Successful Antibiotic Stewardship Byron Health Center & GrandView Pharmacy Learning Objectives Understand the core requirements of an antibiotic stewardship program as defined by the CMS Requirements of Participation, AKA the "Mega Rule. Reflect on the challenges and successes of a fully implemented antibiotic stewardship program. Discuss the implementation of a successful antibiotic stewardship program in a variety of patient care settings. 1
What is required, and when? Effective November 28, 2017 (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases (2) Written standards, policies, and procedures for the program, including a. A surveillance system b. Reporting (to whom, and when) c. Transmission based precautions d. Resident isolation protocols e. Employee isolation protocols f. Hand hygiene procedures Requirements continued (3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. (4) A system for recording incidents identified under the facility s Infection Prevention Control Plan (IPCP) and the corrective actions taken by the facility. 2
Future Requirements Effective November 28, 2019: The facility must designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility's IPCP. The IP must: (1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field (2) Be qualified by education, training, experience or certification (3) Work at least part time at the facility and (4) Have completed specialized training in infection prevention and control. Future Requirements, continued The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis. 3
Implementation Plan Action Step Identify antimicrobial stewardship champions Initially Action Step Incorporate antimicrobial stewardship issues in a committee/work group Initially Action Step Provide regular antimicrobial stewardship education and training to all healthcare personnel, including providers Quarterly Action Step Provide education and training to nursing staff, at all levels, within the community to promote the timely and accurate recognition, assessment, communication and documentation of change in a resident s condition Quarterly Action Step Communicate antimicrobial stewardship messages to healthcare community, residents, families and visitors ly Implementation Plan continued Action Step Develop and communicate policies and protocols based on clinical guidelines for antimicrobial stewardship, infection management and diagnostic testing Twice annually Action Step Conduct surveillance for infections ly Action Step Evaluate the community s process to assess, communicate, and document resident s change in condition Quarterly Action Step Community sets the expectation that a change in a resident s condition is consistently communicated between nursing assistants and nursing through the use of a standardized process ly 4
Implementation Plan continued Action Step Community sets the expectation that a change in a resident s condition is consistently documented ly Action Step Diagnostic testing results, including microbiology, are accessible in a timely manner for clinical decision making and infection surveillance ly Action Step All licensed providers, in the community, follow clinical practice guidelines for infection management ly Action Step Measure antimicrobial use ly, and yearly Case Study: Byron Health Center Patient Population Characteristics: Approximately 100 Residents Median age ~ 65 years Age Range 28 94 years 55% Male, 45% Female High variability in independence High prevalence of psychological disease Located in Fort Wayne, Indiana 5
Byron UTI Rate What else did Byron do? Root Cause Analysis on all Antibiotics Prescribed Probiotics Infection Control Rounding CMS Optimistic Program 6
Reflection: Challenges 1 - Physician Engagement 2 - Staff Education 3 - Accurately Documenting Impact 4 - Culture of Change RESULTS 7
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Some tough questions... 1 The program was initiated in January 2017. Cost of therapy numbers had been decreasing before this. Why was this? Can you still say that the program was successful? A Violet s Form. B Yes. 2 Cost of therapy appears to have declined, but days of therapy remained about the same. Did we really reduce incidence of infection? Or did we just start using less expensive therapies? Potentially both. There are too many factors and variables to hold constant. What was truly accomplished? 1 Protocols for identifying infection were integrated through nursing staff. 2 Protocols for initiating non pharmacologic and pharmacologic treatment were integrated with nursing, medical staff. 3 Appropriate treatment options were reviewed with medical staff. 9
Implementation in your setting 1 Approach and process and implementation may be similar between communities 2 Individualized approaches for residents will vary 3 Education of nurses and prescribers will vary Be prepared to improvise! Take Home Points The primary goal of an antibiotic stewardship program is increased judiciousness in identifying and treating infection. Even a great antimicrobial stewardship program may see increases in incidence of infection and costs. The best way to ensure success is to get staff to buy in. 10
Questions, Comments, Observations? Successful Antibiotic Stewardship G. Michael Eldridge, PharmD, RPh Consultant Pharmacist M: 1.260.247.9962 michael.eldridge@grandrx.com 11
866.827.7575 Measure Antimicrobial Use Ensure Adherence to Practice Guidelines Ensure Timely Diagnostic Procedures Ensure Change of Condition Documentation Ensure Nurse-CNA Communication Evaluate Communication Processes Infection Surveillance Develop and Communicate Protocols, Policies Communicate Stewardship Messages - All Change of Condition Training - Nursing Stewardship Training - All providers Organize Champions Identify Champions 2 3 4 5 7 8 9 www.grandrx.com 6 10 11 12 Program Implementation Plan solutions@grandrx.com 1 Antimicrobial Stewardship Copyright 2017 GrandView Pharmacy, Inc. All Rights Reserved.
