Successes, Challenges, and Directions Forward for …...Successes, Challenges, and Directions...

Successes, Challenges, and Directions Forward for

New Hampshire Stewardship

Michael S. Calderwood, MD, MPH

Regional Hospital Epidemiologist, Dartmouth-Hitchcock Medical Center

Assistant Professor of Medicine, Geisel School of Medicine at Dartmouth

May 23, 2018

Outline

• Overview of Inpatient/Outpatient Antibiotic Use

• Discussion of Core Element Performance Data

• Outpatient Stewardship…A New Frontier

• In the inpatient setting…

• 55-64% of adult patients in U.S. hospitals receive at least one antibiotic drug while hospitalized1,2,3

• With the use of extended-spectrum antibiotics on the rise, including later generation cephalosporins, beta-lactam/beta-lactamase inhibitor combinations, carbapenems, and glycopeptides3,4

Setting the Stage

1. Clin Infect Dis 2011;53:1100-10 3. JAMA Intern Med 2016;176:1639-48 2. MMWR Morb Mortality Wkly Rep 2014;63:194-200 4. J Antimicrob Chemother 2013;68:2393-9

Where Do We Stand in New England?

JAMA Intern Med 2016;176:1639-48

Mean Days of Therapy per 1,000 Patients Days (2006-2012) Top Performing Census Divisions: - New England - Mid Atlantic - Pacific

JAMA Intern Med 2016;176:1639-48

BUT…

There was a 10% increase in inpatient DOT/1,000 patient days across New England from 2006 to 2012

Where Do We Stand in New England?

JAMA Intern Med 2016;176:1639-48

AND…

There are limited publicly available data on inpatient antibiotic use since 2012

Where Do We Stand in New England?

• In the outpatient setting…

• 423-553 antibiotic prescriptions written for every 1,000 people in the U.S.1

• More than one antibiotic per child per year under the age of 2

• 13% of outpatient office visits in the U.S. results in an antibiotic prescription2

• 154 million office visits per year

• 30% are unnecessary3

• 44% for acute respiratory conditions, many of which are viral

Thinking Beyond Inpatient Stewardship

1. http://www.pewtrusts.org/~/media/assets/2016/05/antibioticuseinoutpatientsettings.pdf 2. J Antimicrob Chemother 2013;68:715-8. 3. JAMA 2016;315:1864-73.

How is New Hampshire Doing?

10th best state in the U.S. 2nd best state in New England

https://gis.cdc.gov/grasp/PSA/AUMapView.html

How is New Hampshire Doing?

https://resistancemap.cddep.org

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Outpatient antibiotic prescriptions declined in NH by 2.1% per year from 1999 through 2010 Reduced by ~200 prescriptions per 1,000 persons Over 243,000 presumably unnecessary outpatient prescriptions avoided in 2010

How is New Hampshire Doing?

https://resistancemap.cddep.org https://gis.cdc.gov/grasp/PSA/AUMapView.html

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20102010 2011 2012

Unfortunately, there was then a significant increase through 2012

How is New Hampshire Doing?

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20102010 2011 20122012 2013 2014

With improvements seen in 2013 and 2014…but not back to low seen in 2010

https://gis.cdc.gov/grasp/PSA/AUMapView.html

What is Being Prescribed?

https://resistancemap.cddep.org

What is Being Prescribed?

https://resistancemap.cddep.org

#1 Outpatient Prescribed Antibiotic = Azithromycin (Clin Infect Dis 2015;60:1308-16)

What is Being Prescribed?

https://resistancemap.cddep.org

Quinolones most common in older adults [Medicare] (BMC Infect Dis 2016;16:744)

Hospital Stewardship Programs

The local performance is even more impressive when you realize that only 27% of NH hospitals in 2015 had a stewardship program that followed all 7 of the CDC’s Core Elements

Hospital Stewardship Programs

However, this 27% hides the fact that all but one NH hospital had at least one element of stewardship in place by 2015… Compared with 81% nationally in 2015 [According to a survey by The Advisory Board Company, 11/2015]

