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Pharmacist Monitoring Tools for Antimicrobial
StewardshipDianna Gatto, Pharm.D., BCPS
Pharmacy Clinical ManagerChris Beuning, Pharm.D., BCPS
Pharmacy Clinical AnalystMultiCare Health System
September 10, 2012
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MultiCare Health System
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MultiCare Health System 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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Objectives Be familiar with antimicrobial stewardship Understand key pharmacist workflows Identify tools for patient monitoring
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Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Pharmacist tools Key pharmacist workflows Challenges Future directions
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Outline
Overview of MultiCare Health System What is Antimicrobial Stewardship Pharmacist tools Key pharmacist workflows Challenges Future directions
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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
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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
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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 criteria
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Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Key pharmacist workflows Pharmacist tools Challenges Future directions
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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
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Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Key pharmacist workflows Pharmacist tools Challenges Future directions
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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
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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
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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
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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
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Tools – Microbiology Results Best Practice Advisories – Properties
(Vendor specific screen capture removed)
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Tools – Pharmacist/Physician Rounding
Accordion Reports General
Medication administration visual Culture information Lab data, Vital information Pertinent drug levels Allow changes to time view
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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
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Accordion Reports - Antimicrobial
(Vendor specific screen capture removed)
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Accordion Reports – Vancomycin22
(Vendor specific screen capture removed)
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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
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Tools - System Lists and Patient Scoring
Rule based columns ScoreCreatinine clearance (CrCl)
Value of 0 to 1 based on level of renal dysfunction (0 = >70 mL/min; 1 = < 10 mL/min)
On antimicrobial Value of 1 for each antimicrobial
AMS target medications Value of 1 for each target antimicrobial
Aminoglycoside/Vancomycin
Value of 1 if on either
On 3 or more antimicrobials for 2 or more days
Value of 1 if true
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Tools - System Lists and Patient ScoringRule based columns ScoreOn 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-Vents Value of 1 for each open I-Vent
Rx Protocol Value of 1 for each open protocol
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Tools - System Lists and Patient Scoring
(Vendor specific screen capture removed)
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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
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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
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Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Key pharmacist workflows Pharmacist tools Challenges Future directions
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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
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Mitigating Challenges Creative use of BPA’s 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
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Outline Overview of MultiCare Health System What is Antimicrobial Stewardship Key pharmacist workflows Pharmacist tools Challenges Future directions
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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
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Conclusion What is Antimicrobial Stewardship Pharmacist tools Key pharmacist workflows Pharmacist tools Challenges Future directions
