The Core Elementsof Antibiotic Stewardship

with CMS and QAPI Updates

Emily Lutterloh, MD, MPH

Director, Bureau of Healthcare Associated Infections

New York State Department of Health

February 8, 2017

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Outline

• Antibiotic stewardship (ASP)in nursing homes

• Core elements for ASP

• CMS and ASP

• QAPI and ASP

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Antimicrobial Stewardship

https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

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Stewardship for Nursing Homes

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Core Elements

• Leadership commitment

• Accountability

• Drug expertise

• Action

• Tracking

• Reporting

• Education

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Leadership Commitment

• Statements supporting improved antibiotic use shared with staff, residents, families

• Stewardship duties included in position descriptions for medical director, nurse leads, consultant pharmacists

• Communicate expectations and enforcement regarding antibiotic use

• Create a culture promoting stewardship

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Accountability• Medical director sets prescribing

standards for credentialed staff

– Accountable for adherence

– Reviews antibiotic use data

• Director of nursing sets standards for communicating a resident’s condition

– Role in decision-making

– Knowledge of guidelines

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Drug Expertise

• Consultant pharmacist with training in

infectious disease or antibiotic stewardship

• Infectious disease consultants

• Partner with hospital stewardship leads

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Action: Policy and practice

change to improve antibiotic use• Medication regimen review applied

to antibiotics

• Standardization of antibiotic start process– Communication

– Diagnostic testing

• Antibiotic time-out

• Pharmacist integration

• Interventions to improve use in specificclinical situations

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Action

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Action

• Documentation of dose, duration, indication

• Best practices for microbiology testing

• Treatment recommendations based on national guidelines and local susceptibilities

• Review accessibility of drugs off hours

• Develop and disseminate antibiograms

• Reduce prolonged courses of antibiotics

• Specific interventions– Asymptomatic bacteriuria, prevention of UTI

– Pneumonia

– Superficial wound cultures

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Tracking

• How and why antibiotics are prescribed

• How often and how many antibiotics

are prescribed

– Starts, DOT

• Adverse outcomes and costs

– C. difficile, antibiotic resistance,

adverse drug events

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Tracking

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Tracking

• Completeness of documentation

– Clinical assessment, prescribing

• Point prevalence survey of antibiotic use

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Reporting

• Share data with prescribers and nurses

• Future: NHSN reporting?

– Summary data

– National benchmarking

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Education

• Clinicians, nursing staff, residents, families

• “Academic detailing”

• Feedback to clinicians

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Partners• Infection preventionists

– Tracking antibiotic starts

– Monitoring adherence to guidelines

– Reviewing resistance patterns

• Consultant pharmacist– Medication review

– Reporting antibiotic use data

• Consultant laboratory– Alerts for resistant organisms

– Antibiograms

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Resources

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Antimicrobial Stewardship“SHEA, IDSA, and PIDS recommend that the Centers for

Medicare and Medicaid Services (CMS) require participatinghealthcare institutions to develop and implement antimicrobial

stewardship programs. This can be achieved by incorporatingthe requirement into existing regulations via expansion of

interpretive guidelines of the relevant regulation(s). Allhealthcare facilities, including hospitals, long-term care

facilities, long-term acute care facilities, ambulatory surgicalcenters, and dialysis centers should develop and implementan antimicrobial stewardship plan that is modeled after theIDSA and SHEA “Guidelines for Developing an Institutional

Program to Enhance Antimicrobial Stewardship.”*

*Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA),the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect ControlHospital Epidemiol. 2012;33:322-7.

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CMS – CFR 42.483

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Timeline

• Nov 2016 - Phase 1 (existing, straightforward, minor changes)

• Nov 2017 - Phase 2 (more time to develop)– Antibiotic stewardship

• Nov 2019 - Phase 3 (more time to develop and/or implement, personnel/training requirements)– Infection preventionist

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Surveys and Worksheets

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-09.pdf

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Infection Control Worksheets

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Infection Control Worksheets –

Antibiotic Stewardship

• Has stewardship program approved by

governing body

• Accountable clinical leader(s) per their

position description

• Written protocols on antibiotic prescribing

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Infection Control Worksheets –

Antibiotic Stewardship• Infection assessment tools/management

algorithms for at least one infection

– Ex. SBAR for UTI assessment, Loeb minimum criteria for initiation of antibiotics

• Report summarizing antibiotic use from pharmacy data within last 6 months

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Infection Control Worksheets –

Antibiotic Stewardship• Antibiogram created within past 24 months

• Clinical leadership provides prescribers with feedback about antibiotic prescribing

• Clinical leadership has provided training on antibiotic use to nursing staff and prescribers within last 12 months

• Educational materials on stewardship for residents and families

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Infection Control Worksheets –

QAPI

• Infection preventionists provides

documentation of infections to QAA

Committee

• QAA Committee plan includes oversite of

infection control program

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Infection Control Worksheets –

QAPI

• QAA Committee develops plans of action

to address infection prevention issues

• Infection prevention related adverse

events analyzed using root cause analysis

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Infection Control Worksheets –

Care Transitions (selected)

• Documentation of infection, colonization,

h/o MDRO, C. difficile, etc.

• Communication about antibiotic dose,

route, indication, start/stop date, last

administered

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Thank you!