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Lessons Learned

Lessons Learned. From the 2013 CT Antimicrobial Stewardship Collaborative April 10, 2014 Deborah Quetti RN, MBA, BSN, CPHQ Consulting Director, Qualidigm. Background. CT DPH was awarded two CDC grants in 2012 Objectives Decrease use of antibiotics across the care continuum

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Lessons Learned

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  1. Lessons Learned From the 2013 CT Antimicrobial Stewardship Collaborative April 10, 2014 Deborah Quetti RN, MBA, BSN, CPHQ Consulting Director, Qualidigm

  2. Background • CT DPH was awarded two CDC grants in 2012 • Objectives • Decrease use of antibiotics across the care continuum • Reduce rates of C. difficile infections in long term care • Project management outsourced to Qualidigm • Two collaboratives formed • Sevenmonths in duration • Kick-off and monthly conference calls introduced / reviewed evidence-based practices • All teach, all learn format

  3. The Problem “Growing concern about antimicrobial resistance and the need for practical strategies to manage antimicrobial use effectively has reached a global scale, and demand for education, tools and expertise has increased both in the U.S. and internationally. There is a need for a multifaceted strategy to increase the number of effective antimicrobials available, to reduce resistance to available antibiotic treatments, and to put existing research on this important topic into practice.”

  4. Why An Antimicrobial Stewardship Collaborative? • To measure and promote appropriate use of antimicrobials by selecting an appropriate agent, dose, duration and route of administration to: • Improve patient outcomes • Minimize toxicity • Prevent emergence of antimicrobial resistance

  5. Why the Community Model? Assisted Living Long Term Care Facilities Physicians Nursing Homes Hospitals Community-based organizations Home Health

  6. HAIs and Hospital Readmissions Patients with + cultures for MRSA, VRE or C difficile (> 48 hours post hospital admission) were: • 40% more likely to be readmitted within one year • 60% more likely to be readmitted within 30 days* *J. Furuno PhD, University of Maryland Medical Center Infection Control and Hospital Epidemiology, June 2012

  7. Project Goal To assist hospitals and their community partners to work together from January through July, 2013 to develop and implement antimicrobial stewardship programs based on their community-specific needs.

  8. What is “Antimicrobial Stewardship”? Ensuring that every patient gets: • An antibiotic only when one is needed • The right agent • At the right dose • For the right duration ArjunSrinivasan, MD (CAPT, USPHS)

  9. Participant expectations • Commit to appropriate antibiotic usage at their facility • Attend meetings with community partners • Participate in monthly conference calls with Qualidigm • Confer rights to NHSN data to Qualidigm (hospitals only) • Participate in kick-off and wrap up collaborativeface-to-face sessions

  10. Project Timeline

  11. Antibiotic Stewardship GNYHA Antimicrobial Stewardship Toolkit

  12. Planning and Implementation GNYHA Antimicrobial Stewardship Toolkit

  13. Antibiotic Stewardship GNYHA Antimicrobial Stewardship Toolkit

  14. Antibiograms • Used by clinicians (hopefully) to: • Assess local susceptibility rates • Aid in selecting empiric therapy • Monitor susceptibility and resistance trends

  15. Antibiogram Usage

  16. Sample performance measures • “Measure something!”….Dale Bratzler DO • MRSA bacteremia rate • CDI rate • Number of antibiotics reviewed concurrently, number of • changes recommended by concurrent reviewer, number of • recommended changes approved by treating MD, and • resulting potential and actual cost savings • All antibiotic orders have an indication and therapy is • reassessed within 72 hours • Cultures are obtained before antibiotics are administered for • sepsis or systemic inflammatory response syndrome • Patients who can be switched from intravenous to oral • antibiotics are switched

  17. Sample performance measures, continued….. • Review of all positive blood cultures for bug/drug mismatch • Non-treatment of asymptomatic bacteriuria • Compliance with SCIP antibiotic measures • Antibiogram resistance • Defined Daily Dose of antibiotic (DDD) per 1000 patient days • Days of Therapy (DOT) per 1000 patient days • IHI: decreased cost per patient stay, decreased harms per 100 patient days (using IHI global trigger tool), decreased readmissions within 30 days

  18. Project Overview AIM Statement

  19. The Original Model Dellit TH et al. “Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship” Clin Infect Dis 2007;44: 159-77.

