alaska division of public health alaska state hospital and nursing home association mountain-pacific...

ALASKA DIVISION OF PUBLIC HEALTHALASKA STATE HOSPITAL AND NURSING HOME

ASSOCIATIONMOUNTAIN-PACIFIC QUALITY HEALTH ALASKAALASKA NATIVE TRIBAL HEALTH CONSORTIUM

ALASKA PHARMACISTS ASSOCIATION

Alaska Antimicrobial Stewardship Collaborative

(A2SC)

LCDR Thaddus Wilkerson, PharmD, BCPSRyan Stevens, PharmD, BCPS

October 24, 2014

Objectives

Be able to list 3 goals of the Alaska Antimicrobial Stewardship Collaborative Antimicrobial Stewardship Assessment Tool Get Smart about Antibiotics Spring Summit

Be able to discuss 2 successful strategies and 2 potential barriers when implementing an effective program The PAMC and ANMC experiences

Be able to list at least 2 CDC Core Elements Adaptation to small rural settings Long Term Care Facilities

A combination of personnel and procedures that promote the wise use of antimicrobials

When providers prescribe broad-based antimicrobials for too long, or when they are not needed, it can lead to an increase in complications

Clinics can create a reliable system that optimizes outcomes through appropriate selection of: Agent Dose Duration

Antimicrobial StewardshipA Quality and Patient Safety Initiative

• ASPs minimize antimicrobial use, thereby:• Reducing drug costs• Prevent hospital admissions• Decreasing hospital length of stay• Minimizing drug-resistant and nosocomial infections• Avoiding drug-related toxicity

The ASP Basic Framework

CID 2003;37:742-743.CID 1997;24:9-11.

Prospective audit & feedback

Restriction & preauthorization

Education

Guidelines & clinical pathways

Avoidance of combination

therapy

Dose, frequency & duration

Streamlining tx / de-escalation

IV-to-oral conversion

Stewardship Interventions

A2SCShare Information

Learn from Common Experiences

Surveys

Webinars

Workshops

Conference Calls

Statewide Strategic Planning

Reach the Public

A2SC <[email protected]>

State ASP surveyCEO letter of commitment

to stewardship

Criteria for treating wounds

UTI diagnosis & treatmentAccess to ID physiciansPatient education materials

for abx use and appropriateness

Clinician education on bacteriuria

Create A2SC Educational Calendar October 29, 2014

Leadership education Cost Utilization Sustainability

1ST A2SC WEBINAR SEPTEMBER 19, 2014Alaska Regional Hospital

Heritage Place

Norton Sound Health Corp

State of Alaska Section of Epi

Denali Center and Fairbanks Memorial Hospital

Alaska Psychiatric Institute

Yukon-Kuskokwim Health Corp

Petersburg Medical Center

Peace Health Ketchikan Medical Center

Providence Alaska Medical Center

Alaska Native Medical Center

Alaska State Hospital and Nursing Home Assoc.

Wrangell Medical Center

A2SC: Why now?

The rise of antibiotic resistant bacteria represents a serious threat to public health and the economy.

Antibiotic resistance is responsible for over 2 million illnesses and 23,000 deaths annually in the U.S.

A successful campaign will require collaborative efforts between public & private entities and is a national priority.

www.whitehouse.gov Executive order—Combating Antibiotic-resistant bacteria Sept 18, 2014CDC “Antibiotic resistance threats in the United States, 2013.”

Executive OrderCombating Antibiotic-Resistant Bacteria

Sec. 5. Improved Antibiotic Stewardship “By the end of calendar year 2016, HHS shall review

existing regulations and propose new regulations…that require hospitals and other inpatient healthcare delivery facilities to implement robust antibiotic stewardship programs…”

“HHS shall also take steps to encourage other healthcare facilities, such as ambulatory surgery centers and dialysis facilities, to adopt antibiotic stewardship programs.”

“Task force agencies shall…define, promulgate, and implement stewardship programs in…office-based practices, outpatient settings, emergency departments, and institutional and long-term care facilities…nursing homes, pharmacies, and correctional facilities.”

http://www.whitehouse.gov/the-press-office/2014/09/18/executive-order-combating-antibiotic-resistant-bacteria

CDC’s Core Elements

Complement existing guidelines on ASPs

No single templateFlexibility in

implementationExperience in a wide

varietySuccess depends on

Defined leadership Coordinated

multidisciplinary approach

Core Elements in Summary

Leadership Commitment Dedicating necessary human, financial and information technology resources.

Accountability Appointing a single leader responsible for program outcomes. Experience with

successful programs show that a physician leader is effective. Drug Expertise:

Appointing a single pharmacist leader responsible for working to improve antibiotic use.

Action: Implementing at least one recommended action, such as an “antibiotic time

out” after 48-72 hours. Tracking:

Monitoring antibiotic prescribing and resistance patterns. Reporting:

Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff.

Education: Educating clinicians about resistance and optimal prescribing.

