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(Pseudo) Antimicrobial Stewardship Program in a Critical Access Hospital

(Pseudo) Antimicrobial Stewardship Program in a Critical Access Hospital. Presented by Karen Burk RPh Clinical Pharmacy Coordinator Powell Valley Healthcare. Who we are…. 25 bed Critical Access Hospital in rural Wyoming-also cover another 25 bed CAH 30 miles away

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(Pseudo) Antimicrobial Stewardship Program in a Critical Access Hospital

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  1. (Pseudo) Antimicrobial Stewardship Program in a Critical Access Hospital Presented by Karen Burk RPh Clinical Pharmacy Coordinator Powell Valley Healthcare

  2. Who we are… • 25 bed Critical Access Hospital in rural Wyoming-also cover another 25 bed CAH 30 miles away • 4 Full time pharmacists including myself and our pharmacy director • 3 Full time technicians • 1 Full time secretary

  3. Who we are cont’d… • 6 Family Practice physicians • 5 OB physicians – 3 are also Family Practice • 1 Internal Medicine/Pediatrician • 1 Orthopedic surgeon with 1 PA and 1 NP • 1 General surgeon • 1 ER physician-down from 4-locums filling in

  4. AND… • ZERO Infectious Disease Specialists

  5. What are the goals of an Antimicrobial Stewardship Program?

  6. Goals of an ASP • Improve patient care and health outcomes • Work with health care practitioners to help each patient receive the most appropriate antimicrobial with the correct dose and duration. • Reduce patient’s length of stay • Reduce money spent for patient and facility

  7. Goals of an ASP cont’d • Prevent antimicrobial overuse, misuse and abuse • Avoid unnecessary use of antibiotics. • Minimize the development of resistance

  8. Approaches to Antimicrobial Stewardship • 2 major approaches: • Front-end or preprescription approach uses restrictive prescriptive authority • Restrict certain antimicrobials and require prior authorization • Back-end or postprescription approach uses prospective review and feedback • Review current antibiotic orders and recommend to continue, adjust, change or discontinue the therapy based on available microbiology results

  9. How we started • Process of evolution-one step at a time • Utilized information from previous facilities • Routinely review list serves such as American Society of Health System Pharmacists. Encourage you to join Mountain-Pacific Quality Health list serve

  10. Developed Pharmacist Driven Protocols • Aminoglycoside and Vancomycin protocols were developed and approved through the Pharmacy and Therapeutics Committee • Pharmacist performs all dosing and monitoring of the patient • Able to order labs as appropriate

  11. Developed Pharmacist Driven Protocols • Renal dosing of certain medications by the pharmacist as approved by the P&T committee • 35 medications can be modified based on creatinine clearance • Able to order labs as appropriate

  12. Hospital Protocols • Community acquired Pneumonia • Standards originally were antibiotics within 4 hours of entering the ED but then relaxed to 6 hours • We kept ours at 4 hours

  13. Physician Standing Orders • Changed our post op antibiotic order sets to discontinue last prophylactic dose by 23 hours of end of surgery

  14. Monitoring form • Developed an excel spreadsheet to assist in patient monitoring by the pharmacists

  15. Working with Infection Prevention RN • Excel spreadsheet with basic information on new admits with an infectious process going on • Work together on antibiogram with Lab and IP RN

  16. Learn to think outside the box

  17. Barriers… • NO INFECTIOUS DISEASE PHYSICIAN! • Reasons beyond your control- physician wants to keep on IV abx so patient can stay in hospital or acute care • Doctor hangs up on you-chase him down • Doctor is rude to you in front of other health care professionals-try to deal with it-it’s about the patient

  18. Barriers cont’d • Drug reps! Luckily banned from our institution • Lose staffing - hard to maintain standards you have set

  19. Barriers cont’d • One doc thinks should be on antibiotics until the wound is completely healed • One doc has a treatment failure and refuses to ever use that antibiotic again • One doc hears about a specific med and only wants to use that one for everyone and everything

  20. Barriers cont’d • Pharmacy stats for FTE’s are still based on doses dispensed and not on clinical knowledge

  21. Interventions • If you didn’t document it - you didn’t do it!

  22. CLINICAL INTERVENTIONS

  23. Barriers cont’d • For clinically relevant antibiogram need at least 30 isolates • Guess how many times we have 30 isolates in our critical access hospital?

  24. Our partners • Physicians • Nurses • Lab • Infection Prevention • Patients

  25. Physicians • Earn respect-can take a long time to earn and a short time to lose! • How do your physicians like to be contacted? • Notes, phone, cell phone, face to face

  26. Nurses • Biggest allies • Also takes a long time to earn respect and a short time to lose it! • RN should shadow pharmacist and pharmacist should shadow RN • Be persistent-will take time to turn things around

  27. Lab • Utilize the experts! • Educate regarding the antibiotics, organ penetration etc • D zone inhibition • ESBL’s • FQ not for MRSA!

  28. Patients • You have to be able to interact with the patient • Compliance • Cost • Side effects

  29. What we’ve tried that didn’t work • IV to PO conversion by pharmacist • 1 physician hold out stopped the process • 100% acceptance rate when we do suggest it • I’ve heard physicians say sometimes only way to keep patient in the hospital is to be on iv antibiotics

  30. Moving Towards… • Formalizing an Antimicrobial Stewardship committee • Physician champion • Review requirements for non critical access hospitals to see where we could improve • Print a daily report from lab with culture results • Bring in a specialist to teach providers how to obtain a proper culture sample • See if we can link up with an Infectious Disease physician for consults • Help our IP RN more with identifying patients in LTCC

  31. How to get started • Identify and create your team • Identify your goals • Identify what you are already doing • Inform your facility of your plan • Create an antibiogram • Get a mentor-network • Russ Forney; list serves

  32. Questions? Karen Burk RPh Clinical Pharmacy Coordinator Powell Valley Healthcare Phone 307-754-1179 kburk@pvhc.org

  33. References • Gauthier, T. & Unger, N [2013] Antimicrobial stewardship program: A review for the formulary decision-maker. Formulary Journal 48:7-17. • Doron, S. & Davidson, L. 2011 Nov Antimicrobial Stewardship. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3203003/ • APIC Text of Infection Control and Epidemiology 3rd Ed 2009 Section V 62:9 • Ritter, Al, 2010 The 100/0 Principle. The Secret of Great Relationships

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