Texas Children’s Hospital: Pediatric Collaboration to Develop an Antimicrobial Stewardship Program Ruston S. Taylor, PharmD

Antimicrobial Stewardship Program Texas Children’s Hospital Department of Pharmacy

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DISCLOSURES

•Grant support from Pfizer for the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) collaborative

•Jason Newland, MD gave permission to utilize selected SHARPS slides

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Background •33-60% of hospitalized children receive at least one antibiotic during their stay1,2

•Approximately 50% of antibiotic use is inappropriate

•Among 39 free-standing children’s hospitals, 16 had a formal Antimicrobial Stewardship Program (ASP) 3

•The most effective methods for stewardship are unknown

1. Gerber J et al., Pediatrics 2010 126:1067 2. Pakyz AL et al. ICHE 2009 30:600-03 3. Newland et al. ICHE 2014 35:265-71

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Historic ASP Elements Utilized at TCH

•Formulary restrictions existed: -Allowing order by physician specialty:

•Voriconazole (Heme/Onc, BMT, Lung txplant, ID)

•Caspofungin (BMT, ID)

•Meropenem (Pulmonary, ID) [formally peer-reviewed by single ID physician]

-By drug:

•Vancomycin (3-day stop order): Pharmacist reviews at 72-hours, extends therapy if criteria met. [Formally peer-reviewed by single ID physician]

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Vancomycin Usage Changes

0

2

4

6

8

10

7/12

8/12

9/12

10/1

2

11/1

2

12/1

2

1/13

2/13

3/13

Per

cent

Date

Non-Adherence to Vancomycin Restrictions: 2012 - 2013 Measure

Discontinuation of Peer Review by single ID physician

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Meropenem Usage Changes

0

10

20

30

40

50

60

2/12

3/12

4/12

5/12

6/12

7/12

8/12

9/12

10/1

2

11/1

2

12/1

2

1/13

2/13

3/13

4/13

5/13

6/13

7/13

8/13

Per

cent

Date

Non-Adherence to Meropenem Restrictions: 2012 - 2013 Measure

Discontinuation of Peer Review by single ID physician

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Multidisciplinary ASP Implementation

Who, What, When, Where, Why of Antimicrobial Usage at TCH

Multidisciplinary Team Formed – November 2013

Understand prescribing

climates between ‘silos’

Understand microbiology

at TCH

Study antimicrobial patterns of

use

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TCH Barriers •Limited real-time data

•Lack of electronic notification of culture positivity to care team providers

•Lack of alert to care team providers of updated culture information

•Inability to rapidly review existing culture data

•Frequent changes in care team providers

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Initial SHARPS Hospitals 09/13

Seattle

Salt Lake City

Omaha

Kansas City

Chicago

Cincinnati

Philadelphia

All hospitals provide data to PHIS

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Objective •Establish an antimicrobial stewardship quality improvement collaborative that would:

-Provide antimicrobial use reports to guide ASP interventions

-Allow for benchmarking among institutions

-Share successful interventions

-All teach, All learn philosophy

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Methods

•Pediatric Health Information Systems Database

•Free standing children’s hospitals

•Provides billing and administrative data on discharged patients

•Data pulls occur quarterly

•Data quality checks performed

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Methods •Standard and customized benchmarking reports were provided. Examples include:

-Overall antibiotic days of therapy (DOT)

-Ampicillin use for pneumonia

-Anti-pseudomonal antibiotic use for appendicitis

-Overall carbapenem DOT and in BMT unit

-% oral DOT for highly bioavailable drugs

•Monthly webinars to discuss progress and barriers with interventions

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Actions by initial hospital cohort Interventions implemented by hospitals:

• Implementation of various forms of rapid diagnostic tests (RDT).

