Alaska Antimicrobial Stewardship Collaborative (A2SC) Alaska division of public health Alaska state hospital and nursing home association Mountain-pacific quality health Alaska Alaska native tribal health consortium Alaska pharmacists association LCDR Thaddus Wilkerson, PharmD, BCPS Ryan Stevens, PharmD, BCPS October 24, 2014

Objectives Be able to list 3 goals of the Alaska Antimicrobial Stewardship Collaborative Antimicrobial Stewardship Assessment Tool Get Smart about Antibiotics Spring Summit Be able to discuss 2 successful strategies and 2 potential barriers when implementing an effective program The PAMC and ANMC experiences Be able to list at least 2 CDC Core Elements Adaptation to small rural settings Long Term Care Facilities The purpose of this activity is to enable the learner to understand the benefits of participating in the Alaska Antimicrobial Stewardship Collaborative in developing your own ASP, accessing resources, sharing information and meeting regulatory requirements.

Antimicrobial Stewardship A Quality and Patient Safety Initiative A combination of personnel and procedures that promote the wise use of antimicrobials When providers prescribe broad-based antimicrobials for too long, or when they are not needed, it can lead to an increase in complications Clinics can create a reliable system that optimizes outcomes through appropriate selection of: Agent Dose Duration

The ASP Basic Framework ASPs minimize antimicrobial use, thereby: Reducing drug costs Prevent hospital admissions Decreasing hospital length of stay Minimizing drug-resistant and nosocomial infections Avoiding drug-related toxicity CID 2003;37:742-743. CID 1997;24:9-11.

Stewardship Interventions Prospective audit & feedback Restriction & preauthorization Education Guidelines & clinical pathways Avoidance of combination therapy Dose, frequency & duration Streamlining tx / de-escalation IV-to-oral conversion

A2SC Share Information Learn from Common Experiences Surveys Webinars Workshops Conference Calls Statewide Strategic Planning Reach the Public Collaboratives State health agencies worked with groups of facilities and other partners to share information and learn from common experiences. Specific activities undertaken by collaboratives included surveys, webinars, workshops, and conference calls. - Audience: Collaborative members included a range of partners, such as state health agencies, acute care hospitals, long-term care facilities, long-term acute care facilities, hospital associations, quality improvement organizations, local health departments, and infection prevention associations. - Topics: Most collaboratives focused on a range of antimicrobial resistance and stewardship issues. A few focused on C. difficile infections.

A2SC <akantimicrobialstewards@gmail.com> Criteria for treating wounds UTI diagnosis & treatment Access to ID physicians Patient education materials for abx use and appropriateness Clinician education on bacteriuria Create A2SC Educational Calendar October 29, 2014 Leadership education Cost Utilization Sustainability 1ST A2SC WEBINAR SEPTEMBER 19, 2014 Alaska Regional Hospital Heritage Place Norton Sound Health Corp State of Alaska Section of Epi Denali Center and Fairbanks Memorial Hospital Alaska Psychiatric Institute Yukon-Kuskokwim Health Corp Petersburg Medical Center Peace Health Ketchikan Medical Center Providence Alaska Medical Center Alaska Native Medical Center Alaska State Hospital and Nursing Home Assoc. Wrangell Medical Center Alaska Pharmacist Association Board of Directors joined the Collaborative and sent the survey to its members on 10/17/2014 Education/training with subject matter experts on NHSN or clinically focused treatment for CAUTI, UTI, and wounds. Discuss and pull together a list of ID physicians available to consult throughout state.  They are independent practitioners but may be open to resource list. Lots available….what specifically do they want? Dr Nimalie Stone from CDC did a presentation several years ago that did address this issue.  We can offer education/training on identification and treatment of bacteriuria. Education/training for leadership buy-in, utilization and costs. State ASP survey CEO letter of commitment to stewardship

A2SC: Why now? The rise of antibiotic resistant bacteria represents a serious threat to public health and the economy. Antibiotic resistance is responsible for over 2 million illnesses and 23,000 deaths annually in the U.S. A successful campaign will require collaborative efforts between public & private entities and is a national priority. www.whitehouse.gov Executive order—Combating Antibiotic-resistant bacteria Sept 18, 2014 CDC “Antibiotic resistance threats in the United States, 2013.”

Executive Order Combating Antibiotic-Resistant Bacteria Sec. 5. Improved Antibiotic Stewardship “By the end of calendar year 2016, HHS shall review existing regulations and propose new regulations…that require hospitals and other inpatient healthcare delivery facilities to implement robust antibiotic stewardship programs…” “HHS shall also take steps to encourage other healthcare facilities, such as ambulatory surgery centers and dialysis facilities, to adopt antibiotic stewardship programs.” “Task force agencies shall…define, promulgate, and implement stewardship programs in…office-based practices, outpatient settings, emergency departments, and institutional and long-term care facilities…nursing homes, pharmacies, and correctional facilities.” http://www.whitehouse.gov/the-press-office/2014/09/18/executive-order-combating-antibiotic-resistant-bacteria

CDC’s Core Elements Complement existing guidelines on ASPs No single template Flexibility in implementation Experience in a wide variety Success depends on Defined leadership Coordinated multidisciplinary approach In 2014 the CDC recommended that all acute care hospitals implement Antibiotic Stewardship Programs Core elements of success complement existing guidelines on ASPs from organizations including the Infectious Diseases Society of America in conjunction with the Society for healthcare epidemiology of America, American Society of Health System Pharmacists and the Joint Commission. There is no single template for a program to optimize antibiotic prescribing in hospitals and a great deal of flexibility is required in implementation. Experience demonstrates that antibiotic stewardship programs can be implemented effectively in a wide variety of hospitals and that success is dependent on defined leadership and coordinated multidisciplinary approach.

Core Elements in Summary Leadership Commitment Dedicating necessary human, financial and information technology resources. Accountability Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective. Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use. Action: Implementing at least one recommended action, such as an “antibiotic time out” after 48-72 hours. Tracking: Monitoring antibiotic prescribing and resistance patterns. Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff. Education: Educating clinicians about resistance and optimal prescribing.

State Strategies to Address Antimicrobial Resistance – Survey Results ASTHO conducted a survey to better understand current state health department strategies HAI coordinators from the states, DC and Puerto Rico in July 2013 with a response rate of 69% (36/52) 25 states (69%) reported antimicrobial stewardship activities 11 states (32%) considered policy, 5 developed/implemented Suggested incentives: trainings, certification, awards, physician leadership, demonstration of benefits, public reporting States conducting surveys Data gathered used to inform state stewardship activities Acute & long-term care facilities Range of targeted audiences ASTHO conducted a survey to better understand current state health department strategies to address antimicrobial resistance Antimicrobial stewardship programs (ASPs) can ensure judicious use to improve individual patient outcomes, prevent death from resistant infections, slow resistance, and reduce healthcare costs. ASTHO conducted a survey of healthcare-associated infections (HAI) coordinators from the states, DC, and Puerto Rico in July 2013, with a response rate of 69 percent (36/52). The survey’s purpose was to identify (1) what activities and policies the health agencies are using to promote antimicrobial stewardship; (2) what incentives and tools the health agencies need; and (3) promising practices to share with other states and territories. (69%) reported conducting antimicrobial stewardship activities including education or training, communications, surveys, collaboratives, demonstration projects Eleven states (32%) have considered policy on antimicrobial stewardship, and in 5 of those the policy has been developed/implemented. Some suggested incentives that would motivate implementation of antimicrobial stewardship activities include: trainings, certification, awards, physician leadership, demonstration of benefits, and public reporting. Education/Training Several states held day-long conferences, one-time live trainings, or webinars. Several held webinar series or conference calls. Almost half provided printed materials. - Audience: States mainly targeted healthcare providers in acute care hospitals and long-term care facilities. Topics: Education or training often covered an overview of stewardship, suggestions or considerations for implementing stewardship activities or ASPs, or targeted stewardship topics ©Association of State and Territorial Health Officials 2014 www.astho.org

Alaska Antimicrobial Stewardship Assessment Tool Adopted from the CDC Checklist for Core Elements Released on October 1st to members of ASHNA Released on October 17th to members of AKPhA 31 responses to date 19 facilities represented from throughout the state including: Anchorage, Barrow, Fairbanks, Homer, Juneau, Ketchikan, Sitka, Soldotna, Valdez and Wrengell Various responder titles including: Nurses, pharmacists, clinical resource coordinator, coordinated care managers, infection preventionists, hospital education coordinator Alaska Native Medical Center Alaska Psychiatric Institute Alaska Regional Hospital Alaska VA Healthcare System Bartlett Regional Hospital Central Peninsula Hospital Chief Andrew Isaac Health Center Denali Center Fairbanks Memorial Hospital Heritage Place JBER DoD Joint Venture Hospital Ketchikan Medical Center Providence Alaska Medical Center Providence Valdez Medical Center Samuel Simmonds Memorial Hospital Sitka COmmunity Hospital South Peninsula Hospital Wildflower Court Wrangell Medical Center

Alaska Antimicrobial Stewardship Assessment Tool Facility Size: < 50 beds: 7 50-100 beds: 9 > 100 beds: 3 Alaska Antimicrobial Stewardship Assessment Tool Alaska Native Medical Center Alaska Psychiatric Institute Alaska Regional Hospital Alaska VA Healthcare System Bartlett Regional Hospital Central Peninsula Hospital Chief Andrew Isaac Health Center Denali Center Fairbanks Memorial Hospital Heritage Place JBER DoD Joint Venture Hospital Ketchikan Medical Center Providence Alaska Medical Center Providence Valdez Medical Center Samuel Simmonds Memorial Hospital Sitka COmmunity Hospital South Peninsula Hospital Wildflower Court Wrangell Medical Center

Alaska Antimicrobial Stewardship Assessment Tool About half of facilities surveyed (10/19) have a multidisciplinary committee focused on appropriate antimicrobial use? Those that do have an ASP meet regularly. 5 facilities receive budgeted financial support for antimicrobial stewardship activities. 7 facilities have supported training on appropriate antimicrobial use within the last year. Only 6 facilities have access to clinical infectious disease consultation on the same day as requested? There is a physician identified as a leader for stewardship activities in 8 facilities. Half of these physicians receive funding specific for ASP activities. Alaska Native Medical Center Alaska Psychiatric Institute Alaska Regional Hospital Alaska VA Healthcare System Bartlett Regional Hospital Central Peninsula Hospital Chief Andrew Isaac Health Center Denali Center Fairbanks Memorial Hospital Heritage Place JBER DoD Joint Venture Hospital Ketchikan Medical Center Providence Alaska Medical Center Providence Valdez Medical Center Samuel Simmonds Memorial Hospital Sitka COmmunity Hospital South Peninsula Hospital Wildflower Court Wrangell Medical Center

Alaska Antimicrobial Stewardship Assessment Tool 11 sites have a pharmacist or nurse identified as a leader of stewardship activities. This role is included in the job description and annual review in only 6 facilities. Similarly, 6 of these individuals have received specialized training in ID or antimicrobial stewardship. What staff contribute to assuring appropriate antimicrobial use at your facility? Infection Preventionist 9 Microbiologist 8 Pharmacy 4 Quality officer 3 Hospital Epidemiologist 2 Informatics 1 Only 5 facilities require an indication for an antimicrobial Rx 10 sites have facility-specific guidelines, based on national guidelines and local susceptibility, to assist with antimicrobial selection for common infections. Less than half (4) make these easily accessible on all wards and to prescribers (e.g., printed 'pocket guide' or electronic summaries on appropriate networked computers) Alaska Native Medical Center Alaska Psychiatric Institute Alaska Regional Hospital Alaska VA Healthcare System Bartlett Regional Hospital Central Peninsula Hospital Chief Andrew Isaac Health Center Denali Center Fairbanks Memorial Hospital Heritage Place JBER DoD Joint Venture Hospital Ketchikan Medical Center Providence Alaska Medical Center Providence Valdez Medical Center Samuel Simmonds Memorial Hospital Sitka COmmunity Hospital South Peninsula Hospital Wildflower Court Wrangell Medical Center

Alaska Antimicrobial Stewardship Assessment Tool Only 3 facilities have IV to PO protocols in place. Only 1 facility reported having a formal protocol in place for de-escalation of therapy based on microbiology results. 5 sites have protocols for antimicrobial dose adjustment in patients with renal or hepatic insufficiency. 4 facilities have a clinician guide for ordering or collecting cultures appropriately. At 5 sites specified antimicrobial agents need to be approved by a physician or pharmacist prior to dispensing. Prospective audit and feedback is actively performed at 10 facilities surveyed. An “antibiotic time out” is formally implemented in 3 facilities. Alaska Native Medical Center Alaska Psychiatric Institute Alaska Regional Hospital Alaska VA Healthcare System Bartlett Regional Hospital Central Peninsula Hospital Chief Andrew Isaac Health Center Denali Center Fairbanks Memorial Hospital Heritage Place JBER DoD Joint Venture Hospital Ketchikan Medical Center Providence Alaska Medical Center Providence Valdez Medical Center Samuel Simmonds Memorial Hospital Sitka COmmunity Hospital South Peninsula Hospital Wildflower Court Wrangell Medical Center

Alaska Antimicrobial Stewardship Assessment Tool Only 3 sites utilize an order entry system with embedded clinical decision support for prescribing antimicrobials. Results of antimicrobial audits or reviews are provided directly to prescribers through in-person, telephone, or electronic communication at 4 sites. 4 have time-sensitive automatic stop orders. Just over half (10) monitor antimicrobial consumption on a regular basis. Pharmacy purchasing data 5 Days of Therapy (DOT) 4 Reports on antimicrobial use is provided to prescribers in 5 facilities Adherence to facility-specific policies, guidelines or protocols to assist with antimicrobial selection is monitored at least annually at 3 sites. If antibiotic recommendations are routinely provided, acceptance by the primary prescriber is tracked at 3 facilities. Alaska Native Medical Center Alaska Psychiatric Institute Alaska Regional Hospital Alaska VA Healthcare System Bartlett Regional Hospital Central Peninsula Hospital Chief Andrew Isaac Health Center Denali Center Fairbanks Memorial Hospital Heritage Place JBER DoD Joint Venture Hospital Ketchikan Medical Center Providence Alaska Medical Center Providence Valdez Medical Center Samuel Simmonds Memorial Hospital Sitka COmmunity Hospital South Peninsula Hospital Wildflower Court Wrangell Medical Center

Alaska Antimicrobial Stewardship Assessment Tool The majority of facilities (12) perform routine microbiology tests on site (urine, blood, sputum cultures). Most (13) produce and distribute an antibiogram (cumulative antimicrobial susceptibility report) at least annually. Healthcare information technology is utilized frequently. Electronic medical or health care record 17 Computerized order entry 13 Electronic medication administration 13 When asked if the facility has received feedback and/or penalty for presence or absence of policies or procedures regarding antibiotic surveillance or stewardship, 4 replied yes. Alaska Native Medical Center Alaska Psychiatric Institute Alaska Regional Hospital Alaska VA Healthcare System Bartlett Regional Hospital Central Peninsula Hospital Chief Andrew Isaac Health Center Denali Center Fairbanks Memorial Hospital Heritage Place JBER DoD Joint Venture Hospital Ketchikan Medical Center Providence Alaska Medical Center Providence Valdez Medical Center Samuel Simmonds Memorial Hospital Sitka COmmunity Hospital South Peninsula Hospital Wildflower Court Wrangell Medical Center

Alaska Antimicrobial Stewardship Assessment Tool Additional Comments regarding educational needs, challenges, or perceived barriers to implementation: The biggest barrier to implementation is a lack of pharmacist training. Additional funding and creating training opportunities is essential for success. We are just now starting an ASP, hope to create a standing committee, and are looking to collaborate with a hospital in town. Examples of other ASPs in small hospitals would be helpful to start a program here. There might be resistance from prescribers. We would need help with pharmacist and provider education. We are hindered by limited staffing and software. Challenges for our program include: lack of quick and easy data extraction from the EHR for tracking abx use, interface issues between electronic systems, and lack of staffing for epidemiologic data analysis.

Alaska Antimicrobial Stewardship Assessment Tool Additional Comments (cont…) Plans underway to discuss newly developed outpatient antibiogram, however, providers often have a misperception that antibiotic resistance is less of a concern. Ambulatory providers often prescribe the same antibiotics over and over for the same patient. Lack of an in-house microbiology lab complicates our ability to track resistance trends. We hope our new electronic health record will provide more comprehensive reporting. Our ASP just started a few months ago and we need guidance on what to do in an outpatient facility. Our program needs administrative support and an ID physician. Although there is no formal ASP, there is a stewardship pharmacist who conducts most of the activities using national guidelines and has demonstrated positive outcomes.