Results from Antimicrobial Stewardship (AMS) Program Implementation Joe Dula, Pharm.D., MBA, BCPS Regional Vice President, Clinical Operations jdula@pharmacysystems.com Pharmacy Systems, Inc. PSI Supply Chain Solutions PSI Rehabilitation Services
Objectives Review results from implementing AMS strategies in a single hospital. Review results from implementing AMS strategies across a health system. Revisit tips to influence stakeholders and achieve buy-in for an AMS program. 1
Introduction
Recent Developments 3
Recent Developments 1. Ladd J. AMS in small hospitals: Breaking down barriers. Pharmacy Today. November 2017. 2. https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements-small-critical.html 4
Emphasis on Compliance Sharing of resources / sample binders from successful surveyed facilities available through shared resources Educational offerings (both podium and webinar) Monthly new content slicks, targeted info 5
Assess Current State CDC Checklist / Core Elements https://www.cdc.gov/getsmart/healthcare/pdfs/checklist.pdf 6
AMS Resource Portal Pharmacy Systems, Inc. 7
Assess Current State Pharmacy Specific Activity Audit 8
ASP Binder Contents 9
Example Stakeholders Antimicrobial Stewardship Team: Infection Prevention Microbiology Lab Clinical Staff Pharmacists IODINE Data Mining Alerts ASP Team Leads ID Physician, P&T Chair + ID Clinical Pharmacist Critical Care Decentralized Pharmacists Case Management and Quality Dept. Hospital Leadership Providers Committed to Proper Abx Use
Example Goals A. Strategies/Actions Create required Queries in Meditech to capture Type of Treatment and Indication for all prescribed antimicrobials Increase IV to PO conversion rate by 10% for antimicrobials i. Reinforce importance and target education with pharmacists ii. Increase the number of approved antimicrobials for IV to PO pharmacist conversion Increase percentage of Severe Sepsis/Septic Shock patients receiving appropriate antibiotics i. Trigger patients with Sepsis diagnosis in pharmacy ii. Monitor patients with this diagnosis and make recommendations when needed Medication Utilization Evaluations i. Complete an MUE on Teflaro (Ceftaroline) by March 2017 11
Example Targets Key Drivers of Existing Program Success: Strong, engaged program and hospital leadership Infectious disease physician is a key strategic partner Interdisciplinary teamwork Clinical pharmacists (ID specialty, clinical staff and decentralized) Goals for 2017: Implement education programs (Q1-17) Improve % vancomycin troughs < 10 g/dl (Q2-17) Maintain existing antimicrobial expenses rate (Q3-17) Decrease quinolone use Decrease duration of antibiotic treatment Institute 48 hour antibiotic time out in critical care How will we know our new program was successful? 90% + of medical/hospital staff and patients are educated % vancomycin troughs < 10 g/dl maintained at 15% (or less) Total Antibiotic $ at or below FY and system position retained
Core Stewardship Program Supplements Adapted from: Dellit TH et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin lnfect Dis. 2007;44:159 177. http://cid.oxfordjournals.org/content/44/2/159.full.pdf+html
Accomplishments at the Hospital Level Pharmacy Systems, Inc. PSI Supply Chain Solutions PSI Rehabilitation Services
At the Hospital level Culture sensitivity suppression Review of lab critical and therapeutic range values Informatics generated hard stops Implementation of PCN skin testing Added emphasis on Sepsis care pathways Additional detail during antibiogram review 15
At the Hospital level Hard stops guided by the P&T Committee 16
At the Hospital level Achieved decrease in Days and Duration of Therapy 17
At the Hospital level Achieved decrease in Days and Duration of Therapy 18
At the Hospital level Significant increase in requested detail from IT 19
At the Hospital level Medication Use Evaluation follow-up 20
At the Hospital level Additional detail during antibiogram review 21
At the Hospital level Comparative Benchmarking to show need for action 22
At the Hospital level 23
At the Hospital level 24
Accomplishments Across a System Pharmacy Systems, Inc. PSI Supply Chain Solutions PSI Rehabilitation Services
2017 PSI Clinical Scorecard 5 = Carbapenem spend for the quarter is below hospital s 2016 baseline per wholesaler and benchmarking data Appropriate Use of Carbapenem Antibiotics (Safety, Resistance Prevention, Antimicrobial Stewardship) 4 = Guidelines for carbapenem usage criteria are approved by AMS committee and Medical Executive (or similar). 3 = A plan is in place for hospital compliance to antimicrobial stewardship requirements as defined by PSI. 1 = No program is in place to monitor or impact the use of carbapenem antibiotics. 26
2017 PSI Clinical Scorecard OVERALL SCORE 1Q2017 2Q2017 3Q2017 4Q2017 Hospitals Reporting 2016 70 78 Average 3 and above 2016 69 (98%) 78 (100%) Average 4 and above 2016 45 (64%) 55 (71%) By Indicator 1Q 2Q 3Q 4Q Antimicrobial Stewardship Protect against resistance Regulatory compliance Below 3* X 4 2 Best Practice (5) X 33 41 *Facilities scoring below a 3 were found to lack a policy to govern pharmacist participation. 27
Across a Health System No system-wide data mining software for AMS metrics. $ and $/CMI-APD and CMI-Adjusted Discharge metrics available to all. AMS Process driven by system-wide AMS committee, pharmacy steering committee and local subsidiaries. * Spend data represents AHFS broad classification 08:00 derived from wholesaler purchases from 10/1/15-9/30/16 and excludes direct purchases.
