1. 1 Pharmacist Monitoring Tools for Antimicrobial Stewardship Dianna Gatto, Pharm.D., BCPS Pharmacy Clinical Manager Chris Beuning, Pharm.D., BCPS Pharmacy Clinical Analyst MultiCare Health System September 10, 2012

2. 2 MultiCare Health System 2

3. 3  Not for profit organization in the greater Tacoma, East Pierce and South King County regions in Washington state  879 licensed beds  Tacoma General – 402 beds  Good Samaritan – 275 beds  Allenmore – 130 beds  Mary Bridge Children’s – 72 beds  Specialized Services  Level II trauma at TGH and Mary Bridge Children’s  Level III NICU at TGH  Rehabilitation program at Good Samaritan  Primary Care Clinics  Urgent Care Centers  Free standing Emergency Department  Employed Providers  HIMSS Davies Award winner 2009

4. 4 Objectives  Be familiar with antimicrobial stewardship  Understand key pharmacist workflows  Identify tools for patient monitoring

5. 5 Outline  Overview of MultiCare Health System  What is Antimicrobial Stewardship  Pharmacist tools  Key pharmacist workflows  Challenges  Future directions

6. 6 Outline  Overview of MultiCare Health System  What is Antimicrobial Stewardship  Pharmacist tools  Key pharmacist workflows  Challenges  Future directions

7. 7 What is Antimicrobial Stewardship  Antimicrobial Stewardship (AMS)  Systematic, multi-faceted approach to the use of antimicrobial agents, to optimize clinical outcomes while minimizing unintended consequences  Goals of programs  Achieve the best clinical outcomes  Reduce emergence of resistant organisms  Decrease costs

8. 8 Antimicrobial Stewardship at MHS  Specialized ID pharmacist  Prospective audit of targeted hospitalized patients receiving antimicrobial agents and/or diagnosis of infection  Patient identification based on the following:  Selected antimicrobials  Bug-drug mismatches  Inappropriate durations of therapy  De-escalation opportunities

9. 9 Role of Decision Support in AMS  Efficiently identify patients who need to be reviewed  Pharmacists spend time assessing patient therapy versus report generation and data mining  Easily generate daily reports in a timely manner that pharmacists can utilize  Target patients by running reports based on flexible criteri a

10. 10 Outline  Overview of MultiCare Health System  What is Antimicrobial Stewardship  Key pharmacist workflows  Pharmacist tools  Challenges  Future directions

11. 11 Key Pharmacist Workflows  Order entry and order verification  Prescriptive authority (dosing) protocols  Pharmacist Inbasket message review  Consults  Medication messages  Best practice alerts  Intervention documentation  Ongoing drug monitoring  Microbiology results

12. 12 Outline  Overview of MultiCare Health System  What is Antimicrobial Stewardship  Key pharmacist workflows  Pharmacist tools  Challenges  Future directions

13. 13 Tools  Need specialized tools that drill down to increase the number of patients served, focusing on outcomes and decreasing costs  Selected antimicrobials  Bug-drug mismatches  Inappropriate durations of therapy  De-escalation opportunities

14. 14 Tools – Order Entry/Verification  Order sets  Appropriate agents and doses  Links to guidelines from order sets  Targeted medication build  Appropriate defaults  Linked labs  Order instructions  Reference Links

15. 15 Tools – Microbiology Results  Best Practice Advisories - General  New properties allow creative rules based on culture results  Rules can be used in BPA criteria  Do not fire to end user  Trigger Inbasket message to pharmacists or pools  Pharmacists can monitor messages based on workflows and time  Custom Inbasket message created to provide patient specific information within message

16. 16 Tools – Microbiology Results  Best Practice Advisories – Applications  Updated micro results available  Positive blood culture and no antimicrobial  Resistant culture  Duplicate anaerobic coverage  Duplicate C. difficile coverage

17. 17 Tools – Microbiology Results  Best Practice Advisories – Properties  (Vendor specific screen capture removed)

18. 18 Tools – Pharmacist/Physician Rounding  Accordion Reports  General  Medication administration visual  Culture information  Lab data, Vital information  Pertinent drug levels  Allow changes to time view

19. 19 Tools – Pharmacist/Physician Rounding  Antimicrobial Accordion  Challenge – complicated patients, multiple antimicrobial orders, changes in regimen over time  Visual timeline of all antimicrobial administrations  Vancomycin Accordion  Challenge – vancomycin often non-continuous therapy with stops, starts and dosing changes  Visual timeline of vancomycin administrations

20. 20 Accordion Reports - Antimicrobial  (Vendor specific screen capture removed)

21. 21 Accordion Reports – Vancomycin 22  (Vendor specific screen capture removed)

22. 22 Tools - Pharmacist Rounding: Scoring  System Lists and Patient Scoring Tools  Utilize same BPA properties to create rules  Ability to sort columns and relative overall score to identify key patients  Rules/Columns in Antimicrobial Stewardship Scoring  Patient specific information: location, name, age, primary problem, weight, height and creatinine clearance 22

23. 23 Tools - System Lists and Patient Scoring Rule based columnsScore Creatinine clearance (CrCl)Value of 0 to 1 based on level of renal dysfunction (0 = >70 mL/min; 1 = < 10 mL/min) On antimicrobialValue of 1 for each antimicrobial AMS target medicationsValue of 1 for each target antimicrobial Aminoglycoside/VancomycinValue of 1 if on either On 3 or more antimicrobials for 2 or more days Value of 1 if true 23

24. 24 Tools - System Lists and Patient Scoring Rule based columnsScore On quinolone, vanco or imipenem for 3 or more days Value of 1 if true On ceftriaxone and azithromycin IV for 5 or more days Value of 1 if true On nitrofurantoin and CrCl < 60 mL/min Value of 1 if true Open I-VentsValue of 1 for each open I-Vent Rx ProtocolValue of 1 for each open protocol

25. 25 Tools - System Lists and Patient Scoring (Vendor specific screen capture removed)

26. 26 Tools - Surveillance/Effectiveness Reports  Drug Usage  By patient, location, physician and drug  Days of therapy  Individual drug per 1000 patient days  Entire patient hospitalization per 1000 patient days  IV compared to PO  Track antibiotic use and days of therapy by provider and specialty groups  Antimicrobial cost per patient day

27. 27 Tools - Surveillance/Effectiveness Reports  Process/Outcome Measurements  Antimicrobial use and impact on Clostridium difficile infection rates  Intervention acceptance rate by physicians  Direct antimicrobial expenditures  Track discharge antibiotic trends

28. 28 Outline  Overview of MultiCare Health System  What is Antimicrobial Stewardship  Key pharmacist workflows  Pharmacist tools  Challenges  Future directions

29. 29 Challenges  Identifying specific interventions  Incorporating tools into pharmacist workflows  Quirky BPA behavior based on free text  Lacking interfaced lab system  Free text data sent for microbiology results from lab system  Competing requests for reporting resources

30. 30 Mitigating Challenges  Creative use of BPA’s and searching for free text strings  Use of reports with data already in the Enterprise Data Warehouse (EDW) for other initiatives (sepsis metrics)  Leverage expertise from outside the pharmacy team

31. 31 Outline  Overview of MultiCare Health System  What is Antimicrobial Stewardship  Key pharmacist workflows  Pharmacist tools  Challenges  Future directions

32. 32 Future Directions  Introduction of QlikView for reporting from Epic  AMS program outcomes  Antimicrobial usage trends  Drug use patterns related to infection control data  Comparative reports by drug, facility and prescriber to identify improvement areas  Financial impact  Expand AMS to all hospitals in system  Consideration of changes to lab system

33. 33 Conclusion  What is Antimicrobial Stewardship  Pharmacist tools  Key pharmacist workflows  Pharmacist tools  Challenges  Future directions

34. 34 Questions  chris.beuning@multicare.org chris.beuning@multicare.org  dianna.gatto@multicare.org dianna.gatto@multicare.org