Antimicrobial Stewardship in Chicago Nursing Homes February 2019 Amy Hanson, PharmD, BCPS AQ-ID Project Administrator, Antimicrobial Stewardship Infectious Disease Pharmacist Chicago Department of Public Health

Intro to Antimicrobial Stewardship Needs in Nursing Homes *incorrectly = prescribing the wrong drug, dose, duration or reason 1 AHCA Quality Report 2013. 2 Lim CJ, Kong DCM, Stuart RL. Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives. Clin Interven Aging. 2014; 9: 165-177. 3 Nicolle LE, Bentley D, Garibaldi R, et al. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol 2000; 21:537–45.

Intro to Antimicrobial Stewardship Needs in Nursing Homes 1 Strausbaugh LJ, Joseph CL. Burden of Infections in Long-Term Care. Infect Control Hosp Epidemiol 2000;21:674-679. 2 Daneman, N et.al. Variability in Antibiotic Use Across Nursing Homes and the Risk of Antibiotic-Related Adverse Outcomes for Individual Residents. JAMA Intern Med. 2015; E1-E9.

More than science, the art of prescribing antimicrobials Fishman N. Antimicrobial stewardship. Am J Infect Control. 2006 Jun;34(5 Suppl 1):S55-63; discussion S64-73.

Antimicrobial Use Correlates with Antimicrobial Resistance As use of fluoroquinolones increases, the percentage of Pseudomonas isolates resistant to fluoroquinolones increases proportionately. Polk RE, et al. Predicting hospital rates of fluoroquinolone-resistant Pseudomonas aeruginosa from fluoroquinolone use in US hospitals and their surrounding communities. Clin Infect Dis. 39:497–503, Aug. 15, 2004.

Impact of Restricting Use of Broad-Spectrum Antimicrobials Hospitals with carbapenem restriction (n=8) have lower rates of carbapenem resistance than hospitals without carbapenem restriction (n=14). Pakyz AL, Oinonen M, Polk RE. Relationship of carbapenem restriction in 22 university teaching hospitals to carbapenem use and carbapenem-resistant Pseudomonas aeruginosa. Antimicrob Agents Chemother. 53:1983–1986, May 2009.

Antimicrobial Resistance in Chicago Exposure network graph showing extensive transfer of KPC-positive patients throughout the exposure network of 14 acute care hospitals, 2 LTACHs, and 10 nursing homes. Won SY, Munoz-Price LS, Lolans K, Hota B, Weinstein RA, Hayden MK. Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis.2011 Sep;53(6):532-40.

Antimicrobial Stewardship is Mandated by CMS As part of the revised Requirements for Participation, the Centers for Medicare and Medicaid Services (CMS) required all long-term care (LTC) facilities to have an antibiotic stewardship program by November 28, 2017. If surveyors haven’t visited facility yet, they likely will in 2019 to assess the 7 CDC Core Elements of Nursing Home Antimicrobial Stewardship Programs are in place. Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Available at: https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of- requirements-for-longterm-care-facilities; 2016. Medicare State Operations Manual, Appendix PP: Interpretive Guidelines for Long-Term Care Facilities. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-ManualsIOMsItems/CMS1201984.html.

Good Cop, Bad Cop: We’re the Good Cops! Free consultation (several other companies not part of a public health department charge significant cost for same service) Completely confidential No penalties 100% quality improvement focused We will provide you step-by-step guidance to ensure your facility's antimicrobial stewardship program in “Surveyor Ready”!

Goals: remember “Chicago” Combat antimicrobial resistance, and decrease Health-care associated Infections, including Clostridium difficile, by expanding Antimicrobial stewardship initiatives to Gain improved clinical Outcomes in Chicago Nursing Homes

Outcomes from other Nursing Home Antimicrobial Stewardship Programs 42 Nursing Homes in North Carolina demonstrated, after implementing an Antimicrobial Stewardship Program: Reduced overall antibiotic prescribing between 10% and 28% Reduced hospitalizations between 8% and 11% Reduced Clostridium difficile infections between 11% and 21% Reduced MRSA infections by 8% Optimizing Antibiotic Use in Nursing Homes Through Antibiotic Stewardship. North Carolina Medical Journal. 77:324-329, 2016. Successfully Reducing Antibiotic Prescribing in Nursing Homes. Journal of the American Geriatrics Society. 62:907-912, 2014. Clinical Situations in Long-Term Care for which Antibiotics are Often Prescribed but are Rarely Necessary. Annals of Long-Term Care. 20(4):23-29, 2012.

