Antibiotic Stewardship Key Clinical Strategies for Successful Outcomes Louann Lawson, BA, RN, RAC-CT, CIMT Nurse Consultant Clinical Reimbursement Team Leader/Clinical Education Manager Pathway Health Objectives Upon completion of this presentation, attendees should be able to: 1. Understand the new Centers for Disease Control (CDC) requirements and expectations for an antibiotic stewardship program; 2. Identify the key expectations of the director of nursing and nursing home administrator for quality outcomes 3. Describe three essential leadership strategies for implementation and quality monitoring for successful outcomes Antibiotics - Are they OVERUSED? Pathway Health 1
Use of Antibiotics - CDC Are overused Are misused Reactions and Side Effects Can only work with infections=bacteria Resistance is growing Reactions and Side Effects http://www.cdc.gov/getsmart/week/downloads/antibiotics-arent-always-the-answer-forparents.pdf 4 Definition of Antibiotic Stewardship The CDC Defines Antibiotic Stewardship as: a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use The Core Elements of Antibiotic Stewardship for Nursing Homes https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html Antibiotic Stewardship - CDC Antibiotics are among the most frequently ordered drugs in nursing homes Up to 70% of residents in nursing homes receive 1 or more systemic antibiotics when they are followed for over a year 40-75% of antibiotics prescribed in Nursing Homes may be unnecessary or inappropriate Residents taking antibiotics are at risk for harm o C-difficile o Adverse drug events o Drug interactions o Colonization o Antibiotic Resistant Organisms The Core Elements of Antibiotic Stewardship for Nursing Homes https://www.cdc.gov/longtermcare/prevention/antibiotic stewardship.html Pathway Health 2
INDUSTRY EXPERT RESOURCES Let s Start with the Regulatory Requirements! CMS-State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf CMS-State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities F881 483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: 483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. https://www.cms.gov/regulations and Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf Pathway Health 3
F881: Antibiotic Stewardship INTENT The intent of this regulation is to ensure that the facility: Develops and implements protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic; Reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; and Develops, promotes, and implements a facility-wide system to https://www.cms.gov/regulations-andmonitor the use of antibiotics. Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf F881: Antibiotic Stewardship Guidance: As part of their IPCP programs, facilities must develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms. https://www.cms.gov/regulations and Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf F881: Antibiotic Stewardship The facility must develop an antibiotic stewardship program which includes the development of protocols and a system to monitor antibiotic use. This development should include leadership support and accountability via the participation of the medical director, consulting pharmacist, nursing and administrative leadership, and individual with designated responsibility for the infection control program if different https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf Pathway Health 4
F881: Antibiotic Stewardship The antibiotic stewardship program protocols shall describe how the program will be implemented and antibiotic use will be monitored, consequently protocols must: Be incorporated in the overall infection prevention and control program; Be reviewed on an annual basis and as needed; Contain a system of reports related to monitoring antibiotic usage and resistance data. Incorporate monitoring of antibiotic use, o including the frequency of monitoring/review. o Monitor/review when the resident is new to the facility; when a prior resident returns or is transferred from a hospital or other facility o during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic regimen review as requested by the QAA committee. https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/s om107ap_pp_guidelines_ltcf.pdf F881: Antibiotic Stewardship Continued: In addition, establish the frequency and mode or mechanism of feedback (e.g., verbal, written note in record) to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols. Assess residents for any infection using standardized tools and criteria Include the mode (e.g., verbal, written, online) and frequency (as determined by the facility) of education for prescribing practitioners and nursing staff on antibiotic use (stewardship) and