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Texas Antimicrobial Stewardship Program
UpdateMichael Fischer, M.D., MPH & TM
Antimicrobial Stewardship ExpertEmerging and Acute Infectious Disease Branch
Texas Department of State Health Services
Common Acronyms• ACH – Acute Care Hospital• ALF – Adult Living Facility• AS – Antimicrobial/Antibiotic Stewardship• ASP – Antimicrobial Stewardship Program• CDC – Centers for Disease Control and Prevention• CEs – Core Elements• DSHS – Texas Department of State Health Services• FTE – Full Time Equivalent• ICAR – Infection Control Assessment and Response• IP – Infection Preventionist• LTCF – Long Term Care Facility• NHSN – National Healthcare Safety Network• PHR – Public Health Region• SNF – Skilled Nursing Facility• TxHSN – Texas Healthcare Safety Network• UTI – Urinary Tract Infection
10/18/2018 2
An Update on Antimicrobial Stewardship Programs (ASPs) in Texas Healthcare Facilities
1. Update on the Long-Term Care Facility Initiative
2. Overview of the Texas ASP’s Current & Upcoming Activities
3. Review of Survey Data From:
The CDC’s National Healthcare Safety Network’s (NHSN) Patient Safety Component of the Annual Hospital Survey Relating to Antimicrobial Stewardship, 2015-2017
The Texas Infection Control Assessment and Response (ICAR) Survey, 2017
10/18/2018 3
UTI/ASB Diagnostic Algorithm
UTI Diagnostic Algorithm Template for Long-Term Care Facilities
Indwelling catheter?NO
If no other site for infection is apparent, do any of the following apply?
New or worsening: Fever > 100°F (37.9°C) Suprapubic pain Costovertebral angle
tenderness Flank pain Delirium Rigors Hypotension Acute hematuria
Do any of the UTI criteria listed below apply?
UTI criteriaNew or worsening:�Urgency� Frequency�Urinary incontinence� Suprapubic pain�Hematuria� Costovertebral angle
tenderness or flank pain
Collect urine specimen for UA, UCx
& AST.Consider empiric
treatment.
Review culture and antimicrobial sensitivity test (AST) results (within 72 hours) & optimize treatment
Acute dysuria?
Fever? (> 100°F or > 37.9°C)
CONSIDER INDIVIDUALS WITH • AN INTERMITTENT CATHETER
OR • A CONDOM CATHETER
AS IF THEY WERE NOT CATHETERIZED
NO
NO
NO
YES
YES
YES
YES
YES
YES
Minimum criteria for initiating antibiotics are NOT MET• Encourage fluid intake daily until urine is light yellow in color• Record fluid intake• Assess vital signs & temperature• Request notification if symptoms worsen or if unresolved • Evaluate for other illnesses
YES
Do ≥2 of the UTI criteria listed below apply?
NO
NO
Based on the Agency for Healthcare Research and Quality’s minimum criteria for UTIs. https://www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/toolkit3-minimum-criteria.html
10/18/2018 4
See handout for more information
Overview of Other AS Program Activities
ANTIBIOTIC AWARNESS WEEK• Promote local and regional activities
and events during antibiotic awareness week
• Promote central office antibiotic awareness week activities by: Participating in CDC web and other social
media events Promote awareness through postings on the
DSHS AS website Speak & attend antimicrobial awareness
week events in Texas
10/18/2018 5
CDC’s Report on NHSN DataTexas and National Counts for
ACHs Utilizing All Seven Core Elementshttps://gis.cdc.gov/grasp/PSA/STMapView.html
10/18/2018 6
2014 2015 2016Texas 4% 41% 58%National 36% 48% 64%
4%
41%
58%
36%
48%
64%
0%
10%
20%
30%
40%
50%
60%
70%
Perc
ent
of A
cute
Car
e H
ospi
tal U
tiliz
ing
All
Sev
en C
ore
Elem
ents
National
Texas
?