• CAP pathways developed with order sets

• Clinical pathway/guideline for empiric abx use in BMT steering away from carbapenems

• Heme/onc de-escalation process when carbapenems are used

• IV to PO conversion protocol

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SHARPS member additions: 06/14

Seattle

Salt Lake City

Omaha

Kansas City

Chicago

Cincinnati

Philadelphia

Grand Rapids Boston Houston St. Petersburg San Diego Denver Palo Alto Birmingham Little Rock Miami Indianapolis Portland Stony Brook- LI Corpus Christie All hospitals provide data to PHIS

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Results: FTEs per hospital

0

0.5

1

1.5

2

2.5

5 13 18 20 26 21 19 23 25 15 14 27 9 16 17 28 7 11 2 8 24 1 3 10 12 4 6 22

Pharmacist Physician Data Analyst

FTE

Hospital

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SHARPS Hospitals as of 02/15

Seattle

Omaha

Salt Lake City

Kansas City

Chicago

Cincinnati

Philadelphia

Connecticut

Minnesota

Los Angeles

Atlanta

Columbus

Memphis

Charleston

Louisville

Boston

Grand Rapids

Fort Worth

Houston

St. Petersburg

San Diego

Denver

Palo Alto

Birmingham

Little Rock

Miami

Indianapolis

Portland

Stony Brook- LI

Corpus Christi

D.C.

St. Louis

All hospitals provide data to PHIS

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Overall DOT

350

400

450

500

550

600

650

700

750

800

850

Ove

rall

DO

T

200120

2410

1020

3020

1820

1120

1720

0620

1510

0820

2720

2020

1020

0520

2810

1120

3630

0120

2920

0420

0220

1320

0920

2120

0710

0720

3720

1610

0510

0320

0320

2620

2320

1220

2220

3320

2520

0820

3110

1220

3930

02

PHIS Hospitals

Study Hospitals Other PHIS Hospitals

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0

5

10

15

20

25

30

35

40

45

50

55

60

Over

all C

arba

pene

m D

OT

20182020

20302007

20162021

10082017

10032005

20363001

20041010

20032025

20102024

20232037

10112011

10052009

20262013

10122008

20282029

20022027

20222015

3002

PHIS Hospitals

Study Hospitals Other PHIS Hospitals

Carbapenem Use

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SHARPS Conclusions • Benchmarking data reports aid ASPs in

determining areas to target

• Collaborative approach provides expertise and experience for others to learn best practices

• Collaborative approach allows best practices to be implemented that will work for each unique hospital

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Rapid Diagnostic Test: GeneXpert Our ‘Quick Win’

www.cepheid.com

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ASP Intervention: GeneXpert Result Notification Pre-intervention (March to June 2014)

n=221 Post-intervention (July to October 2014)

n=236

Gram-stain: GPCs in clusters (n=173) n (%) • MRSA 11 (6.4) • MSSA 20 (11.6) • CoNS 142 (82)

Gram-stain: GPCs in clusters (n=183) n (%) • MRSA 10 (5.5) • MSSA 24 (13.1) • CoNS 149 (81.4)

Time to traditional identification: 1836 + 768 min

Time to molecular identification: 180 + 250

ASP notification (n=102)

MSSA: Time to de-escalate from Vanc 2632 + 1236 min

MSSA: Time to de-escalate from Vanc 115 + 121 min

CoNS [excluded: pts with CL, NICU, immunocompromised]

(n=58) 704 + 581 min

CoNS [excluded: pts with CL, NICU, immunocompromised] (n=68)

241 + 305 min GPC= Gram-positive cocci, MRSA=methicillin-resistant Staph aureus, MSSA=methicillin-sensitive Staph aureus, CoNS=coagulase-negative Staphylococcus, CL=central line

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TCH Executives Recognize Opportunity •Building needs/requests approved for further investigation:

-Integration of patient parameters within the EHR

-EPIC 2014-Infection Control/ASP module

-Additional analytics: real-time dashboards facilitating:

•ASP activities

•Provider notification when new data exists

•Discrete microbiology data

•Surveillance of antimicrobial usage and microbial resistance

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Future TCH actions

• Continue to utilize PHIS data to monitor progress longitudinally

• Optimize integration of data elements within the EHR

• Effectively implement/utilize additional RDT

• Utilize the SHARPS collaborative to perform multi-centered studies for stewardship and ID practice

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Questions