Antibiotic Stewardship Program (ASP) Development Acute Care

Presenter— Sara Cosgrove Sara Cosgrove, MD, MS Title: Professor of Medicine, Division of Infectious Diseases, Director, Antimicrobial Stewardship Program, Associate Hospital Epidemiologist Place of work: Johns Hopkins School of Medicine Program email address: antibioticsafety@norc.org

Housekeeping Keep phone on mute Use ‘chat’ feature in WebEx if you need to speak Hold off most questions until the end during Q&A Participate when asked

Objectives By the end of this module, participants will be able to— Understand the key personnel involved in developing an Antibiotic Stewardship Program (ASP) Understand how to work with a senior executive to further program goals Discuss the pros and cons of common ASP interventions Discuss evaluation metrics for ASPs Understand the steps involved in establishing an ASP

Key Personnel and Essential Relationships

Essential Team Members Role Qualification Physician Physician leadership critical as most interactions are with medical staff Determining program goals Settling differences of opinion between other AS members and prescribers Bridge to executive leadership Ideally trained in infectious diseases Interest in antibiotic use and patient safety Diplomatic and collegial Pharmacist Interventions Coordination of data needs Bridge to department of pharmacy Same as for physician Comfortable advising physicians and other providers

Groups and Departments Antibiotic Stewardship Program Medical Staff Information Technology Department Senior Executive Leadership Pharmacy Microbiology Department of Nursing Infectious Diseases Physicians Infection Control Department Regulatory Affairs Patient Safety Department Quality Improvement Department P&T Committee 17

Essential Relationships: The Role of the Senior Executive in ASPs Member Role Senior executive Assists ASP with aligning programs goals with the organization’s strategic goals Identifies financial resources for the ASP and its activities Connects ASP to stakeholders across the institution Ensures the ASP leadership is included in high-level meetings Assists with reducing barriers to progress “Outlier” clinician prescribing practices

Engaging Senior Executives Invite to join the hospital AS Committee Invite to periodically attend unit CUSP meetings Provide regular executive summaries of work being performed Show appreciation for resources provided

Essential Relationships Member Role Department of Pharmacy Enforces prescribing policies Generates data on antibiotic use Identifies prescribing trends Assists with some AS interventions (non-stewardship pharmacists) IV to oral conversion protocols Therapeutic antibiotic monitoring protocols Pharmacy and Therapeutics (P&T) Committee Decisions regarding formulary and restriction status of antibiotics Endorsement of guidelines and restriction policies Some AS programs/committees report to P&T

Essential Relationships Member Role Medical Staff Source of clinical champions Collaborators in development of guidelines and policies Management of outlier prescribers Other Infection Diseases Physicians Endorse guidelines in their practice Perform consults for patients with complicated infectious disease problems or for patients receiving certain antibiotics Their buy-in is important to prevent undermining program!

Essential Relationships Member Role Information Technology Assist with collating antibiotic, microbiology and clinical data to facilitate identification of cases for intervention Provide antibiotic use data for the institution and for reporting to the CDC NHSN AUR module Ensure ASP involvement in relevant decisions regarding EHRs and other software Microbiology Laboratory Practical interpretation of microbiology data Antibiogram development Selective reporting of susceptibility testing Selection and implementation of rapid diagnostic tests

Essential Relationships Member Role Infection Control Department Knowledge of trends regarding resistant organisms, Clostridium difficile, and clinician behaviors in the institution Familiarity with acquiring, tabulating, and disseminating data Department of Nursing Education of nurses regarding their role in antibiotic stewardship Indication and duration of antibiotic therapy Adverse event detection Appropriate microbiology specimen collection Timing of therapeutic drug level acquisition

Essential Relationships Member Role Regulatory Affairs Collaboration to ensure compliance with The Joint Commission Standard and other regulations Quality Improvement Department Collaboration to ensure optimal compliance with quality metrics while ensuring rational antibiotic use (e.g., Sepsis Core Measure) Patient Safety Department Resources for interventions to improve antibiotic use or laboratory testing

Establishing an AS Committee Membership ASP members Senior executive Medical staff representing different departments Nursing representative Pharmacy representatives Meetings Monthly or quarterly Minutes Take and distribute

Establishing an AS Committee: Activities Evaluate Antibiotic use data CDI rates Antibiogram changes over time Recommend areas for improvement interventions Review Guidelines and practices developed to optimize antibiotic prescribing in the facility Materials for patient and healthcare worker education regarding optimal antibiotic prescribing ASP responses to antibiotic shortages Assure ASP and its procedures and policies meet relevant regulations and guidelines Review approaches for reporting culture and susceptibility data

Development of Institutional Guidelines for Antibiotic Use Why are guidelines important? Evidenced-based and standardized recommendations based on local data Adherence to the use of formulary drugs Intellectual back-up for ASP Available at the point of care Engagement of thought leaders in their development

Approach to Development of Guidelines Select common conditions that contribute significantly to antibiotic prescribing in your institution Community-acquired pneumonia Urinary tract infections/asymptomatic bacteriuria, Healthcare-associated pneumonia/ventilator-associated pneumonia Skin and soft tissue infections Intra-abdominal infections Provide recommendations for interpretations of rapid diagnostic tests Prioritize syndrome-based over antibiotic-based guidelines Consider guidelines for select antibiotics Those that are expensive, highly toxic, and/or used for specific indications