  20. Re-Thinking the Model • The goal of the stewardship program is not to dictate antibiotic choices. • It’s to ensure that there are systems and support to help every provider use antibiotics optimally. • For this to work, every provider has to play a role in stewardship. ArjunSrinivasan, MD (CAPT, USPHS)

  21. The New Model: A Spectrum of Activities Comprehensive program led by ID trained physician and pharmacist Individual interventions based on goals of institution led by individual (s) with interest Many approaches in between Bottom Line: Function Trumps Structure ArjunSrinivasan, MD (CAPT, USPHS)

  22. How Can We Get There? • One key first step is to identify concrete steps that people can take to improve antibiotic use. • Not necessarily “create a stewardship program” • But “implement a stewardship intervention” ArjunSrinivasan, MD (CAPT, USPHS)

  23. Community Focus Areas • Asymptomatic bacteriuria • Handoff communication: hospital nursing home, HHA

  24. Asymptomatic Bacteriuria • Toolkit available on Qualidigm web-site http://www.qualidigm.org/index.php/current-initiatives/antimicrobial-stewardship-collaborative/asymptomatic-bacteriuria-tookit/ • Antibiotic order form • Poster: “Ask me” campaign • Handout for residents and family members • Masonicaresample handout • Handout for staff • Monitoring tool • Staff training curriculum outline • Staff training scenarios

  25. Data from Antimicrobial Stewardship CollaborativeNHSN C. difficile LabID EventJanuary – May 2013 * Four months of data

  26. Data from this collaborativeNHSN MRSA bacteremia LabID EventJanuary – May 2013 * Four months of data

  27. Lessons Learned by Participants • Availability of tools in the public domain e.g. CDC • The significant impact of antibiotic use and serious sequellae to residents/patients. • ASP’s are worthwhile but challenging to get to work optimally; but any progress is better than none • Increase use of urine dipsticks leads to increase in antibiotics. Need to eliminate use of dipsticks, need to education MD’s, APRN’s and nursing staff. Need to include antibiotic stewardship in nursing orientation program. • How important it is to have open communication with families and physicians. • Some practical approaches to stewardship (much data on stewardship emphasizes the “why” but not the “how” to go about it) • Multidisciplinary participation is essential • That good data-based, evidence-based answers are being developed. • Antimicrobial stewardship program represents an opportunity to improve patient safety

  28. Lessons Learned (cont.) • I’ve learned a lot about the barriers to implementing antimicrobial stewardship programs in health care facilities • Decrease antibiotic use, decrease infections, increase staff and family awareness • How important it is to decrease the use of antibiotics • Obtain lab test before treating resident • One step at a time; this has been very informative • The need to educate staff, families and residents. The need to utilize antibiograms • That there is much work to be done • Commonalities among hospital systems • Don’t forget CNAs • Value of communication • Utilize other Communities of Care to assist our current program • The power of data to measure success or progress

  29. Collaborative Year One Observations • Community of care meetings worked to help keep a focus on the work to be done; competitiveness was checked at the door; all were partners at the table • Data collection was a challenge to most facilities • McGeer’s criteria commonly utilized in nursing homes • Leadership commitment to performance improvement was critical to success • Family members can play a significant role in pressuring staff to start antibiotics unnecessarily • Nursing homes appreciated assistance with training materials, signage, and hand outs

  30. Challenges • Engaging community partners that weren’t part of kick off session • Practical application and impact in nursing homes and home health agencies hasn’t been reported in the literature • Data driven decision making • Focus and follow through, given monthly community meetings • Rapid cycle performance improvement • Different approached to stewardship programs in each care setting; one size doesn’t fit all

  31. Plans for Year 2 • Community-based antimicrobial stewardship collaborative • Expand number of communities; conduct orientation session for newbies • Expand scope to actively engage HHA’s • Pay more attention to antibiogram usage • Kick-off session to reinforce knowledge • Wrap-up session to share lessons learned and celebrate success • Require self-assessment of antimicrobial stewardship practices by providers • Qualidigm staff to attend monthly team meetings of participating communities • Continue monthly webinars to share evidence-based practices to prevent infections • Focus on importance of data collection, analysis and reporting

  32. Questions?

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