Antimicrobial Stewardship at Swedish Medical Center John Pauk MD, MPH Medical Director Infection Control and Epidemiology Antimicrobial Stewardship John Zarek, RPH Director of Clinical Pharmacy Swedish Medical Center Stewardship the conducting, supervising, or managing of something; especially : the careful and responsible management of something entrusted to one's care The moral and ethical responsibility for The moral and ethical responsibility for caretaking on behalf of others. 1
Swedish Hospital System 4 Hospital campuses 1297 total patient beds 226,100 patient days per year 7 full time Infectious Disease clinicians Surgical and Family Practice Residency Programs Pre-existing structure of antimicrobial stewardship at Swedish Restricted Formulary e.g. Linezolid, Daptomycin, Voriconazole, caspofungin, tigecycline, ertapenem Care pathways Pneumonia, UTI, SSTI, Sepsis Education 2
Planning for AMS program at Swedish 2008 Business plan submitted to administration (Pharmacy and Infection prevention) 2009-2010 Purchase and install of Theradoc software Early 2010: Intensive planning for implementation of prospective audit and intervention team September 2010: Go live date for AMS team Antimicrobial Stewardship Key issues in building a program Administrative Support Business plan that supports the program in terms of personnel time and software investment Estimated cost savings Effect on quality measures and compliance Length of stay and readmission rates 3
Antimicrobial Stewardship Key issues in building a program Infection Control Decision support software will be also used for surveillance Business plan will effect both pharmacy and infection control Strategizing how epidemiology data will be used to evaluate impact of AMS program ( C diff, MRSA, VRE, resistant GNR rates, etc.) Antimicrobial Stewardship Key issues in building a program Clinician Acceptance Support from other key groups is essential (Hospitalists, critical care, etc.) Educate about the AMS program before implementation Focus on patient safety and quality Plan ahead carefully as to how AMS team s recommendations will be documented Stress voluntary nature of the program 4
Antimicrobial Stewardship Infectious Disease Support Concern that AMS will replace ID consults AMS could be seen as threat t to autonomy of ID physicians Stewardship not always the traditional priority for ID consultation AMS interventions on patients followed by ID could lead to conflict Antimicrobial Stewardship Addressing Infectious Disease Concerns All ID doctors included in planning and evaluation of the program CME for time on committee as well as great opportunity to learn and discuss best practice ID docs are compensated for their time on the AMS committee Impact on ID consults in patient care is a net positive Sensitivity to avoid conflicts of the AMS team with ID management of cases 5
Structure of Swedish antimicrobial stewardship program (ASP) Antimicrobial Stewardship Oversight committee Formulary Approval And Restriction Antimicrobial Stewardship Team Care pathways And protocols Antimicrobial Stewardship: Oversight Steering Committee Monthly 2 hour meetings to review the program and discuss strategies for AMS Infectious Disease Epidemiology/Infection Control Pharmacy Microbiology Adult Hospitalist Team and Critical Care Representation 6
Antimicrobial Stewardship: Oversight Antimicrobial Stewardship Steering Team: Advisory role for AMS team Develop evidence based guidelines for the interventions of the AMS team Review effectiveness of interventions Review feedback on the program and factors effecting acceptance Measure impact of program Monitor for unintended consequences Antimicrobial Stewardship: Oversight Review Policies and Protocols related to antimicrobial i use in the hospital Develop and maintain admission order sets Monitor pharmacy policies for dosing and monitoring of antimicrobial use Control of which antimicrobials are on the hospital formulary Facilitate discussion on and help implement best practice in infectious disease 7