Hospital Stewardship Programs

By 2016, 38% of NH hospitals had a stewardship program that followed all 7 of the CDC’s Core Elements • 50% of acute care

hospitals with ≥200 beds • 71% of acute care

hospitals with <200 beds • 17% of critical access

hospitals

http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf

Core Elements of Hospital Antibiotic Stewardship Programs

N = 25 NH Hospitals (3,041 beds)

All Responding Hospitals - 2015

All Responding Hospitals - 2016

Leadership Commitment 52% 72% Accountability 72% 88% Drug Expertise 88% 92% Action 88% 92% Tracking 48% 60% Reporting 84% 76% Education 64% 64% All 7 Core Elements 28% 40%

Things are Improving Overall

N = 25 NH Hospitals (3,041 beds)

All Responding Hospitals - 2015

All Responding Hospitals - 2016

Leadership Commitment 52% 72% Accountability 72% 88% Drug Expertise 88% 92% Action 88% 92% Tracking 48% 60% Reporting 84% 76% Education 64% 64% All 7 Core Elements 28% 40%

Things are Improving Overall

But, the following continue to be areas for improvement 1. Leadership commitment in critical access hospitals (50% in 2016) 2. Tracking (and reporting) of use metrics 3. EDUCATION

Leadership Commitment

• In making a case for your ASP, it is important to engage both the C-Suite and Quality Leadership

– Outline your Mission Statement

– Focus on Patient Safety

– Develop a Business Case

“[Optimize] antimicrobial selection, dosing, route, and duration of therapy to maximize clinical cure or

prevention of infection while limiting the unintended consequences, such as the emergence of resistance,

adverse drug events, and cost. The ultimate goal of antimicrobial stewardship is to

improve patient care and health care outcomes.”

Clin Infec Dis 2007;44:159-77

ASPs associated with:

1. 20-35% in antimicrobial use

2. 40% in appropriate recommendation

3. 20% in clinical cure rate

4. 10-15% in treatment failure

5. Fewer reported adverse drug events

Link to Patient Safety/Quality

Clin Infect Dis 2001;33:289-95 Clin Infect Dis 2007;44:159-77 PLoS One 2016;11:e0150795

ASPs associated with:

1. Reductions in Clostridium difficile infections

2. Reductions in colonization or infection with:

• Fluoroquinolone, cephalosporin, and aminoglycoside-resistant gram (-) bacteria

• Methicillin-resistant Staphylococcus aureus

• Vancomycin-resistant Enterococcus

Link to Patient Safety/Quality

Infect Control Hosp Epidemiol 2006;27:155-69 Clin Infect Dis 2007;45S:S112-21 J Antimicrob Chemother 2012;67:2988-96 Int J Antimicrob Agents 2013;41:137-42 Cochrane Database of Syst Rev 2013;4:CD003543

J Antimicrob Chemother 2014;69:1748-54 J Clin Microbiol 2016;54:2343-7 Infect Control Hosp Epidemiol 2017;38:461-8

Barriers to Implementation of ASP

Infect Control Hosp Epidemiol 2009;30:1211-7

Cost Savings from ASP

ASP started in 2001 46% in antimicrobial costs (FY01-FY08)

Infect Control Hosp Epidemiol 2012;33:338-345

Cost Savings from ASP

Hospital cut funding for ASP in 2008 32% in antimicrobial costs (FY09-FY10)

Infect Control Hosp Epidemiol 2012;33:338-345

Leadership Commitment in New Hampshire

• 12 out of 19 surveyed hospitals have a formal letter of support for their stewardship program from senior leadership

• But…only 5 out of 19 surveyed hospitals have financial support from the hospital to support stewardship activities

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Accountability

• It is important to identify a leader or co-leads who will take ownership of the hospital stewardship program and outcomes

Survey by The Advisory Board Company, published 11/2015

Accountability in New Hampshire

Physician 16%

Pharmacist 31%

Co-Led by Physician

and Pharmacist

53%

NH STEWARDSHIP LEADERSHIP

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Infrastructure

Infection Control and Prevention

Clinical Microbiology

Information Technology

Frontline Providers

ID Physician(s)

ID Pharmacist(s)

Antimicrobial

Subcommittee

P&T Committee

Hospital

Administration

Clin Infect Dis 2007;44:159-77

Infrastructure in New Hampshire

• 16 out of 19 surveyed hospitals involve the microbiology lab in stewardship activities

• But…

– Only 8 out of 19 involve IT

– Only 8 out of 19 involve nursing

• NOTE: Survey did not address involvement of (or integration with) infection prevention team

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Drug (Antimicrobial) Expertise

• Knowledge & skills required for antimicrobial stewardship leaders outlined in a SHEA White Paper1

• Having a clinical pharmacist with formal ID training is associated with: – Improved adherence to local treatment guidelines for initial

antimicrobial therapy2

– Higher rates of therapy modification within 24 hrs of laboratory data2

– Decreases in overall antimicrobial use3

• BUT…training opportunities outside of formal ID residency are available for pharmacists!

1. Infect Control Hosp Epidemiol 2014; 35:1444-51 2. Hosp Pharm 2015;50:477-83 3. Infect Control Hosp Epidemiol 2016;37:647-54

Drug (Antimicrobial) Expertise

• Knowledge & skills required for antimicrobial stewardship leaders outlined in a SHEA White Paper1

• Having a clinical pharmacist with formal ID training is associated with: – Improved adherence to local treatment guidelines for initial

antimicrobial therapy2

– Higher rates of therapy modification within 24 hrs of laboratory data2

– Decreases in overall antimicrobial use3

• BUT…training opportunities outside of formal ID residency are available for pharmacists!

1. Infect Control Hosp Epidemiol 2014; 35:1444-51 2. Hosp Pharm 2015;50:477-83 3. Infect Control Hosp Epidemiol 2016;37:647-54

Antimicrobial Expertise in New Hampshire

• While only 7 surveyed hospitals in NH have a pharmacist with formal ID/stewardship training…

• All but 1 have one or more pharmacists involved in providing expertise at the point-of-care

– With a median of 1 pharmacist overall per 18.8 beds in NH (IQR 1 per 12.5-28.1 beds)

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Action

• Core strategies – Formulary restriction and preauthorization – Prospective daily audit with intervention and feedback

• Supplemental strategies – Education, guidelines, clinical pathways

• Antimicrobial order forms/order sets to optimize empiric antimicrobial selection in real-time

– Dose optimization • Prolonged infusion of beta-lactams • Aminoglycoside/vancomycin monitoring program • Renal/obesity dosing review

– Timely de-escalation/optimization • Antibiotic pause • Computerized decision support

– IV PO dose conversion • Link to management of outpatient parenteral antibiotic therapy

Action

• Core strategies – Formulary restriction and preauthorization – Prospective daily audit with intervention and feedback

• Supplemental strategies – Education, guidelines, clinical pathways

• Antimicrobial order forms/order sets to optimize empiric antimicrobial selection in real-time

– Dose optimization • Prolonged infusion of beta-lactams • Aminoglycoside/vancomycin monitoring program • Renal/obesity dosing review

– Timely de-escalation/optimization • Antibiotic pause • Computerized decision support

– IV PO dose conversion • Link to management of outpatient parenteral antibiotic therapy

* Increasingly a “core strategy,” especially in hospitals with limited resources

Core Stewardship Activities in New Hampshire

• 12 out of 19 surveyed hospitals have implemented formulary restriction and pre-authorization

• 18 out of 19 surveyed hospitals have a system for prospective daily audit with intervention and feedback

• BUT…only 9 out of 19 surveyed hospitals have implemented a 48-72hr antibiotic pause/“time-out”

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Comparing Interventions

“Restrictive” interventions had greater impact on prescribing at one month 32% difference 95% CI 2-61%

