Place picture here

Nov. 14, 2017

MHA/OHA HIIN Antibiotic Stewardship/MDRO Collaborative

Please note – this webinar is being recorded.

▪ For best sound quality, dial in at 1-800-791-2345 and enter code 11076

▪ Please use the chat box to ask questions!

Reminders

Housekeeping

▪ Education Credit

• Nursing Education Credit – 1 hour

• Pharmacy Education Credit – 0.1

Agenda

▪ Welcome

▪ Presentation:

• Sanford Bemidji Medical Center Antibiotic Stewardship Program – Stefani Anderson, BSN, RN, PHN, CIC & Matt Webb, Pharm.D, BCPS

▪ Questions/discussion

▪ Resources & ASP 101 reminders

▪ Wrap-up

Sanford Bemidji Medical Center

Antibiotic Stewardship Program (ASP)

Stefani S. Anderson BSN, RN, PHN, CIC

Matt Webb, Pharm.D., BCPS

Sanford Health of Northern Minnesota

▪ 118-bed regional medical center based in Bemidji, Minnesota.

▪ 78-bed skilled nursing home

▪ Home care and hospice

▪ 25-bed critical access hospital

▪ 37 Ambulatory clinics

Sanford Health of Northern Minnesota ASP Program and History

Our program began in 2015

▪ Team members include Pharmacy, Chief Medical Officer, Infectious Disease Physician, Infection Control Specialist, Quality, and Microbiology.

▪ Meet every other month

▪ Bemidji ASP reports to the Enterprise ASP committee as well as the local Pharmacy and Therapeutics (P&T)

▪ Early initiatives included▪ Incorporation of antimicrobial review into clinical pharmacist workflow

▪ Training pharmacists

▪ Provider education about ASP

▪ Determining committee structure and reporting

▪ Garnering administrative support

ASP Regulatory Entities

▪ Joint Commission

▪ Centers for Medicare and Medicaid Services (CMS)

▪ NHSN Antimicrobial Usage (AU) and Antimicrobial Use and Resistance (AUR)

What is antimicrobial stewardship?

Infectious Disease Society of America (IDSA) defines antimicrobial stewardship as “coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal

antimicrobial drug regimen, dose, duration of therapy, and route of administration.”

▪ Can be practiced in all healthcare settings as well as on an individual and system wide level.

▪ Often a collaborative effort from providers, pharmacists, microbiologists, infection control, and information technologists.

Why is it important?

Antibiotics are prescribed unnecessarily or

inappropriately 20 – 50 % of the time in United States

acute care hospitals.

▪ This can lead to antimicrobial resistance which is a

growing problem and serious threat to our

society’s collective health.

▪ About 23,000 people die as a result of resistant

organism each year.

IDSA Antimicrobial Stewardship Targets

▪ Discontinue antimicrobials when no clear evidence of infection

▪ Adjust antimicrobial regimens to account for community acquired vs healthcare associated infection

▪ Recommend guideline-based empiric therapy and definitive therapy when pathogen is known

▪ De-escalate treatment to the narrowest spectrum drug(s) they can give to accomplish the goal

▪ Set an appropriate duration (stop date) for antibiotics▪ Transition from intravenous to oral therapy when able

Sanford Bemidji ASP

Data Definitions

▪ Days of Therapy (DOT)/1000 days present

▪ NHSN numerator: Inpatient locations, facility-wide

inpatient, and specific outpatient acute care settings

▪ Standard Antibiotic Administration Ratio (SAAR) –

national benchmark not available until NHSN

submission

Sanford Bemidji ASP Projects

▪ Establish local ASP committee with

leadership support

▪ Educate pharmacists

▪ Educate providers

▪ Develop patient review plan with ID MD

▪ DUEs▪ Vancomycin

▪ Fluoroquinolones for UTI

Daily Workflow

▪ Pharmacists ▪ Decentralized clinical pharmacists available

Monday through Friday

▪ ASP is one of many responsibilities

▪ Review all patients on antimicrobials for

appropriateness (drug, dose, route, duration)

▪ Infectious Disease Physician

▪ Communicates daily via inbox and detailed

conversations regarding high-risk patients

FY17 Goals

▪ Improve patient outcomes▪ Reduce resistance▪ Healthcare-associated Clostridium difficile▪ Hospital survival▪ Length of stay▪ Reduce 30-day readmission incidence▪ Pneumonia▪ Sepsis▪ Reduce carbapenem use▪ Reduce quinolone use