the facility s antibiotic use protocols. https://www.cms.gov/regulations and Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf CMS: LTC Survey Pathways Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes: Written antibiotic use protocols on antibiotic prescribing, including the documentation of the indication, dosage, and duration of use of the antibiotics Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g. SBAR tool for urinary tract infection (UTI) assessment. Loeb minimum criteria for initiation of antibiotics). CMS Infection Prevention, Control & Immunizations, CMS 20054 (5/2017): https://www.cms.gov/medicare/provider Enrollment and Certification/GuidanceforLawsAndRegulations/Downloads/LTC Survey Pathways.zip Pathway Health 5
Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes: A process for periodic review of antibiotic use by prescribing practitioners; for example, review of laboratory and medication orders, progress notes and medication administration records to determine whether or not an infection or communicable disease has been documented and whether an appropriate antibiotic has been prescribed for the recommended length of time. Determine whether the antibiotic use monitoring system is reviewed when the resident is new to the facility, when a prior resident returns or is transferred from a hospital or other facility, during each monthly drug regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic drug regimen review requested by the QAA committee CMS: LTC Survey Pathwayscontinued https://www.cms.gov/medicare/provider Enrollment and Certification/GuidanceforLawsAndRegulations/Downloads/LTC Survey Pathways.zip Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes: Protocols to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotic; A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner CMS: LTC Survey Pathwayscontinued Did the facility conduct ongoing review for antibiotic stewardship YES NO F881 https://www.cms.gov/medicare/provider Enrollment and Certification/GuidanceforLawsAndRegulations/Downloads/LTC Survey Pathways.zip CDC Centers for Disease Control and Prevention https://www.cdc.gov/ 18 Pathway Health 6
Best Practice Resources: The Core Elements of Antibiotic Stewardship for Nursing Homes https://www.cdc.gov/longtermcare/prevention/antibiotic stewardship.html CDC http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html 20 CDC http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf 21 Pathway Health 7
22 Antibiograms An antibiogram is a tool aimed at improving appropriate antibiotic prescribing. Report that displays the organisms present in diagnostic clinical specimens that nursing homes send for laboratory testing Referring to an antibiogram report helps the physician make prompt, empirically based decisions. Intended to improve the use of antibiotics in nursing homes by helping prescribing clinicians select the most appropriate therapies for residents with suspected infections https://www.ahrq.gov/nhguide/toolkits/help-clinicians-choose-the-right-antibiotic/toolkit2-concise-antibiogramtoolkit.html 23 Example: AHRQ Tools for Infection Criteria https://www.ahrq.gov/nhguide/toolkits/dete rmine-whether-to-treat/index.html Pathway Health 8
AHRQ - Another GREAT RESOURCE Catheter Associated UTI s CAUTI-Catheter Associated Urinary Tract Infections AHRQ toolkit Developed based upon 500 nursing homes across the country Was a 3-year implementation project Toolkit is organized in 3 main sections o Implementation o Sustainability o Resources https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cautiltc/index.html?utm_source=ahrq&utm_medium=generic&utm_term=&utm_content=2&u tm_campaign=ahrq_cauti4ltc_2017 Examples of Infection Control Risk Assessment Tools http://community.apic.org/sierra/resources/overview Pathway Health 9
CDC Toolkit for Influenza https://www.cdc.gov/flu/profession als/index.htm CDC-Guidance on the Use of Antivirals https://www.cdc.gov/flu/professio nals/antivirals/antiviral-useinfluenza.htm Minnesota Department of Health Long-Term Care: Influenza http://www.health.state.mn.us/divs/idepc/diseases/flu/ltc/index.html Pathway Health 10
C-Diff CDC has developed a Toolkit http://www.cdc.gov/hai/pdfs/toolkits/cdi-primer-2-2016.pdf 31 User Friendly System Inclusions! Preadmission Assessment Do you have a comprehensive Preadmission Screening Process? 33 Pathway Health 11
