antibiotic stewardship where are you?...antimicrobial stewardship measures •structural...

Antibiotic Stewardship Where Are You?

Suzanne F. Bradley, M.D.

Professor of Internal Medicine

Division of Infectious Disease

University of Michigan Medical School

VA Ann Arbor Healthcare System

Hospital Epidemiologist, Infection Control

Antimicrobial UseUS - 2010

Fridkin S et al. MMWR 2014;63:195.

How to Combat Resistance?

Antibiotic Stewardship ProgramsCore Elements

• Leadership

Commitment

• Accountability

• Drug expertise

• Action to improve use

• Tracking

• Reporting

• Education

http://www.cdc.gov/getsmart/healthcare/evidence.html

7 Core Elements

Stewardship

Leadership

•human

• financial

• IT Resources

Accountability

•outcomes

• report committee

Drug Expertise

•pharmacist leader

Tracking

•process measures

Action

• Implement one

Reporting

• regularly to staff

Education

•optimal prescribing

Pollack et al.

CID 2014;59:S98

Improving Antimicrobial UseInvolves Everyone!

Reduction Antibiotic

Use

Hospitals

Patients and

Families

Post-Acute Care

Outpatient Facilities

Patient Education

AE, AP, AS, GU, VI data are not shown due to 7 or fewer hospital respondents but are included in the overall percentage.

*Prescribing data from 2014; population data from 2013

Source: IMS Health

7 - 33%

46 - 54%

55 - 77%

34 - 45%

48%

37%

54%

30%

33%

77%

48%

70%

63% 40%

49%

12%

33%

31%

28%

35%

41%

24%

26%

36%

43%

33%

47%

48%

24%

45%

54%51%

54%

41%

47%

47%

45% 48%

64%

56%

67%

60%

24%

59%

51%7%

27%59%67%47%58%38%60%50%

60%

40%

Percent of Hospitals with Antibiotic Stewardship Programs by State, 2015*

*A hospital stewardship program is defined as a program following all 7

of CDC’s Core Elements of Hospital Antibiotic Stewardship Programs.

Source: CDC’s National Healthcare Safety Network (NHSN) Survey

Nationally, 48.1% of all hospitals have stewardship programs (2,199 of 4,549); the national goal is 100% of hospitals by 2020.

VA StewardshipImpact

Kelly AA et al. ICHE 2017;38:513.

ASP program 41-89%

ASP policy 17-92%

ATB use drops 12%

Quality MeasuresHow to Define Success

• Structure to deliver high quality care?–personnel?

– resources?

–policies?

• Process for healthcare delivery?– what is the process?

– is it being done?

• Outcomes of healthcare delivery

Dodds Ashley ES et al. SHEA ASP Textbook 2018 pp 131

Antimicrobial StewardshipMeasures

• Structural– leadership commitment

–multidisciplinary protocols

–designated ASP leader

–expert pharmacist

– tracking resistance

– tracking antimicrobial use

–education staff, patients, & families

Dodds Ashley ES et al. SHEA ASP Textbook 2018 pp 131

Antimicrobial StewardshipProcess Measures

Pt Management Stewardship Program ATB Consumption

Adherence guidelines Antibiotic courses reviewed Days of therapy-DOT

Duration antibiotic therapy Electronic alerts reviewed Defined daily doses-DDD

De-escalation events Recommendations made Length of therapy

IV to PO conversion Types of interventions Doses dispensed

Dual anaerobe therapy Approval restricted ATB Antimicrobial starts

Time to appropriate therapy Excess drug use

Diagnostic utilization Device days

Orders include indication ICU days

Orders include duration

ATB free days

ID consult performed

Antimicrobial StewardshipOutcome Measures

Clinical Financial

Mortality overall & infection-

related

Drug costs

LOS overall & after ATB Hospitalization costs

Re-admission rates Overall therapy cost

ATB adverse events Cost per pt per day

ATB resistance rates Attributable infection costs

Cure & clinical or micro

response

QUALYs

Clinical failures

HAI rates

Antimicrobial StewardshipHorizontal vs Vertical Action Items

Horizontal

Formulary Restriction

Antibiotic Time Out

Alerts for Duplicative Therapy

(Ex: Double Anaerobic Coverage)

Vertical

Targeting Specific Antimicrobials

(Ex: Anti-MRSA agents)

Cellulitis Order Set

UTI Stewardship

Patel PK. ICHE 2017;38:532.

