Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Stewardship Presentation MRPRC

523 views

Published on

  • Be the first to comment

  • Be the first to like this

Stewardship Presentation MRPRC

  1. 1. Impact of a Pharmacist-Led Antimicrobial Stewardship Program Using Clinical Decision Support Nathan Peterson, Pharm.D. npeterson1@stez.org CHI - St. Elizabeth Lincoln, Nebraska
  2. 2. DISCLOSURE I have no actual or potential conflict of interest in relation to this program/presentation I have no actual or potential conflict of interest in relation to this program/presentation
  3. 3. Outline • Introduction – Catholic Health Initiatives- St. Elizabeth – Why antimicrobial stewardship? • Objectives – Cost savings – Improved antibiotic use • Methodology – Clinical Decision Support • Results – Cost savings – Clinical pathway optimization – Success stories • Discussion • Conclusion
  4. 4. Introduction • Catholic Health Initiatives – 105 hospitals – 4 academic medical centers – 19 states – 30 critical access hospitals • St. Elizabeth – 260 bed community hospital – Medical, Pharmacy, and Nursing students from University of Nebraska and Creighton University
  5. 5. Antimicrobial Stewardship • Centers for Disease Control and Prevention (CDC): – 3/2014; Published Core Elements of Hospital Antibiotic Stewardship Programs(ASPs) • Leadership Commitment • Accountability • Drug Expertise • Action • Tracking • Reporting • Education • President Obama: – 9/2014; Presidential Order mandating Task Force and 5-Year Plan for combating antibiotic resistance
  6. 6. Antimicrobial Stewardship • Centers for Medicare and Medicaid Services(CMS): – 12/2014; Updated checklist for infection control in hospitals 1.c.9 The hospital has written policies and procedures whose purpose is to improve antibiotic use (stewardship). 1.c.10 The hospital has designated a leader (e.g., physician, pharmacist, etc.) responsible for antibiotic stewardship outcomes. 1.c.11 Policy and procedures require practitioners to document an indication, dose, and duration for all antibiotics. 1.c.12 The hospital has a formal procedure for all practitioners to review antibiotics prescribed after 48 hours (e.g., antibiotic time out). 1.c.13 The hospital monitors antibiotic use (consumption) at the unit and/or hospital level.
  7. 7. Background • Pre - ASP Operations – Decentralized pharmacists cover Critical Care, Progressive Care, Medical, Oncology, and Burn Units – Pharmacokinetic Services by Pharmacy for select antibiotics – Infection Control Committee – Infectious Disease Physicians not employees of the hospital – contract with provider group – Verigene • Rapid detection of G+ and G- blood stream infections • Pharmacy occasionally called first; dependent on microbiologist discretion – Yearly antibiogram
  8. 8. Pharmacist-Led Antimicrobial Stewardship Program • Recruit Committee – monthly meetings – ID Physician, 2 Internal Medicine Physicians, Infection Control, Microbiology, Chief Medical Officer – Pharmacy Clinical Coordinator attended meetings to assist in the handoff after the pharmacist completed residency • Identify Goals – Cost reduction, clinical pathway optimization, success stories • Process Implementation – Clinical Decision Support – Quality and quantity metric development – Provider education
  9. 9. Pharmacist-Led Antimicrobial Stewardship Program What is Clinical Decision Support(CDS)? “CDS systems link health observations with health knowledge to influence health choices by clinicians.” - Robert Hayward, Center for Health Excellence Software that applies rules (e.g. if-then statements) to patient data. -Computerized alerts and reminders for providers -Clinical guidelines -Condition-specific order sets -Patient data reports and summaries -Documentation templates (interventions, etc.) TheradocTM
  10. 10. ASP Pharmacist using Theradoc Intervention period • Pharmacy resident spent 1 to 3 hours/day for three months using a Clinical Decision Support (CDS) System report tailored to Antimicrobial Stewardship – Process accelerated as pharmacist and hospital physicians grew familiar with process • Pharmacy resident made interventions to providers based on daily report via face to face conversation or phone/pager • The report was broken up by unit following the intervention period for clinical pharmacists to use • Interventions during the 3 month period will be compared to baseline
  11. 11. ASP Pharmacist using Theradoc Intervention period Criteria that prompted alert: -Antibiotic level, new -Relevant culture: blood, respiratory -Therapeutic Antibiotic Monitoring; -drug-bug mismatch -inadequate/no coverage -overlapping therapy -broad spec. de-escalation -no positive cultures (72 hrs) -redundant therapy -IV to PO switch – anti-infectives TIME INTENSIVE STEP
  12. 12. Pharmacist-Led Antimicrobial Stewardship Program Example: Two separate providers providing overlapping empiric therapy
  13. 13. • Pharmacist documents all interventions • Cost savings assigned by Catholic Health Initiatives • Cost savings comparison of pharmacist interventions before and after ASP Pharmacist implementation
  14. 14. Pre-ASP (Monthly Ave) ASP (Monthly Ave) Duplicate Therapy 3.25 9.3 Narrow Spectrum 6.5 19.3 No ABX Coverage 0.7 10.3 No Indication 2 16 Prolonged Duration 2.8 36.6 Drug Optimization 0.5 15.6 Total Theradoc Antibiotic Stewardship Interventions 15.8/month 107.3/month Vancomycin Consult 156.8 229 IV to Oral ABX 2.3 15 ABX Dose Adjust by Pharmacy 55.8 84 Non-Theradoc ABX Interventions 214.9/month 328/month Total Antibiotic Interventions 230.7/month 435.1/month
