1 pharmacist monitoring tools for antimicrobial stewardship dianna gatto, pharm.d., bcps pharmacy...

Download 1 Pharmacist Monitoring Tools for Antimicrobial Stewardship Dianna Gatto, Pharm.D., BCPS Pharmacy Clinical Manager Chris Beuning, Pharm.D., BCPS Pharmacy

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3  Not for profit organization in the greater Tacoma, East Pierce and South King County regions in Washington state  879 licensed beds  Tacoma General – 402 beds  Good Samaritan – 275 beds  Allenmore – 130 beds  Mary Bridge Children’s – 72 beds  Specialized Services  Level II trauma at TGH and Mary Bridge Children’s  Level III NICU at TGH  Rehabilitation program at Good Samaritan  Primary Care Clinics  Urgent Care Centers  Free standing Emergency Department  Employed Providers  HIMSS Davies Award winner 2009

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1 Pharmacist Monitoring Tools for Antimicrobial Stewardship Dianna Gatto, Pharm.D., BCPS Pharmacy Clinical Manager Chris Beuning, Pharm.D., BCPS Pharmacy Clinical Analyst MultiCare Health System September 10, 2012 2 MultiCare Health System 2 3 Not for profit organization in the greater Tacoma, East Pierce and South King County regions in Washington state 879 licensed beds Tacoma General 402 beds Good Samaritan 275 beds Allenmore 130 beds Mary Bridge Childrens 72 beds Specialized Services Level II trauma at TGH and Mary Bridge Childrens Level III NICU at TGH Rehabilitation program at Good Samaritan Primary Care Clinics Urgent Care Centers Free standing Emergency Department Employed Providers HIMSS Davies Award winner 2009 4 Objectives Be familiar with antimicrobial stewardship Understand key pharmacist workflows Identify tools for patient monitoring 5 Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Pharmacist tools Key pharmacist workflows Challenges Future directions 6 Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Pharmacist tools Key pharmacist workflows Challenges Future directions 7 What is Antimicrobial Stewardship Antimicrobial Stewardship (AMS) Systematic, multi-faceted approach to the use of antimicrobial agents, to optimize clinical outcomes while minimizing unintended consequences Goals of programs Achieve the best clinical outcomes Reduce emergence of resistant organisms Decrease costs 8 Antimicrobial Stewardship at MHS Specialized ID pharmacist Prospective audit of targeted hospitalized patients receiving antimicrobial agents and/or diagnosis of infection Patient identification based on the following: Selected antimicrobials Bug-drug mismatches Inappropriate durations of therapy De-escalation opportunities 9 Role of Decision Support in AMS Efficiently identify patients who need to be reviewed Pharmacists spend time assessing patient therapy versus report generation and data mining Easily generate daily reports in a timely manner that pharmacists can utilize Target patients by running reports based on flexible criteri a 10 Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Key pharmacist workflows Pharmacist tools Challenges Future directions 11 Key Pharmacist Workflows Order entry and order verification Prescriptive authority (dosing) protocols Pharmacist Inbasket message review Consults Medication messages Best practice alerts Intervention documentation Ongoing drug monitoring Microbiology results 12 Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Key pharmacist workflows Pharmacist tools Challenges Future directions 13 Tools Need specialized tools that drill down to increase the number of patients served, focusing on outcomes and decreasing costs Selected antimicrobials Bug-drug mismatches Inappropriate durations of therapy De-escalation opportunities 14 Tools Order Entry/Verification Order sets Appropriate agents and doses Links to guidelines from order sets Targeted medication build Appropriate defaults Linked labs Order instructions Reference Links 15 Tools Microbiology Results Best Practice Advisories - General New properties allow creative rules based on culture results Rules can be used in BPA criteria Do not fire to end user Trigger Inbasket message to pharmacists or pools Pharmacists can monitor messages based on workflows and time Custom Inbasket message created to provide patient specific information within message 16 Tools Microbiology Results Best Practice Advisories Applications Updated micro results available Positive blood culture and no antimicrobial Resistant culture Duplicate anaerobic coverage Duplicate C. difficile coverage 17 Tools Microbiology Results Best Practice Advisories Properties (Vendor specific screen capture removed) 18 Tools Pharmacist/Physician Rounding Accordion Reports General Medication administration visual Culture information Lab data, Vital information Pertinent drug levels Allow changes to time view 19 Tools Pharmacist/Physician Rounding Antimicrobial Accordion Challenge complicated patients, multiple antimicrobial orders, changes in regimen over time Visual timeline of all antimicrobial administrations Vancomycin Accordion Challenge vancomycin often non-continuous therapy with stops, starts and dosing changes Visual timeline of vancomycin administrations 20 Accordion Reports - Antimicrobial (Vendor specific screen capture removed) 21 Accordion Reports Vancomycin 22 (Vendor specific screen capture removed) 22 Tools - Pharmacist Rounding: Scoring System Lists and Patient Scoring Tools Utilize same BPA properties to create rules Ability to sort columns and relative overall score to identify key patients Rules/Columns in Antimicrobial Stewardship Scoring Patient specific information: location, name, age, primary problem, weight, height and creatinine clearance 22 23 Tools - System Lists and Patient Scoring Rule based columnsScore Creatinine clearance (CrCl)Value of 0 to 1 based on level of renal dysfunction (0 = >70 mL/min; 1 = < 10 mL/min) On antimicrobialValue of 1 for each antimicrobial AMS target medicationsValue of 1 for each target antimicrobial Aminoglycoside/VancomycinValue of 1 if on either On 3 or more antimicrobials for 2 or more days Value of 1 if true 23 24 Tools - System Lists and Patient Scoring Rule based columnsScore On quinolone, vanco or imipenem for 3 or more days Value of 1 if true On ceftriaxone and azithromycin IV for 5 or more days Value of 1 if true On nitrofurantoin and CrCl < 60 mL/min Value of 1 if true Open I-VentsValue of 1 for each open I-Vent Rx ProtocolValue of 1 for each open protocol 25 Tools - System Lists and Patient Scoring (Vendor specific screen capture removed) 26 Tools - Surveillance/Effectiveness Reports Drug Usage By patient, location, physician and drug Days of therapy Individual drug per 1000 patient days Entire patient hospitalization per 1000 patient days IV compared to PO Track antibiotic use and days of therapy by provider and specialty groups Antimicrobial cost per patient day 27 Tools - Surveillance/Effectiveness Reports Process/Outcome Measurements Antimicrobial use and impact on Clostridium difficile infection rates Intervention acceptance rate by physicians Direct antimicrobial expenditures Track discharge antibiotic trends 28 Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Key pharmacist workflows Pharmacist tools Challenges Future directions 29 Challenges Identifying specific interventions Incorporating tools into pharmacist workflows Quirky BPA behavior based on free text Lacking interfaced lab system Free text data sent for microbiology results from lab system Competing requests for reporting resources 30 Mitigating Challenges Creative use of BPAs and searching for free text strings Use of reports with data already in the Enterprise Data Warehouse (EDW) for other initiatives (sepsis metrics) Leverage expertise from outside the pharmacy team 31 Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Key pharmacist workflows Pharmacist tools Challenges Future directions 32 Future Directions Introduction of QlikView for reporting from Epic AMS program outcomes Antimicrobial usage trends Drug use patterns related to infection control data Comparative reports by drug, facility and prescriber to identify improvement areas Financial impact Expand AMS to all hospitals in system Consideration of changes to lab system 33 Conclusion What is Antimicrobial Stewardship Pharmacist tools Key pharmacist workflows Pharmacist tools Challenges Future directions 34 Questions

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