Antimicrobial StewardshipHorizontal vs Vertical

Vertical Action ItemsSyndrome-Culture Strategies

Strategy Description Benefits Challenges

Susceptibility

Reports

(low effort or $)

Select or censor

ATB to include on

culture reports

Improve ATB use Providers assume

susceptible even if

agents not

reported

Clincal Pathways &

Order Sets

( mod effort or $$)

ATB & Dx guidance Guideline Tool

Kit

Standardized care

Design & maintain

Need IT

Uptake limited

Rapid diagnostics

(mod effort or $$)

Rapid ID or

susceptibility info

Improve time to

appropriate Rx &

rapid de-escalation

May not change

ATB use alone

Add audit &

feedback

Audit & Feedback

(high effort or $$$)

Direct to providers Improve ATB

selection &

outcomes, ATB de-

escalation

Need system to ID

patients for review

Need IT resources

Adapted from Moehring RW et al. SHEA ASP Textbook 2018, pp:63-84

Horizontal Action ItemsBroad-Based Strategies


Guidelines

(low effort or $)

Tailored national

recommendations,

local resistance

patterns, formulary

Standardized care

Improved selection

& outcomes

Maintain updates

Assess adherence

Education

(mod effort or $$)

Group format,

policies

Reach many

providers

Change not

sustained

Preauthorization


Review & approval

Restricted ATB

Improve use &

outcomes, Reduce

use & costs, Some

education

Time intensive

Skilled personnel

Loss autonomy

Use other ATB

Audit & Feedback


After Rx started

Feedback given

Improve use &

outcomes, Reduce

use & costs, Direct

education

Time intensive

Skilled personnel

Need IT to identify

Adherence

voluntary


Horizontal Action ItemsBroad-Based (2)


Allergy initiatives

(low effort or $)

Improve allergy

assessments

Increase use first-

line drugs

Education

providers, nurses,

pharmacy, patients

Dose optimization

(mod effort or $$)

Pt & drug specific

factors

Better dosing

Improves safety

Improve drug

levels

Pharmacy

workload

Ongoing

assessments

IV to PO

Conversion

(mod effort or $$)

Automatic

conversion high

bioavailability ATB

Decrease costs

No change safety

Decrease LOS

Pharmacy

workload

Frequent review

Automatic ID

Consult


Eligible pts per

policy

Improve survival

Reduce

complications &

readmissions

Need ID docs

Acceptance by

non-ID docs


Horizontal Action ItemsBroad-Based (3)


Antibiotic Time

Outs

(low effort or $)

Providers review &

document choice,

dose, duration,

cultures, &

indication

Increase

awareness

Use in limited

resource areas

Integrate in EMR

No data on impact

Providers may not

change decisions

Alert fatigue

Automatic Stop

Orders

(low effort or $)

Require approval

for continuation

Improve use

Decrease

resistance

ATB stopped

inappropriately

Maintain process

Peer Comparison

Feedback

(high effort or $)

Feedback data vs

other prescribers

Positive

reinforcement

good prescribers

Target education

Collect & analyze

data, Adequate

sample size, what

is appropriate

use?

High Risk Unit ASP

Routine Rounds

(high effort or $)

Target high priority

areas,

Multidisciplinary

team

Direct education

In depth pt review

Time & labor

intensive

Engaging provider

groupsAdapted from Moehring RW et al. SHEA ASP Textbook 2018, pp:63-84

Antimicrobial StewardshipSetting Priorities - Leadership

Basic Intermediate Advanced

Board Statement importance of ASP

Make top management -ASP Champion

Ensure training for ASP leaders

CEO/CMO Newsletter Facility strategic goals –include ASP

IT funding & support for ASP

Dedicate salary - ASP leaders

QI & Safety - include ASPreporting to leadership

Micro & lab data access by ASP

Specify ASP time & goals Provider education - includeASP

All departments responsible for improving antimicrobial use

Funding ASP consultants if none locally

Financial incentives for departments that improve antimicrobial use

Articulate that ATB use important hospital goal

Ensure other departments support ASP

Share stories, speakers & resources - ASPs improve outcomes

Hold providers accountable for antibiotic use

Engage pts & advocates

National Quality Partners Playbook: AS in Acute Care.