Join the “GAIN” Collaborative Our goal is 100% facility participation! Chicago Department of Public Health (CDPH)’s new Generating Antimicrobial Stewardship Initiatives in Chicago Nursing Homes, or GAIN collaborative, will seek to: Define compliance rates to the CDC 7 Core Elements of Antimicrobial Stewardship Programs for Nursing Homes Participate in implementing any recommended action items to bridge any gaps in compliance after free consultation Optional pre- and post- chart review “snap shot” of antimicrobial use in facility

Details on Participation in GAIN

Benefits of participating in GAIN Participating in the Generating Antimicrobial Stewardship Initiatives in Chicago Nursing Homes, or GAIN collaborative, will allow access to the following Antimicrobial Stewardship Tools: Sample Leadership Commitment Statements to Stewardship Sample Antimicrobial Stewardship Policies McGreer Criteria for common infections Pocketcards with Loeb criteria SBAR communication forms when an infection is suspected City-wide, cumulative nursing home antibiogram Facility-specific treatment guidelines

Participation makes your facility eligible for a new CDPH Center of Excellence Designation! There are three levels of achievement in the new CDPH Center of Excellence (CoE) designation, recognizing the efforts Chicago Nursing Homes are making in advancing their Antimicrobial Stewardship Programs: CDPH Bronze CoE: participate in on-site visit and demonstrate 7 CDC Core Elements are achieved CDPH Silver CoE: Complete CDPH recommended action plan CDPH Gold CoE: Demonstrate improved antimicrobial use and/or improved clinical outcome

7 CDC Core Elements for Antimicrobial Stewardship in Nursing Homes

Self-Assessment: Reflection on the CDC Core Elements for Nursing Homes The following slides ask self-assessment questions regarding the 7 CDC Core Elements of Antimicrobial Stewardship Programs for Nursing Homes Thinking about these questions will help in preparation for the intake survey (you will receive a surveymonkey link via email), and preparation for any action items after an on-site initial learning visit

CDC Core Element #1: Leadership Support Facility can demonstrate leadership support for antibiotic stewardship: Written statement of leadership support to improve antibiotic use Antibiotic stewardship duties are included in medical director and director of nursing job descriptions Leadership monitors adherence to antibiotic stewardship policies Antibiotic use and resistance data are reported in the quality assessment and assurance (QAA) meetings

CDC Core Element #2: Accountability Facility has identified at least one leader who is accountable for antimicrobial stewardship activities: Medical Director Director or Assistant Director of Nursing Consultant Pharmacist / Facility Pharmacist Other (Infection Prevention Nurse)

CDC Core Element #3: Drug Expertise Amy during CDC Be Antibiotics Aware week Facility has access to individual(s) with antibiotic stewardship expertise: Consultant pharmacist with training/experience in antibiotic stewardship Antibiotic stewardship team at partnering hospital External infectious diseases/antibiotic stewardship consultant group

CDC Core Element #4: Action Facility has policies to improve antibiotic prescribing/use: All antibiotic orders have dose, frequency, duration, and indication Use of facility-specific algorithms to assess residents for suspected infections and request diagnostic tests for specific infections Use of facility-specific treatment recommendations for infections Antibiotics are reviewed before being added to the medication formulary, if one exists

CDC Core Element #4: Action Continued Facility has implemented practices to improve antibiotic use: Standard assessment/communication tools (SBAR) Antibiotic use information are communicated/received on transfers Reports summarizing antibiotic susceptibility patterns (antibiogram) Antibiotic reviews/time-outs are performed for antibiotic orders At least one infection-specific intervention to improve antibiotic use has been successfully implemented

CDC Core Element #4: Action Continued Facility has a consultant pharmacist to support antibiotic stewardship activities: Reviews antibiotic appropriateness based on agent selected, dosing regimen, duration of therapy AND indication Establishes standards for clinical/laboratory monitoring for antibiotic-associated adverse drug events Reviews microbiology culture data to assess and guide antibiotic selection

CDC Core Element #5: Tracking Facility monitors one or more measures of antibiotic use: Adherence to clinical assessment documentation (including signs/symptoms, vital signs, physical exam findings) Adherence to include dose, frequency, duration and indication for antibiotic orders Adherence to facility-specific treatment recommendations for infections Point prevalence of antibiotic use, new antibiotic starts/1000 resident-days, and antibiotic days of therapy/1000 resident-days

CDC Core Element #5: Tracking Continued Facility monitors one or more outcomes of antibiotic use: Rates of Clostridium difficile infections Rates of antibiotic-resistant organisms (e.g., MRSA, VRE, ESBL Gram negative bacilli) Rates of antibiotic-associated adverse drug events

CDC Core Element #6: Reporting Facility shares facility-specific reports on antibiotic use and outcomes with clinical providers and nursing staff: Measures of antibiotic use at the facility Measures of outcomes related to antibiotic use (i.e., C difficile rates) Report of facility antibiotic susceptibility patterns within the past 18-24 months (i.e., antibiogram) Personalized feedback on antibiotic prescribing practices (shared only with individual clinical providers)

CDC Core Element #7: Education Facility provides educational resources/materials on antibiotic resistance and opportunity to improve antibiotic use: Staff Clinical providers (e.g., MDs, PAs, NPs, pharmacists) Nursing staff (e.g., RNs, LPNs, CNAs) Patients Nursing home residents and residents’ families

Staff Antimicrobial Stewardship Training for Nursing Homes

Staff Antimicrobial Stewardship Training for Nursing Homes

Sample Patient Education Flyer https://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-what-you-need-to-know.pdf

What Questions Do You Have? Amy Hanson, PharmD, BCPS AQ-ID Project Administrator, Antimicrobial Stewardship Infectious Disease Pharmacist, Chicago Department of Public Health Office: 312-746-0304 Email: Amy_Hanson@cityofchicago.org