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TRANSCRIPT
Script UP Sprint
Amanda Keilholz, CPHQ
Program Manager
October 30, 2018
Sprint Details
No data submission required for the sprints
One hour initial webinar taking a deep dive into each UP Intervention.
One hour midway facilitated call discussing application of the interventions into practice.
Sprint Details
A single tollgate due at the end of each sprint that provokes thought around:
current policy
are changes needed
policy review processes
barriers
addressing drift.
Sprint Details
An estimated time commitment would be 4-12 hours per sprint.
Time commitment is really dependent upon how in-depth you choose to take the interventions throughout the sprint.
The sprints will give you tools to use and allow you to begin to think through the interventions and how the application may be within your facility.
Up Coming Sprints
Welcome
Steve Tremain, MD, FACPE
Cynosure Health
Missouri Hospital Assn HIINSCRIPT UPSteven Tremain, MD, FACPE
Cynosure Health
October 30, 2018
Optimize Medications
ADE Delirium Readmissions Falls Sepsis All HAI’s
S C R I P T - U P
Why It Matters
Adverse drug events are the most common cause of harm (AHRQ)
Overuse and inappropriate use of antibiotics is the key cause of antibiotic resistance (CDC)
Beers Criteria Medications are linked to poor health outcomes, including confusion, falls, and mortality (Am. Geriatric Society)
Risk of ADEs almost doubles with > 5 meds (Bourgeois, Shannon et al, 2010)
What It Means to YOU and YOUR Hospital
What It Means to YOU and YOUR Hospital
Joy of Work
Organizational Survival Avoid penalties
Avoid harms (that no one but you pays to fix)
Grows your image in the community
Reduces out-migration
Optimize Medications
ADE Delirium Readmissions Falls Sepsis All HAI’s
S C R I P T - U P
Understand Your Audience
Craft the message
Craft the messenger
Craft the modality
Who is this?
William Dawes
I’ll give you a hint…
WHAT DOES THIS STORY TELL US?
The messenger matters
The Tipping Point –
Malcolm Gladwell
The Message Also Matters
Know the
Score!
Customize the WAY You Communicate
SHAREINFORMATION
SHAPE BEHAVIOR
GeneralPublications
flyersnewslettersvideosarticlesposters
PersonalTouch
letterscardspostcards
InteractiveActivities
telephoneemailvisitsseminarslearning setsmodeling
PublicEvents
Road showsFairsConferencesExhibitionsMass meetings
Face-to-face
one-to-onementoringsecondingshadowing
Adapted from Ashkenas, 1995 (C) 2001, Sarah W. Fraser
The Modality Matters
SIMPLE
EASY
FUN
SCRIPT UP MUST DO's
SCRIPT UP MUST DO’s
Match the drug to the bug
Follow Beers’ age appropriate criteria if they're up in years
Use appropriate meds -- Less may be more Ask, “Does the patient needs any medication changes or
adjustments?”
Must Do #1 Match the Bug to the Drug
Implement antibiotic time outs at 48 or 72 hours to de-escalate and modify therapy
Verify the presence of a bacterial or fungal infection
Antimicrobial Stewardship Program (ASP)
A structured program that promotes appropriate use of antimicrobials by selecting:
the appropriate agent,
dose,
frequency,
duration, and
route of administration.
Goals of an Antimicrobial Stewardship Program
Improved patient outcomes
Reduced adverse events (e.g. C. difficile infection)
Improved rates of antibiotic susceptibilities to targeted antibiotics
Reduced length of stay
Reduced healthcare expenditures
Optimization of resource utilization across the continuum of care
Barlam TF et al. Clin Infect Disease. 2016:62;51-76.
Antibiotic Stewardship: Does it Work?
