Make your Data Work for You!ASP Dashboard Development

Kathryn K. Davis, PharmD, BCPSCatholic Medical Center

Drowning in Data…

Information Systems to the Rescue!

ASP Dashboard created using Microsoft Power BI (Business Intelligence)

Improved ASP Reporting and Analysis

Visualize trends• Begin to understand the underlying cause

Identify opportunities for intervention

Determine effectiveness of interventions

Mechanism for provider feedback

Visualize Trends

Oral vancomycin utilization is trending up• Drill down to begin to understand the underlying cause• Go back to spreadsheet to review orders, indication

Task Force gathered to reduce CDI infection

Identify Opportunities for Intervention

Select by indication to review antimicrobial use for a particular disease state

Do we have any

work to do here?

Identify Opportunities for Intervention

Select by medication to evaluate indications for use

or here?

Determine Effectiveness of Interventions

Monitor success/failure of ASPs FQ interventions Medical staff education

• Risks associated with FQ and therapeutic alternatives Fluoroquinolone use decreased by 30% (2017 Q1 to 2018 Q4)

FDA Warning, July 2016 ASP Education, Nov-Dec 2017 ASP Education, Dec 2018

Mechanism for Provider Feedback

Mechanism for Provider Feedback

We can do better!

Contact InformationKathryn K. Davis

Catholic Medical Center100 McGregor Street

Manchester, NH 03102603-665-2436

kathryn.davis@cmc-nh.org

Penicillin Allergy Testing and Antibiotic Stewardship

• 51,582 unique pcn “allergic” hospitalized individuals matched to 2 unique subjects each.

• PCN allergic cases averaged a 10% longer LOS compared to well matched cohort patients (matched for discharge diagnosis, sex, age, date of admission)

• PCN “allergic” patients were treated with significantly more FQ, clindamycin, and vancomycin ( p<0.0001) compared to controls.

• pcn “allergic” cases had 23.4% more C. difficile infections, 14% more MRSA, and 30.1% more VRE than controls.

• Conteras M L. Allergy and Clinical Immunol 2014;133:790-6

Penicillin Allergy Testing Protocol

-Assess likely hood of penicillin allergy (review algorithm)

-Define treatment plan:

A. GIVE PCN full doseB. Amoxicillin challenge.C. Skin test with Pre-Pen, if negative give amoxicillin challenge.D. Call specialist or desensitization following published protocol.E. Avoid B lactam antibiotics.

-Discuss treatment plan with provider.

Amoxicillin challenge procedure:

Patient must not be taking beta antagonists (beta -blockers) or H1 antagonists (antihistamines) for 24 hours prior to challenge.

Existing IV access optional depending on allergy history.

Administer amoxicillin 250mg po X1 observe patient every 15 minutes for 1 hour. If the patient reports no adverse events, the patient may receive a penicillin product. RN to document patient response. Pharmacy will remove penicillin from the allergy profile. A note regarding the test will be made in the EMR.

Allergy Assessment Tool

PCN Allergy Testing Results in Less Healthcare Utilization

308 cases matched to 1251 controls

3.6 year F/U

9% fewer outpatient visits / year

13% fewer ED visits

$2 million of utilization saved over 3.6years

Macy E. JACI in Practice 2017; 5: 705-10

Penicillin- Associated Anaphylaxis Epidemiology

6,144,422 unique individuals with at least one healthcare encounter over 8yr period. 37,387,312 patient years.All potential cases audited for actual anaphylaxis.

22 cases (1 in 207,191 or 0.00048%) of anaphylaxis associated with PO PCN.

13 females

16 amoxicillin related

4 amox/ clav

2 dicloxacillin related

3 cases ( 1 in 95,298 or 0.00105%) of anaphylaxis associated with a parenteral penicillin.

1 female

1 amp/sulbactam, 2 pip/tazo

IV exposure more likely to result in anaphylaxis (p < 0.001)

Macy and coworkers Manuscript in preparation

Risk Stratification for PCN Testing

• Low risk Hx• Nonallergic symptoms (GI), solely with a Hx of family members with PCN

allergy. Pruritis with out rash, unknown Hx > 10 years ago.• Amoxicillin challenge

• Moderate risk Hx• Urticaria or other pruritic rashes with features of IgE-mediated reaction

• PCN skin test, followed by amoxicillin challenge (95-100% negative predictive value)

• High risk Hx• Anaphylaxis ,positive PCN skin test, recurrent PCN reaction, documented

hypersensitivity to multiple β- lactams.• Evaluated by specialist or desensitized

Penicillin Allergy Testing and Antibiotic StewardshipAssociated Amoxicillin Risk

• The risk of causing death with an oral amoxicillin exposure is extremely rare. One death in 100,000,000 amoxicillin courses in Great Britain over 35 years. Most oral.

• Seven additional amoxicillin-associated deaths with parenteral or unknown routes of exposure.

• Oral 3gm amoxicillin single dose prophylaxis, 0 fatal reactions per million. 22.62 non-fatal reactions / million.

• Oral 600mg clindamycin single dose prophylaxis, 13 fatal reactions per million, 149 non-fatal reactions / million (most C. diff.).

Thornhil MH. JAC 2015: 70; 2382-88Lee P. JAC 2007: 60; 1172-9

Who Needs Penicillin Allergy Testing?Key Messages

Reasons Why PCN Hypersensitivity Has Been Higher in the Past

• “We discussed what to do with the pungent brown red powder. We decided to dissolve it in saline and pass it through an E.K Seitz pad (asbestos pad) to sterilize it.” 1

• Immunologically mediated sensitization are more likely with topical exposure, followed by parenteral exposures, and least likely with oral exposures.

• By 1946 there were 47 PCN ADE case reports• Allergic hydrarthrosis, urticaria, serum sickness, anaphylactic shock-like syndrome. All after

IM administration.

• Reaction frequency ~0.5% 2

• Now known that PCN left in solution degrades to adverse reactive substances

1. Grossman, CM. The first use of penicillin in the United States. Ann Intern Med. 2008; 149: 135–136

2. Suchecki, AI. Allergic reactions to penicillin. Br Med J. 1946; 2: 938–940

Date Patient

Reported Abx Allergy Description of Allergy by patient

Adjudicated Allergy Allergy Assessment Process Result

12/6/18 J.S. Macrolides,PCN, TCN

Not Sure, LTA* Amox challenge tolerated

12/6/18 C.T. Zosyn Hives on infusion Amox challenge tolerated

12/18/18 A.B. PCN May be rash, LTA Amox challenge tolerated

12/26/18 J.F. PCN 7yr old, bee stings IM PCN abdomen

Amox challenge tolerated

12/30/18 A.G. PCN Rash Amox challenge tolerated

1/2/19 J.H. PCN Rash 7 days after PCN start Amox challenge tolerated

1/2/19 A.C. PCN IM, 1950’s Amox challenge tolerated

1/7/19 M.A. PCN Anaphylaxis as child Did not go to hospital for treatment

Amox challenge tolerated

1/10/19 K.D. Amoxicillin Hives as child > 48hr post 1st dose Amox challenge tolerated

1/14/19 R.W “PCN” in ICU Gums swelled, son has Hx PCN allergy

Amox challenge tolerated

1/18/19 A.G. PCN Hives when young Amox challenge tolerated

1/15/19 L.P. PCN 82yo, PCN allergy as child Zosyn full dose tolerated

1/28/19 C.C. Amoxicillin Rash in teen years Not immediate Amox challenge tolerated

3/1/19 L.H. PCN “Red butt” as child Amox challenge tolerated

3/14 M.M PCN Anaphylaxis, rash, tongue swelling

Post-op, no clear S+S of anaphylaxis, only SOB

Amox challenge tolerated

Risks Associated With not Evaluating Individuals With a PCN Allergy

• Inferior Clinical Outcomes• More SSI when PCN is the SOC and not used• More deaths and inferior outcomes is PCN s not used in MSSA

infections• Longer hospitalizations and exposure to antibiotics associated with

C. difficile and VRE

IN A SMALL COMMUNITYHOSPITAL

JONATHAN NAPOLI, PHARMD, MHA, BCPSCLINICAL PHARMACY MANAGER

Objectives

• Describe the AMP program at Parkland including committee and stewardship rounds structure

• Detail the creation and utility of reporting tools

• Discuss how reporting is presented at varyinglevels of facility committees.

Parkland Medical Center• Derry, NH

– 86 Licensed Beds• Emergency Room• Intensive Care Unit (8 bed)• Med/Surg• Intermediate Cardiac• Progressive Care (Step-down)• Behavioral Health• Post op/Pediatrics Floor• Labor/Maternity

– Level III Trauma Center– 24/7 Cath Lab, Chest PainAccredited– TJC Primary Stroke Center

– 23,094 Emergency Room Visits in 2017– 4,394 Admissions in 2018

Antimicrobial Management Program

• Bi-Monthly Committee Meetings

• Twice-weekly Stewardship Rounds

• Reporting Structure

AMP Committee Meetings

• Membership:– Pharmacist and ID Physician Co-Chairs– CMO– Hospitalist– Infection Prevention– Micro– Nursing– Informatics

AMP Committee Meetings

• Clinical literature review• Order set updates• New protocol development• Anti-infective formulary review• Medication use evaluations• Stewardship activity review• DOT review, drilled down to provider level

Stewardship Rounds

• Occur twice weekly

Dedicated AMS Pharmacist runs report for current

inpatients on antibiotics

RPH performs in-depth review of abx appropriateness, clinical

parameters and DOT (2-3 hrs)

Pharmacist meets with ID Physician to review cases

(1 hr)

Pharmacist follows up discussingrecommendations with

attending providers (1 hr)

Changes made in EMR(0.5 hrs)

All recommendations/provider discussions are documented and sent to ID and Clinical Pharmacy

Manager (0.5 hrs)

Stewardship Rounds

• Clinical Pharmacy Manager compiles recommendation information into spreadsheet

Stewardship Rounds• Data in spreadsheet used to create pivot tables, graphs, and dashboards.

Stewardship Rounds

• Collateral benefit:– Pharmacists report significant education from

discussions with ID physician which is leveraged on non-stewardship days

– Clinical manager able to identify opportunities with improper use of certain medications or practice discussions with specific providers

– Clinical manager better positioned to explainparticular trends seen in antibiotic utilization

Reporting

Antimicrobial Management ProgramCommittee (AMP)

Pharmacy and Therapeutics (P&T)

Medical Executive Committee (MEC)

AMP Committee

• Goals of reporting: Identify opportunities/action plans– Educational opportunities

• Use data and visuals to highlight providers who may be over-utilizing resources

• Review acceptance rates of stewardship recs

– Utilization opportunities• If over-utilization: is it specific provider or generalized? If

generalized, a medication use evaluation may be necessary.• Reports can help show impact of previous strategies.

AMP Committee• Using EMR or Pharmacy Surveillance Software – calculate DOT of abx by provider

AMP Committee• Use EMR data to calculate Days of Therapy, normalized by patient days.• Import into Excel, create pivot tables/graphs, update regularly

Dec Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec Jan 19Pip/Tazo 50.6 49.5 63.5 57.5 50.3 48.2 43.4 38 55.6 60.85 61.06 50.89 47.19 48.51Meropenem 23 27.7 25 30.4 15 21.7 19.5 17 15.7 17.45 21.23 16.51 19.01 13.12Vancomycin 38.3 40 47 44.8 25.9 41.2 32.3 37 31.5 35.36 28.89 32.57 34.82 34

Dec Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec Jan 19Total Antibiotics 339 331 307 314 242 304 269 237 302 292 307 279 287 272

% ChangePip/Tazo 0.98 1.28 0.91 0.87 0.96 0.90 0.88 1.46 1.09 1.00 0.83 0.93 1.03Meropenem 1.20 0.90 1.22 0.49 1.45 0.90 0.87 0.92 1.11 1.22 0.78 1.15 0.69Vancomycin 1.04 1.18 0.95 0.58 1.59 0.78 1.15 0.85 1.12 0.82 1.13 1.07 0.98Total Abx 0.98 0.93 1.02 0.77 1.26 0.88 0.88 1.27 0.97 1.05 0.91 1.03 0.95

AMP Committee• Ability to show visuals of stewardship efforts on overall utilization and

specific initiatives

AMP Committee

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220

240

260

280

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320

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Abx Indications by Month

October November December Jan 19

Total Antibiotic Utilization

• Antibiotic indications are required whenever order is placed.

AMP Committee• Can breakdown antibiotics used for specific indications

– Ex. Initiative to reduce FQ utilization in cystitis• Only 3% of abx orders for cystitis are FQ’s

Pharmacy and Therapeutics

• Goals of reporting:– Broader education for nursing leadership,

providers, admin• Monthly reports of utilization and stewardship activities

informs other disciplines what we do in stewardship• Engage other disciplines in helping to reach goals of

decreasing utilization• Accountability to report outcomes associated with new

protocols– Can be leveraged as justification for new protocol

approvals

Medical Executive Committee

• Annual or biannual high-level report demonstrating results of the AMPprogram

• Goals of reporting:– Garner support from senior leadership to dedicate

resources for stewardship– Accountability for AMP committee for goals set.

Example of Annual Report for MEC

Antimicrobial Management Program 2018

Accomplishments-2017 Antibiogram-Updated order sets to reduce prominence offluoroquinolones-Revised Vancomycin Protocol – yielded highest percentage ofgoal troughs to date-Updated C Diff Order Sets based on new guidelines-Reviewed Intra-abdominal Sepsis treatmentguidelines-Meropenem Usage Evaluation – about 48% inappropriate use in Q4 2017

Clinical Patient Outcomes:IV to PO: less risk of line infection, thrombophlebitis. Earlier Discharge. De-Escalation: reduce resistance, unnecessary side effects, Vanco Trough between 10-25: Narrow therapeuticwindow.Decreasing Fluoroquinolone Use in UTI: increasing resistance to gramneg’s,

Side effects of FQ’s

2018 Antimicrobial “Activations” (Pharmacy Interventions)a. Includes: De-escalation, IV to PO conversions,

Vancomycin/AG consults, Renal Adjustments, Mismatched “drug/bug” occurrences

Antimicrobial Stewardship Rounds (Bi-weekly rounds with InfectiousDisease MD)Total recs/patients: 642/1343

For nearly every two patientsreviewed, one targeted abx recommendation is made

Antimicrobial Management Program 2018

Antibiotic Utilization:

--

2018 Antimicrobial Spend:2017 2018 Δ

Hospital Antimicrobial Expense

*** *** ***

Exp Per APD $3.91 $3.77 ↓4%

2019 Goals:-2018 Antibiogram-Revise urine culture reflex criteria-Procalcitonin protocol-Jon to complete Society of Infectious Disease Pharmacists(SIDP)Stewardship Certification

Summary• In a smaller-sized community hospital, structured

stewardship rounding helps to promote appropriate use/de-escalation of antibiotics

• Developing systems to collect stewardship recommendations and antibiotic utilization makes it easier to identify trends and opportunities for improvement

• Creating targeted reports to deliver at various committee meetings can be leveraged to accomplish specific goals