Monitoring Compliance with Infection Control Review Administrative Policies Appendix C Date: Time: Conducted By: All Depts, Reviewed by IC Committee Surveillance Item Yes No Not Nnow Not Applicable Comments Corrective Action Recommended Nursing Services Is equipment clean (i.e., bedpans, basins, urinal, etc.)? Are personal belongings marked, stored? Is water pitcher clean, marked; are water and ice fresh? Is resident clean and dry? (select 10 residents, add report to checklist) Is there evidence of oral care, handwashing? Are isolation precautions communicated to staff and visitors, when appropriate? Is equipment cleaned per facility protocol and manufacturer instructions, i.e. glucometer, AED, PT/INR machines? Foley Catheters Is hygiene practiced before and after handling catheter system? Is tubing anchored? Is bag below the bladder? Is bag off the floor? Are separate marked, disinfected graduates available for each resident? Is the urine clear? Is Foley free from grit or sediment? Copyright 2017 GrandView Pharmacy, Inc. All Rights Reserved. Tube Feeding Is hand hygiene practiced before and after handling tubing system, administering feeding solution? Is administration tubing marked and dated? Has tubing been in place under 24 hours? Is feeding syringe marked, dated, cleaned and stored according to established practices? Is solution correct solution, date, and rate? Is solution not separated? Is there evidence of good oral hygiene? A Project Funded and Facilitated by the Rhonda Eldridge Center for Healthy Aging 1
Monitoring Compliance with Infection Control Review Administrative Policies Appendix C Surveillance Item Yes No Not Nnow Not Applicable Comments Corrective Action Recommended Ostomy/Wound Care Is hand hygiene practiced before and after procedure? Is skin site clean? Are aseptic/sterile techniques used as appropriate? Is contamination avoided? Does the resident have own (dedicated) supplies for ostomy care? Are solutions marked and dated, stored separately? Is there safe handling of blood and infectious fluids? Is antiseptic applied to site per physician order? IV Therapy Is hand hygiene practiced before and after procedure? Are IV tubings dated (not over 72 hours)? Is site free from signs/symptoms of inflammation, purulent drainage, pain or tenderness? Is site care performed? Is insertion practice in standard with policy and procedure? Is sterile technique used for insertion? Needle Handling Copyright 2017 GrandView Pharmacy, Inc. All Rights Reserved. Is aseptic technique used when administering injections? Are needles recapped by hand? Are needles recapped with a recapping device? Are needles deposited uncapped into designated sharps container? Is the sharps container overfilled? Is the sharps container marked BIOHAZARD? Is the sharps container properly stored? Does safe handling of needles appear to be a staff priority? When asked what to do if needlestick occurs, is response appropriate? A Project Funded and Facilitated by the Rhonda Eldridge Center for Healthy Aging 2
Monitoring Compliance with Infection Control Review Administrative Policies Appendix C Surveillance Item Yes No Not Nnow Not Applicable Comments Corrective Action Recommended Infection Control Is there monitoring for healthcare-associated infections? Is a surveillance log maintained? Are residents free from healthcare-associated infections? Does prevention of healthcare-associated infections appear to be a staff priority? Are infection rates evaluated? Are residents at high risk of infection identified and monitored? Are infection control practices and procedures adopted and used appropriately? Are residents immunized against Pneumococcus, Influenza? Are communicable diseases/infections reported to the health department? Is there documentation of monthly infection control meetings? Is infection control policy and procedure manual