  15. 15. $0.00 $2,000.00 $4,000.00 $6,000.00 $8,000.00 $10,000.00 $12,000.00 $14,000.00 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Antimicrobial Stewardship Interventions ($) Duplicate Therapy Narrow Spectrum No Abx Coverage No Indication Prolonged Duration Drug Optimization Project began September 1st
  16. 16. Goals -Cost savings -Clinical pathway optimization -Success stories Cost savings (soft) from improved antibiotic use before ASP Pharmacist: $23,336/month Cost savings (soft) from improved antibiotic use with ASP Pharmacist: $40,110/month Worth noting; -Self reported -Costs are based on best available literature -Length of stay and ABX $$/Patient Day data is pending
  17. 17. Results -Cost savings -Clinical pathway optimization -Success stories Infectious Disease Physician suspected we were poorly treating empiric Urinary Tract Infection (UTI) What could a stewardship pharmacist do?
  18. 18. MS-DRG Custom Groups (ICD-9) Anti-Infective % Use Quantity/Resource Case Urinary Tract Infection LEVOFLOXACIN 64.76% 2.65 Urinary Tract Infection PIPERACILLIN/TAZO 32.15% 3.29 Urinary Tract Infection CEFTRIAXONE 28.57% 0.70 Urinary Tract Infection VANCOMYCIN 11.90% 3.00 Urinary Tract Infection CEFAZOLIN 5.12% 5.88 Urinary Tract Infection CIPROFLOXACIN 4.76% 1.38 Urinary Tract Infection CEPHALEXIN 3.90% 1.33 Urinary Tract Infection CEFEPIME 3.57% 2.67 Presented at December Meeting; Baseline data (3 month average) from PremierTM
  19. 19. Per Johns Hopkins Antibiotic Guide*: • Empiric Inpatient Treatment for Acute Uncomplicated Cystitis – “Fluoroquinolones are no longer considered first line treatment and should be reserved for special situations such as allergy or intolerance to other agents” • Empiric Inpatient Treatment for Acute Uncomplicated Pyelonephritis – “Use local antibiotic susceptibility data to guide initial empiric therapy” Ciprofloxacin 400 mg IV q12h (if local fluoroquinolone resistance rates < 10%) Levofloxacin 500 mg IV once daily (if local fluoroquinolone resistance rates <10%) • Complicated – “Fluoroquinolones (FQ) are reasonable empiric choices if patient has not received an FQ in recent past, is not from a long-term care facility, and FQ resistance is low.” *Guide preferred by internal medicine service
  20. 20. % Urine Isolates Sulfamethoxazole / TrimethoprimNitrofurantoin Cephalexin Levofloxacin E Coli 58% 76% 98% 92% 76% Klebsiella 12% 94% 57% 98% 98% Enterococcus faecalis 8% NI 100% NI 63% Proteus 7% 74% 74% 84% 70% Pseudomonas 5% NI NI NI 72% Citrobacter 4% 75% NI NI 88% MSSA 3% 100% 100% 100% 66% MRSA 2% 100% 100% 0% 16% Hospital Urine Antibiogram minus Emergency Department* *Emergency Department urine E. Coli susceptibility to Levofloxacin: 86% ** NI = Not indicated
  21. 21. Situation: We regularly use a fluoroquinolone for UTI treatment despite local resistance rates
  22. 22. Action: ASP Pharmacist -Targeted patients being empirically treated for UTI with FQ -Provider education
  23. 23. 64% 71% 75% 17% 14% 11% October November December January February March Levofloxacin usage for UTI % of UTI cases “UTI” Stewardship Meeting; December 16th Result: Levofloxacin usage for UTI decreased
  24. 24. Results -Cost savings -Clinical pathway optimization -Success stories KJ admitted for Sepsis (unknown source- respiratory?) at 0115 • From LTC -> admitted to critical care unit(CCU) • Medical Resident empirically selected Piperacillin- Tazobactam, Vancomycin, and Levofloxacin • ESBL Klebsiella – Microbiology left message with nurse at 0430 • Alerted via Theradoc – seen in morning review @ 0800 – Needed carbapenam – contacted attending MD • Pt. switched by 0830
  25. 25. Clinical Decision Support (cont’d) Other functionalities of Clinical Decision Support that an ASP Pharmacist could use • Patient flags • Antibiogram • Estimated doses for antibiotics • Frequency * number of days • 741 doses of levofloxacin during December vs. 624 during February (~5 minutes to run this report)
  26. 26. Obstacles • Non-residency/infectious disease trained pharmacist using unfamiliar software to make infectious disease interventions – Providers not always receptive • Initial Theradoc reports took entire day to sift through – No expert on site • Data not readily available (usage, etc.) • Wide variation on what antimicrobial stewardship looks like across and within academic and non-academic medical centers – Differing metrics, process, medication use systems Pharmacist-led Antimicrobial Stewardship Using Clinical Decision Support
  27. 27. Pharmacist-led Antimicrobial Stewardship Using Clinical Decision Support Conclusions • A pharmacist can lead an antimicrobial stewardship program at a 260-bed community hospital • Clinical Decision Support(CDS) can identify intervention opportunities for pharmacists with little/no specialty training • Minimal daily activity on CDS alerts is financially lucrative and benefits patients and institutions
  28. 28. Pharmacist-led Antimicrobial Stewardship Using Clinical Decision Support Future • Skin/soft tissue order set • CAP/HCAP order set • Provider eduction • Reporting – ABX $/1000 patient days – Length of stay for sepsis, pneumonia – Monthly reports of antibiotic usage for sepsis, pneumonia, and UTI • FTE Request submitted using stewardship and intervention data – Approved by position control and facility
  29. 29. Questions/Concerns Comments Nathan Peterson, Pharm.D. CHI-St. Elizabeth, Lincoln, Nebraska npeterson1@stez.org

×