Data Collection

Statistics

1 2 422 23 30 31

57 48 44 47 56

105

173 163 177 175

427 415392 396 383 381

416 427

362

0

50

100

150

200

250

300

350

400

450

Month

# of ASP iVents By Month = Bemidji

Total

Required Indications Within Drug Order

Carbapenems/

Meropenem

Piperacillin/

Tazobactam

Quinolones/

Levofloxacin

a

386

446440

494

390

422433

468

519

447

533

465

481 487 492

456

434

459

492

574

523

551

523512

456

437423

300

350

400

450

500

550

600Ju

l-15

Au

g-15

Sep

-15

Oct

-15

No

v-15

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-16

Sep

-16

Oct

-16

No

v-16

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-17

Sep

-17

DO

T/1

00

0 P

t D

ays

Month

Facility-Wide Antibiotic DOT/1000 Patient Days = Bemidji

Outcomes

Pneumonia and Sepsis

PNEUMONIA

Hospital Encounters - Pneumonia as Principal Diagnosis at Discharge

30-day Readmission- Pneumonia

3%2%

4%

4%3% 3%

4%

1%

4%

5%

3%3%

3%

2%

3%

1%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

2014 2015 2016 2017

% H

osp

ita

l M

ort

ali

ty

Fiscal Year

Pneumonia - SANFORD BEMIDJI MEDICALCENTER - N

Pneumonia - SANFORD BISMARCK MEDICALCTR - N

Pneumonia - SANFORD MEDICAL CENTERFARGO - N

Pneumonia - SANFORD USD MEDICALCENTER - N

Pneumonia - Hospital Mortality

Pneumonia - Avg LOS

4.52

4.08

3.37

3.91

5.845.62

5.14

4.885.31

5.78

5.25

5.61

5.194.64

5.28

4.90

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

2014 2015 2016 2017

Avg

LO

S

Fiscal Year

Pneumonia - SANFORD BEMIDJI MEDICALCENTER

Pneumonia - SANFORD BISMARCK MEDICALCTR

Pneumonia - SANFORD MEDICAL CENTERFARGO

Pneumonia - SANFORD USD MEDICALCENTER

SEPSIS

449

501

415434

668

787818

849

0

100

200

300

400

500

600

700

800

900

2016 2017

# o

f H

osp

ital

En

cou

nte

rs

Fiscal Year

Sepsis - SANFORD BEMIDJIMEDICAL CENTER

Sepsis - SANFORD BISMARCKMEDICAL CTR

Sepsis - SANFORD MEDICALCENTER FARGO

Sepsis - SANFORD USD MEDICALCENTER

# Hospital Encounters - Sepsis as Principal Diagnosis at Discharge

3.6% 4.2%3.4%

5.3%

4.3% 5.3%

7.6% 5.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

2016 2017

30

d R

ead

mit

%

Fiscal Year

SANFORD BEMIDJI MEDICALCENTER - N

SANFORD BISMARCK MEDICALCTR - N

SANFORD MEDICAL CENTERFARGO - Y

SANFORD USD MEDICALCENTER - Y

30-day Readmission- Sepsis

6%

4%

13%

12%

15%

14%

10%10%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2016 2017

% H

osp

ital

Mo

rtal

ity

Fiscal Year

Sepsis - SANFORD BEMIDJI MEDICALCENTER - N

Sepsis - SANFORD BISMARCKMEDICAL CTR - N

Sepsis - SANFORD MEDICAL CENTERFARGO - N

Sepsis - SANFORD USD MEDICALCENTER - N

Sepsis - Hospital Mortality

5.255.63

8.65

7.48

10.01

8.53

7.48

6.94

0.00

2.00

4.00

6.00

8.00

10.00

12.00

2016 2017

Avg

LO

S

Fiscal Year

Sepsis - SANFORD BEMIDJIMEDICAL CENTER

Sepsis - SANFORD BISMARCKMEDICAL CTR

Sepsis - SANFORD MEDICALCENTER FARGO

Sepsis - SANFORD USD MEDICALCENTER

Sepsis - Avg LOS

Ordersets and Protocols

a

a

a

Cost Analysis

Year-end total coming to July meeting as of March 2017

High cost antibiotic targets next year– Zosyn

– Daptomycin

– Micafungin

a

$281,376 , 55%$117,658 , 23%

$62,523 , 12%

$28,831 , 6%

$17,936 , 3%

$7,500 , 1% $417 , 0%

Daptomycin $516K

PHARMACEUTICALSERVICES SMC

PHARMACY FGO

PHARMACEUTICALSERVICES SBK

PHARMACEUTICALSERVICES SMB

PHARMACY FGO SU

PHARMACY ADN

$113,309 , 69%$16,596 ,

10%

$19,175 ,

12%

$4,892 , 3%

$2,291 , 1%

$4,876 , 3%

$3,159 , 2% Ertapenem $164K

PHARMACEUTICALSERVICES SMC

PHARMACY FGO

PHARMACEUTICALSERVICES SBK

PHARMACEUTICALSERVICES SMB

