How we Got Here: Implementing Stewardship in Rochester Nursing Homes Ghinwa Dumyati, MD Professor of Medicine Center for Community Health University of Rochester Medical Center Ghinwa_dumyati@urmc.rochester.edu February 28, 2018
Outline Describe how we assisted several Rochester nursing homes in implementing the CDC core elements of antimicrobial stewardship Discuss our successes and challenges Review options to sustain a successful program
The Objectives of the Rochester Nursing Home Collaboration 1. Implement antibiotic stewardship programs in Nursing Homes (NH) 2. Reduce the use of quinolones for the treatment of urinary tract infections (UTI) and pneumonia 3. Reduce the overall incidence of C. difficile infections (CDI)
Setting ASP Implementation Dissemination Project Implementation Rochester, NY 33 nursing homes (NH) Initially recruited 6 NH-expanded to 10 Size: 120-550 beds ASP implemented successively moving from one NH to another Tools and approach tailored depending on NH context and needs Through a Medical Directors Advisory Group Regional workshops Website * Project started in 2014 *http://www.rochesterpatientsafety.com/
CDC Core Elements of Antibiotic Stewardship Provide a framework to improve antibiotic prescribing 1. Leadership support 2. Accountability 3. Drug expertise 4. Actions to improve use 5. Tracking 6. Reporting info to staff 7. Education http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
I. Leadership, Accountability, Expertise
Hospital and NH Teams Collaboration Advisory Group Hospital Expert Team NH Leadership NH Stakeholders Several NH Medical Directors Hospital Infectious Diseases physician Hospital Antimicrobial Stewardship Pharmacist Project Infection Preventionist and coordinator Nursing Home Administrator Medical Director Director of Nursing Director of Quality Infection Preventionist Nursing Educator Nurse practitioner/physician Assistant In house Dispensing Pharmacist Consultant Pharmacist
Implementation Strategy Data Collection by Hospital Team Antibiogram collection and interpretation Urine culture data Antibiotic use data Education and Tools by Hospital Team with input from Medical Directors Advisory team Feedback of data Testing and treatment guidelines Education Pocket cards, posters, pamphlets NH Implementation of antimicrobial stewardship Implementation of tools and guidelines Antibiotic reviews and feedback Review of urine culture testing and UTI treatment Education
II. Tracking Data for Action
Understanding the Data 8 most common antibiotic indications by days of therapy (DOT) 8 most common indications by number of residents HEAD AND ENT 178 UTI PROPHYLAXIS 12 BONE/JOINT 284 HEENT 12 C. DIFFICILE 435 C. DIFFICILE 13 PNEUMONIA 531 BRONCHITIS 13 SKIN AND SOFT TISSUE 562 DENTAL PROPHYLAXIS 19 PENPHIGOID 689 PNEUMONIA 48 UTI PROPHYLAXIS 878 SKIN AND SOFT TISSUE 62 UTI 980 UTI 102 0 200 400 600 800 1000 1200 0 20 40 60 80 100 120
Improving Your Knowledge Linezolid Fluconazole Doxycycline Cefpodoxime Trimethoprim Amox/K Clav Ceftriaxone Ampicillin Amoxicillin SMZ-TMP Cephalexin Nitrofurantoin Levofloxacin Ciprofloxacin Treatment for UTI 0 10 20 30 40 50 60 70 80 90 100 Number of Patients
Ampicillin Amoxicillin/Clav Ampicillin/sulbactam Cefazolin Ceftazidime Ceftriaxone Cefepime Ciprofloxacin Gentamicin Imipenem Levofloxacin Piperacillin/tazobactam Tobramycin Trimethoprim/sulfa Nitrofurantoin Linezolid Daptomycin Vancomycin Doxycycline Tetracycline Improving Your Knowledge Organism # of Isola tes Gram Negative Organisms Escherichia coli 87 62 90 72 92 94 94 94 62 89 100 50 99 90 80 97 Klebsiella 19 0 10 100 100 100 100 100 100 100 100 100 100 10 100 47 pneumonia * 0 0 Proteus mirabilis * 25 84 96 92 88 100 100 100 88 92 92 88 100 96 88 0 Gram Positive Organisms Enterococcus faecalis * 12 100 75 75 100 100 100 100 42 42 *Differences in the % susceptible for an organism represented by <30 isolates may not be statistically significant from year to year.