current? Are infection control policies and procedures reviewed annually? Dietary Services Copyright 2017 GrandView Pharmacy, Inc. All Rights Reserved. Do food handlers wash hands upon entering room, before handling food, and after handling soiled dishes? Are food tray temperatures below 45 F or above 140 F? Are refrigerator temperatures 45 F or below? Any missing temperatures? Are freezer temperatures 0 F or below? Is food held at the bedside? Are sanitizing procedures (dishes, glassware, utensils, equipment, etc.) appropriate, clear? Is dishwasher temperature recorded? Is uncooked food stored over cooked food? Is environment clean? Continued on next page... A Project Funded and Facilitated by the Rhonda Eldridge Center for Healthy Aging 3
Monitoring Compliance with Infection Control Review Administrative Policies Appendix C Surveillance Item Yes No Not Nnow Not Applicable Comments Corrective Action Recommended Laundry Services Do employees wash hands and use gloves appropriately? Is environment clean? Are clean and dirty linen carts kept separate? Is linen visually clean and intact? Is linen stored in enclosed area? Is protective gear (gloves, gowns) worn during sorting, handling of soiled laundry? Is contaminated linen sent to laundry in plastic BIOHAZARD bags? Is linen held away from the employee s clothing? Maintenance Services Is hygiene and glove use practiced during plumbing work? Are masks used during heating/ventilator/ air-conditioning work? Are plumbing spills contained? Are heating/ventilators/air-conditioning filters clean? Do construction sites have barriers to prevent dust? Is area free from standing water/condensate? Is the ice-machine PM log maintained? Is the ice-machine visibly clean? Is there a designated, secure area for trash holding? Are ice machine drains/hoses installed per manufacturer s instructions to prevent potential backflow? Copyright 2017 GrandView Pharmacy, Inc. All Rights Reserved. Housekeeping Services Are hand hygiene and gloves used during procedures? Are cleaning containers properly marked? Are disinfectants EPA registered for hospital use and effective in 5%organic soil? Are disinfectants properly diluted? Is mop water clear? Are blood/body fluid spills handled properly? Are bathroom fixtures clean? Is there proper trash handling/storage, 3 mil bags? Are BIOHAZARD signs available for infectious waste? Are rooms designated with precautions cleaned per protocol? Continued on next page... A Project Funded and Facilitated by the Rhonda Eldridge Center for Healthy Aging 4
Monitoring Compliance with Infection Control Review Administrative Policies Appendix C Surveillance Item Yes No Not Nnow Not Applicable Comments Corrective Action Recommended Employee Health Program Is pre-employment TB testing done? Is HBV available to employees? Is there a post-exposure plan in place? Are exposure reports filed and reviewed by the Infection Preventionist? Do employees report infectious conditions? Are employees trained and competent in the application of Standard and Transmission-Based Precautions? Is a first aid kit available for employee use? Personal Protective Equipment and Hand Hygiene Are gloves, gowns, masks and protective eyewear available and in a readily accessible location? Are solutions for cleaning blood/body fluid spills or blood spill kits available? Are sharps disposal containers available and conveniently located? Are sinks, towels, soap, hand sanitizer and trash receptacles available and convenient? Are hand hygiene reminder signs posted? Do employees answer questions about availability of personal protective equipment? Do employees know where personal protective equipment is stored? Are proper hand hygiene procedures followed? Copyright 2017 GrandView Pharmacy, Inc. All Rights Reserved. Other A Project Funded and Facilitated by the Rhonda Eldridge Center for Healthy Aging 5