Antimicrobial Stewardship Key issues in building a program Technology Electronic Health Record with order entry (EPIC) Clinical decision support software (TheraDoc) Linking pharmacy and microbiology database systems Pharmacy data monitoring plan to evaluate change pre and post implementation (McKesson) Centralized decision making and interventions enabled by technology Prospective audit with intervention and feedback Review individual patients in real time Feedback to clinician with recommendation for voluntary changes in antimicrobial use Monitor for acceptance of recommendations and subsequent follow-up 8
AMS Team at Swedish Core Team Members 3 Adult Infectious Disease MDs 7 pharmacists (1.5 pharmacy FTE) Daily 2 hour meeting scheduled to review cases EPIC documentation, microbiology, radiology, and pharmacy data can all be reviewed for all four campuses from one location. Documentation of intervention in EPIC charting Notification of care team of an intervention Monitor patient for acceptance of intervention TheraDoc Alerts Alert Types from TheraDoc System Significant positive culture not receiving ing appropriate treatment No positive bacterial or fungal culture on ABX Poly-antimicrobials Targeted drugs (e.g., cefepime, daptomycin, imipenem, Zosyn, caspofungin, vancomycin > 72 hours) Targeted organisms (e.g., ESBL producer, MRSA) 9
Antimicrobial Stewardship Team: Interventions Identify bug-drug mismatches Streamlining i or de-escalation of therapy De-escalate therapy on the basis of cultures Eliminate redundant coverage Dose optimization Parenteral to oral conversion Ensure appropriate length of therapy Identify complex cases who need earlier Infectious Disease consultation Clinical Vignette 74 y/o male with history of urosepsis and bacteremia with ESBL E coli sensitive only to Imipenem is readmitted with new fevers, UTI, and GNR bacteremia Started on Zosyn/Levaquin by admitting team Threaded alert for polymicrobials fires AMS team calls MD to recommend change to Imipenem and consider ID consult Therapy changed and resistance later confirmed 10
AMS team EPIC note The AMS team reviewed this patient's current antimicrobial therapy on 1/13/10 2010. The patient is currently receiving antimicrobial therapy consisting of piperacillin-tazobactam and Levofloxacin. Patient with gram negative rods in blood cultures and history of bacteremia with ESBL E coli. Please consider changing antimicrobial coverage to Imipenem to cover possibility of ESBL organism. If felt to be indicated, could consider infectious disease consultation. Dr. has followed the patient in the past. The patient's clinical data from Epic including microbiology, labs, radiology, and chart notes were used in formulating this recommendation. This recommendation is not a substitute for the clinical judgment of a provider directly involved in the patient's care or an infectious disease consultation. This recommendation has been reviewed with the infectious disease physician serving on the AMS program. Please contact the AMS team with any questions and we will review any relevant documentation in the chart concerning these recommendations. Measuring the impact of AMS programs Acceptance rate of interventions Antibiotic use Defined Daily Doses/1000 patient days Antibiotic costs Longitudinal changes vs. benchmarking Rate of adverse drug events Impact on rates of resistant pathogens Length of stay and readmission rates by DRG Compliance with guidelines on best practice 11
Alert type Number/Percent Positive culture - any 1341 (33.9%) Unrelated to alert 843 ( 21.3%) No positive bacterial cultures 318 (8.0%) Target drug: Zosyn 304 (7.2%) TAM polyantimicrobials: 3 or more 237 (7.7%) antimicrobials TAM inpatient : Organism not covered 206 (5.2%) by current antibiotics Relevant culture: blood 176 (4.5%) Relevant culture: urine 90 (2.3%) Target drug: vancomycin > 72 hours 71 (1.8%) Relevant culture: respiratory 40 (1.0%) Top ten alerts = 91.6% of all alerts 2011 alert review by AMS team = 4,316 Number Percent Streamline/de-escalate coverage 1,700 39.4% Recommend shortened duration of therapy 581 13.5% Recommend antibiotic culture positive 517 12.0% Recommend ID consult 513 11.9% Correct drug-bug mis-match 438 10.1% Discontinue antibiotic no culture positive 431 10.0% Dosage change antibiotic/antifungal therapy 75 1.7% Change IV to PO 38 0.9% Recommend discharge therapy for home 12 0.3% Interventions/week = 20.3 Accepted/modified interventions = 89.1% Patients monitored, no action = 3,258 12