III.Action Improve Antibiotic Use for UTI
More Data: Understanding the prescribing process through antibiotic use review Clinical Situation Diagnostic Process and Decision Makings Decision to treat or active monitoring Monitor Clinical situation and Lab results Reassessment at 48-72 hours: Stop, or change antibiotic, decide on duration
Appropriateness of UTI Testing and Treatment: Symptoms Breakdown (n=42) New onset confusion Dysuria Nausea/Vomitting/Diarrhea Frequency Other Fever Urgency New Onset Retention Incontinence & Bladder Spasm Hematuria Elevated WBC Flank Pain None Suprapubic Pain 0 1 1 2 2 2 2 3 3 3 4 5 11 15* 0 2 4 6 8 10 12 14 16 Number of Patients
Appropriateness of UTI Testing and Treatment: Symptoms Breakdown (n=42) New onset confusion 15* Dysuria 11 Nausea/Vomitting/Diarrhea 5 Frequency 4 Other 3 Fever Urgency New Onset Retention Incontinence & Bladder Spasm Hematuria 2 2 2 3 3 *12 patients, confusion delirium was the only symptom that triggered a urine culture Elevated WBC 2 Flank Pain 1 None 1 Suprapubic Pain 0 0 2 4 6 8 10 12 14 16 Number of Patients
Appropriateness of UTI Testing and Treatment: Symptoms Breakdown (n=42) New onset confusion 15* Dysuria 11 Nausea/Vomitting/Diarrhea 5 Frequency 4 Other 3 Fever 3 Urgency New Onset Retention Incontinence & Bladder Spasm Hematuria Elevated WBC Flank Pain 1 2 2 2 2 3 Most of the patients were treated for asymptomatic bacteriuria A positive Urine Culture Triggers Treatment None 1 Suprapubic Pain 0 0 2 4 6 8 10 12 14 16 Number of Patients
IV. Development of Guidelines and Tools Nursing Staff Medical Staff Residents and Families Poster Testing and treatment Guidelines Pamphlet
V. Face to Face Education Nursing Staff Medical Staff Residents and Families
VI. Feedback-Regular and Face to Face Review progress toward completing all the ASP core elements Review processes Communication (use of SBAR) Documentation Follow up on culture results Additional educational needs Next intervention Sustaining progress- who will collect data and give feedback?
Start Rate Per 1,000 Resident Days Culture Rate per 1,000 Resident Days Measuring Progress 3 Urine Cultre Rate and Antibiotic Start Rate for UTI: Q1 2014 -Q2 2017 Start of the ASP 7 2.5 6 2 1.5 1 5 4 3 2 0.5 1 0 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 0 Median Length of Treatment (LOT) for UTI = 5 days 94% of UTI treatments were for 7 days or less Start Rate Culture Rate
DOT Rate (per 1000 Resident Days) Comparative Feedback-Reporting Antibiotic Use 300 250 200 150 100 50 DOT: days of therapy 0 1 2 3 4 5 6 8 9 Nursing Home 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4 2017Q1 2017Q2 2017Q3 Data unpublished
DOT Rater (per 1000 resident days) Ciprofloxacin Use 25 20 15 10 5 0 1 2 3 4 5 8 9 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4 2017Q1 2017Q2 2017Q3
Incidence (per 10,000 Resident Days) CDI Incidence- NH Collaborative 2.5 2 Start of the antimicrobial stewardship project 1.5 1 0.5 0 2012 2013 2014 2015 2016 2017 Data from Rochester/NYS EIP
Successes Antibiotic Data Microbiology Lab Collaboration NH team collaboration Obtained data from in-house and a large dispensing pharmacy Summarized data to be actionable Provided monthly or quarterly urine culture data Citywide antibiogram for smaller NH Sensitivity testing for fosfomycin Medical directors advisory group Intra-facility communication across facilities (e.g. IP team meetings and assistance for new IP)
