Education
Leadership Commitment Facility leadership, both owners and administrators, as well as regional and national leaders if the facility is part of a larger corporation, should demonstrate support by: Write statements to support improved antibiotic use Include stewardship-related duties in position descriptions Medical Director, Clinical Nurse leads, Consultant Pharmacists Communicate with nursing, medical, and pharmacy the expectations, monitoring, and enforcement of stewardship policies Create a culture of improved antibiotic use through messaging, education, and celebrating improvement
Accountability Empower the Medical Director to set standards for antibiotic prescribing for all providers..and be accountable for adherence. Empower the Director of Nursing to set the practice standards for assessing, monitoring and communicating changes in a resident s condition by front-line nursing staff. Engage the Consultant Pharmacist in supporting antibiotic stewardship oversight through quality assurance activities.
Accountability resources Infection prevention program coordinators have expertise and data to create strategies to improve antibiotic use Tracking, monitoring adherence to evidence based criteria, and reviewing antibiotic resistance patterns within the facility Contracted laboratories can provide reports and services to support stewardship Alert facility if AROs identified, education on diagnostic tests, and provide antibiograms State & local health departments provide resources on ASP and HAI programs
Drug Expertise Infectious disease consultants and consultant pharmacists with training in antibiotic stewardship can help a nursing home reduce antibiotic use and experience lower rates of AROs Work with a consultant pharmacist who has received specialized infectious diseases or antibiotic stewardship training Partner with antibiotic stewardship program leads at the hospitals within your referral network Develop relationships with infectious disease consultants in your community
Take Action Through Policy and Practice Change Step-wise implementation of new policies and procedures which address antibiotic use. Prioritize interventions based on the needs of your facility and share outcomes from successful interventions with nursing staff and clinical providers.
Policy & Practice Change Policies that support optimal antibiotic use Ensure that current medication safety policies, including medication regimen review, developed to address Centers for Medicare and Medicaid Services (CMS) regulations are being applied to antibiotic prescribing and use. Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. Improve the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection Optimizing the use of diagnostic testing Implementing an antibiotic review process (antibiotic time-out) Algorithms Require prescribers to document dose, duration, and indication
Policy & Practice Change Integrate the dispensing and consultant pharmacists Ensure antibiotics are ordered appropriately Review culture data Develop antibiotic monitoring & infection management guidance Infection syndrome specific interventions to improve antibiotic use Asymptomatic bacteriuria or urinary tract infection prophylaxis Facility specific treatment regimens for specific infections Suspected UTIs account for 30-60% of antibiotic prescribing in nursing homes
Tracking and Reporting Antibiotic Use and Outcomes Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship.
Measures of Antibiotic Prescribing, Use, and Outcomes Tracking how and why antibiotics are prescribed Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices Tracking how often and how many antibiotics are prescribed Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions Snap-shot vs. Days of Therapy (DOT) impact Tracking the adverse outcomes and costs from antibiotics Monitor clinical outcomes such as rates of C. difficile infections, antibioticresistant organisms, or adverse drug events to demonstrate that antibiotic stewardship activities are successful in improving patient outcomes
Education Provide antibiotic stewardship education to clinicians, nursing staff, residents and families Effective programs address both nursing staff and clinical providers on the goal of an antibiotic stewardship intervention, and the responsibility of each group for ensuring its implementation Flyers, pocket-guides, newsletters or electronic communications Interactive academic detailing (face-to-face interactive workshops) = most effective!! Sustain improvements by incorporating both education and feedback to providers Studies show improvement when feedback provided to providers on inappropriate/nonadhering prescribing Engage residents and their family members in antibiotic use and stewardship educational efforts to ensure clinicians have their support to make appropriate antibiotic use decisions
Nursing home Antimicrobial Stewardship Modules The Nursing Home Antimicrobial Stewardship Modules include four tested, evidence-based toolkits to help optimize antibiotic use in nursing homes. The modules are intended to assist nursing homes develop antimicrobial programs. Module 1: Improving Communication and Decisions About Antibiotic Use in Nursing Homes Module 2: Antibiograms Choosing an Appropriate Antibiotic http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/nh-aspguide/index.html
Implementing Change in Antimicrobial Stewardship Programs: Two Educational Activities in Virtual Poster Format Virtual Poster 1 Implementing Change in Antimicrobial Stewardship Programs: Focus on New Laboratory Procedures, Time to Effective Therapy, and Incidence of C. difficile Infection Virtual Poster 2 Implementing Change in Antimicrobial Stewardship Programs: Focus on Time to Effective Therapy, Asymptomatic Bacteriuria in the Emergency Department, and Pneumonia Risk Assessment http://www.teamasp.org/ Sponsored by ASHP
Implementing an ASP: Guidelines by the IDSA and the SHEA Published April 2016 Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) released 27 antibiotic stewardship recommendations to improve patient outcomes, optimize resources, and address the growing problem of antibiotic resistance http://cid.oxfordjournals.org/content/early/2 016/04/11/cid.ciw118.full
Conclusion Improving use of antibiotics in healthcare is a national priority SNFs are statutorily required to adopt antimicrobial stewardship policy by January 1, 2017 CDC Core Elements of Antibiotic Stewardship for Nursing Homes provides guidance
Questions?