Antimicrobial Stewardship - Washington State Hospital .
Antimicrobial StewardshipWashington State InitiativeDecember 16th, 2014Meg Kilcup, PharmD, Director Safe Medication Practices, WSHARupali Jain, PharmD, BCPS, UWMC Antimicrobial Stewardship PharmacistBlythe Steele, RPh, PharmD, BCPS, Confluence Health Clinical CoordinatorPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
PartnersPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Objectives: Review the “Three Tiers” of a strong ASP program Review the data definition and process used tocollect data across the state. Hear from two organizations: “Clinical Pharmacistsin Action in ASP” in their facilities UW/Harborview Medical Center Confluence Health Central Washington HospitalPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Statewide Antimicrobial Stewardship (ASP) Initiative – Three TiersAll Washington hospitals and health systems will have an Antimicrobial Stewardship ProgramPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Measure DefinitionData Definition – Antimicrobial UtilizationNumerator: Total days of therapy (DOT) of select antibiotics*A Day of Therapy (DOT) will be defined as at least one doseof a selected antibiotic given on a calendar day to a patient inan inpatient unit (Med/Surg, ICU/Tele, OB). A patient onmultiple antibiotics on the selected list would be counted foreach separate antibiotic given each calendar day.Denominator: Patient daysPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Measure DefinitionAntibiotic Focuses FluoroquinolonesClindamycinPenicillins (broad spectrum)Cephalosporins (3rd and 4th generation,broad spectrum) CarbapenemsPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Updates to definition:Updated Measure Definition cillin/Tazobactam (Zosyn)Ticarcillin/Clavulanate (Timentin)Ampicillin/Sulbactam (Unasyn)Amoxicillin/Clavulanate (Augmentin)Cephalosporins:Ceftriaxone (Rocephin)Cefotaxime (Claforan)Ceftazidime (Fortaz)Cefepime (Maxipime)Ceftaroline (Teflaro)Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Data Submission Input data into the WSHA Quality BenchmarkingSystem (QBS) at the following link or NHSN. Current users may log in with their QBS credentials. If you need access to QBS, contact Decision Support atdecisionsupport@wsha.orgGoal: Identify areas of opportunity to optimizeantimicrobial utilization and decrease antimicrobialresistance patterns, development of secondaryinfections and adverse medication effects.Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
The Pharmacist’s Role in anAntimicrobial Stewardship ProgramRupali Jain, PharmD, BCPS
Rupali Jain, PharmD, BCPSRupali Jain, PharmD, BCPS is theAntimicrobial Stewardship ClinicalPharmacist for the UWMC.She has extensive clinical experiencewith Infectious Diseases sincecompletion of her InfectiousDiseases fellowship in 2004. In hercurrent role, she is responsible forthe daily activities with theantimicrobial stewardship program,including tracking resistance, patientmanagement, and clinical guidelinedevelopment.Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Outline1. Review the role and activities of an AntimicrobialStewardship Program (ASP) pharmacist, in general2. Discuss the role of the clinical pharmacist in the ASPat University of Washington Medical CenterPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
ASP needs you! “Core members of a multidisciplinary antimicrobialstewardship team include an infectious diseasesphysician and a clinical pharmacist with infectiousdiseases training (A-II) who should be compensated fortheir time (A-III) ”Clin Infect Dis 2007:44Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Strategies for ASPIV to POEducation II) All strategiesrequire pharmacyinput! Don’t FRET! Everymedical center willhave differentstrategies based ontheir size, patientpopulation,resources, staff, etcClin Infect Dis 2007:44Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
How the prescription flows Patient EvaluationGuidelines / EducationChoice of antimicrobialRestriction / PreauthorizationPrescription OrderingComputer-AssistedStrategiesDispensing AntimicrobialReview and FeedbackAdapted from Clin Micro Rev. 2005;18(4) 638.Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
How do we apply thesestrategies to our setting?