State Strategies to Address Antimicrobial Resistance – Survey Results

ASTHO conducted a survey to better understand current state health department strategies HAI coordinators from the states, DC and Puerto Rico in July

2013 with a response rate of 69% (36/52) 25 states (69%) reported antimicrobial stewardship activities 11 states (32%) considered policy, 5 developed/implemented Suggested incentives: trainings, certification, awards,

physician leadership, demonstration of benefits, public reporting

States conducting surveys Data gathered used to inform state stewardship activities Acute & long-term care facilities Range of targeted audiences

©Association of State and Territorial Health Officials 2014 www.astho.org

Alaska Antimicrobial Stewardship Assessment Tool

Adopted from the CDC Checklist for Core ElementsReleased on October 1st to members of ASHNAReleased on October 17th to members of AKPhA31 responses to date19 facilities represented from throughout the state

including: Anchorage, Barrow, Fairbanks, Homer, Juneau, Ketchikan,

Sitka, Soldotna, Valdez and WrengellVarious responder titles including:

Nurses, pharmacists, clinical resource coordinator, coordinated care managers, infection preventionists, hospital education coordinator


Facility Size:

< 50 beds: 7

50-100 beds: 9

> 100 beds: 3


About half of facilities surveyed (10/19) have a multidisciplinary committee focused on appropriate antimicrobial use? Those that do have an ASP meet regularly.

5 facilities receive budgeted financial support for antimicrobial stewardship activities.

7 facilities have supported training on appropriate antimicrobial use within the last year.

Only 6 facilities have access to clinical infectious disease consultation on the same day as requested?

There is a physician identified as a leader for stewardship activities in 8 facilities. Half of these physicians receive funding specific for ASP activities.


11 sites have a pharmacist or nurse identified as a leader of stewardship activities. This role is included in the job description and annual review in only 6 facilities. Similarly, 6 of these individuals have received specialized training in ID or

antimicrobial stewardship. What staff contribute to assuring appropriate antimicrobial use at your

facility? Infection Preventionist 9 Microbiologist 8 Pharmacy 4 Quality officer 3 Hospital Epidemiologist 2 Informatics 1

Only 5 facilities require an indication for an antimicrobial Rx 10 sites have facility-specific guidelines, based on national guidelines

and local susceptibility, to assist with antimicrobial selection for common infections. Less than half (4) make these easily accessible on all wards and to prescribers (e.g.,

printed 'pocket guide' or electronic summaries on appropriate networked computers)


Only 3 facilities have IV to PO protocols in place.Only 1 facility reported having a formal protocol in place

for de-escalation of therapy based on microbiology results.5 sites have protocols for antimicrobial dose adjustment in

patients with renal or hepatic insufficiency.4 facilities have a clinician guide for ordering or collecting

cultures appropriately.At 5 sites specified antimicrobial agents need to be

approved by a physician or pharmacist prior to dispensing.Prospective audit and feedback is actively performed at 10

facilities surveyed.An “antibiotic time out” is formally implemented in 3

facilities.


Only 3 sites utilize an order entry system with embedded clinical decision support for prescribing antimicrobials.

Results of antimicrobial audits or reviews are provided directly to prescribers through in-person, telephone, or electronic communication at 4 sites.

4 have time-sensitive automatic stop orders. Just over half (10) monitor antimicrobial consumption on a regular

basis. Pharmacy purchasing data 5 Days of Therapy (DOT) 4 Reports on antimicrobial use is provided to prescribers in 5 facilities

Adherence to facility-specific policies, guidelines or protocols to assist with antimicrobial selection is monitored at least annually at 3 sites.

If antibiotic recommendations are routinely provided, acceptance by the primary prescriber is tracked at 3 facilities.


The majority of facilities (12) perform routine microbiology tests on site (urine, blood, sputum cultures).

Most (13) produce and distribute an antibiogram (cumulative antimicrobial susceptibility report) at least annually.

Healthcare information technology is utilized frequently. Electronic medical or health care record 17 Computerized order entry 13 Electronic medication administration 13

When asked if the facility has received feedback and/or penalty for presence or absence of policies or procedures regarding antibiotic surveillance or stewardship, 4 replied yes.


Additional Comments regarding educational needs, challenges, or perceived barriers to implementation: The biggest barrier to implementation is a lack of pharmacist

training. Additional funding and creating training opportunities is essential for success.

We are just now starting an ASP, hope to create a standing committee, and are looking to collaborate with a hospital in town.

Examples of other ASPs in small hospitals would be helpful to start a program here.

There might be resistance from prescribers. We would need help with pharmacist and provider education. We are hindered by limited staffing and software. Challenges for our program include: lack of quick and easy data

extraction from the EHR for tracking abx use, interface issues between electronic systems, and lack of staffing for epidemiologic data analysis.


Additional Comments (cont…) Plans underway to discuss newly developed outpatient antibiogram,

however, providers often have a misperception that antibiotic resistance is less of a concern.

Ambulatory providers often prescribe the same antibiotics over and over for the same patient.

Lack of an in-house microbiology lab complicates our ability to track resistance trends.

We hope our new electronic health record will provide more comprehensive reporting.

Our ASP just started a few months ago and we need guidance on what to do in an outpatient facility.

Our program needs administrative support and an ID physician. Although there is no formal ASP, there is a stewardship pharmacist

who conducts most of the activities using national guidelines and has demonstrated positive outcomes.

alaska division of public health alaska state hospital and nursing home association mountain-pacific...

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