Successes Citywide treatment guidelines Citywide recognition of ASP effort Provision of expertise beyond ASP Provision of educational opportunities Implementation of the guidelines in nursing homes not involved in the project Nursing Homes are asking to be part of our initiative Infectious diseases Infection control Pharmacy Support for national conference attendance Webinars and educational talks by national speakers
Challenges-Nursing Homes Lack of infrastructure to independently implement an ASP Dedicated personnel, expertise, easily retrievable data Interest does not always translate into action Competing priorities, high staff turnover, lack of dedicated time, unavailability of key personnel to form an ASP team Difficult to adapt to new systems (e.g. NHSN reporting, use of Excel program) Pressure to avoid re-hospitalization
Challenges-Hospital Antimicrobial Stewardship Team Inability to obtain antibiotic data from all nursing homes and a large commercial dispensing pharmacy Inability to provide education to covering medical providers and all nursing staff Limited capacity to perform antibiotic use evaluations No capacity to provide prospective antibiotic audit and feedback
Solutions and Sustainability Need a NH champion (physician, nurse, IP, NP) with dedicated time to lead/ assist with the AS program Requires leadership buy-in and a job description that includes antimicrobial stewardship Involve multiple team members to provide resilience and flexibility in case of personnel change Antimicrobial stewardship works needs to be integrated into the daily work flow and NH quality and performance improvement (QAPI)
Solutions and Sustainability Involve the consultant pharmacists through a change in their scope of work We provided an educational workshop Training of nursing leadership and IP in data collection and ownership We provided an educational workshop and a tool for tracking antibiotic and infection data Assistance from hospital AS experts can facilitate the implementation and sustainability of the program
Additional Resources Our website: www.rochesterpatientsafety.com Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings. Jump LR. et al. JADMA 2017 Nursing Home Antimicrobial Stewardship Guide: https://www.ahrq.gov/nhguide/index.html Do Bugs Need Drugs, Antimicrobial Stewardship in Long Term Care Facilities: http://www.dobugsneeddrugs.org/healthcare-professionals/antimicrobial-stewardship-in-ltcf/ Improving Evaluation of Urinary Tract Infections in the Elderly: Massachusetts coalition: http://www.macoalition.org/evaluation-and-treatment-uti-in-elderly.shtml Promoting Wise Antibiotic Use In Nursing Homes: https://nursinghomeinfections.unc.edu/ Nebraska Antimicrobial Stewardship Assessment and Promotion Program: https://asap.nebraskamed.com/ Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities: http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/ Washington State Department of Health: Jump start antimicrobial stewardship: https://www.doh.wa.gov/portals/1/documents/5000/420-non-doh-jumpstartstewardshipnursinghomes.pdf
BIG THANKS! Christina Felsen, MPH Grant Barney Gail Quinlan Elizabeth Dodds Ashley PharmD
More Acknowledgments Medical Director Advisory Group Alexandra Yamshchikov, MD Dallas Nelson, MD Joseph Nicholas, MD Timothy Holahan, MD Annette Medina Walpole, MD Scott Schabel, MD Diane Kane, MD Pharmacy All the Nursing Homes Dispensing Thomas Pingree, MD Pharmacists Mary Aydelotte, MD Vince Galetta, Pharm D, Buffalo Rena Pine, MD Pharmacies Kim Petrone, MD Brandi Van Valkenburg, Pharm D, Brian Heppard, MD Health Direct Pharmacy Nirmala Nicholas, MD Alexander Karlic, MD All the nursing Homes IPs All the Nursing Home Staff Microbiology Labs
Acknowledgments