Preadmission Assessment Review the Medical Record Diagnosis(es) Antibiotic Use Vital Signs Lab Work (Results or Pending Tests) Imaging Ask the nursing staff at the hospital (or other entity) about infections or symptoms 34 Admission Screening Risk Factors Antibiotic use past 30 days Current symptoms or diagnosis Cultures taken and results Immunization history Duration of indwelling catheter Presence of MDROs Prior infection 2-step Mantoux - history of positive reaction Vaccines **Facilities will be required to incorporate any infection-related care needs on the initial 48 hour baseline care plan 35 Do You Have User-Friendly Systems/Forms? Example: Criteria for Infection Report Forms (UTI, Respiratory, Wound, Skin/Soft Tissue, etc.) These forms assist the nurse in determining if the resident exhibits criteria for infection! Great Resources include: Loeb M, Brazil K, Lohfeld L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331:669 Stone, N., Ashraf, M., Calder, J., Crnich, C., Crossley, K., Drinka, P.,... For the Society for Healthcare Epidemiology Long-Term Care Special Interest Group. (2012). Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology, 33(10), 965-977. doi:10.1086/66774 Pathway Health 12
Tracking Log Infection Preventionist Tools There is a requirement to establish the frequency and mode or mechanism of feedback (e.g., verbal, written note in record) to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols. https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/so m107ap_pp_guidelines_ltcf.pdf Audit Tools Pathway Health 13
Leadership Strategies for Oversight of the Antibiotic Stewardship Program-Alignment with CDC Core Elements of Antibiotic Stewardship in Nursing Homes Leadership Commitment Policies and Procedures Job Descriptions Identification of a solid communication system Culture Change **All these efforts assist the facility with oversight of proper and safe antibiotic use https://www.cdc.gov/longtermcare/prevention/antibiotic stewardship.html 41 Policies and Procedures Include policies for criteria for infection Use Evidence-Based Standards of Practice Professionally Accepted Resources o CDC: Core Elements of Antibiotic Stewardship o AHRQ: Nursing Home Antimicrobial Stewardship Guide Loeb, M., Brazil, K., Lohfeld, L., McGeer, A., Simor, A., Stevenson, K., Zoutman, D..Walter, S.D. (2005). Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial. BMJ, 331, 669 http://www.bmj.com/content/bmj/early/2004/12/31/bmj.38602.586343.55.full.pdf Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria http://www.jstor.org/stable/10.1086/667743 42 Pathway Health 14
Policies and Procedures Other Areas to Consider when drafting P&P s: Antibiotic Ordering and Use Drug, Dosage, Duration, etc. Prophylactic Antibiotic Ordering Diagnostic Testing and Reporting Medical Director Involvement Pharmacy Consultant Involvement Communication and Education Staff Residents Families 43 Job Descriptions Antibiotic Stewardship Responsibilities should be included in the job descriptions of: Infection Preventionist Director of Nursing Licensed Nurses Medical Director Pharmacy Consultant https://www.cdc.gov/longtermcare/prevention/antibiotic stewardship.html 44 Communication: Do You Have a Good System? Nurse to Practitioner Nurse to DON Medical Director Families Residents Pharmacy Consultant 45 Pathway Health 15
Culture 46 Accountability Medical Director DON Infection Preventionist Consultant Pharmacist Lab https://www.cdc.gov/longtermcare/prevention/antibiotic stewardship.html 47 Drug Expertise Pharmacist Identify what specific training does the consultant pharmacist (and pharmacists at the contracted pharmacy) **You can work with your Pharmacy Consultant on attending a course Physicians Enlist Medical Director Hospital Partners https://www.cdc.gov/longtermcare/prevention/antibiotic stewardship.html 48 Pathway Health 16
Action **Identify ONE area that can improve antibiotic use practices for care improvement Put into QAPI Process! One example is an Antibiotic Time-Out o After culture results obtained (24-48 hours) talk to physician and re-evaluate the therapy Still necessary Appropriate (based on lab results) Can even assist in plan (i.e. duration) https://www.cdc.gov/longtermcare/prevention/antibiotic stewardship.html 49 QAPI Action Plan 50 Tracking and Reporting In order for organizations to be able to appropriately monitor success of the antibiotic stewardship program, organizations will need to have a solid system to be able to track data. CMS has outlined information on how to track process measures, antibiotic use measures and antibiotic outcome measures as well as costs at: http://www.cdc.gov/longtermcare/pdfs/core-elementsantibiotic-stewardship.pdf 51 Pathway Health 17