TxHSN Data: Percent of Texas Hospitals Utilizing All Seven Core Elements by
Year (2015-2017)
165
226
277
363 357 357
45.5%
63.3%
77.6%
5.5 6.2 6.60%
20%
40%
60%
80%
100%
120%
0
50
100
150
200
250
300
350
400
2015 2016 2017
Number of Facilities Utilizing All 7 Core Elements
Total Number of Facilities Surveyed
Percent of Facilities Utilizing All 7 Core Elements
Avg Number of Core Elements Utilized
Linear (Percent of Facilities Utilizing All 7 Core Elements)
2018 2019
10/18/2018 7
Acute Care Hospital DataNHSN-ICAR Matched Hospitals, 2017
Surveys
25 28 32 30 29 25 22 1833 34 35 34 30 34 34 27
71%80%
91%86% 83%
71%63%
51%
94% 97% 100% 97%
86%
97% 97%
77%
0%
20%
40%
60%
80%
100%
120%
0
5
10
15
20
25
30
35
40
Counts ICAR Counts NHSN Percent ICAR Percent NHSN
10/18/2018 8
Texas Public Health Regions (PHRs)
10/18/2018 9
Pareto Chart: Number of Hospitals Not Utilizing All Seven Core Elements by
Public Health Region (PHR) 2015-2017
10/18/2018 10
58
3628
19 18 16 149
42
23 2015 12 9 6 4
28
12 11 8 7 7 6 1
29%
47%
62%
71%
80%
88%95% 100%
32%
50%
65%
76%85%
92%97% 100%
35%
50%
64%
74%
83%
91%99%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
10
20
30
40
50
60
70H
SR 2
/3
HSR 6
/5S
HSR 8
HSR 4
/5N
HSR 7
HSR 1
HSR 1
1
HSR 9
/10
HSR 2
/3
HSR 6
/5S
HSR 8
HSR 4
/5N
HSR 1
HSR 7
HSR 9
/10
HSR 1
1
HSR 2
/3
HSR 6
/5S
HSR 4
/5N
HSR 8
HSR 1
HSR 7
HSR 9
/10
HSR 1
1
2015 2016 2017Number of Facilities Not Fully Utilizing All 7 Core Elements Cumulative Percentage
PHR
PHR PH
R
PHR
PHR
PHR
PHR
PHR
PHR
PHR PH
R
PHR
PHR
PHR
PHR PH
R
PHR
PHR
PHR PH
R
PHR
PHR
PHR PH
R
Percent of Hospitals Utilizing All Seven Core Elements By Facility Type and Year
40%42%
60%54%
69%
86%
46%
65%
79%
100%100%
100%
33%
100%
67%
42%
57%
71%
50%50%
100%
25 24 2513 13 14
283 279 278
1 1 1 3 3 3
36 35 34
2 2 20%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
50
100
150
200
250
300
2015
2016
2017
2015
2016
2017
2015
2016
2017
2015
2016
2017
2015
2016
2017
2015
2016
2017
2015
2016
2017
HOSP-CAH HOSP-CHLD
HOSP-GEN HOSP-ONC HOSP-ORTHO
HOSP-SURG
HOSP-WOMCHILD
Percent of Facilities Utilizing All 7 Core ElementsTotal Number of Facilities Surveyed
∆+18%
∆+17%
∆+14%
∆ 0% ∆-33%
Averaged+17%
∆+14% ∆+50%
Critical Access Hospital
Children’s Hospital
General Hospital
Cancer Hospital
Orthopedic Hospital
Surgical Hospital
Women Children’s Hospital
10/18/2018 11
Percent of Hospitals Utilizing All Seven Core Elements & Mean Number of Core Elements Utilized by Teaching Hospital Type and Year
