Pharmacist Monitoring Tools for Antimicrobial Stewardship

1. Pharmacist Monitoring Tools for Antimicrobial Stewardship Dianna Gatto, Pharm.D., BCPS Pharmacy Clinical Manager Chris Beuning, Pharm.D., BCPS Pharmacy Clinical Analyst MultiCare Health System September 10, 2012

2. MultiCare Health System

3. MultiCare Health System • Not for profit organization in the greater Tacoma, East Pierce and South King County regions in Washington state • 879 licensed beds • Tacoma General – 402 beds • Good Samaritan – 275 beds • Allenmore – 130 beds • Mary Bridge Children’s – 72 beds • Specialized Services • Level II trauma at TGH and Mary Bridge Children’s • Level III NICU at TGH • Rehabilitation program at Good Samaritan • Primary Care Clinics • Urgent Care Centers • Free standing Emergency Department • Employed Providers • HIMSS Davies Award winner 2009

4. Objectives • Be familiar with antimicrobial stewardship • Understand key pharmacist workflows • Identify tools for patient monitoring

5. Outline • Overview of MultiCare Health System • What is Antimicrobial Stewardship • Pharmacist tools • Key pharmacist workflows • Challenges • Future directions

6. Outline • Overview of MultiCare Health System • What is Antimicrobial Stewardship • Pharmacist tools • Key pharmacist workflows • Challenges • Future directions

7. What is Antimicrobial Stewardship • Antimicrobial Stewardship (AMS) • Systematic, multi-faceted approach to the use of antimicrobial agents, to optimize clinical outcomes while minimizing unintended consequences • Goals of programs • Achieve the best clinical outcomes • Reduce emergence of resistant organisms • Decrease costs

8. Antimicrobial Stewardship at MHS • Specialized ID pharmacist • Prospective audit of targeted hospitalized patients receiving antimicrobial agents and/or diagnosis of infection • Patient identification based on the following: • Selected antimicrobials • Bug-drug mismatches • Inappropriate durations of therapy • De-escalation opportunities

9. Role of Decision Support in AMS • Efficiently identify patients who need to be reviewed • Pharmacists spend time assessing patient therapy versus report generation and data mining • Easily generate daily reports in a timely manner that pharmacists can utilize • Target patients by running reports based on flexible criteria

10. Outline • Overview of MultiCare Health System • What is Antimicrobial Stewardship • Key pharmacist workflows • Pharmacist tools • Challenges • Future directions

11. Key Pharmacist Workflows • Order entry and order verification • Prescriptive authority (dosing) protocols • Pharmacist Inbasket message review • Consults • Medication messages • Best practice alerts • Intervention documentation • Ongoing drug monitoring • Microbiology results

12. Outline • Overview of MultiCare Health System • What is Antimicrobial Stewardship • Key pharmacist workflows • Pharmacist tools • Challenges • Future directions

13. Tools • Need specialized tools that drill down to increase the number of patients served, focusing on outcomes and decreasing costs • Selected antimicrobials • Bug-drug mismatches • Inappropriate durations of therapy • De-escalation opportunities

14. Tools – Order Entry/Verification • Order sets • Appropriate agents and doses • Links to guidelines from order sets • Targeted medication build • Appropriate defaults • Linked labs • Order instructions • Reference Links

15. Tools – Microbiology Results • Best Practice Advisories - General • New properties allow creative rules based on culture results • Rules can be used in BPA criteria • Do not fire to end user • Trigger Inbasket message to pharmacists or pools • Pharmacists can monitor messages based on workflows and time • Custom Inbasket message created to provide patient specific information within message

16. Tools – Microbiology Results • Best Practice Advisories – Applications • Updated micro results available • Positive blood culture and no antimicrobial • Resistant culture • Duplicate anaerobic coverage • Duplicate C. difficile coverage

17. Tools – Microbiology Results • Best Practice Advisories – Properties • (Vendor specific screen capture removed)

18. Tools – Pharmacist/Physician Rounding • Accordion Reports • General • Medication administration visual • Culture information • Lab data, Vital information • Pertinent drug levels • Allow changes to time view

19. Tools – Pharmacist/Physician Rounding • Antimicrobial Accordion • Challenge – complicated patients, multiple antimicrobial orders, changes in regimen over time • Visual timeline of all antimicrobial administrations • Vancomycin Accordion • Challenge – vancomycin often non-continuous therapy with stops, starts and dosing changes • Visual timeline of vancomycin administrations

20. Accordion Reports - Antimicrobial • (Vendor specific screen capture removed)

21. Accordion Reports – Vancomycin • (Vendor specific screen capture removed)

22. Tools - Pharmacist Rounding: Scoring • System Lists and Patient Scoring Tools • Utilize same BPA properties to create rules • Ability to sort columns and relative overall score to identify key patients • Rules/Columns in Antimicrobial Stewardship Scoring • Patient specific information: location, name, age, primary problem, weight, height and creatinine clearance

23. Tools - System Lists and Patient Scoring 23

24. Tools - System Lists and Patient Scoring

25. Tools - System Lists and Patient Scoring (Vendor specific screen capture removed)

26. Tools - Surveillance/Effectiveness Reports • Drug Usage • By patient, location, physician and drug • Days of therapy • Individual drug per 1000 patient days • Entire patient hospitalization per 1000 patient days • IV compared to PO • Track antibiotic use and days of therapy by provider and specialty groups • Antimicrobial cost per patient day

27. Tools - Surveillance/Effectiveness Reports • Process/Outcome Measurements • Antimicrobial use and impact on Clostridium difficile infection rates • Intervention acceptance rate by physicians • Direct antimicrobial expenditures • Track discharge antibiotic trends

28. Outline • Overview of MultiCare Health System • What is Antimicrobial Stewardship • Key pharmacist workflows • Pharmacist tools • Challenges • Future directions

29. Challenges • Identifying specific interventions • Incorporating tools into pharmacist workflows • Quirky BPA behavior based on free text • Lacking interfaced lab system • Free text data sent for microbiology results from lab system • Competing requests for reporting resources

30. Mitigating Challenges • Creative use of BPA’s and searching for free text strings • Use of reports with data already in the Enterprise Data Warehouse (EDW) for other initiatives (sepsis metrics) • Leverage expertise from outside the pharmacy team

31. Outline • Overview of MultiCare Health System • What is Antimicrobial Stewardship • Key pharmacist workflows • Pharmacist tools • Challenges • Future directions

32. Future Directions • Introduction of QlikView for reporting from Epic • AMS program outcomes • Antimicrobial usage trends • Drug use patterns related to infection control data • Comparative reports by drug, facility and prescriber to identify improvement areas • Financial impact • Expand AMS to all hospitals in system • Consideration of changes to lab system

33. Conclusion • What is Antimicrobial Stewardship • Pharmacist tools • Key pharmacist workflows • Pharmacist tools • Challenges • Future directions

34. Questions • chris.beuning@multicare.org • dianna.gatto@multicare.org