The New World of Stewardship
Jim Hutchinson
Medical Director - Antimicrobial Stewardship
Island Health
Clinical Lead – Ant...
Muir Glacier Alaska

1940

2004
Penicillin Resistant S. aureus

Chambers et al EID 2001
Resistance to antibiotics rapidly rising
No new antibiotics
Infections are not diagnosed well
Antibiotics are not prescribed well
The Solution?
Structure
Thought
Care
Collaboration
Data
Required Organizational
Practice:
The organization has a program for
antimicrobial stewardship to optimize
antimicrobial u...
Spurred BC Action
BC Ministry of Health
• New Clinical Care Management area
• Established Provincial Antimicrobial
Clinical Expert group
PACE
PACE
• Co-Chaired by Richard Bachand and I with
ministry support
• Established in spring 2013
• Aggressive work plan
PACE activities
•
•
•
•

Best practice review completed
Survey of stewardship capacity completed
Business case RFP out
Ass...
PACE activities
•
•
•
•

Best practice review completed
Survey of stewardship capacity completed
Business case RFP out
Ass...
Which targeted antimicrobial stewardship activities are
done at this facility?
Time-sensitive Automatic Stop Orders
Formal...
Which targeted antimicrobial stewardship activities are
done at this facility?
Time-sensitive Automatic Stop Orders
Formal...
Prospective Audit with Intervention and Feedback
By Health Authority
5

Number of Facilities

4

3

2

1

0

FHA

IHA

NHA...
Audit and Feedback
Unsolicited Help
Helping everyone use antibiotics well
Clinical Pharmacy backbone
• Clinical Pharmacists are the “Foot
Soldiers”
• We don’t have enough
• We MUST build capacity
Clinical Pharmacy backbone

This is essential
Centralized medical oversight
• Infection specialists (ID and Medical
microbiologists) provide direct and
responsible coll...
Multidisciplinary help
the process
• Clinical pharmacists find people with
infections
– By antibiotic prescription
– By mi...
Multidisciplinary help
the process

It’s not Rocket Science
Multidisciplinary help
the process

But it is tricky!
Multidisciplinary help
the process
• Trust must be established
• Collegial, educational, non-punitive
• Direct physician t...
Progress in Island Health
• Friends are being made
• Foundations are being built
Unsolicited Help
Clinical pharmacists hired in:
•
•
•
•

Nanaimo
Campbell River
Cowichan District
Victoria
Unsolicited Help
• They have found hundreds of patients
• They have phoned me (and my
colleagues) many, many times
• They ...
And most importantly…
Now they are local, trusted, collaborative
colleagues
PACE activities
•
•
•
•

Best practice review completed
Survey of stewardship capacity completed
Business case RFP out
Ass...
Which of the following metrics are used to evaluate
antimicrobial usage?
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Defined Dai...
Not much measuring
But every prescription is electronic…
Hmmm…
SEISMIC
SEISMIC
Surveillance and Epidemiology of Infections, Stewardship,
Microbiology, and Infection Control

A Quality Assurance...
“a roadmap for the development of
enhanced clinical analytical capacity within
Island Health”
SEISMIC
• Extension of the Business Intelligence
Data Warehouse
• Re-purposing transactional data to
facilitate quality ca...
What data is needed for quality
management of infections?
• Antibiotic use
• Antibiotic resistance
– “Antibiogram”

• Meas...
First blush
• Antibiotic use
• Based on orders
– Much better to use administration data
Future of SEISMIC
• Relate antibiotic use to resistance
• Relate antibiotic use to outcomes
• Predict appropriate empiric ...
Future of SEISMIC

Iterative analysis
Forever
The ultimate vision
• All people on Vancouver Island will have
their infections anticipated, prevented,
diagnosed and trea...
The ultimate vision
• All people in British Columbia will have
their infections anticipated, prevented,
diagnosed and trea...
We are building a permanent
system
Why just antibiotics?
Stewardship of everything
There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential
There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential
There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential
There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential
There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential
There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential
There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential
There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential
Upcoming SlideShare
Loading in …5
×

There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential

648 views

Published on

This presentation was delivered in session C5 of Quality Forum 2014 by:

Jim Hutchinson
Medical Microbiologist, Island Health
Clinical Lead, BCPSQC

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
648
On SlideShare
0
From Embeds
0
Number of Embeds
20
Actions
Shares
0
Downloads
16
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential

  1. 1. The New World of Stewardship Jim Hutchinson Medical Director - Antimicrobial Stewardship Island Health Clinical Lead – Antimicrobial Stewardship BCPSQC
  2. 2. Muir Glacier Alaska 1940 2004
  3. 3. Penicillin Resistant S. aureus Chambers et al EID 2001
  4. 4. Resistance to antibiotics rapidly rising
  5. 5. No new antibiotics
  6. 6. Infections are not diagnosed well
  7. 7. Antibiotics are not prescribed well
  8. 8. The Solution?
  9. 9. Structure
  10. 10. Thought
  11. 11. Care
  12. 12. Collaboration
  13. 13. Data
  14. 14. Required Organizational Practice: The organization has a program for antimicrobial stewardship to optimize antimicrobial use.
  15. 15. Spurred BC Action
  16. 16. BC Ministry of Health • New Clinical Care Management area • Established Provincial Antimicrobial Clinical Expert group
  17. 17. PACE
  18. 18. PACE • Co-Chaired by Richard Bachand and I with ministry support • Established in spring 2013 • Aggressive work plan
  19. 19. PACE activities • • • • Best practice review completed Survey of stewardship capacity completed Business case RFP out Assuming responsibility for the Antibiotic / Probiotic portions of the Provincial Hospital Formulary
  20. 20. PACE activities • • • • Best practice review completed Survey of stewardship capacity completed Business case RFP out Assuming responsibility for the Antibiotic / Probiotic portions of the Provincial Hospital Formulary
  21. 21. Which targeted antimicrobial stewardship activities are done at this facility? Time-sensitive Automatic Stop Orders Formalized IV to PO Conversion Program Education Program Guidelines and Clinical Pathways Pre-Authorization Prospective Audit with Intervention and Feedback Other 0% 10% 20% 30% 40% 50% 60% 26 70% 80%
  22. 22. Which targeted antimicrobial stewardship activities are done at this facility? Time-sensitive Automatic Stop Orders Formalized IV to PO Conversion Program Education Program Guidelines and Clinical Pathways Pre-Authorization Prospective Audit with Intervention and Feedback Other 0% 10% 20% 30% 40% 50% 60% 27 70% 80%
  23. 23. Prospective Audit with Intervention and Feedback By Health Authority 5 Number of Facilities 4 3 2 1 0 FHA IHA NHA PHC PHSA VHCA VIHA
  24. 24. Audit and Feedback
  25. 25. Unsolicited Help
  26. 26. Helping everyone use antibiotics well
  27. 27. Clinical Pharmacy backbone • Clinical Pharmacists are the “Foot Soldiers” • We don’t have enough • We MUST build capacity
  28. 28. Clinical Pharmacy backbone This is essential
  29. 29. Centralized medical oversight • Infection specialists (ID and Medical microbiologists) provide direct and responsible collaborative help to clinical pharmacists. • This is not the usual model of physician interaction and oversight
  30. 30. Multidisciplinary help the process • Clinical pharmacists find people with infections – By antibiotic prescription – By microbiologic Dx – By algorithm • Advise on their management in collaboration with Specialist physician • Follow-up
  31. 31. Multidisciplinary help the process It’s not Rocket Science
  32. 32. Multidisciplinary help the process But it is tricky!
  33. 33. Multidisciplinary help the process • Trust must be established • Collegial, educational, non-punitive • Direct physician to physician interaction very important at the outset
  34. 34. Progress in Island Health • Friends are being made • Foundations are being built
  35. 35. Unsolicited Help Clinical pharmacists hired in: • • • • Nanaimo Campbell River Cowichan District Victoria
  36. 36. Unsolicited Help • They have found hundreds of patients • They have phoned me (and my colleagues) many, many times • They have helped!
  37. 37. And most importantly…
  38. 38. Now they are local, trusted, collaborative colleagues
  39. 39. PACE activities • • • • Best practice review completed Survey of stewardship capacity completed Business case RFP out Assuming responsibility for the Antibiotic / Probiotic portions of the Provincial Hospital Formulary
  40. 40. Which of the following metrics are used to evaluate antimicrobial usage? 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Defined Daily Dose Days of Therapy Length of Therapy Total Cost of Antibiotics None 45 Other
  41. 41. Not much measuring
  42. 42. But every prescription is electronic… Hmmm…
  43. 43. SEISMIC
  44. 44. SEISMIC Surveillance and Epidemiology of Infections, Stewardship, Microbiology, and Infection Control A Quality Assurance & Surveillance Analytical Environment for Microbiology, Antibiotic Stewardship and Infection Control “a roadmap for the development of enhanced clinical analytical capacity within Island Health”
  45. 45. “a roadmap for the development of enhanced clinical analytical capacity within Island Health”
  46. 46. SEISMIC • Extension of the Business Intelligence Data Warehouse • Re-purposing transactional data to facilitate quality care
  47. 47. What data is needed for quality management of infections? • Antibiotic use • Antibiotic resistance – “Antibiogram” • Measures of inflammation – e.g. WBC, Temperature, Procalcitonin • Outcome measures – e.g. LOS, mortality, complications, readmissions
  48. 48. First blush • Antibiotic use • Based on orders – Much better to use administration data
  49. 49. Future of SEISMIC • Relate antibiotic use to resistance • Relate antibiotic use to outcomes • Predict appropriate empiric therapy by personal microbiologic history • Etc., etc., etc.
  50. 50. Future of SEISMIC Iterative analysis
  51. 51. Forever
  52. 52. The ultimate vision • All people on Vancouver Island will have their infections anticipated, prevented, diagnosed and treated in a thoughtful, efficient, SYSTEMATIC fashion.
  53. 53. The ultimate vision • All people in British Columbia will have their infections anticipated, prevented, diagnosed and treated in a thoughtful, efficient, SYSTEMATIC fashion.
  54. 54. We are building a permanent system
  55. 55. Why just antibiotics?
  56. 56. Stewardship of everything

×