40%54%
70%
51%
78%
89%
80%88%
89%
75%78%
91%5.4
6.06.4
5.6
6.6 6.96.5 6.7 6.8 6.8 6.8 6.9
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
2015 2016 2017 2015 2016 2017 2015 2016 2017 2015 2016 2017
Graduate Major Undergraduate
Non-TeachingHospital
Teaching Hospital
10/18/2018 12
Pareto Chart: Number of Hospitals by Core Element Not Utilized for Survey Year 2017
40
32
27
19
14
7 6
28%
50%
68%
81%
91%96% 100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
5
10
15
20
25
30
35
40
45
Facilities Not Utilizing The Core Element Cummulative Percentage
10/18/2018 14Texas NHSN Data, Annual Hospital Survey, Patient Safety Component
Pareto Chart: Number of Hospitals Not Utilizing All Seven Core Elements by Ownership Type
94
76
15 13
60
51
11 9
0
30 28
17
50
47%
86%93%
100%
46%
85%93%
100%100%
38%
73%
94%100%100%
0%
20%
40%
60%
80%
100%
120%
0
10
20
30
40
50
60
70
80
90
100
NP P PHY GOV NP P GOV PHY MIL P NP GOV PHY MIL
2015 2016 2017
Not Utilized Cumulative Percentage
10/18/2018 16NP = Not-Profit P = Profit PHY = Physician Owned GOV = Government MIL = Military
Pareto Chart: Number of Hospitals Not Utilizing All Seven Core Elements by Number of IPs
162
2111
2 1 1
87
21 20
1 1 1
51
187 2 1 1
82%
92%98%99%99% 100%
66%
82%
98% 98% 99% 100%
64%
86%95%98% 99%
100%
0%
20%
40%
60%
80%
100%
120%
0
20
40
60
80
100
120
140
160
1801-
1.99
2.0-
3.99
0.01
-0.9
9
>6 0
4.0-
5.99
1-1.
99
2.0-
3.99
0.01
-0.9
9 0
4.0-
5.99 >6
1-1.
99
0.01
-0.9
9
2.0-
3.99 >6 0
4.0-
5.99
2015 2016 2017Number of Facilities Not Utilizing All Seven Core Elements Cumulative Percentage
10/18/2018 17
Number of Hospitals Not Utilizing All 7 Core Elements
by Number of Beds (2015-2017)
8276
32
8
64
42
20
5
44
24
93
41%
80%96%
100%
49%
81%
96% 100%
55%
85%96%
100%
0%
20%
40%
60%
80%
100%
120%
0
10
20
30
40
50
60
70
80
9050
or
less
51-2
00
201-
400
>40
0
50 o
r le
ss
51-2
00
201-
400
>40
0
50 o
r le
ss
51-2
00
201-
400
>40
0
2015 2016 2017
Number of Facilities Not Fully Utilizing All 7 Core Elements Cumulative Percentage
10/18/2018 18
Pareto chart: Number of Hospitals Not Utilizing All Seven Core Elements by Number of Epi FTEs
per Year (2015-2017)
198
79
3016
3 2 1
53
13 8 4 1 1
100%
60%
83%
95% 98% 99% 100%
66%
83%93%
98% 99% 100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%U
nkno
wn
0.00
0.51
-1.0
0
0.01
-0.5
0
>2.
0
1.51
-2.0
0
1.01
-1.5
0
0.00
0.51
-1.0
0
0.01
-0.5
0
>2.