Hospital Antibiotic Stewardship Programs have been shown to: Improve antibiotic resistance
Reduce C. difficile
Improve patient outcomes
Save $$$$$
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The Magnificent Seven
Leadership Commitment
Accountability
Drug Expertise
Action
Tracking
Reporting
Education
Add to That…
Pharmacy and Physician Champions
IP Champion
Nurse Champion
Strategies
CDC Gap Analysis Tool
Antimicrobial Management Program Gap Analysis Checklist, Centers for Disease Control and Prevention, 2010. Retrieved at https://www.cdc.gov/getsmart/healthcare/improve-efforts/resources/pdf/AMP-GapAnalysisChecklist.pdf
Key Strategies
Pre-Prescription Authorization
Post-Prescription Audit and Feedback
Target the high risk antibiotics
48 to 72 hour Antibiotic Time Out
Advantages ↓ initiation of antibiotics
↓ costs
Directly controls use
Preauthorization
Disadvantages Limited to restricted agents
Loss of prescriber autonomy
May delay therapy
Requires skill
Real-time resource intensive
Shifts to other agents that may be worse
Mother, May I?
Advantages ↑ visibility of ASP
↑ clinical data available
↑ flexibility in timing of recommendations
Les than daily
Educational
Prescriber autonomy
Promotes teamwork
Addresses de-escalation & duration
Post-Prescription audit and feedback
Disadvantages Compliance voluntary
Labor-intensive
Success driven by delivery
Fear of change; is patient doing well
May require IT/data mining
May take longer to achieve ↓ in targeted antibiotic use
Pre or Post?
Significant reduction in use of restricted agents and $$
Decreased antibiotic use
Decreased antibiotic resistance particularly gram-negative pathogens
Both have advantages and disadvantages
Unintended consequences
Seek Forgiveness not
Permission?
Antibiotic Time Out
1. Infected?
2. If yes, Bacterial?
3. If yes, source? Culture? Sensitivity?
4. Right drug?
5. Right dose?
6. Right frequency?
7. Right duration
8. Right route?
Measurement
Days of therapy (DOT)
True Costs based on prescriptions
The Math
Admitted tonight at 2300, given Amp + Gent before midnight
Receive 4 doses of amp and 3 doses of Gent tomorrow
Switched to Cephalosporin the next day and receives 3 doses, Amp + Gent both discontinues prior to dosing
4th day discharged before any abx dosing.
DOT = 2 + 2 + 1 + 0/4 days = 1.25 then X 1000 = 1250
Education and skill development for front line pharmacists
Barriers/Solutions
Staff development Bugs and drugs
Guideline familiarity
Provide resources Sanford Guide
John Hopkins Antibiotic Guide
Pharmacist Guide to ASP-ashp.org
www.mad-id.org
www.sidp.org
Metric for tracking
Barriers/Solutions
Internal IT involvement
External vendors
Software / data mining
Build into budget and seek approval Sentri7
Theradoc
Vigilanz
Don’ts and Do’s
Don’t: Talk about saving money
Start hammering outliers
Do: Talk about the 5 rights:
Antibiotic
Dose
Frequency
Duration
route
Next Steps…
Become Knowledgeable
Engage physicians and pharmacists
Guide structure
Oversee gap analysis
Provide necessary resources (does not need to be expensive!)
Seek monthly updates and data
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One Idea
Pharmacists focus review on patients with a fluoroquinolone order ≥ 48 hours if cultures are back
Review 7-10 patients daily
~50% require intervention
Antibiotic monitoring form is completed by pharmacists
Recommendations made during interdisciplinary rounds or by phone call
Stop Talking. Get Started.
Decide what antibiotic to target by considering: Potential risk
Volume used
High cost
Set up a review process
Monitor your results
Spread to other antibiotics when you can
Resources: HRET HIIN Change Package
http://www.hret-hiin.org/Resources/asp/17/antibiotic-stewardship-program-change-package.PDF
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http://www.hret-hiin.org/Resources/asp/17/antibiotic-stewardship-program-asp-case-study-large-medical-center-mississippi-baptist-medical-center.pdf
Resources:Case Studies – Large & Small Hospitals
http://www.hret-hiin.org/Resources/asp/17/antibiotic-stewardship-program-asp-case-study-critical-access-hospital-southwest-health-system.pdf
References
National Quality Partners Playbook: Antibiotic Stewardship in Acute Care, National Quality Forum. Retrieved at http://www.qualityforum.org/Publications/2016/05/National_Quality_Partners_Playbook__Antibiotic_Stewardship_in_Acute_Care.aspx . Last accessed May 16, 2017.