Across a Health System Antimicrobial Stewardship Compliance MLR MCM MBR MBSC MPH OAK MAC KCI MGL MNM M Complete Pharmacy Systems, Inc. AMS Binder for CMS/TJC Readiness hospital-specific mission/vision/goals procedures identified team members identified outcomes tracking RPh education (AMS webinars, live at PSI annual, extra) Physician, nursing, patient education Implement an Antimicrobial Stewardship Program to comply with the CMS Conditions of Participation development of a team/committee monitoring parameters reporting strategies Evidence to support the above, such as administration attestation letter and committee meeting minutes? Passed TJC in March Passed TJC in February Passed TJC in May 29
AMS: Key Points Lots of important team members at corporate and local levels Most important piece of all is to have a physician and pharmacist to take ownership of AMS and to do it with passion Bomb from 30,000 feet, bomb from 5,000 feet, bring in the ground troops Target and prioritize set achievable goals "Squeeze the balloon"
AMS: Key Points What has worked for us Tackling to pseudo penicillin/cephalosporin cross allergy Using real time alert system (IODINE) to target individual microbes Minimizing carbapenems and aztreonam Eliminating tigecycline and ceftaroline Continuing to be a "vancomycin" hospital Areas that we feel we need to pursue Decrease duration of treatment (procalcitonin?) Decrease quinolone use Rapid Testing Improve IT (Data is knowledge/power)
Establishing a Corporate AMS
MedMined Comparative 33
Outcome Tracking Days of Therapy, Defined Daily Doses, etc Medication Stewardship Advisor BD MedMined Services National Healthcare Safety Network (NHSN) http://www.cdc.gov/nhsn/ Onsite informatics department reports on demand Robust Medication Use Evaluation (MUE) program is powerful 34
Filling the Void: Healthcare Professional Education Pharmacy Systems, Inc. PSI Supply Chain Solutions PSI Rehabilitation Services
Education Compliance Program Education by PSI begins with universal content followed by a customized approach unique to each healthcare professional. The program provides education using a combination of Self-study: Web-based voice-over presentations Examination: Case-based questions to test retention Application: Peer-review competency assessments A certificate of completion is available for the employee s file. Each organization is encouraged to host electronic materials using the native learning management software. 36
Program Components Practitioners 1 Implementing an Antimicrobial Stewardship Program Nursing, Quality & Infection Prevention Implementing an Antimicrobial Stewardship Program Pharmacists Implementing an Antimicrobial Stewardship Program Bugs and Drugs 101 Bugs and Drugs 101 Bugs and Drugs 101 AMS Considerations for Practitioners AMS Considerations for Nursing & IP Staff AMS Considerations for Pharmacists Case Study Questions Case Study Questions Case Study Questions Profession-specific Competency Assessment Profession-specific Competency Assessment Intervention Log submitted to show impact 1. The term practitioner is intended to include physicians, nurse practitioners, and other professionals given prescriptive authority under the guidance of the medical staff by-laws. 37
Educational Offering 38
Educational Offering 39
Influencing Stakeholders (revisited) Leadership Engagement in Antimicrobial Stewardship Pharmacy Systems, Inc. PSI Supply Chain Solutions PSI Rehabilitation Services
Influence 41
Influence 42
Influence 43
COMPETITION!! An effective MUE program can show individual physician performance relative to a peer group. 44
COMPETITION!! Comparing the hospital to others can show areas for success or improvement. 45
COMPETITION!! Tracking interventions relative to peers or setting expectations on performance evaluation can improve activity level. 46
It is recommended to implement as many ASP strategies at once, to ensure you have a robust program. True or False? 47
Results from Antimicrobial Stewardship Program Implementation Joe Dula, Pharm.D., MBA, BCPS Regional Vice President, Clinical Operations jdula@pharmacysystems.com Pharmacy Systems, Inc. PSI Supply Chain Solutions PSI Rehabilitation Services
Key Resources Core Elements of Hospital Antibiotic Stewardship Programs from the Centers for Disease Control CDC Checklist (www.cdc.gov/getsmart/healthcare/pdfs/checklist.pdf) Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Antibiotic Stewardship Program Checklist (http://cid.oxfordjournals.org/content/early/2016/04/11/cid.ciw118.full.pdf+html) National Quality Forum (NQF) Playbook: A Practical Approach to Antibiotic Stewardship Antibiotic Stewardship Playbook (www.qualityforum.org/publications/2016/05/antibiotic_stewardship_ Playbook.aspx) 49
Other AMS Resources CDC Get Smart for Healthcare is a CDC campaign focused on improving prescribing practices in inpatient healthcare facilities. (www.cdc.gov/getsmart/healthcare/index.html) CDC Overview and Evidence to Support Stewardship Training Programs (www.cdc.gov/getsmart/healthcare/evidence.html) MAD-ID (http://mad-id.org/antimicrobial-stewardshipprograms/) SIDP (http://s3.proce.com/res/pdf/sidp- ASP_Announcement.pdf) 50