University of Washington MedicalCenter Academic medical center in Seattleserving Washington, Wyoming,Alaska, Montana and Idaho Part of the UW Medicine HealthSystem Beds: 410– Critical care beds: 50 Admissions: 19,260 (2010) ED visits: 25,602 (2010) Solid Organ Transplants: 310 (2009) Bone Marrow Transplants: 500(2011)Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Our teamDirector: Paul Pottinger, MDClinical Pharmacist: Rupali Jain, PharmDStakeholders: Decentralized clinical pharmacists Microbiologist Infection Control Infectious Disease Consult Team (3 teams)Committees: Infectious Diseases P&T Infection ControlPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Vital Stats Over 3500 prescriptions filled per day in our inpatientpharmacy 12,000 blood cultures sent each year 26 Decentralized Clinical pharmacists Three Infectious Diseases consult servicePresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Components of our ASP:1. Education Dosing cards2. Guideline development CPOE VAP, sepsis protocolAntibioticsare NOTrestricted!!!3. Prospective feedback Carbapenems Linezolid/ Daptomycin4. Review antimicrobials for formulary consideration5. Innovative practicesPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Prospective FeedbackUse Theradoc to identify HighCost/Toxicity/Broad Spectrum drugsASP Pharmacist reviews microbiology,clinical status, etcContact Clinical Pharmacist/ InfectiousDiseasesRECOMENDATIONSPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Triggers for Prospective Feedback Daptomycin, Linezolid, Amikacin, Colistin, HIVmedications, Non-formulary antimicrobials, Combinationantifungals Carbapenems prescribed with a positive blood culture Vancomycin used for MSSA infection Multi-drug resistant bacteria Adverse eventsPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Supplemental strategy: Microbiology rounds Monday, Wednesday, Fridays Review all positive blood cultures and some cultures fromother sterile sites (CSF, pleural fluid, etc) ID teams and ASP are present Responsibility of the medical teams: Present the clinical history Stewardship discusses de-escalation and optimization strategies ASP Goal: Ensure appropriate therapy, testing and appropriateconsultation of Infectious Disease Service.Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Selected Innovative Practices
Prolonged Pip-tazo Automatic switch to prolonged piperacillin-tazobactam. Prolonged infusion of piperacillin-tazobactam has been associatedwith improved clinical outcomes compared to intermittent infusion. Increased resistance at UW Medicine and nationwide --- we arelosing the battle! Financial benefits because less drug is used. Harborview: Costs reduced by 43% and number of doses decreasedby 16% UWMC: Costs reduced by 35% and number of doses decreased by48%Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
IV to PO program P&T approved list of “IVto PO” drugs Switch can occurwithout MD order Clinical Pharmacistsactively engageproviders to switch Impact unclear Ciprofloxacin Digoxin Fluconazole Levofloxacin Linezolid Metronidazole Moxifloxacin Pantoprazole Ranitidine Rifampin VoriconazolePresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Collaborations with AllergyNEW! 10% of our patients have a documentedpenicillin allergy As we know, this is over reported! True incidence of penicillin allergy is probably around 1% Patients with penicillin allergies are more likely to: have longer hospitalizations receive fluoroquinolones, clindamycin or vancomycin duringtheir hospitalizations have more cases of C.difficile, more MRSA and VRE infectionsContreras J Allergy Clin Immunol Mar 2014Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Solution Allergists are automatically notified (via Theradoc) ofany prescription for aztreonam They do a bedside assessment of the penicillin allergy Recommend alternative antibiotic Remove penicillin allergy from chart Hoping to expand to additional antimicrobialsPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
C.difficile initiative Multi-disciplinary committee to reduce the hospitalacquired (HAI) C.difficile Infection control, environmental services, nursing,stewardship and medical director Monthly Quality Improvement meeting to discuss HAICdiff cases ASP reviews the antibiotic therapy preceding thedevelopment of HAI Cdifficile Follow-up with providers when inappropriate antibiotictherapy contributes to CdifficilePresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Others initiatives1. Multidrug resistant infection pathway2. CPOE alerts3. Allergy assessment pre-opPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Metrics
925132931808University Hospital Consortium antibiotic use data (2011)Administrative claim data reported to UHC from 115 academic medical centerhospitals and 250 affiliated hospitalsPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
UWMC Pharmacy Expenditures 30,000,000.00 250.00Total Pharmacy ExpendituresAntimicrobial ExpendituresPharmacy Cost per pt-dayAntimicrobial Cost per pt-day 25,000,000.00 200.00 20,000,000.00 150.00Total pharmacy costsCost per pt-day 15,000,000.00 100.00 0.00 - 10,000,000.00 50.00 2013Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Challenges Cost savings substantial with ASP, but consumption stillhigher than optimal Overuse of carbapenems for empiric therapy in oncologypatients Increased expenditures for inhaled ribavirin Increased expenditures for antifungal therapy Working together with providers to consider stewardshipwhen developing guidelinesPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Summary of program Academic medical center program with highlyimmunocompromised patients with many careproviders Focus on education, clinical pathways, innovativeprograms and formulary reviewPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Thanks!Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
The Anatomy of Confluence Health’sAntimicrobial Stewardship ProgramBlythe Steele, RPh, PharmD, BCPS
Blythe Steele, RPh, PharmD, BCPS BS Pharm, University of Cincinnati 1996 PharmD, University of Cincinnati 2007 BCPS Certified in 2010 SIDP Certification earned in 2012 Corporate Clinical Manager and ResidencyProgram Director for Confluence Healthsince November 2012. Prior to 2012, worked for TriHealth inCincinnati, Ohio as Clinical Coordinator. Adjunct/field faculty, various universities.Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Objectives1. Discuss limitations of data collection for Confluencehealth pharmacists-driven recommendationacceptance rates.2. Provide examples of metrics to determine the successof an antimicrobial stewardship program.3. Explain how order sets can be helpful in anantimicrobial stewardship program.Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Confluence HealthPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