Antimicrobial Management Program Gap Analysis Checklist, Centers for Disease Control and Prevention, 2010. Retrieved at https://www.cdc.gov/getsmart/healthcare/improve-efforts/resources/pdf/AMP-GapAnalysisChecklist.pdf . Last accessed June 2, 2017.
Barlam, T. F., Cosgrove, S. E., Abbo, L. M., MacDougall, C., et al, Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society and the Society for Healthcare Epidemiology of America, Clinical Infectious Diseases, 62:e51-77, 2016. Retrieved at https://www.ncbi.nlm.nih.gov/pubmed/27080992 . Last accessed May 16, 2017.
Doron, S., and Davidson, L. E., Antimicrobial Stewardship, Mayo Clinical Proceedings, 86:1113-1123, 2011. Retrieved at https://www.ncbi.nlm.nih.gov/pubmed/22033257 . Last accessed May 16, 2017.
Approved: New Antimicrobial Stewardship Standard, Joint Commission Perspectives, 36:1-4, 2016. Retrieved at https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf . Last accessed May 15, 2017.
Antimicrobial Stewardship, American Hospital Association’s Physician Leadership Forum. Retrieved at http://www.ahaphysicianforum.org/resources/appropriate-use/antimicrobial/ . Last accessed May 16, 2017.
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Must Do #2 Follow Beers’ age appropriate criteria if they're up in years
Flag, stop and replace medications on the Beers’ list
If needed, switch to a safer agent
If not needed, discontinue medication
Classes of Medications to Avoid
Provide Alternatives
Drug Class Preferred Alternative Special dosing considerations for the elderly
Benzodiazepines - For insomnia: - emphasize sleep hygiene- treat for underlying disrupters- evaluate timing of other medications and
alcohol- For chronic anxiety:
- consider buspirone or SSRIs or SNIRs- consider psych referral
- Risk of fall doubled if used more than 14 days
Opioid analgesics Avoid meperidine
Provide Alternatives
Drug Class Preferred Alternative Special dosing considerations for the elderly
Cardiovascular agents - For HTN alone- ACE inhibitors,
betablockers, or calcium channel blockers preferred
Most significant risk is orthostatic hypotensionMonitor closely and educate patient Slowlyincrease to full dose
Skeletal muscle relaxants Monitor length of use and discontinue as soon as no longer indicated; recommended for short use only
Help your physicians by
providing guidelines about alternatives and
any special dosing or monitoring
considerations.
Must Do #3
Use appropriate meds -- Less may be more
Ways to Start
Consider shortening med lists, especially PRN medications When adding a med, ask “What can I discontinue?”
Why less may be better
There is no set number of medications defining polypharmacy –The CDC uses 6
Concerns Increased ADE
Increased drug interactions
Increased costs
Prescribing cascade
Associated with Decreased quality of life, mobility and cognition
Take Action
Set a threshold number for review Consider the volume of patients who are
at or above the threshold and the amount of pharmacist time that can be dedicated
Have pharmacist review and consult with physician
Monitor the impact of your intervention
Let’s Combine #2 and #3
Deprescribe medications that have high harm:benefit ratio
PFE Is critical!
Involve patients and families in the discussion
Find out why the medication was started and how long they have been taking it
Find out if they have current concerns about the medicine
PFE Is critical!
Understand what benefit the patient or family believe the medication is providing
Understand what fears the patient or family have about stopping a certain medication
Segment….
See if medications can be listed by class
Look for duplicates
Target one class
One area (clinic, unit)
Follow up!
2-3 day phone call
30 day check
What’s Next
Midway Interactive Discussion
Tuesday, November 13 10:00 a.m.
Register
Tollgate Due
Friday, November 30
Amanda Keilholz, CPHQ
Program Manager
573/893-3700, ext. 1405
Contact Information