PHARMACY FGO SU

PHARMACY ADN

$235,205 , 36%

$289,535 , 45%

$63,388 , 10%

$38,518 , 6%

$9,881 , 2%

$7,855 , 1%

$2,619 , 0%

Zosyn $647K

PHARMACEUTICALSERVICES SMC

PHARMACY FGO

PHARMACEUTICALSERVICES SBK

PHARMACEUTICALSERVICES SMB

PHARMACY FGO SU

PHARMACY ADN

$56,267 , 55%$26,585 , 26%

$19,039 , 19%

$367 , 0%

$415 , 0%

$123 , 0%

Micafungin $102K

PHARMACEUTICALSERVICES SMC

PHARMACY FGO

PHARMACEUTICALSERVICES SBK

PHARMACEUTICALSERVICES SMB

PHARMACY FGO SU

PHARMACY ADN

Jul 2016 – May 2017

ASP Response

Engagement

• Sanford-wide ASP participation

• Leadership support throughout

Sanford

• Local executive leadership support

• Financial support

Successes

• Decreased carbapenem use

• Allocated ID MD time to ASP

• ASP tool in Epic

• ASP related data / reports

Barriers

• Antibiotic-related order set uptake

• Expanding ASP to ambulatory clinics

Additional Projects

• Procalcitonin (PCT)

• Lower respiratory tract infections

• ICU patients with sepsis/severe sepsis

• Ambulatory ASP DUEs

• Collaboration with Long-term Care facilities

Recommendation

• ID involvement and accountability

• ASP data presented to relevant committees

• Dedicated time for program

• Data collection to support program

FY18 Goals

• Reducing Zosyn by 15%

• Continue expanding required indications for

antibiotics

• Complete UTI fluoroquinolone DUE for select

ambulatory clinics

ReferencesBarlam, T, et al. (2016). Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Disease Society for Healthcare Epidemiology of America. Clinical Infectious Disease, 62(10), e51-77.

Centers for Disease Control and Prevention. (2017). Checklist for Core Elements of Hospital Antibiotic Stewardship Programs. Retrieved from https://www.cdc.gov/antibiotic-use/healthcare/implementation/checklist.html

National Quality Form. (2016). National Quality Partners Playbook: Antibiotic Stewardship in Acute Care. Retrieved from http://www.qualityforum.org/Publications/2016/05/National_Quality_Partners_Playbook__Antibiotic_Stewardship_in_Acute_Care.aspx

The Joint Commission. (2016). Joint Commission Perspectives, 36(7), 1-8.

Place picture here

Resources & ASP 101 Reminders

U.S. Antibiotic Awareness WeekNov. 13-19

#BeAntibioticsAware

▪ Stakeholder toolkitnow available!

▪ Thursday, Nov. 16 -CDC & Federal Office of Rural Health Policy webinar on ASP in CAH

ASP 101 Reminders

ASP 101 Resources – CDC Core Elements 5 & 6

Homework▪ Review ASP Toolkit for Rural and

Critical Access Hospitals, pages 28-29• Action Item: create an

antibiotic use report or scorecard on at least one antibiotic that is being tracked in the facility.

• Action Item: Determine to how and with what frequency the antibiogram will be shared with all prescribers in the facility

• Action item: Determine how and with what frequency prescribers will receive direct, personalized communication about how they can improve their antibiotic prescribing.

Supplemental Resources▪ Sample Antibiotic Stewardship

Scorecard ▪ http://www.ihi.org/Engage/Members

hips/Passport/Documents/IHI%20Antibiotic%20Stewardship%20Expedition%20-%20Session%205%20Handouts.pdf

▪ NQF Core Elements Playbook: pages 19-20 http://www.qualityforum.org/Publications/2016/05/National_Quality_Partners_Playbook__Antibiotic_Stewardship_in_Acute_Care.aspx

▪ CDC Strategies to Assess Antibiotic Use in Hospitals:

▪ https://www.cdc.gov/getsmart/healthcare/pdfs/Strategies-to-assess-antibiotic-use-in-hospitals-508.pdf

Thank you for joining us!

Next Webinar:

“ASP Education Strategies: Challenges & Successes”

Tuesday, Dec. 12 at 11:30am CST/ 12:30pm EST

Register online:

https://zoom.us/j/874320868