Approach to Development of Guidelines Identify collaborators who are subject matter experts Review national guidelines and guidelines from other institutions Use the Four Moments of Antibiotic Decision-Making approach Diagnostic criteria for infection Appropriate cultures and empiric therapy Diagnosis including relevant cultures, Narrowing and IV to oral conversion Duration Be succinct! Determine how to get guidelines to the point of care Electronic, handbook, pocket card, available in EHR

Options for Interventions Approach Definition Pros Cons Pre-prescription approval of antibiotics Phone call placed or form filled out before pharmacy dispenses antibiotic Reduces initiating unnecessary antibiotics Optimizes empiric antibiotic choices Opportunity to advise about sending appropriate cultures Impacts use of restricted agents only Addresses empiric use more than downstream use Real time resource intensive Post- prescription review and feedback of antibiotics Downstream review of appropriateness of antibiotic therapy, usually at 48-72 hours More clinical data available to enhance uptake of recommendations Greater flexibility in timing of interventions Can address duration of therapy Recommended action generally optional and may not be followed Syndrome-specific stewardship interventions Stewardship “bundle” about a specific disease process (e.g., CAP) Addresses empiric and downstream therapy More engaging for clinicians Opportunity for sustained learning Must have a method to identify cases

Specific Examples of Interventions Use of a costly or salvage drug (e.g., daptomycin, meropenem, ceftolozane/tazobactam) IV to PO conversion Approach Pro Con Prior approval or post-prescription review and feedback Easy to identify cases Does not address the majority of antibiotic use in hospitals Approach Pro Con IV to PO conversion of the same agent (easier); IV to PO conversion of different agents (more difficult) Easy to identify opportunities if same agent; can involve staff pharmacists; can reduce length of stay and need for IV access Impacts a limited number of agents if converting same agents only

Specific Examples of Interventions Implementation of an antibiotic time out (self-stewardship) Implementation of rapid diagnostic testing Approach Pro Con Providers or teams of clinicians review their patient’s receiving antibiotics to determine if the antibiotics are truly needed or if they could be modified. Engages frontline clinicians/teams to think about optimizing prescribing Can be challenging to implement; sometimes clinicians don’t know what they don’t know Approach Pro Con Call prescribers with results of rapid tests to assist with optimal antibiotic choice Often seen as more of an “educational” interaction May impact limited numbers of patients, need to ensure test is highly accurate for prescriber “buy-in”

Metrics

What to Measure and Report Know your audience. Clinicians want to know their patients won’t be harmed. Administrators want to see cost-savings. Measure Number and type of interventions performed Results of a specific initiative Improvement in peri-operative antibiotic use Improvement in not treating asymptomatic bacteriuria Reduction in daptomycin use and associated cost after an intervention

What to Measure and Report Decrease in (or stable) use of antibiotics over time Evaluate quarterly Stratified by unit or service and agent (or group of agents) Normalize antibiotic use data (e.g. per 1000 patient-days present) Allow targeting of areas with high or increased use If infrastructure available use CDC NHSN AU definitions and methodology Attach costs to the antibiotic use Patient outcomes Clostridium difficile infection rates Length of hospital stay

How Do I Get Started?

Change According to John Kotter Institutional change from the business perspective 8-step model to facilitate change in an institution Morris AM et al. Healthcare Quarterly. 2010;13:64-70.

Leading Change Steps Step 1: Create a sense of urgency Focus on patient safety, regulatory requirements, and drug costs with hospital leaders “Our CDI rates are too high and we are hurting patients” “We are not compliant with The Joint Commission Antimicrobial Stewardship Standard and run the risk of a citation at our next visit” Step 2: Form a powerful guiding coalition Team of leaders who represent key stakeholders Team member characteristics: position power, expertise, credibility, leadership

Leading Change Steps Step 3: Create a compelling vision for change Vision statement “Helping patients receive the right antibiotics when they need them” Step 4: Communicate the vision effectively Communicate to all levels (senior leadership/boards; department heads/unit directors; physicians/prescribers) Communicate regularly Develop an elevator speech Step 5: Empower others to act on the vision Work with teams to develop mutually acceptable approaches (compromise) Empower non-traditional decision-makers Non-ASP Pharmacists Nurses

Leading Change Steps Step 6: Plan for and create short term wins Begin with low hanging fruit Asymptomatic bacteruria Durations of therapy Feed back the data Recognize the team and the frontline staff as critical in making the changes

Leading Change Steps Step 7: Consolidate improvements and create still more change Step 8: Institutionalize new approaches Ensure the understanding of the positive results Strive for prescribers to be stewards of antibiotics One of the primary goals of this project is to assist ASPs in working with frontline teams to permanently change how they think about antibiotic prescribing.

Program Website Access

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Next Steps Antibiotic Stewardship Program Development Improving Antibiotic Use Is a Patient Safety Issue Questions? antibioticsafety@norc.org