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Meeting The Joint Commission’s New Antimicrobial Stewardship Standard
Joy Peterson, Pharm.D., BCPS
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Learning Objectives Pharmacists:
List the components of the new standard Describe methods for tracking and reporting antimicrobial data Discuss methods to provide required education to staff and patients
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Learning Objectives Technicians: Define antimicrobial stewardship
List the components of the new standard Describe methods tracking and reporting antimicrobial data
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What is Antimicrobial Stewardship?
Coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of: The right drug The right dose The right route The right duration Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51.
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Why is Antimicrobial Stewardship Important?
Per the Centers for Disease Control and Prevention (CDC): Roughly 30% of antibiotic use in hospitals is inappropriate Antibiotics are continued for longer than recommended Healthcare providers are pressured to prescribe antibiotics even when not indicated Broad-spectrum agents used to treat susceptible bacteria Patients receive the wrong dose or incorrect antibiotic to treat infections Inappropriate use of antibiotics has contributed to increasing antibiotic resistance, which has become one of the most serious threats to public health worldwide Centers for Disease Control and Prevention. Antibiotic use in the United States: Progress and opportunities, (Accessed on September 5, 2017).
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Why is Antimicrobial Stewardship Important?
Antimicrobial stewardship (AMS) can: Improve patient outcomes Decrease C. difficile infections Decrease antibiotic resistance Decrease costs Benefits the patient and facility Centers for Disease Control and Prevention. Antibiotic use in the United States: Progress and opportunities, (Accessed on September 5, 2017).
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The Joint Commission’s New Antimicrobial Stewardship Standard
Began January 1, 2017 Falls under Medication Management (MM ) Largely based on the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs ion/core-elements.html
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The Joint Commission’s New Antimicrobial Stewardship Standard
Elements of Performance: Leaders establish AMS as an organizational priority Educate staff and licensed independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and AMS. Educate upon hire/granting privileges and periodically thereafter Educate patients/families regarding appropriate use of antimicrobial medications The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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The Joint Commission’s New Antimicrobial Stewardship Standard
Elements of Performance (cont’d): Have a multidisciplinary AMS team AMS program includes core elements: Leadership commitment Accountability Drug expertise Action Tracking Reporting Education Use organization-approved, multidisciplinary protocols The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Leaders Establish AMS as an Organizational Priority
What is acceptable evidence? Budget plans Positions dedicated to AMS Information Technology (IT) resources Applications (ex: electronic medical record (EMR), TheraDoc) Manpower Performance improvement plans Identifying problem agents and developing a plan to improve utilization The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Staff Education Anyone involved in ordering, dispensing, administering, or monitoring antimicrobial agents Physicians Advanced practitioners Nurses Pharmacists Pharmacy technicians Staff and licensed independent practitioners The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Staff Education Upon hire and periodically thereafter
MUST be a component of onboarding process Periodically thereafter “based on organizational need” Newsletters Inservices Continuing medical education (CME) presentations In response to issues The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Staff Education Subject matter must contain information on antimicrobial resistance and AMS practices Not enough to just show evidence of education materials The staff at your facility should be able to speak to your AMS program if questioned by a surveyor The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Patient Education Patients (and families as needed) should be educated on appropriate use of antimicrobial medications Broad statement Can interpret “appropriate use” to include when they should not be used Should be hardwired process with documentation The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Multidisciplinary AMS Team
Group of individuals that review antimicrobial use data, develop initiatives, and/or implement actions Subgroup of Infection Prevention (IP) Subcommittee of Pharmacy and Therapeutics (P&T) Does not have to be Infectious Disease (ID) physician if not available For systems, a system level chair can be used The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Core Elements Leadership commitment: similar to item 1
Letter/statement of commitment helpful Accountability: single leader, ideally physician Who would administration go to if the antimicrobial spend is off the charts? Drug expertise: pharmacist with ID experience The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Core Elements Action: they want to see things implemented based on data Medication use evaluations Projects or initiatives … WITH recommendations implemented Tracking Antibiotic consumption Defined daily doses (DDD) vs days of therapy (DOT) Purchase data vs administration data vs charge data The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Core Elements Tracking (cont’d) Resistance patterns Antibiograms
Stratification The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Core Elements Reporting Education Tracked information must be reported
IP committees Subcommittee of P&T Distribution to medical staff and administration Education The Joint Commission. Prepublication Requirements – New Antimicrobial Stewardship Standard. Issued June 22, 2016.
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Where to Start? Gap analysis: JC Standard MM.09.01.01 Hospital A
Hospital B Leaders establish antimicrobial stewardship as an organizational priority. Examples: YES Accountability documents X Budget plans Infection Prevention plans Performance improvement plans Strategic plans Using the EHR to collect antimicrobial stewardship data Education of staff and licensed independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and antimicrobial stewardship practices. Education occurs upon hire or granting of initial privileges and periodically thereafter, based on organizational need NO Education of patients and their families as needed, regarding the appropriate use of antimicrobial medications, including antibiotics Antimicrobial stewardship multidisciplinary team that includes: Infectious disease physician Infection preventionist Pharmacist Practitioner Antimicrobial stewardship program includes these core elements: Leadership commitment Accountability Drug expertise Action Tracking If yes, what type and how often? DDD/1000 pt days; monthly Reporting Education Antimicrobial Stewardship program uses organization-approved multidisciplinary protocols. Examples: Formulary restriction Assessment of appropriateness of antibiotics for CAP Assessment of appropriateness of antibiotics for SSTI Assessment of appropriateness of antibiotics for UTI Care of the patient with CDI Guidelines for antimicrobial use in adults Guidelines for antimicrobial use in pediatrics For Pre-op procedures (ie. ENT) Plan for IV to PO conversion Preauthorization requirements for specific antimicrobials Use of prophylactic antibiotics Collects, analyzes, and reports data on its antimicrobial stewardship program If yes, to whom? Antimicrobial Subcommittee Takes action on improvement opportunities identified in its antimicrobial stewardship program
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Where to Start? Identified gaps Leadership support Staff education
New position? Signed statement Policy Budget plans Staff education Add material to existing onboarding process Description of AMS, information on bacterial resistance, details of AMS activities at your facility
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Where to Start? Identified gaps Staff education (cont’d)
Make sure to include licensed independent practitioners and contracted nursing staff For “periodically thereafter” consider: Newsletter from IP or AMS team Annual updates tied to release of antibiogram Patient education Which patients to educate? Discharged on antibiotics Difficult to identify Inpatients on antibiotics For how long? Even if they won’t be continued at discharge?
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Where to Start? Identified gaps Patient education (cont’d)
Which patients to educate? Those with viral illnesses that don’t need antibiotics Emergency department All patients? How is education triggered? Varies depending on system used and capabilities Alerts Education activity Brochure in all welcome packets Should be hard wired
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Where to Start? Identified gaps Patient education (cont’d)
Who provides education? Nursing Educators Pharmacists Pharmacy students How is education provided? Brochures Videos Posters English and Spanish? Resources available at: references/print-materials/index.html
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Where to Start? Identified gaps Patient education (cont’d)
How is the education documented? Varies with system used Should be visible in medical record Ideally a method that allows for tracking
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Where to Start? Identified gaps Multidisciplinary AMS team
Recruit physician(s) and infection preventionist(s) Consider representatives from microbiology, IT, and nursing Have scheduled meetings to discuss antimicrobial use data and opportunities Reimbursement for physician? Core Elements Leadership commitment Accountability
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Where to Start? Identified gaps Core Elements (cont’d) Drug expertise
Staff development? MAD-ID certification? Action Design and implement a change to improve antimicrobial use Formulary restriction Time outs Mandatory indications and durations IV to PO initiative
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Where to Start? Identified gaps Core Elements (cont’d) Tracking
Antibiotic use: Ideally DOT Most accurate Used for benchmarking by NHSN Difficult to obtain DDD reasonable alternative if DOT unavailable Administration data preferred Charge data reasonable alternative Purchase data only if no other option
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Where to Start? Identified gaps Core Elements (cont’d) Tracking
Resistance Antibiograms Stratified By location: intensive care units vs acute care By source: respiratory vs blood vs urine Reporting Set up process to report to IP committee or P&T Distribute information to medical and nursing staff Education
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Where to Start? Identified gaps
Organization-approved multidisciplinary protocols Formulary restriction Order sets: Community acquired pneumonia order set with automatic 5 day stop Perioperative with automatic stops on prophylactic antibiotics Organization guidelines on recommended agents, treatment durations, and/or renal dose adjustments IV to PO protocol
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Where to Start? Identified gaps Collect, analyze, and report data
You can’t just collect data Want to see that you’re analyzing it, acting on it, and reporting the information Takes action on improvement opportunities
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The Surveyors are Coming!
Review Survey Activity Guide Document list List of patients receiving antimicrobials ED Hospitalized who will be discharged on antimicrobials Leadership support Signed statement Budget plans How the organization is using the CDC’s Core Elements Policy Project proposals/results The Joint Commission. Accreditation Survey Activity Guide for Health Care Organizations 2017.
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The Surveyors are Coming!
Review Survey Activity Guide Document list (cont’d) AMS protocols Policies/procedures AMS activities IV to PO conversions Dose optimization Order sets AMS data Antimicrobial use AMS team interventions AMS reports documenting improvement (or no improvement needed) The Joint Commission. Accreditation Survey Activity Guide for Health Care Organizations 2017.
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The Surveyors are Coming!
Review Survey Activity Guide Staff interviews Antimicrobial resistance The organization’s antimicrobial stewardship program AMS topic hits multiple tracers Data Management Medication management Leadership session The Joint Commission. Accreditation Survey Activity Guide for Health Care Organizations 2017.
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Questions?
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