Cochrane Database of Systematic Reviews 2013;4:CD003543

“Restrictive” interventions had greater impact on microbial outcomes at 6 months 53% difference 95% CI 31-75%

Comparing Interventions

Cochrane Database of Systematic Reviews 2013;4:CD003543

BUT…no difference at 12 or 24 months

Comparing Interventions

Cochrane Database of Systematic Reviews 2013;4:CD003543

Concept of the Antibiotic “Time Out”

• At a minimum, all clinicians should perform a review of antibiotics 48-72 hours after initiation

– Does this patient have an infection that will respond to antibiotics?

– If so, is the patient on the right antibiotic(s), dose, and route of administration?

– Can a more targeted antibiotic be used to treat the infection (de-escalate)?

– How long should the patient receive the antibiotic(s)?

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Concept of the Antibiotic “Time Out”

• At a minimum, all clinicians should perform a review of antibiotics 48-72 hours after initiation

• Ordering providers should specify the dose, duration, and indication for all antibiotics

– This information should be readily accessible to all members of the care team

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Concept of the Antibiotic “Time Out”

• At a minimum, all clinicians should perform a review of antibiotics 48-72 hours after initiation

• Ordering providers should specify the dose, duration, and indication for all antibiotics

• To do this…many hospitals have begun to incorporate checklists into their daily rounding

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Clin Infect Dis 2015;60:1252-8

But Do These Work?

• A checklist alone is not the solution…

But Do These Work?

• A checklist alone is not the solution…

• …to be effective, providers need prompting to use these tools

• This prompting can come from any member of the healthcare team as part of a daily “antibiotic pause”

Improved Patient Outcomes

• In a study with two arms, prompted and unprompted (both with access to checklist):

– Prompted group had:

• Significant decline in empiric antibiotic days

• Lower risk adjusted ICU mortality (OR 0.36, 95% CI 0.13-0.96) and hospital mortality (OR 0.34, 95% CI 0.15-0.76)

• 40% decline in LOS in prompted vs. non-prompted group (p-value 0.02)

Am J Respir Crit Care Med 2011;184:680-6

Improved Patient Outcomes

• Similar results seen comparing face-to-face prompting vs. an electronic checklist:

– Four-fold increase in discontinuing or narrowing of empiric antibiotics

– Lower proportion of patient-days on which empiric antibiotics were administered compared to electronic checklist group patients (63.1% vs 70.0%, p = 0.002)

– Each additional day of empiric antibiotics predicted higher risk-adjusted mortality (OR 1.14, 95% CI 1.05-1.23)

Crit Care Med 2013;41:2563-9

Improved Patient Outcomes

• Decline came in antibiotic use for possible/empirical infection

Crit Care Med 2013;41:2563-9

Supplemental Stewardship Activities in New Hampshire

• 17 out of 19 surveyed hospitals have pharmacists involved in dose optimization: – Renal dose adjustment – IV-to-PO conversion – Aminoglycoside/vancomycin monitoring

• 17 out of 19 surveyed hospitals have developed order sets for empiric antibiotic selection: – Pneumonia – UTI – Skin and Soft Tissue Infection – Sepsis – Perioperative Prophylaxis – C. difficile – MRSA

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Stewardship Education in New Hampshire

• Only 7 out of 19 surveyed hospitals have a formal stewardship education for providers

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Stewardship Education in New Hampshire

• Only 7 out of 19 surveyed hospitals have a formal stewardship education for providers

• This is a real opportunity for the state’s Antimicrobial Resistance Advisory Workgroup

– Start with today’s symposium

– Share current local guidelines

– Develop teaching materials

Education

• But didactic educational materials should not be the end of your stewardship efforts

– While educational campaigns have been associated with 11-43% improvements in antibiotic use…

Cochrane Database Syst Rev 2013;4:CD003543.