Auditing Example: Appropriate Antibiotic Use Diagnosis Practitioner Order Site of Infection Start/Stop Date of Medication Resident presents with signs/symptoms of infection (using evidence based definitions of infection) Organism identified through laboratory testing (i.e. C&S) Care Planning 52 Reporting Nursing Staff o Appropriate Use o Prescribing Practices Pharmacy Consultant Leadership Team Medical Director https://www.cdc.gov/longtermcare/prevention/antibiotic stewardship.html 53 Facility Staff Education CDC Core Elements of Antibiotic Stewardship for LTC Facilities Infection Criteria (McGeer s Criteria, Loeb, AHRQ, etc.) Facility Policy and Procedures Multidrug Resistant Organisms o Prevention o Treatment 54 Pathway Health 18
Clinician Education Required! Include the mode (e.g., verbal, written, online) and frequency (as determined by the facility) of education for prescribing practitioners and nursing staff on antibiotic use (stewardship) and the facility s antibiotic use protocols Develop an action plan in association with: o Pharmacy Consultant o Medical Director Determine opportunities for improvement Utilize evidence-based best practice Determine method of delivery 55 Resident/Family Education-CDC http://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-what-to-ask.pdf 56 Additional Clinical Processes Pathway Health 19
Key Clinical Processes Ongoing analysis that includes: Auditing all antibiotic use in the facility o Review nurse assessment information o Root cause analysis: what information was discussed with the physician? (Criteria for Infection?) o Documentation Ensure that the resident is taking the right antibiotic for the right amount of time Appropriate discussion with practitioner regarding antibiotic use - may need to involve the Medical Director and the Pharmacy Consultant 58 Facility Assessment The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Must be reviewed/revised annually Must be reviewed/revised when any change would require a substantial modification to the assessment Assessment must address a facility-based and community-based risk assessment using an all-hazards approach The results of the facility assessment must be used to establish and update the Infection Prevention and Control Program, including policies and procedures TB screening per State requirements Facility Assessment Administrative Measures Risk Assessment Education Antibiotic Use Evaluation and Antibiotic Stewardship Surveillance Hand Hygiene Standard and Transmission Based Precautions Environmental Measures 60 Pathway Health 20
Leadership Strategies Stay up to date with the most current recommendations, guidelines, evidence based standards of practice and regulatory requirements. 61 Summary 1. Become familiar with the regulatory requirements (F881) for Antibiotic Stewardship 2. Understand best practices for infection criteria 3. Work with the IDT, Medical Director, Pharmacy Consultant and hospital partners to ensure a solid system (Policies, Procedures, Preadmission Process, etc.) 4. Education! 5. Surveillance, tracking, data analysis, audits 6. QAA involvement Resources 63 Pathway Health 21
CDC Education https://www.train.org/cdctrai n/course/1075730 References and Resources CMS State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities: https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_pp_gu idelines_ltcf.pdf 65 References and Resources CDC - Core Elements of Antibiotic Stewardship for Nursing Homes http://www.cdc.gov/longtermcare/prevention/antibioticstewardship.html U.S. Department of Health & Human Services: AHRQ: Nursing Home Antimicrobial Stewardship http://www.ahrq.gov/nhguide/index.html 66 Pathway Health 22
Resources National Healthcare Safety Network (NHSN) LTC facilities Tracking Infections Training Protocols Forms Support Materials And More! https://www.cdc.gov/nhsn/ltc/index.html 67 Resources Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3538836/ 68 References and Resources AHRQ: CAUTI - Catheter Associated Urinary Tract Infections http://www.annalsoflongtermcare.com/article/antibioticstewardship-programs-long-term-care-facilities https://www.ahrq.gov/professionals/quality-patientsafety/quality-resources/tools/cautiltc/index.html?utm_source=ahrq&utm_medium=generic&ut m_term=&utm_content=2&utm_campaign=ahrq_cauti4ltc _2017 Pathway Health 23
Resources and References 70 References and Resources Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases Advance Access published April 13, 2016 http://cid.oxfordjournals.org/content/early/2016/04/11/cid.ci w118.full.pdf+html 71 Resources World Health Organization Antibiotic Resistance http://www.who.int/mediacentre/factsheets/antibioticresistance/en/ CDC: Antibiotic Stewardship Statement for Antibiotic Guidelines Recommendations of the Healthcare Infection Control Practices Advisory Committee http://www.cdc.gov/hicpac/pubs/antibiotic-stewardship- Statement.html 72 Pathway Health 24
Questions? Disclaimer This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health. Pathway Health 25