University of Missouri Antimicrobial Stewardship Program : Patient Safety and NPSG Compliance

1. University of Missouri Antimicrobial Stewardship Program : Patient Safety and NPSG Compliance Performance Improvement Leadership Develop Program University of Missouri – Columbia February 19, 2010

2. Team Members • Joe Cameron, Pharm.D., BCPS • Gordon Christensen, MD • Ed Ege, Pharm.D. • Stephanie Lumley-Hemme, RPh • Jennifer Meyer, Pharm.D., BCPS • Stevan Whitt, MD

3. Focus Area • With the arrival of the Centers for Medicare & Medicaid's no-pay rules, The Joint Commission's National Patient Safety Goals, and the ever-growing emphasis on quality improvement of patient care, prevention has become the standard of care. • Participation in multiple quality improvement, automated data surveillance, and antimicrobial stewardship programs have garnered successes for hospitals in terms of improving systems, and in turn care and cost.

4. AIM Statement • University of Missouri Hospital aims to implement a process for monitoring and an intervention protocol intended to standardize the use of evidence based antibiotic regimens in the adult surgical intensive care unit. • The process starts with a list of new antibiotic orders and a daily culture and sensitivity report from the lab. • The process ends with conclusion of antibiotic therapy

5. AIM Statement • Our goal is to standardize empiric antibiotic therapy • Our secondary outcomes include: improving patient outcomes, decreasing duration of antibiotic therapy, containing antibiotic costs, and decreasing antibiotic resistance and related adverse reactions compared to current practice.

6. Institutional Strategic Goals • National Patient Safety Goal 7 : Reduce the risk of health care associated infections • New standards for 2009 • NPSG.07.03.01: Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals. • NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. • NPSG.07.05.01: Implement best practices for preventing surgical site infections.

7. Institutional Strategic Goals • Diagnosis Driven Therapy • Uniformity in Prescribing Practices • Cost Avoidance • Education

8. Project Timeline Data analysis and modification ECOMS Initial Approval ID Acceptance New Process Development Lab Report Order Sheet Creation with ID Process Modification and Initiation Presentation and Implementation of Program Feb 2010 August 2009 Sept 2009 Oct 2009 Nov 2009 Dec 2009 Jan 2010 Current Process Evaluation Discussion withPowerChart Documentation ECOMS Approval to move forward IV to PO Conversion Policy Preliminary Data SICU Intial Acceptance

9. Current Process Continued on Next Slide

10. Current Process

11. Fishbone Diagram

12. Stakeholders Point of Change Stakeholders Upstream Stakeholders Downstream Stakeholders • Infection Control • Units throughout hospital • Pharmacy • Patients • Administration • Pharmacy • ICU Physicians • Attendings • Residents • Infectious Disease • Pathology • IT Dept. • Pharmacy

13. Interventions Considered Strategy 1 Strategy 2 & 3 • Active Intervention and Feedback • Location Based • Patient Based • Organism Based • Prior-authorization • ID Physician or Pharmacist withauthority • Restricted Formulary • Partially implemented, noauthority in Pharmacy • Education • Driven by Attending Physicians

14. Suggested Pathway Yes No Continued on Next Slide

15. Suggested Pathway Yes No Yes Continued on Next Slide No

16. Suggested Pathway No Yes Yes No

17. Key Driver Diagram

18. Order Sheets

19. Order Sheet

20. Microbiology Reports

21. Microbiology Reports

22. Measurements • Diagnosis Stated / Use of Preprinted Order Set >75% • De-escalation >75% • IV to PO Conversion >75%

23. Baseline Data (2 Weeks) • Diagnosis Stated • Zero (0%) • Patients in SICU • 21 Patients • Antibiotics Prescribed • 37 Antibiotics • One Time Dose (Pre-op) • 4 Antibiotics • De-escalation • 2 Accomplished (40%) • 3 Missed • IV to PO Conversion • None (0%)

24. Process and Outcomes Indicators • Outcome Indicators • Increased knowledge of appropriate therapy for common infectious diagnoses throughout the institution. • Bacteremia, Pneumonia, and Intra-abdominal Infections • Compliance with JCAHO NPSG 7 • Process Indicators • De-escalation of therapy when appropriate • IV to PO Conversion

25. Anticipated Return on Investment / Benefits Realized • Increased resident understanding of appropriate empiric evidence based therapy and de-escalation • Consistent management of patient specific disease states • Decreased development of multi-drug resistant organisms • Decreased medication expenditure

26. Lessons Learned • Health care team acceptance • Analysis of current practice • Prediction of program implementation • Process improvement application

27. Next Steps • Encompass all intensive care units • Education of Pharmacists, Nurses, and Physicians • Increase number of disease state protocols • Increase roll out to all of institution • Successful reduction in multi-drug resistant organisms • Decreased length of antibiotic therapy and potentially patient stay

28. Questions? Joe Cameron Ed Ege Stephanie Lumley-Hemme Jennifer Meyer

29. Thank You!