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Antimicrobial Steward Call August 14, 2018 Tennessee Department of Health Healthcare Associated Infections and Antimicrobial Resistance Program

Antimicrobial Steward Call August 14, 2018

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Page 1: Antimicrobial Steward Call August 14, 2018

Antimicrobial Steward Call August 14, 2018

Tennessee Department of Health Healthcare Associated Infections and Antimicrobial Resistance Program

Page 2: Antimicrobial Steward Call August 14, 2018

Welcome

Page 3: Antimicrobial Steward Call August 14, 2018

Adobe Connect Housekeeping

• All lines have been muted • Press *6 to unmute your line • Also can use the chat box to ask questions/comment

Page 4: Antimicrobial Steward Call August 14, 2018

Announcements

Page 5: Antimicrobial Steward Call August 14, 2018

US Antibiotic Awareness Week

• November 12–18, 2018 • Mark your calendars now!

• Educational and promotional materials available at CDC

– https://www.cdc.gov/antibiotic-use/week/overview.html

Page 6: Antimicrobial Steward Call August 14, 2018

CDC AS Training Module

• Free CE for HCP – MD, NP, PA, Health

Education Specialists, RN, RPh, Public Health Practitioners

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

• Module 2 AVAILABLE NOW – Outpatient Stewardship

Presenter
Presentation Notes
Today, CDC’s Office of Antibiotic Stewardship launched the first section of a four-part web-based training course on Antibiotic Stewardship. While this particular course is primarily for clinicians who prescribe antibiotics, CDC recognizes that everyone plays an important role in improving antibiotic use. Doctors, nurse practitioners, physician assistants, certified health education specialists, nurses, pharmacists, and public health practitioners with a master’s degree in public health are all eligible to receive up to eight hours of CE from this course, which is accessible in multiple modules offered in four sections. The first section is available now, with additional content releasing later this year.
Page 7: Antimicrobial Steward Call August 14, 2018

DART Communications Training

• Dialogue Around Respiratory Illness Treatment: Optimizing Communication with Parents

• Targets antibiotic prescribing for respiratory infections

• http://www.seattlechildrens.org/research/child-

health-behavior-and-development/mangione-smith-lab/dart-learning-modules/

Page 8: Antimicrobial Steward Call August 14, 2018

TDH AU PP Survey

• Q2 2018 Packets are complete and disseminated

• Questions contact: [email protected]

• Next deadline – October 31 for all data for Q3 2018

Page 9: Antimicrobial Steward Call August 14, 2018

Culture Review in the Emergency Department

Page 10: Antimicrobial Steward Call August 14, 2018

Nicole M. Acquisto, Pharm.D., FCCP, BCCCP Emergency Medicine Clinical Pharmacy Specialist,

Department of Pharmacy Associate Professor, Department of Emergency Medicine

University of Rochester Medical Center Rochester, NY

Stewardship in the Emergency Department: Culture Surveillance and Follow-Up

Page 11: Antimicrobial Steward Call August 14, 2018

Conflict of Interests

I have no actual or potential conflict of interest in relation to this presentation or program

Page 12: Antimicrobial Steward Call August 14, 2018

Objectives

Describe differences in ED antimicrobial stewardship compared to traditional stewardship activities

Explain the development and implementation of an ED culture surveillance and follow-up program

Discuss associated metrics

Summarize additional ED stewardship quick wins

Page 13: Antimicrobial Steward Call August 14, 2018

136 million

34.5 million

One-third

5-39%

142,500 ED visits annually

Antibiotics prescribed during ED

visits

Of antibiotics are

inappropriate

ED visits a year are due to antibiotic

ADEs

Of patients on

antibiotics develop AAD

Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary. Available at: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf. Accessed January 20, 2016. Haran et al. Am J Emerg Med. 2014;32:1195-1199.; May et al. Ann Emerg Med. 2013;62(1):69-77.

Why is ASP Important in the ED?

Presenter
Presentation Notes
130 million ED visits in 2010 103 million visits – At least 1 medication administered Average 2.1 medications/visit Total medication doses administered ~255 million Antibiotics were the second most common therapeutic drug class prescribed during ED visits 34,442,000 million drug mentions (13.5%) Estimated 142,500 ED visits/year – adverse effects associated with systemic antibiotic use 19.3% of all ED visits for drug related adverse effects 78.7% allergic reactions 136 million visits annually to the ED (2011 CDC) 5 of top 10 most common reasons for presentation were potentially infection related Fever 3rd, cough 4th, SOB 6th, throat 9th, vomiting 10th 160 million antibiotics are prescribed each year – 12.9% of all medications given in the ED or rx patients are d/c with are abx 1/3 of the 160 million rx for abx are inappropriate – inappropriate abx use has been described as the most important preventantable cause of drug resistance in the inpatient and outpatient setting 142,500 (0.1%) ED visits that occur each year are for an ED event 80% allergic reaction Between 5-39% of pts started on abx will go on to develop antibiotic associated diarrhea
Page 14: Antimicrobial Steward Call August 14, 2018

Patient satisfaction

Limited time

Why It’s Not A Simple Fix

Barriers of antimicrobial stewardship in ED setting

Provider liability

Variety in provider practice

Lack of patient info

Patient turnover

Lack of awareness

Quick decision making

Empiric therapy

Trinh TD, et al. Infect Dis Ther. 2015;4 (Suppl 1):S39–S50.; May et al. Ann Emerg Med. 2013;62(1):69-77.; Bishop BM. J Pharm Pract. 2015:1-8.

Quality measures

Presenter
Presentation Notes
Unique environment Quick decision making Limited patient information Difficult to sustain knowledge ED as a unique environment High patient volume and turnover Need for quick decision making High rates of staff turnover compared to other clinical areas Difficult for sustained knowledge Limited information No culture information or susceptibilities for that presentation Institution antibiograms often include the ED with inpatient isolates Also, may not be employed by the hospital – ED contract groups Goals are to: Decrease Overall and inappropriate use Costs Treatment duration Adverse effects and collateral damage Local resistance Representation/readmission Improve Healthcare outcomes Overall antibiotic utilization Overall strategies: Surveillance Data evaluation Policies/guidelines Education 1. Empiric therapy - Lack of information about the patient (cannot determine risk factors, recent hospitalizations or abx use, etc.) – come in alone or with EMS transporters that have incomplete stories Unclear source of infection – Altered, but CXR hazy infiltrate (meningitis, PNA, UTI) Culture history 2. Provider obstacles Pressure to see as many patients as possible Limits amount of time they can spend investigating patient’s previous hospitalizations Rapid turnover quick decision making (usually don’t have time to wait for consultation) Medical liability – concern for failure to diagnose and treat Pressure from local and/or national quality measures – inappropriate use of vanco/zosyn for HCAP criteria Patient satisfaction rates linked directly with prescribing of abx
Page 15: Antimicrobial Steward Call August 14, 2018

Traditional ASP

Selection/Dose/Formulary restriction Drug monitoring Review of culture data and susceptibilities De-escalation or discontinuation of therapy IV to PO interchange Scheduled evaluation at 72 hours Duration Cost reduction

All ASPs Aren’t Created Equal

Trinh TD, et al. Infect Dis Ther. 2015;4 (Suppl 1):S39–S50.; May et al. Ann Emerg Med. 2013;62(1):69-77.; Bishop BM. J Pharm Pract. 2015:1-8.

Presenter
Presentation Notes
Maximize the appropriateness of BROAD SPECTRUM abx and Traditional activities: Selection Dose Rapid initiation De-escalation of therapy IV to oral interchange Scheduled evaluation at 72 hrs Duration
Page 16: Antimicrobial Steward Call August 14, 2018

Guidelines Order sets Computer-based decision

support ED specific antibiogram Rapid initiation

Emergency medicine clinical pharmacist

Culture surveillance and follow-up

Medication availability Drive prescribing Re-presentation prevention

Strategies for ASP in the ED

Presenter
Presentation Notes
Right empiric drug/dose/duration Prompt administration Preventing re-presentations/re-admissions Guidelines- interdisiplinary development, consider national recommendations, institution factors, availability to providers (available on intranet) Disease specific order sets – Empiric regimens and also to direct length of treatment, direct important laboratory and culture data, auto-selected and linked, direct treatment as outlined in the guideline (lab and medication direction) Computer based decision support – direct appropriate selection, direct appropriate dose, limitations (does not take into consideration patient specific factors (drug and dose selection) Education - Identify the need based on practice trends or pointed medication DUE Focused UTI/SSTI education program Interactive lecture at weekly EM attending/resident conference Pocket guides and ID badge cards were prepared and distributed to EM providers with brief education Educational e-mail Evaluate education program – review of appropriate vs. inappropriate prescribing practices (before and after education program) Re-education and Feedback Barriers to prospective order review Availability of medications on override in the medication cabinets Limited time for review of the order and intervention Orders may not be seen by a pharmacist at all Centralized pharmacist location Paper orders “Autoverify” Retrospective order review and pointed education Focused on disease state management, selection, optimal dose, not “tweeking” Reference to the guidelines or reference tools
Page 17: Antimicrobial Steward Call August 14, 2018

Widely recognized as an important component of any comprehensive antimicrobial stewardship program

Facilitates appropriate antibiotic selection and dose

Improve time to antibiotic administration

Point person to identify problem areas, implement improvement strategies, and follow-up on the results

Ability to monitor all ED patients simultaneously

Identify and triage any medication misadventures

May L, et al. Ann Emerg Med 2013;62:69-77

Emergency Medicine Clinical Pharmacist

Presenter
Presentation Notes
Medication misadventures: Medication errors, adverse effects, adverse drug reactions, drug interactions
Page 18: Antimicrobial Steward Call August 14, 2018

American College of Emergency Physicians. Clinical Pharmacist Services in the Emergency Department . Available at : https://www.acep.org/Clinical---Practice-Management/Clinical-Pharmacist-Services-in-the-Emergency-Department/. Accessed June 13, 2016.

The Role of the EM Pharmacist

Page 19: Antimicrobial Steward Call August 14, 2018

Patanwala AE, et al. Ann Emerg Med 2012;59:369-73

Target the ED for Decentralization Multicenter evaluation of 16,446 patients and 364 intercepted

medication errors Medication error interceptions are most often from the

pharmacist consulting with the team compared to order review 51.4% vs. 34.9%

82.4% of errors are identified during the prescribing phase Wrong dose (44.2%) and wrong drug (13.7%) were the most

common URMC (unpublished) – 40% of medication error interceptions

were antibiotic related

Presenter
Presentation Notes
In our ED, over 50% of the orders in the evening are from the ED – good place to target decentralization if you have >/= 2 pharmacists
Page 20: Antimicrobial Steward Call August 14, 2018

EM Pharmacist and Sepsis 585 consults, 130 patients Recommendations: dose, selection of appropriate

empiric antimicrobials, or to add antimicrobial agents

Weant K and Baker SN. J Pharm Pract 2013;26:401-05

Presenter
Presentation Notes
Talk about the EM clinical pharmacist
Page 21: Antimicrobial Steward Call August 14, 2018

Acquisto NM and Baker SN. J Pharm Pract 2011;24:196-202

Culture Surveillance and Follow-up Evaluation of culture and susceptibility reports for treat and release

or transferred patients

Contact patient, PCP, specialist, DOH, patient’s pharmacy

Getting Started: Identify the current process at your institution

Routine and immediate review Are there areas of breakdown in the current system? Differences in weekdays vs. weekends

Presenter
Presentation Notes
to determine appropriateness of empiric therapy Areas of breakdown: Ex: Delays to review due to direct patient care activities
Page 22: Antimicrobial Steward Call August 14, 2018

Interdisciplinary group

Determine: How will you be notified of results (routine and immediate)? Paper or electronic process? Who will be available to discuss cases? Where will follow-up and outcome be documented? Who else will be involved to provide consistent coverage?

URMC program development

Acquisto NM and Baker SN. J Pharm Pract 2011;24:196-202

Culture Surveillance and Follow-up

Presenter
Presentation Notes
Collaboration with physicians, advanced practice providers, nurses, and microbiology staff to streamline the system for follow-up on all microbiologic cultures for patients discharged from the ED Collaborative practice agreement vs. face to face conversation
Page 23: Antimicrobial Steward Call August 14, 2018

Barriers • Advanced practice providers responsible for weekend coverage • Time requirement • Paper system • Sterile site culture review (pager system)

Baker SN, Acquisto NM, et al. J Pharm Pract 2012;25:190-94

Previous Program 11/2007-1/2008

EPh Program 11/2008-1/2009

Median Time to Positive Culture Review, Days (range)

3 (1-15) n = 104

2 (0-4) n = 73

Median Time to Patient or PCP Notification, Days (range)

3 (1-9) n = 74

2 (0-4) n = 36

Evaluate the Impact/Evolve

Presenter
Presentation Notes
Call schedule pager coverage consistent APP phone coverage Limitation – currently not deescalating therapy (Glowacki RC, et al. Antibiotics combinations with redundant antimicrobial specta: clinical epidemiology and pilot intervention of computer-assisted surveillance. Clin Infec Dis. 2003;37:59-64. Target those discharged on multiple medication regimens, concern for community antibiotics availability of unused antibiotics
Page 24: Antimicrobial Steward Call August 14, 2018

Electronic system 7 days/week – 365 days Sterile site review Culture hotline (telephone) Expanded cultures/serology Regional coverage (off-campus ED, urgent care) Electronic vs. phone call notification De-escalation

Optimization

Presenter
Presentation Notes
Collaboration with physicians, advanced practice providers, nurses, and microbiology staff to streamline the system for follow-up on all microbiologic cultures for patients discharged from the ED Collaborative practice agreement vs. face to face conversation
Page 25: Antimicrobial Steward Call August 14, 2018

Evaluate the Impact

Retrospective chart review (n = 4639) 12 months before and after implementation

*Treatment failure, noncompliance due to cost or other reason, allergy, ADE

Randolf TC, et al. Am J Health-Syst Pharm 2011;68:916-9

Physician (n = 2278)

Pharmacist (n = 2361)

Modified regimen, n (%) 275 (12) 355 (15)

Unplanned readmissions at 96 hrs, n (%)*

432 (19) 165 (7)

Page 26: Antimicrobial Steward Call August 14, 2018

Other Metrics

Davis LC:1270-1274.; Dumkow LE, et al. Infect Dis Ther 2014;3:45-53.; Miller K, et al. Am J Emerg Med 2014;32:1270-1274; Dumkow LE, et al. Infect Dis Ther 2014;3:45-53.

Pharmacist-driven antimicrobial optimization in the ED 30% increase in interventions for inappropriate antimicrobial

therapy based on culture data Pharmacist addition to the post-ED visit review of discharge

antimicrobial regimens 31.9% reduction of inappropriate revision of antibiotics after

culture review Impact of a multidisciplinary culture follow-up program of antimicrobial

therapy in the ED 12.9% reduction in return ED visits among uninsured

after culture review

Page 27: Antimicrobial Steward Call August 14, 2018

Education Opportunities

Retrospective discharge prescription review for routine cultures Provide feedback based on drug, dose, duration, prescription writing

errors Reference to guidelines or institution tools during re-education

Retrospective blood culture review and education Review decision making process – gram stain data, patient clinical

information, oral vs. IV antibiotics Contamination vs. infectious

Presenter
Presentation Notes
Pharmacist involvement likely decreases overall use of antimicrobials and re-presentation to the ED for contaminated cultures (ex: blood, urine, vaginal) Barriers to prospective order review Availability of medications on override in the medication cabinets Limited time for review of the order and intervention Orders may not be seen by a pharmacist at all Centralized pharmacist location Paper orders “Autoverify” Retrospective order review and pointed education Focused on disease state management, selection, optimal dose, not “tweeking” Reference to the guidelines or reference tools
Page 28: Antimicrobial Steward Call August 14, 2018

Education/Reference Tools Identify needs based on practice trends and DUEs

Focused UTI/SSTI education program

Presenter
Presentation Notes
Discuss the process for development – National and institution guidelines, local susceptibility patterns, approval by antimicrobial subcommittee. Already had SSTI guidelines, provided education and a new format for reference
Page 29: Antimicrobial Steward Call August 14, 2018

ED Discharge Panels

Presenter
Presentation Notes
Pharmacist involvement likely decreases overall use of antimicrobials and re-presentation to the ED for contaminated cultures (ex: blood, urine, vaginal) Barriers to prospective order review Availability of medications on override in the medication cabinets Limited time for review of the order and intervention Orders may not be seen by a pharmacist at all Centralized pharmacist location Paper orders “Autoverify” Retrospective order review and pointed education Focused on disease state management, selection, optimal dose, not “tweeking” Reference to the guidelines or reference tools
Page 30: Antimicrobial Steward Call August 14, 2018

ED Discharge Panels

Presenter
Presentation Notes
Pharmacist involvement likely decreases overall use of antimicrobials and re-presentation to the ED for contaminated cultures (ex: blood, urine, vaginal) Barriers to prospective order review Availability of medications on override in the medication cabinets Limited time for review of the order and intervention Orders may not be seen by a pharmacist at all Centralized pharmacist location Paper orders “Autoverify” Retrospective order review and pointed education Focused on disease state management, selection, optimal dose, not “tweeking” Reference to the guidelines or reference tools
Page 31: Antimicrobial Steward Call August 14, 2018

Conners GP and Hays DP. Ann Emerg Med 2007;50:414-18

Does drug storage in the ED change prescribing practices?

Presenter
Presentation Notes
Hypothesized that adding medications previously only available from the hospital central pharmacy to the ED medication cabinets would alter the frequency with which they were ordered 4 medications that were not previously available and were not subject to prescribing practice changes over the study period were included Not available in the ED < 5 orders per month Available in the ED increase in order volume Pantoprazole IV – 25-fold Azithromycin IV – 6.5-fold Moxifloxacin PO – 7.2 fold Moxifloxacin IV – 4-fold Does drug storage in the ED change prescribing practices?
Page 32: Antimicrobial Steward Call August 14, 2018

Batch if possible Vancomycin Ceftriaxone/lidocaine IM syringes

Optimizing Medication Storage in ED

Presenter
Presentation Notes
Talk about pyxis Talk about how to identify what meds have longest TAT and how batching may be helpful
Page 33: Antimicrobial Steward Call August 14, 2018

Drive Use of Meds Readily Available

Presenter
Presentation Notes
Measure the impact by Evaluate order set utilization and compare to ICD9 admission codes Review medication cabinet pulls compared to central pharmacy dispense Direct prescribing practices Built based on medication cabinet availability Details location for specific ED areas (PEDS)
Page 34: Antimicrobial Steward Call August 14, 2018

Re-Presentation Prevention

UTI, cellulitis, dental infection To-Go medications (n = 243) vs. Prescription (n =

4014) Re-presentation 2.5% vs. 5.9%, p = 0.026 Cellulitis 2/122 (1.6%) vs. 71/ 1072 (6.9%), p = 0.024

Return visit avoidance 136

UTI 0/29 (0%) vs. 40/692 (5.8%), p = 0.18 318 medication courses = $1122.80

Hayes BD, et al. Am J Emerg Med 2012;30:2011-4

Presenter
Presentation Notes
Obj: If patients with a complete course of Abx for select conditions would decrease the rate of 7 days representation To-Go med or prescription for UTI, pyelonephritis, cellulitis, or dental infection Jan-Dec 2010; limited health insurance or discharged off hours when nearby pharmacies were closed Prepresentation captured if within 7 days for similar diagnosis Meds were PCN, clindamycin, Bactrim, nitrofurantoin Of 1149, 122 were given Go-To meds 318 medication courses in 243 patients Helps to standardize practice of medications used an duration of therapy
Page 35: Antimicrobial Steward Call August 14, 2018

Conclusions Pharmacist-managed culture surveillance and

follow-up is associated with: Decreased ED re-presentation Faster time to follow-up and intervention Improvement in appropriate interventions

Several different opportunities for ASP in the ED Right empiric drug/dose/duration Prompt administration Preventing re-presentations/re-admissions

Presenter
Presentation Notes
Prompt administration for sick patients and ED throughput
Page 36: Antimicrobial Steward Call August 14, 2018

Thank You!

Page 37: Antimicrobial Steward Call August 14, 2018

Next Steps

• Next Call – October 9 at 2pm Eastern/1pm Central Time – Staphylococcus aureus Bacteremia Care Bundles

• Opportunities for involvement

– Speaker or Topic for future call – Antibiotic Use Reporting into NHSN and TDH AU Point

Prevalence Survey

• Feedback always appreciated – [email protected]