Education

• But didactic educational materials should not be the end of your stewardship efforts

– While educational campaigns have been associated with 11-43% improvements in antibiotic use…

– …the impact is typically lost by 12 months after the introduction of educational materials, in the absence of other interventions

Med J Aust 1988; 149:595–9.

Tracking and Reporting

1. Process Measures: A. Documentation of dose, duration, and indication

B. Compliance with local disease treatment guidelines

C. Obtaining cultures prior to treatment

D. Modifying therapy appropriately based on microbiologic findings

E. Acceptance rate for recommendations

F. Number of dose and/or route optimizations

2. Outcome Measures: A. Total antibiotic expenditures

B. Total days of therapy

C. Mortality, Length of Stay, Readmission

D. Rates of C. difficile

E. Local antibiotic resistance rates

Tracking and Reporting in New Hampshire

• 9/10 out of 19 surveyed hospitals require documentation of dose/indication

– BUT…only 5 out of 18 hospitals require documentation of duration

• All surveyed hospitals publish an annual antibiogram

– BUT…how is this used for education?

• 17 out of 19 surveyed hospitals track data on C. difficile

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Tracking and Reporting in New Hampshire

• Only 4 out of 19 surveyed hospitals track days of therapy

– AND…only 1 surveyed hospital reports DOT data to the CDC via the AUR module

• Only 2 out of 19 surveyed hospitals are providing regular feedback to providers on antibiotic use data compared with peers

2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

Quality Improvement Metrics for Evaluating Antimicrobial Stewardship Programs

1. Days of therapy (DOT) per 1000 patient-days*

2. Number of patients with specific organisms that are drug resistant*

3. Mortality related to antimicrobial-resistant organisms

4. Conservable days of therapy among patients with community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), or sepsis and bloodstream infections (BSI)

5. Unplanned hospital readmission within 30 days after discharge from the hospital in which the most responsible diagnosis was one of CAP, SSTI, sepsis or BSI

* Recommended for public reporting

Infect Control Hosp Epidemiol 2012;33:500-6

http://www.cdc.gov/nhsn/acute-care-hospital/aur/

Quality Improvement Metrics for Evaluating Antimicrobial Stewardship Programs

1. Days of therapy (DOT) per 1000 patient-days*

2. Number of patients with specific organisms that are drug resistant*

3. Mortality related to antimicrobial-resistant organisms

4. Conservable days of therapy among patients with community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), or sepsis and bloodstream infections (BSI)

5. Unplanned hospital readmission within 30 days after discharge from the hospital in which the most responsible diagnosis was one of CAP, SSTI, sepsis or BSI

* Focus of CDC’s Surveillance for Antibiotic Use and Antimicrobial Resistance

Outpatient Stewardship… A New Frontier

https://www.cdc.gov/antibiotic-use/community/improving-prescribing/core-elements/core-outpatient-stewardship.html

Guideline and Resources Available!

Outpatient Stewardship… A New Frontier

• Current interventions in New Hampshire:

– Education around local resistance

• Concerns regarding unnecessary macrolide use and rising Streptococcus pneumoniae resistance

• Efforts to ensure adherence to first-line treatment for UTI to reduce FQ-resistant E. coli

• Tracking of MRSA resistance patterns and education about rising clindamycin resistance in the community

Outpatient Stewardship… A New Frontier

• Current interventions in New Hampshire:

– Peer Comparisons

• Multiple practices have begun tracking and providing antibiotic use data to providers with comparison to peers

• Primary focus has been prescribing for acute respiratory conditions

Outpatient Stewardship… A New Frontier

• Current interventions in New Hampshire:

– Role of Triage

• Work has begun on the creation of a phone algorithm decision tree to assist in recommending an outpatient visit, empiric antibiotics, or watchful waiting

Parting Thoughts

• “Appropriate use of antimicrobials is an essential part of patient safety”

– IDSA/SHEA guidelines for developing an ASP (available at http://www.idsociety.org)

• Antimicrobial stewardship is EVERYONE’S RESPONSIBILITY

Questions?