0
1.01
-1.5
0
1.51
-2.0
0
2015 2016 2017
Number of Facilities Not Fully Utilizing All 7 Core Elements Cumulative Percentage
10/18/2018 20
Overview of TxHSN Hospital Data
1.Approximately 78% of the ACHs reporting to NHSN utilized all seven core elements
2.Approximately 80% of hospitals not incorporating all seven core elements into their stewardship program: Were in PHRs: 2/3, 6/5S, 4/5N, & 8 Were the core elements with highest gap
frequencies include Education > Tracking > Leadership > Reporting
Had FTEs dedicated to Epidemiology of less than 1 in 2016 & 2017
Had less than 200 beds Had less than 2 IPs
10/18/2018 22
Texas ICAR Survey Data – 2017Hospitals Utilizing All Seven Core
Elements
10/18/2018 23
Number of Hospitals SurveyedHospitals Utilizing
All 7 Core Elements Average Number of Core Elements Utilized
Count Percent
58 21 36.2% 4.62
Type of Facility
Number of Hospitals Surveyed
Hospitals UtilizingAll 7 Core Elements Average Number of
Core Elements UtilizedCount Percent
Critical Access Hospital 15 2 13% 2.9
Children’s Hospital 1 0 0% 2.0General Hospital 40 18 45% 5.3Long Term Acute Care 1 0 0% 6.0
Rehabilitation 1 1 100% 7.0
Bed Number Range
Number of Hospitals Surveyed
Hospitals UtilizingAll 7 Core Elements Average Number of
Core Elements UtilizedCount Percent
50 or less 15 2 13% 2.951-200 1 0 0% 2.0201-400 40 18 45% 5.3>400 1 0 0% 6.0
Hospital ICAR Data: Number & Percent of Facilities Utilizing the Core Elements
3437
4945
4035
28
34
59%64%
84%78%
69%
60%
48%
59%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
0
10
20
30
40
50
60
Count Percent
10/18/2018 24
Texas ICAR Survey Data – 2017Pareto Chart: Counts of Hospitals by Core
Elements Not Utilized
10/18/2018 25
16
14
12
10
8
6
4
23%
43%
60%
74%
86%94%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
2
4
6
8
10
12
14
16
18
Number of Hospitals Not Utilizing the Core Element Cummulative Percent
Texas ICAR Survey Data – 2017Percent of Hospitals Utilizing All Seven Core Elements by
Number of Infection Preventionist FTEs
Number of IPs
Number of Hospitals Surveyed
Hospitals Utilizing All 7 Core Elements Average Number of Core Elements UtilizedCount Percent
0.01-0.49 8 1 13% 3.30.5-0.99 15 4 27% 3.9
1.00-1.249 23 9 39% 4.71.25-1.49 - - - -1.50-1.74 3 2 67% 6.31.75-1.99 - - - -2.0-3.99 6 4 67% 6.34.0-5.99 1 0 0% 5.0Unknown 2 1 50% 6.5 27
13%
27%
39%
0%
67%
0%
67%
0%
50%
0%
10%
20%
30%
40%
50%
60%
70%
0
0.2
0.4
0.6
0.8
1
1.2
Texas ICAR Survey Data – 2017Pareto Chart: Counts of Hospitals Not
Utilizing All Seven Core Elements by PHR
7 7
6
5
3 3 3 3
18.9%
37.8%
54.1%
67.6%75.7%
83.8%
91.9%
100.0%
0%
20%
40%
60%
80%
100%
120%
0
1
2
3
4
5
6
7
8
PHR 9/10 PHR 11 PHR 4/5N HSR 2/3 HSR 1 HSR 6/5S HSR 7 HSR 8
All CEs Not Utilized Cummulative Percent
10/18/2018 29
Texas ICAR Survey Data – 2017Pareto Chart: Counts of Hospitals Not
Utilizing All Seven Core Elements (CEs) by Number of Licensed Beds
23
11
21
62.2%
91.9%97.3% 100.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
0
5
10
15
20
25
50 or less 51-200 >400 201-400
All CEs Not Utilized Cummulative Percent
10/18/2018 30
Texas ICAR Survey Data – 2017Pareto Chart: Counts of Hospitals Not
Utilizing All Seven Core Elements (CEs) by Number of IP FTEs
14
11
7
21 1 1
0 0
37.8%
67.6%
86.5%91.9% 94.6% 97.3% 100.0%
100.0%100.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
0
2
4
6
8
10
12
14
16
All CEs Not Utilized Cummulative Percent
10/18/2018 31
Overview of ICAR Hospital Data
1. Approximately 60% of the 58 hospitalsutilized all seven core elements
2. The two least utilized core elements byhospitals are education and leadership,followed by reporting & accountability
3. Over 80% of the “no responses” toutilization of all seven core elements areseen in hospitals of: PHRs: 9/10, 11, 4/5N, 2/3, & 1
Less than 200 licensed beds (particularlythose with “50 or less” licensed beds)
Less than 1.25 IP FTEs
10/18/2018 33
Texas ICAR Survey Data – 2017Percent of LTCFs Utilizing the Core Elements
6.9%
47.4%
37.1%
58.6%
37.1% 39.7%
19.8%25.0%
0%
10%
20%
30%
40%
50%
60%
70%
10/18/2018 34
Texas ICAR Survey Data – 2017Pareto Chart: Counts of LTCFs Not Utilizing
All Seven Core Elements by PHR
30
20
1716
98
53
28%
46%
62%
77%85%
93%97% 100%
0%
20%
40%
60%
80%
100%
120%
0
5
10
15
20
25
30
35
11 4/5N 6/5S 7 9/10 2/3 8 1
Not Utilizing All 7 Core Elements Cumulative Percent
10/18/2018 37
PHR
Texas ICAR Survey Data – 2017Pareto Chart: Counts of LTCFs Not Utilizing
All Seven Core Elements by Number of Licensed Beds
47
38
12
7
2 1 1
44%
79%
90%96% 98% 99% 100%
0%
20%
40%
60%
80%
100%
120%
0
5
10
15
20
25
30
35
40
45
50
101-150 51-100 151-200 26 to 50 25 or less >200 Unknown
Not Utilizing All 7 Core Elements Cumulative Percent
10/18/2018 38
Texas ICAR Survey Data – 2017Pareto Chart: Counts of LTCFs Not Utilizing All Seven Core Elements by IP Hours per Week
40
31
11 11 10
5
37.0%
65.7%
75.9%
86.1%
95.4%100.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
0
5
10
15
20
25
30
35
40
45
6-10 hours 5 hours orless
>20 hours 16-20hours
Unknown 11-15hours
Not Utilizing All 7 Core Elements Cumulative Percent
10/18/2018 39
Overview of ICAR LTCF Data
1. Only 6.9% of the 116 LTCF utilized all seven core elements
2. The least utilized core elements were Reporting > Education followed by Action & Accountability then Tracking
3. Eighty percent of the “no responses” to utilization of all seven core elements are seen in LTCFs of: PHRs: 11, 4/5N, 6/5S, 7, & 9/10
Licensed beds between 51 to 150
≤10 or >20 IP Hours per Week
10/18/2018 40
In summary:
10/18/2018 41
ICAR - LTCFs ICAR - ACHs NHSN-Hospitals
Percent of Facilities Utilizing All 7 Core Elements
6.90% 59% 77.60%
Core Elements with the highest gap frequencies
Reporting>Education> Action & Accountability
>Tracking
Education>Leadership> Reporting
>Accountability
Education>Tracking>
Leadership>Reporting
Factors accounting for approximately 80% of the facilities not utilizing all 7 core elements:
PHRs 11, 4/5N, 6/5S, 7, & 9/10
9/10, 11, 4/5N, 2/3, & 1
2/3, 6/5S, 4/5N, & 8
Bed number Between 51 to 150 Licensed beds
Less than 200 beds (especially facilities
with“50 or less” beds)
Less than 200 beds
Number of dedicated IP hours/FTEs/staff
≤10 or >20 IP Hours per Week
Less than 1.25 IP FTEs less than 2 IPs
Thank youMichael Fischer, M.D., MPH & TM
Antimicrobial Stewardship Expert
Emerging and Acute Infectious Disease Branch
Texas Department of State Health Services
Ph: (512)776-6338
10/18/2018 42
