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Stewardship Presentation MRPRC


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Stewardship Presentation MRPRC

  1. 1. Impact of a Pharmacist-Led Antimicrobial Stewardship Program Using Clinical Decision Support Nathan Peterson, Pharm.D. 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