Antimicrobial StewardshipSetting Priorities -Accountability


Appoint ASP Leader –physician +/- pharmacist

Ensure ASP training & certification

Tie measures to performance/financial incentives

NP as an alternative ASP leader accountable specific outcome measures

IT funding & support for ASP

Dedicate salary - ASP leaders

Document outcome measure in performance evaluations

Tie hospital QI, e.g., SAAR and C. diff rates, to ASP performance

Collaboration between physicians & pharmacy

ASP leader involves other disciplines in stewardshipefforts

ASP leader involved in all QI projects related to ATB


Antimicrobial StewardshipSetting Priorities – Drug Expertise


Ensure pharmacist with ASP expertise

Provide pharmacist ASPtraining & certification

Ensure pharmacy leader trains other pharmacists in ASP throughout the hospital


Antimicrobial StewardshipSetting Priorities - Actions


Antibiotic order review by ASP leader based on local need

ATB time out or post-prescription review 48-72 hrs by primary team or ASP

Rapid diagnostics for organisms or biomarkers to improve ATB use

Require indication, dose, duration for all orders

Guidance for automatic change IV to PO

Timely culture and transport

Provide guidance - antibiotic allergy assessment

Guidance for ATB adjustments if organ dysfunction

Improve ATB use for specific syndromes, e.g., CAP, VAP, SSI, BSI, sepsis

Develop treatment recommendations based on national guidelines & local susceptibility data

Dose optimization for Rx resistant organisms.

Improve ATB use for specific organisms, e.g., MRSA, CDI

Standardize order forms for clinical syndromes

Automatic alerts for duplicative drug therapy

Inappropriate use for contaminants, colonization

Automatic stop orders for specific antibiotics

Treatment protocols for sepsis in ICU

Pt rounds include discussions of ATB


Antimicrobial StewardshipSetting Priorities – Tracking/Monitoring


Adhere documentation

policies - ATB indications &

time outs

Tracking antibiotic

resistance patterns

Track DOT-Days of Therapy

Track diagnosis, drug, dose,

duration, de-escalation

Tracking CDI rates Track DDD-defined daily

dose (grams ATB used)

Adherence facility treatment

guidelines

Readmission rates

pneumonia & CDI at 30

days

Track SAAR-standardized

antibiotic administration ratio

Adherence interventions Direct antibiotic expenditures

– purchasing costs

Accurate allergy & adverse

event reporting


Antimicrobial StewardshipSetting Priorities - Reporting


Regular reports on measures tracked.

Progress reports for meeting facility goals & suggestions for improvement

Provide provider-specific data & suggestions for improvement

Submit report to stakeholders, e.g., Board, QI, Safety. P&T, Staff

Include overall use, trends, interventions, actions taken, appropriate use, & outcome measures

Provide real-time ASPmetrics for all staff by dashboard

Present to Medical Staff quarterly

Make concreterecommendations for improvement

Post data on medical staff websites & by email

Encourage early adoption NHSN modules - SAAR

Reports to leadership, staff, & PTs

Post susceptiibility & use data in news letters

Provide unit specific reports Present ASP to governing bodies

Provide to specific groups Post unit specific data invisible areas

Report to leadership with actionable items


Antimicrobial StewardshipSetting Priorities -Education


Communicate ASP at least quarterly – blogs, website, intranet, newsletters

Give ASP data in grand rounds

Participate in national ASP activities

Highlight ASP goals in education programs & materials

Talk annually to key providers in person or using web-based programs

Annual staff education should include ASP information

Tell stories – physicians who change prescribing habits

Develop concise messages for ASP with clear recommendations for improvement

Patient education should include ATB information

Tell stories – pt adverse events

Educate providers on resistance data and susceptibility interpretation

Medical education & training should include ASP information

Establish an expert collaborative for coaching goals & webinars

New staff orientation should include ASP information


High Antimicrobial Use?How to Respond

CDC/NHSN & Pew Charitable Trust

Antimicrobial StewardshipUS Viewpoint

• Prevention of ATB resistance is important

• Reduction of antibiotic use critical

• Requires everyone to help

• Start simply!

• Multiple goals, actions, & measures

• Everyone can do something!

antibiotic stewardship where are you?...antimicrobial stewardship measures •structural...

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