ASP Models .from Standard to Practical Prospective vs. retrospective Dedicated multidisciplinary rounding team vs.decentralized pharmacist review Metrics– Decrease in complications– C. difficile infection rates– Antibiotic expenditures– Decrease in days of therapyPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Confluence Health ASP StructureAntimicrobialStewardshipCommittee Works with: Infection Control Microbiology Pharmacists Providers Administration P&T CommitteePresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
The structure/function of the committeeMembers include: ID Physician SIDP Certified PharmD Infection Preventionist MicrobiologistReports to: Quality via Infection Control CommitteeMain function: Gives direction to the Antimicrobial StewardshipProgramPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Confluence Health ASP StructureAntimicrobialStewardshipCommittee Works with: Infection Control Microbiology Pharmacists Providers Administration P&T CommitteePharmacists Appropriateness ofantimicrobial Stop dates De-escalation IV to PO Dose optimizationPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Team Pharmacists as Frontline Agents Examples of education provided to team pharmacists––––Asymptomatic bacteriuriaDuration of therapy for infectious processesUrosepsis/pyelonephritisPharmacokinetic dosingRecommendations regarding antimicrobial therapyare made during interdisciplinary roundsPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Recommendations From PharmacistsHOW TO DOCUMENT RECOMMENDATIONS? Cerner Ad hoc– No way to obtain data from this intervention reportingmechanism Manual collection? At this time, YES. Future – may include CORES M Page documentation?Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Pharmacist’s Recommendation FormPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Limitations of using recommendationforms for data collectionIf it’s not documented,It didn’t happen.OROnly the acceptedrecommendations are documentedPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Are recommendations making a difference? How to measure? Antibiotic expenditures? Not at this time– Many corporate changes – difficult to compare expenditures– GPO– 340-B DOT/1000 patient days– To compare month to monthPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Antibiotic Use Over TimeDOT/1000 patient cillins80CephalosporinsCarbapenems6040200Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14 Apr '14 May '14 June '14 July '14 Aug '14 Sept '14 Oct '14Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Carbapenem use over timeCarbapenems180160140120100Carbapenems80Linear (Carbapenems)6040200Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14 Apr '14 May '14June '14 July '14 Aug '14 Sept '14 Oct '14Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Cephalosporin use over inear (Cephalosporins)6040200Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14 Apr '14 May '14 June July '14 Aug '14 Sept '14 Oct '14'14Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Extended spectrum penicillin use over timePenicillins180160140120100Penicillins80Linear (Penicillins)6040200Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14 Apr '14 May '14 June '14 July '14 Aug '14 Sept '14 Oct '14Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Fluoroquinolone use over 80Linear (Fluoroquinolone)6040200Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14 Apr '14 May '14 June July '14 Aug '14 Sept Oct '14'14'14Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Clindamycin use over timeClindamycin180160140120100Clindamycin80Linear (Clindamycin)6040200Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14 Apr '14 May '14 June '14 July '14 Aug '14 Sept '14 Oct '14Presented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Confluence Health ASP StructureAntimicrobialStewardshipCommittee Works with: Infection Control Microbiology Pharmacists Providers Administration P&T CommitteePharmacists Appropriateness ofantimicrobial Stop dates De-escalation IV to PO Dose optimizationProviders Increased awareness Open torecommendations ASP a part of daily rounds Dialog has been initiatedwith outpatient providersPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
In addition to daily rounds discussion Order set utilization rate – data collectionOrder sets for infectious processes are utilized29% of the time, not 100% as previouslyassumed. Order set review Antibiotic duration– 72 hours for Vancomycin if not proven MRSA– Levofloxacin 750mg for pneumonia Antibiotic content of order sets– Is something driving duplication of therapy? Discussion with providers – inpatient and outpatientPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Interventions to include Updating order sets to reflect standards of practice andinstituting stop dates Providers to champion order sets Shopping order sets to providers Antimicrobial Stewardship as part of annual mandatoryeducationPresented at the Washington State Hospital Association Statewide ASP Initiative Webcast on December 16, 2014
Confluence Health ASP Wish List includes: Community education Continuing education for providers, pharmacists
health pharmacists-driven recommendation acceptance rates. 2. Provide examples of metrics to determine the success of an antimicrobial stewardship program. 3. Explain how order sets can be helpful in an antimicrobial stewardship program. Presented at the Washington State Hospital Associat
Chapter 5: Antimicrobial stewardship education for clinicians 123 Acronyms and abbreviations 126 5.1 Introduction 127 5.2 Key elements of antimicrobial stewardship education 128 5.2.1 Audiences 128 5.2.2 Principles of education on antimicrobial stewardship 129 5.2.3 Antimicrobial stewardship competencies and standards 129
A Hospital Pharmacist’s Guide to Antimicrobial Stewardship Programs Greater New York Hospital Association United Hospital Fund — Antimicrobial Stewardship Toolkit - Best Practices from the GNYHA/UHF Antimicrobial Stewardship Collaborative National Quality Pa
Feb 24, 2021 · ix Fig. 1. Steps in clinical decision-making Examples of how to use the practical guide are: z as a reference when planning to implement an antimicrobial stewardship intervention; and z as a tool for educating colleagues and clinicians at your institution about antimicrobial stewardship. Barriers to a
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Antimicrobial Stewardship Clinical Pharmacist for the UWMC. She has extensive clinical experience with Infectious Diseases since completion of her Infectious Diseases fellowship in 2004. In her current role, she is responsible for the daily activities wit
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