University of Missouri Antimicrobial Stewardship Program : Patient Safety and NPSG Compliance Performance Improvement Leadership Develop Program University of Missouri – Columbia February 19, 2010

Team Members Joe Cameron, Pharm.D., BCPS Gordon Christensen, MD Ed Ege, Pharm.D. Stephanie Lumley-Hemme, RPh Jennifer Meyer, Pharm.D., BCPS Stevan Whitt, MD

Focus Area With the arrival of the Centers for Medicare & Medicaid's no-pay rules, The Joint Commission's National Patient Safety Goals, and the ever-growing emphasis on quality improvement of patient care, prevention has become the standard of care. Participation in multiple quality improvement, automated data surveillance, and antimicrobial stewardship programs have garnered successes for hospitals in terms of improving systems, and in turn care and cost.

AIM Statement University of Missouri Hospital aims to implement a process for monitoring and an intervention protocol intended to standardize the use of evidence based antibiotic regimens in the adult surgical intensive care unit. The process starts with a list of new antibiotic orders and a daily culture and sensitivity report from the lab. The process ends with conclusion of antibiotic therapy

AIM Statement Our goal is to standardize empiric antibiotic therapy Our secondary outcomes include: improving patient outcomes, decreasing duration of antibiotic therapy, containing antibiotic costs, and decreasing antibiotic resistance and related adverse reactions compared to current practice. It is important to work on this now b/c external accrediting agencies are demanding improvement and antimicrobial resistance is increasing

Institutional Strategic Goals National Patient Safety Goal 7 : Reduce the risk of health care associated infections New standards for 2009 NPSG.07.03.01: Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms in acute care hospitals. NPSG.07.04.01: Implement best practices or evidence- based guidelines to prevent central line-associated bloodstream infections. NPSG.07.05.01: Implement best practices for preventing surgical site infections.

Institutional Strategic Goals Diagnosis Driven Therapy Uniformity in Prescribing Practices Cost Avoidance Education

Project Timeline Data analysis and modification ECOMS Initial Approval ID Acceptance New Process Development Lab Report Order Sheet Creation with ID Process Modification and Initiation Presentation and Implementation of Program August 2009 Sept 2009 Oct 2009 Nov 2009 Dec 2009 Jan 2010 Feb 2010 Current Process Evaluation Discussion with PowerChart Documentation ECOMS Approval to move forward IV to PO Conversion Policy Preliminary Data SICU Intial Acceptance

Continued on Next Slide Current Process Continued on Next Slide

Current Process

Fishbone Diagram

Stakeholders Point of Change Stakeholders Upstream Stakeholders Downstream Stakeholders Patients Administration Pharmacy Infection Control Units throughout hospital Pharmacy ICU Physicians Attendings Residents Infectious Disease Pathology IT Dept. Pharmacy

Interventions Considered Strategy 1 Strategy 2 & 3 Active Intervention and Feedback Location Based Patient Based Organism Based Prior-authorization ID Physician or Pharmacist with authority Restricted Formulary Partially implemented, no authority in Pharmacy Education Driven by Attending Physicians

Continued on Next Slide Suggested Pathway Yes No Continued on Next Slide

Continued on Next Slide Suggested Pathway Yes No Yes Continued on Next Slide No

Suggested Pathway No Yes Yes No

Key Driver Diagram

Order Sheets

Order Sheet

Microbiology Reports

Microbiology Reports

Measurements Diagnosis Stated / Use of Preprinted Order Set >75% De-escalation IV to PO Conversion

Baseline Data (2 Weeks) Diagnosis Stated Patients in SICU Zero (0%) Patients in SICU 21 Patients Antibiotics Prescribed 37 Antibiotics One Time Dose (Pre-op) 4 Antibiotics De-escalation 2 Accomplished (40%) 3 Missed IV to PO Conversion None (0%)

Process and Outcomes Indicators Outcome Indicators Increased knowledge of appropriate therapy for common infectious diagnoses throughout the institution. Bacteremia, Pneumonia, and Intra-abdominal Infections Compliance with JCAHO NPSG 7 Process Indicators De-escalation of therapy when appropriate IV to PO Conversion

Anticipated Return on Investment / Benefits Realized Increased resident understanding of appropriate empiric evidence based therapy and de- escalation Consistent management of patient specific disease states Decreased development of multi-drug resistant organisms Decreased medication expenditure

Lessons Learned Health care team acceptance Analysis of current practice Prediction of program implementation Process improvement application

Next Steps Encompass all intensive care units Education of Pharmacists, Nurses, and Physicians Increase number of disease state protocols Increase roll out to all of institution Successful reduction in multi-drug resistant organisms Decreased length of antibiotic therapy and potentially patient stay

Joe Cameron Ed Ege Stephanie Lumley-Hemme Jennifer Meyer Questions? Joe Cameron Ed Ege Stephanie Lumley-Hemme Jennifer Meyer

Thank You!