Antibiotic Stewardship-Key Clinical Strategies for

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This document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.

© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2018

Consulting | Talent | Training | Resources

Antibiotic StewardshipKey Clinical Strategies for Successful Outcomes

Louann Lawson, BA, RN, RAC-CT, CIMTNurse ConsultantClinical Reimbursement Team Leader/Clinical Education ManagerPathway Health






Objectives

Upon completion of this presentation, attendees should be able to:

1. Understand the new Centers for Disease Control (CDC) requirements and expectations for an antibiotic stewardship program;

2. Identify the key expectations of the director of nursing and nursing home administrator for quality outcomes

3. Describe three essential leadership strategies for implementation and quality monitoring for successful outcomes






Antibiotics - Are they OVERUSED?

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Use of Antibiotics - CDC

Are overused

Are misused

Reactions and Side Effects

Can only work with infections=bacteria

Resistance is growing

Reactions and Side Effects

http://www.cdc.gov/getsmart/week/downloads/antibiotics-arent-always-the-answer-for-parents.pdf

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Definition of Antibiotic Stewardship

The CDC Defines Antibiotic Stewardship as:

“…a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse

events associated with antibiotic use”

The Core Elements of Antibiotic Stewardship for Nursing Homeshttps://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html






Antibiotic Stewardship - CDC

• Antibiotics are among the most frequently ordered drugs in nursing homes

• Up to 70% of residents in nursing homes receive 1 or more systemic antibiotics when they are followed for over a year

• 40-75% of antibiotics prescribed in Nursing Homes may be unnecessary or inappropriate

• Residents taking antibiotics are at risk for harm

o C-difficile

o Adverse drug events

o Drug interactions

o Colonization

o Antibiotic Resistant OrganismsThe Core Elements of Antibiotic Stewardship for Nursing Homeshttps://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html

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INDUSTRY EXPERT RESOURCES






Let’s Start with the

Regulatory Requirements!

CMS-State Operations ManualAppendix PP-Guidance to

Surveyors for Long Term Care Facilities

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf






CMS-State Operations ManualAppendix PP-Guidance to Surveyors for Long Term Care Facilities

F881 §483.80(a) Infection prevention and control program.

The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

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F881: Antibiotic Stewardship

INTENT “The intent of this regulation is to ensure that the facility: • Develops and implements protocols to optimize the treatment of

infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic;

• Reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; and

• Develops, promotes, and implements a facility-wide system to monitor the use of antibiotics”. https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf







Guidance:

• “As part of their IPCP programs, facilities must develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance”.

• “This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms”.https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf







“The facility must develop an antibiotic stewardship program which includes the development of protocols and a system to monitor

antibiotic use. This development should include leadership support and accountability via the participation of the medical director, consulting

pharmacist, nursing and administrative leadership, and individual with designated responsibility for the infection control program if different”


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The antibiotic stewardship program protocols shall describe how the program will be implemented and antibiotic use will be monitored, consequently protocols must:

• Be incorporated in the overall infection prevention and control program;

• Be reviewed on an annual basis and as needed;

• Contain a system of reports related to monitoring antibiotic usage and resistance data.

• Incorporate monitoring of antibiotic use, o including the frequency of monitoring/review.

o Monitor/review when the resident is new to the facility; when a prior resident returns or is transferred from a hospital or other facility

o during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic regimen review as requested by the QAAcommittee. https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf







Continued:• In addition, establish the frequency and mode or mechanism of

feedback (e.g., verbal, written note in record) to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols.

• Assess residents for any infection using standardized tools and criteria

• Include the mode (e.g., verbal, written, online) and frequency (as determined by the facility) of education for prescribing practitioners and nursing staff on antibiotic use (stewardship) and the facility’s antibiotic use protocols.

https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf






CMS: LTC Survey Pathways

Infection Prevention, Control & Immunizations: Determine whether the facility has an antibiotic stewardship program that includes:

• Written antibiotic use protocols on antibiotic prescribing, including the documentation of the indication, dosage, and duration of use of the antibiotics

• Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g. SBAR tool for urinary tract infection (UTI) assessment. Loeb minimum criteria for initiation of antibiotics).

CMS‐ Infection Prevention , Control & Immunizations, CMS‐20054 (5/2017):https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/GuidanceforLawsAndRegulations/Downloads/LTC‐Survey‐Pathways.zip

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CMS: LTC Survey Pathways-continued


• A process for periodic review of antibiotic use by prescribing practitioners; for example, review of laboratory and medication orders, progress notes and medication administration records to determine whether or not an infection or communicable disease has been documented and whether an appropriate antibiotic has been prescribed for the recommended length of time. Determine whether the antibiotic use monitoring system is reviewed when the resident is new to the facility, when a prior resident returns or is transferred from a hospital or other facility, during each monthly drug regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic drug regimen review requested by the QAA committee

https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/GuidanceforLawsAndRegulations/Downloads/LTC‐Survey‐Pathways.zip






CMS: LTC Survey Pathways-continued


• Protocols to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotic;

• A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner

Did the facility conduct ongoing review for antibiotic stewardship

YES NO F881

https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/GuidanceforLawsAndRegulations/Downloads/LTC‐Survey‐Pathways.zip






CDCCenters for Disease

Control and Prevention

https://www.cdc.gov/

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Best Practice Resources:

The Core Elements of Antibiotic Stewardship for Nursing Homes

https://www.cdc.gov/longtermcare/prevention/antibiotic‐stewardship.html






CDC

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

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CDC

http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf

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Antibiograms

An antibiogram is a tool aimed at improving appropriate antibiotic prescribing.

• Report that displays the organisms present in diagnostic clinical specimens that nursing homes send for laboratory testing

• Referring to an antibiogram report helps the physician make prompt, empirically based decisions.

• Intended to improve the use of antibiotics in nursing homes by helping prescribing clinicians select the most appropriate therapies for residents with suspected infections

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https://www.ahrq.gov/nhguide/toolkits/help-clinicians-choose-the-right-antibiotic/toolkit2-concise-antibiogram-toolkit.html






Example: AHRQ Tools for Infection Criteria

https://www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/index.html

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AHRQ - Another GREAT RESOURCE

Catheter – Associated UTI’s






CAUTI-Catheter Associated Urinary Tract Infections

AHRQ toolkit

• Developed based upon 500 nursing homes across the country

• Was a 3-year implementation project

• Toolkit is organized in 3 main sections

o Implementation

o Sustainability

o Resources

https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/index.html?utm_source=ahrq&utm_medium=generic&utm_term=&utm_content=2&utm_campaign=AHRQ_cauti4ltc_2017






Examples of Infection Control Risk Assessment Tools

http://community.apic.org/sierra/resources/overview

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CDC Toolkit for Influenza

https://www.cdc.gov/flu/professionals/index.htm






CDC-Guidance on the Use of Antivirals

https://www.cdc.gov/flu/professionals/antivirals/antiviral-use-influenza.htm






Minnesota Department of Health Long-Term Care: Influenza

http://www.health.state.mn.us/divs/idepc/diseases/flu/ltc/index.html

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C-Diff

CDC has developed a Toolkit

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http://www.cdc.gov/hai/pdfs/toolkits/CDI-Primer-2-2016.pdf






User Friendly System Inclusions!






Preadmission Assessment

Do you have a comprehensive Preadmission Screening Process?

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Preadmission Assessment

Review the Medical Record

• Diagnosis(es)

• Antibiotic Use

• Vital Signs

• Lab Work (Results or Pending Tests)

• Imaging

Ask the nursing staff at the hospital (or other entity) about infections or symptoms

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Admission Screening Risk Factors

• Antibiotic use past 30 days

• Current symptoms or diagnosis

• Cultures taken and results

• Immunization history

• Duration of indwelling catheter

• Presence of MDROs

• Prior infection

• 2-step Mantoux - history of positive reaction

• Vaccines

**Facilities will be required to incorporate any infection-related care needs on the initial 48 hour baseline care plan

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Do You Have User-Friendly Systems/Forms?

Example: Criteria for Infection Report Forms(UTI, Respiratory, Wound, Skin/Soft Tissue, etc.)

These forms assist the nurse in determining if the resident exhibits criteria for infection!

Great Resources include:Loeb M, Brazil K, Lohfeld L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomisedcontrolled trial. BMJ. 2005;331:669

Stone, N., Ashraf, M., Calder, J., Crnich, C., Crossley, K., Drinka, P., . . . For the Society for Healthcare Epidemiology Long-Term Care Special Interest Group. (2012). Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology, 33(10), 965-977. doi:10.1086/66774

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Tracking Log






Infection Preventionist Tools

There is a requirement to…”establish the frequency and mode or mechanism of feedback (e.g., verbal, written note in record) to prescribing practitioners regarding antibiotic resistance data, their antibiotic use and their compliance with facility antibiotic use protocols.”







Audit Tools

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Leadership Strategies for Oversight of the Antibiotic Stewardship Program-Alignment with CDC Core Elements of

Antibiotic Stewardship in Nursing Homes






Leadership Commitment

• Policies and Procedures

• Job Descriptions

• Identification of a solid communication system

• Culture Change

**All these efforts assist the facility with oversight of proper and safe antibiotic use

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Policies and Procedures

Include policies for criteria for infection

• Use Evidence-Based Standards of Practice

• Professionally Accepted Resources

o CDC: Core Elements of Antibiotic Stewardship

o AHRQ: Nursing Home Antimicrobial Stewardship Guide

Loeb, M., Brazil, K., Lohfeld, L., McGeer, A., Simor, A., Stevenson, K., Zoutman, D…..Walter, S.D. (2005). Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial. BMJ, 331, 669 http://www.bmj.com/content/bmj/early/2004/12/31/bmj.38602.586343.55.full.pdf

“Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria” http://www.jstor.org/stable/10.1086/667743

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Policies and Procedures

Other Areas to Consider when drafting P&P’s:

Antibiotic Ordering and Use

• Drug, Dosage, Duration, etc.

• Prophylactic Antibiotic Ordering

Diagnostic Testing and Reporting

Medical Director Involvement

Pharmacy Consultant Involvement

Communication and Education

• Staff

• Residents

• Families 43






Job Descriptions

Antibiotic Stewardship Responsibilities should be included in the job descriptions of:

• Infection Preventionist

• Director of Nursing

• Licensed Nurses

• Medical Director

• Pharmacy Consultant

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Communication: Do You Have a Good System?

• Nurse to Practitioner

• Nurse to DON


• Families

• Residents


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Culture

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Accountability

Medical Director

DON

Infection Preventionist

Consultant Pharmacist

Lab

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Drug Expertise

Pharmacist

• Identify what specific training does the consultant pharmacist (and pharmacists at the contracted pharmacy)

• **You can work with your Pharmacy Consultant on attending a course

Physicians

• Enlist Medical Director

Hospital Partners

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Action

**Identify ONE area that can improve antibiotic use practices for care improvement—Put into QAPI Process!

• One example is an Antibiotic “Time-Out”

o After culture results obtained (24-48 hours) talk to physician and re-evaluate the therapy

− Still necessary

− Appropriate (based on lab results)

− Can even assist in plan (i.e. duration)

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QAPI Action Plan

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Tracking and Reporting

In order for organizations to be able to appropriately monitor success of the antibiotic stewardship program, organizations will need to have a solid system to be able to track data. CMS has outlined information on how to track process measures, antibiotic use measures and antibiotic outcome measures as well as costs at: http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf

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Auditing

Example: Appropriate Antibiotic Use

Diagnosis

Practitioner Order

Site of Infection

Start/Stop Date of Medication

Resident presents with signs/symptoms of infection (using evidence based definitions of infection)

Organism identified through laboratory testing (i.e. C&S)

Care Planning 52






Reporting

• Nursing Staff

o Appropriate Use

o Prescribing Practices


• Leadership Team


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Facility Staff Education

• CDC Core Elements of Antibiotic Stewardship for LTCFacilities

• Infection Criteria (McGeer’s Criteria, Loeb, AHRQ, etc.)

• Facility Policy and Procedures

• Multidrug Resistant Organisms

o Prevention

o Treatment

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Clinician Education

Required!

“Include the mode (e.g., verbal, written, online) and frequency (as determined by the facility) of education for prescribing practitioners and nursing staff on antibiotic use (stewardship) and the facility’s antibiotic use protocols”• Develop an action plan in association with:

o Pharmacy Consultant

o Medical Director

• Determine opportunities for improvement

• Utilize evidence-based best practice

• Determine method of delivery55






Resident/Family Education-CDC

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http://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-what-to-ask.pdf






Additional Clinical Processes

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Key Clinical Processes

Ongoing analysis that includes:• Auditing all antibiotic use in the facility

o Review nurse assessment information

o Root cause analysis: what information was discussed with the physician? (Criteria for Infection?)

o Documentation

• Ensure that the resident is taking the right antibiotic for the right amount of time

• Appropriate discussion with practitioner regarding antibiotic use -may need to involve the Medical Director and the Pharmacy Consultant

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Facility Assessment

The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.

• Must be reviewed/revised annually

• Must be reviewed/revised when any change would require a substantial modification to the assessment

• Assessment must address a facility-based and community-based risk assessment using an all-hazards approach

• The results of the facility assessment must be used to establish and update the Infection Prevention and Control Program, including policies and procedures

• TB screening per State requirements






Facility Assessment

• Administrative Measures

• Risk Assessment

• Education

• Antibiotic Use Evaluation and Antibiotic Stewardship

• Surveillance

• Hand Hygiene

• Standard and Transmission Based Precautions

• Environmental Measures60

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Leadership Strategies

Stay up to date with the most current recommendations, guidelines, evidence based standards of practice and regulatory requirements.

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Summary

1. Become familiar with the regulatory requirements (F881) for Antibiotic Stewardship

2. Understand best practices for infection criteria

3. Work with the IDT, Medical Director, Pharmacy Consultant and hospital partners to ensure a solid system (Policies, Procedures, Preadmission Process, etc.)

4. Education!

5. Surveillance, tracking, data analysis, audits

6. QAA involvement






Resources

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CDC Education

https://www.train.org/cdctrain/course/1075730






References and Resources

CMS State Operations Manual, Appendix PP –Guidance to Surveyors for Long Term Care Facilities:


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CDC - Core Elements of Antibiotic Stewardship for Nursing Homes

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

U.S. Department of Health & Human Services: AHRQ: Nursing Home Antimicrobial Stewardshiphttp://www.ahrq.gov/nhguide/index.html

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Resources

National Healthcare Safety Network (NHSN) LTC facilities

Tracking Infections

• Training

• Protocols

• Forms

• Support Materials

• And More!

https://www.cdc.gov/nhsn/ltc/index.html67






Resources

“Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/

http://www.annalsoflongtermcare.com/article/antibiotic-stewardship-programs-long-term-care-facilities

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AHRQ: CAUTI - Catheter Associated Urinary Tract Infections

https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/index.html?utm_source=ahrq&utm_medium=generic&utm_term=&utm_content=2&utm_campaign=AHRQ_cauti4ltc_2017

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Resources and References

World Health Organization

Antibiotic Resistance

http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/

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Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases Advance Access published April 13, 2016http://cid.oxfordjournals.org/content/early/2016/04/11/cid.ciw118.full.pdf+html

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Resources

CDC: Antibiotic Stewardship Statement for Antibiotic Guidelines – Recommendations of the Healthcare Infection Control Practices Advisory Committee

http://www.cdc.gov/hicpac/Pubs/Antibiotic-Stewardship-Statement.html

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Questions?






Disclaimer

“This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health.”






Documents

Antibiotic Stewardship-Key Clinical Strategies for