Swedish System Antibiotic Cost/month actual utilization 1st Hill/Cherry Hill Antibiotic Cost/Month $1,450,000 $1,350,000 $1,250,000 Oct09-Aug10 = $1,016,738/month Sep10-Nov11 = $955,836/month $60,902 savings/month Average Cost/month decrease of $60,902 $1,150,000 $1,050,000 $950,000 $850,000 $750,000 $650,000 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Total Average Swedish System Antibiotic Use Cost/Patient Day $105 $95 $85 1st Hill/Cherry Hill Cost/PD Oct09 - Aug10 = $72.51 Sep10 - Nov11 = $67.38 $5.13/PD decrease = 7.1% $1,091,649 Total Savings $75 $65 $55. $45 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Cost/PD AveCost/PD 13
Swedish System Defined Daily Doses (per 1000 patient days) Selected Antibiotics Oct09- Aug10 Sep10- Nov11 Change in DDDs Zosyn 96.0 75.3 21.6% Levofloxacin 147.2 121.8 17.3% Imipenem 18.4 16.9 8.2% Cefepime 23.1 28.4 22.9% Vancomycin 108.8 96.7 11.1% Daptomycin 15.8 14.1 10.5% AMS experience at Swedish: 1 st year impressions High acceptance rate of interventions Overwhelmingly positive feedback from clinicians A number of near misses averted Pharmacy expertise in ID is growing and pharmacists have more ability to intervene when working in other areas besides AMS The AMS team now will get referrals from the care teams to review antibiotic use Clinician Documentation of indications, rationale, and treatment plan is infinitely better Educational impact is apparent 14
Next steps for Swedish AMS Use of the Procalcitonin assay Rapid ultra-sensitive procalcitonin assay now available in house starting February 2012 Plans to utilize as a measure for when to discontinue antibiotic therapy for various infectious disease diagnoses such as sepsis and pneumonia Possible tool to differentiate viral from bacterial respiratory syndromes A multidisciplinary team will be important for success Will plan to use conservatively at first until more clinical data validating this assays use. Next steps for Swedish AMS Extended infusion of Piperacillin-Tazobactam Starting Spring 1012, we will implement extended infusion of Pip-Tazo as the default dosing protocol for all ICUs Pre-implementation education of nursing and physicians as to the benefits of this approach will be key We hope to improve outcomes for severe infections and reduce expenses on one of the costlier drugs on our formulary If ICU implementation is successful, will plan to extend this as the preferred dosing for floor patients when appropriate 15
Next steps for Swedish AMS Increase the variety of patients reviewed and # of interventions done by the AMS team Much of our big measurable impact will be in the first year of the program. How do we continue to show our value to the Swedish system? Analyze other endpoints that might be related to AMS Length of stay and readmission rates by DRG MDRO rates Adherence to quality measures/ guidelines Antimicrobial stewardship and Clostridium difficile: Can we show a benefit? As assays for CDI change over the same interval we implement more rigorous stewardship, will this make it more difficult to see an association? Will a 10-20% reduction in hospital antibiotic use be enough to drive down CDI rates? What other concurrent measures will affect CDI rates? Would targeting a specific drug class (i.e. quinolones) be more a more effective strategy? 16
Acknowledgments John Zarek Pharmacy Core Team Rosie Amini, Andrea Baek, Christine Ondro, Lance Reding, Thomas Rivers, Ashley Wilson, and Shawn Wood Microbiology Glendon Pflugrath Infectious Disease Core Team and all of the ID Doctors Emily Darby, Justin Jin, John Pauk Infection Control Will Shelton, Mavis VanDelict Adult Hospitalist Team and Critical Care Kenji Asakura, Derel Finch, Charlie Lee 17