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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:
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
16
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
22
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
Lisa Mark
Improvement Consultant
Allison Spangler
Improvement Consultant
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: