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Introduction to Learning Session #2 Antibiotic Stewardship
Jeff West, MPH RN Qualis Health
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Qualis Health • A leading national population health
management organization • The Medicare Quality Innovation Network - Quality
Improvement Organization (QIN-QIO) for Idaho and Washington
The QIO Program • One of the largest federal programs dedicated to
improving health quality at the local level
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Objectives
• Introduce resources for nursing home antibiotic stewardship programs
• Motivate participants to avail themselves of resources
EQuIP for LTC
• Training and professional development program for staff in nursing homes
• Goal: to help SNFs meet new CMS requirements for IP and AMS
• Focus on core competencies for infection prevention (IP) and core elements of antimicrobial stewardship (AMS)
• Led by WA & ID DOH in partnership with Qualis Health, APIC, and LTC trade associations
EQuIP Resources
• Monthly webinars, recorded and available for later viewing – 2017 focus on antimicrobial stewardship – 2018 focus on infection prevention and control
• Mentorship/consultation available • Web-based menu of tools, templates, and
resources
EQuIP Small Group Collaborative
• SNFs work together on QI project • Achieve CDC core elements of stewardship • Recognition on Washington State Honor Roll for
Stewardship • Onsite Infection Control Assessment and
Response visit by experienced IP for survey readiness
http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/HealthcareAssociatedInfections/EQuIP/LTC
EQuIP for LTC Webinar Schedule • Monthly live webinars
– 4th Wednesday of the month – 10:00-11:00 AM (PST)
• Registration link: https://attendee.gotowebinar.com/register/5879017588924100354
Additional Information
Marisa D’Angeli, MD, MPH 206-418-5595
10 http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
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Smith, P. W., Bennett, G., Bradley, S., Drinka, P., Lautenbach, E., Marx, J., … Stevenson, K. (2008). SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility. Infection Control and Hospital Epidemiology, 29(9), 785–814. http://doi.org/10.1086/592416
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42 CFR 483.80 Infection Control • 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.
• 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.
Appendix PP Guidance to Surveyors Advanced Copy Transmittal 169 pg 655
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CDC Checklist for Core Elements of Antibiotic Stewardship in Nursing Homes
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Nursing Home Antibiotic Stewardship Gap Analysis
Data from Washington State Department of Health, March 2017
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Demonstration of Leadership Support Attestation Poster
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Demonstration of Leadership Support
Other Evidence of Leadership Support: • Antibiotic Stewardship included in job descriptions • Budget plans for Antibiotic Stewardship • QAPI reports that references Antibiotic Stewardship • Use of electronic health records in A.S. program • Support for Antibiotic Stewardship education • Accountability documents for A.S. program
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Accountability Example Antibiotic Stewardship Accountability Grid (for demonstration purposes only)
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Antibiotic Stewardship Expertise
• Antimicrobial Stewardship Training Programs
• Society for Infectious Disease Pharmacists Certificate Program
• Infect Control Hosp Epidemiol 2014;35(12):1444–1451 https://www.shea-online.org/images/guidelines/Guidance-for-the-Knowledge-and-Skills-Required-for-Antimicrobial-Stewardship-Leaders.pdf
Does your facility have access to individual(s) with antibiotic stewardship expertise? If yes, indicate who is accountable for stewardship activities (select all that apply) • Consultant pharmacy has staff
trained/is experienced in antibiotic stewardship
• Partnering with stewardship team at referral hospital
• External infectious disease/stewardship consultant
• Other:__________________
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Actions to Improve Antibiotic Use: Policies • Sample Antibiotic
Stewardship Policy & Procedure
• Sample Policy: Minimum Criteria for Infections
• Sample Letter to Prescriber
• Clinician Guide to Collecting Cultures
Does your facility have policies to improve antibiotic prescribing/use? If yes, indicate which policies are in place (select all that apply) • Requires prescribers to document a
dose, duration, and indication for all antibiotic prescriptions
• Developed facility-specific algorithm for assessing residents suspected of infection
• Developed facility-specific algorithms for appropriate diagnostic testing (e.g., obtaining cultures) for specific infections
• Developed facility-specific treatment recommendations for infections
• Reviews antibiotic agents listed on the medication formulary
• Other:______________________
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Actions to Improve Antibiotic Use: Practices
• Suspected Urinary Tract Infection SBAR
• Suspected Lower Respiratory Tract Infection SBAR
• Suspected Skin and Soft Tissue Infection SBAR
• A Medical Care Referral Form to document information for prescribing clinicians
• Minimum Criteria for Antibiotics Tool
Has your facility implemented practices to improve antibiotic use? If yes, indicate which practices are in place (select all that apply) • Utilizes a standard assessment and
communication tool for residents suspected of having an infection
• Implemented process for communicating or receiving antibiotic use information when residents are transferred to/from other healthcare facilities
• Developed reports summarizing the antibiotic susceptibility patterns (e.g., facility antibiogram)
• Implemented an antibiotic review process/“antibiotic time out”
• Implemented an infection specific intervention to improve antibiotic use - Indicate for which condition(s):_________________________
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Actions to Improve Antibiotic Use: Practices • Resources for
Antibiogram Created by Lab
• Resources for Creating Antibiogram
• Resources for Antibiogram Reporting Policies and Implementation
• Sample antibiotic time-out policy
Has your facility implemented practices to improve antibiotic use? If yes, indicate which practices are in place (select all that apply) • Utilizes a standard assessment and
communication tool for residents suspected of having an infection
• Implemented process for communicating or receiving antibiotic use information when residents are transferred to/from other healthcare facilities
• Developed reports summarizing the antibiotic susceptibility patterns (e.g., facility antibiogram)
• Implemented an antibiotic review process/“antibiotic time out”
• Implemented an infection specific intervention to improve antibiotic use - Indicate for which condition(s):____________
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Actions to Improve Antibiotic Use: Pharmacy Support
Does your consultant pharmacist support antibiotic stewardship activities? If yes, indicate activities performed by the consultant pharmacist (select all that apply) • Reviews antibiotic courses for appropriateness of administration
and/or indication • Establishes standards for clinical/laboratory monitoring for adverse
drug events from antibiotic use • Reviews microbiology culture data to assess and guide antibiotic
selection
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Tracking Antibiotic Stewardship: Processes
• Sample Antibiotic Use Tracking Tool
• Sample Monthly Antibiotic Summary Report
Does your facility monitor one or more measures of antibiotic use? If yes, indicate which of the following are being tracked (select all that apply) • Adherence to clinical assessment
documentation (signs/symptoms, vital signs, physical exam findings)
• Adherence to prescribing documentation (dose, duration, indication)
• Adherence to facility-specific treatment recommendations
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Tracking Antibiotic Stewardship: Outcomes Does your facility monitor one or more measures of antibiotic use? If yes, indicate which of the following are being tracked (select all that apply) • Performs point prevalence surveys of
antibiotic use • Monitors rates of new antibiotic
starts/1,000 resident-days • Monitors antibiotic days of
therapy/1,000 resident-days • Other:__________________
• Antibiotic point prevalence = % of residents on any antibiotic in a single day
• Antibiotic Use Ratio: Antibiotic days of therapy / 1,000 resident days (in month, quarter, year) • Days of Therapy = total
number of antibiotics x total number of days prescribed
Possible data sources in your nursing home? • Pharmacy? • Electronic medical record (MAR)?
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Tracking Antibiotic Stewardship: Outcomes
• C-Diff Tracking Tool
• Sample MDRO Infection Tracking Tool
• National Healthcare Safety Network
• Antibiotic adverse drug events
Does your facility monitor one or more outcomes of antibiotic use? If yes, indicate which of the following are being tracked (select all that apply) • Monitors rates of C. difficile
infection • Monitors rates of antibiotic-
resistant organisms • Monitors rates of adverse drug
events due to antibiotics • Other: _____________________
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Tracking Antibiotic Stewardship: Outcomes Signs and Symptoms of
Antibiotic Adverse Drug Events*
*https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/QAPI/Downloads/Adverse-Drug-Event-Trigger-Tool.pdf
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Reporting to Staff
• Measures of antibiotic use at the facility • Measures of outcomes related to antibiotic use (e.g., C.-diff
rates) • Report of facility antibiotic susceptibility patterns (within last
18 months) • Personalized feedback on antibiotic prescribing practices (to
clinical providers) • Other:______
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Stewardship Education • Antibiotic Fact Sheets • Nursing Home Training Sessions • EQuIP for LTC Training Materials
and Webinars • Antibiotic Stewardship Educational
Resources for Residents and Families
• PowerPoint Training Medical Care Referral Form
• PowerPoint Training on Minimum Criteria for Common Infections
• Pocket Cards: MRSA, C-Diff, VRE, Situations When Antibiotics Not Indicated
Does your facility provide educational resources and materials about antibiotic resistance and opportunity for improving antibiotic use? If yes, indicate which of the following are being tracked (select all that apply) • Clinical providers (e.g., MDs,
NPs, PAs, PharmDs) • Nursing staff (e.g., RNs, LPNs,
CNAs) • Residents and families • Other:____________
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Qualis Health Support for Nursing Homes • “Office Hours”: Moderated peer support calls
with stewardship subject matter experts • 3 hour in-person peer-support sessions with
subject matter experts • Common framework is the CDC Checklist
See www.Medicare.QualisHealth.org/LS2 for details and registration for office hours and in-person sessions
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Next Steps • Use the CDC
Checklist to identify gaps
• Familiarize your teams with stewardship resources
• Register for Office Hours and In-Person Peer Support Sessions
• Earn Quality Gems while working your way through the CDC Checklist …
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Contact Jeff West, MPH RN
QI Principal Qualis Health
[email protected] 206-288-2465
Brent Schneider, MHA LNHA QI Consultant Qualis Health
[email protected] 208-383-5941
For Event Evaluation https://www.surveymonkey.com/r/HPNGLMQ
For more information:
www.Medicare.QualisHealth.org/LS2
This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, 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. ID/WA-C2-QH-3102-08-17
