Getting Your Antibiotic Stewardship

Program Started

• Health Quality Innovators HQI is your Quality Innovation

Network – Quality Improvement Organization (QIN-QIO) for

MD & VA

• QIN-QIO’s bring Nursing Homes, Hospitals, Communities and

Patients together in data-driven initiatives that:

• Increase resident safety

• Make communities healthier

• Better coordinate post-hospital care

• Improve clinical quality

HQI Nursing Home Improvement Network

So What is “Antibiotic Stewardship” ?

The Maryland Campaign for Appropriate Antibiotic Use (CAAUSE)

Lucy Wilson, MD, ScM, Chief, Center for Surveillance, Infection Prevention and Outbreak Response

Infectious Disease Bureau, Prevention and Health Promotion Administration

Maryland Department of Health and Mental Hygiene

There are many definitions, so let’s keep it simple:

Ensuring that every resident gets:

• An Antibiotic only when one is needed

• The right Antibiotic

• at the right dose

• for the right duration

How Does Antibiotic Resistance Happen?

4

http://www.cdc.gov/drugresistance/about.html

http://www.cdc.gov/drugresistance/about.html

• Resistant bacteria often arise after

antibiotics for suspected UTIs • Think Cipro, Quinolones,

broad-spectrum antibiotics

• Resistant bacteria can stay in the body

longer than 1year

• 1 in 5 of all Adverse Drug Events in nursing

homes are the result of antibiotics

• Antibiotics increase the risk of C. difficile infection 8‐fold

In the nursing home….

Christopher J. Crnich, MD PhD, Associate Professor Department of Medicine, Division of Infectious Diseases

University of Wisconsin School of Medicine and Public Health LAUNCHING AN EFFECTIVE ASP IN NHs pdf

CMS Regulation – 81 FR 6868

AKA “CMS Mega-Rule”

CMS Requirements

6

Requires long term care facilities to

develop an Infection Prevention and

Control Program (IPCP) that includes

an Antibiotic Stewardship Program

a. “includes antibiotic use protocols

and a system to monitor antibiotic

use”

https://www.federalregister.gov/documents/2016/10/04/2016-23503/

medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities

What are the Goals of

Antibiotic Stewardship?

Optimize Resident

Safety

Decrease or Control Costs

Reduce Resistance

Lucy Wilson, MD, ScM, Chief, Center for Surveillance, Infection Prevention and Outbreak Response

Infectious Disease Bureau, Prevention and Health Promotion Administration

Maryland Department of Health and Mental Hygiene

I’m Convinced. Where Do I Start?

• AHRQ Nursing Home Antimicrobial Stewardship Guide

https://www.ahrq.gov/nhguide/index.html

• The Core Elements for Antibiotic Stewardship in Nursing Homes

https://www.cdc.gov/longtermcare/prevention/antibiotic-

stewardship.html

• CDC Checklist of Core Elements of Antibiotic Stewardship in Nursing

Homes https://www.cdc.gov/longtermcare/pdfs/core-elements-

antibiotic-stewardship-checklist.pdf

• QIO NCC Nursing Home Training Sessions: Antibiotic Stewardship

http://qioprogram.org/antibiotic-stewardship

HQI Resources – All in One Document

Document provided by

LeadingAge on the

Tuesday Stand-up Call

event page.

You may also email me:

tmandela@hqi.solutions

or Download the document

from HQI.Solutions

website’s Resource Center

Nursing Home Antimicrobial Stewardship Guide

Agency for Healthcare Research and Quality

(AHRQ) Toolkits

10

Toolkit #1: Implement Stewardship

Toolkit #2: Monitor & Sustain

https://www.ahrq.gov/nhguide/toolkits.html

CDC Core Elements

https://www.cdc.gov/longtermcare/prevention

/antibiotic-stewardship.html

QIO NCC Training Sessions with

Activities, Videos, Tools & Nursing CE’shttp://qioprogram.org

/antibiotic-

stewardship

QIO NCC Training Sessions with

Activities, Videos, Tools & Nursing CE’shttp://qioprogram

.org/antibiotic-

stewardship

Sessions are

designed to

take 30-90

minutes

depending on

time spent on

discussions

and activities.

Big Picture: What Are The Steps?

Nancy Losben, R.Ph., CCP, FASCP, CG, Delivering an Antimicrobial Stewardship Program to Your Facility: How

to Lead and Where to Go. 2016

Today’s webinar

covers

Steps 1-5

Infection Prevention

Nurse

Dir of Nursing and ADON

Consultant Pharmacist

Administrator

QAA Nurse

Physicians, incl. Medical

Director

Put a Strong Antibiotic Stewardship

Committee in Place

Can you

name

others?

Nancy Losben, R.Ph., CCP, FASCP, CG,

Delivering an Antimicrobial Stewardship

Program to Your Facility: How to Lead

and Where to Go. 2016

CDC Core Elements for Antibiotic

Stewardship in Nursing Homes

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1. Leadership Commitment: Demonstrate support and

commitment to safe and appropriate antibiotic use in

your facility

2. Accountability: Identify physician, nursing and

pharmacy leads responsible for promoting and

overseeing antibiotic stewardship activities in your

facility

3. Drug Expertise: Establish access to consultant

pharmacists or other individuals with experience or

training in antibiotic stewardship for your facility

http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

CDC Core Elements for Antibiotic

Stewardship in Nursing Homes

17

4. Action: Implement at least one policy or practice to

improve antibiotic use

5. Tracking: Monitor at least one process measure of

antibiotic use and at least one outcome from antibiotic

use in your facility

6. Reporting: Provide regular feedback on antibiotic use

and resistance to prescribing clinicians, nursing staff and

other relevant staff

7. Education: Provide resources to clinicians, nursing staff,

residents and families about antibiotic resistance and

opportunities for improving antibiotic use

http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

Administrator Duties

Facility Leadership Commitment:

• Communicate necessity of Antibiotic

Stewardship to entire team

• Communicate and engage Laboratory,

Pharmacy, Prescribers, and Consultants

• Take ultimate responsibility for proper

antibiotic use in the building

• Allot resources (Personnel, Time, Funding)

• Accept this as Culture Change for Quality

Adapted from Lenard, Blanche M. PANAC Antibiotic Stewardship in Long Term Care: Keeping it Simple. December 2016

Medical Director Duties

• Sets antibiotic prescribing practices &

standards

• Develops action plan with Pharmacy

Consultant

• Provides in-services to team on:• UTIs and other types of infections including Sepsis

• Recognizing difference: Viral vs. Bacterial infections

• Oversees adherence to antibiotic prescribing

practices• Regularly communicates progress to facility prescribers

• Communicates aggregate/individual antimicrobial use

results to prescribers

• Reviews antibiotic use data and ensures best practices

are followed by prescribers

• Helps evaluate effectiveness of facility’s ASP• Measurement of outcomes

Director of Nursing Duties

• Empower nursing staff to participate from the start of the ASP so they understand the objectives

• Educate nursing staff about importance of antibiotic stewardship and explain policies

• Establish standards for nursing staff to assess, monitor and communicate changes in condition

• Institute a system to ensure antibiotics are prescribed only when appropriate

• Ensure prescribers are notified of pertinent lab results

• Coordinate team to teach nursing staff to differentiate infections responsive to antibiotics from infections unresponsive to antibiotics

Nancy Losben, R.Ph., CCP, FASCP, CG, Delivering an Antimicrobial Stewardship Program to Your Facility: How to Lead and Where to Go. 2016

Why Nurses Hold the Key to

Antibiotic Stewardship in LTCNurses are :• The principal persons for resident care

• In charge of administering medications

• Teaching CNA’s to be part of Infection Prevention Culture

• 24 hour monitors for antibiotic:• Effectiveness, Safety & Outcomes

Nurses influence Prescriber Decision –making:

• Thoroughness of initial assessment • resident change in condition

• Thoroughness of communicating findings

• Nurse requests for testing and treatment

• Follow-up assessment and “watchful waiting”Christopher J. Crnich, MD PhD, Associate Professor Department of Medicine, Division of Infectious Diseases

University of Wisconsin School of Medicine and Public Health LAUNCHING AN EFFECTIVE ASP IN NHs pdf

Consultant Pharmacist Duties

• Provide antimicrobial stewardship education to all licensed staff

• Request indication for antibiotic use on all prescribers’ orders

• Review antibiotic prescriptions as part of the drug regimen review

• Communicate standards and guidelines regarding intravenous-to-oral therapies, and duration of therapy

• Establish lab testing protocols to monitor for adverse events and drug interactions related to use of antibiotics

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You already

have an

EXPERT at the

table

Nancy Losben, R.Ph., CCP, FASCP, CG, Delivering an Antimicrobial Stewardship

Program to Your Facility: How to Lead and Where to Go. 2016

Quality Nurse Duties

• Consider Antibiotic Stewardship for a

QAPI/ Performance Improvement Project

• Utilize their expertise in gathering,

organizing, analyzing and reporting data

• Apply standards of care, federal and state

regulations, and an evidence-based

approach to the Antibiotic Stewardship

Program

• Assist in antibiotic stewardship

educational content development and

training for staff

Infection Preventionist (IP) Duties

• Help integrate antibiotic stewardship

into QAPI program

• Possess education or training related to

infection and antibiotic monitoring

• Records incidents identified under

facility’s infection prevention/control

program & corrective actions taken

• Properly develops, implements, monitors

and maintains the IPCP for the facility

• Tracks C. diff and reports in NHSN if

participating in HQI’s C. diff initiative

Nancy Losben, R.Ph., CCP, FASCP, CG,

Delivering an Antimicrobial Stewardship Program

to Your Facility: How to Lead and Where to Go.

2016

What Not to Do…

The Infection Prevention Nurse cannot take on all

the duties of the Antibiotic Stewardship Team.

Resident/Family on ASP Committee

• Get the Resident & Family Perspective

• Enlist their help selecting educational

materials

• Encourage them to get the word out

Provide Educational Materials:

• Family Meetings

• Admission Packet

• Resident Council Meetings

• Facility Newsletters

• Posters in high traffic areas

Resident & Family Engagement in

Antibiotic Stewardship

http://www.cdc.gov/pubs/CDCInfoOnDemand.aspx

https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T5-Suspect_a_Urinary_Tract_Infection_brochure_MA_Coalition_final.pdf

http://www.macoalition.org/Initiatives/infections/uti_2013/tools/LTC_brochure_final.pdf

Where Can I Find

LTC Consumer Brochures?Websites

• CDC

• AHRQ

• FDA

Send Us Your Questions

28

Theresa Mandela

Improvement Consultant

tmandela@hqi.solutions

Lisa Mark

Improvement Consultant

lmark@hqi.solutions

Allison Spangler

Improvement Consultant

aspangler@hqi.solutions

This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network-Quality Improvement

Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the

U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. HQI|11SOW|20170504-

203116

HQI Nursing Home

Improvement Network Team: