Stewardship Presentation MRPRC

Impact of a Pharmacist-Led

Antimicrobial Stewardship Program

Using Clinical Decision Support

Nathan Peterson, Pharm.D.

[email protected]

CHI - St. Elizabeth

Lincoln, Nebraska

DISCLOSURE

I have no actual or potential conflict of interest in relation to

this program/presentation

I have no actual or potential conflict of interest in relation to this

program/presentation

Outline

• Introduction– Catholic Health Initiatives- St. Elizabeth– Why antimicrobial stewardship?

• Objectives– Cost savings– Improved antibiotic use

• Methodology– Clinical Decision Support

• Results– Cost savings– Clinical pathway optimization– Success stories

• Discussion• Conclusion

Introduction

• Catholic Health Initiatives – 105 hospitals– 4 academic medical centers– 19 states– 30 critical access hospitals

• St. Elizabeth– 260 bed community hospital– Medical, Pharmacy, and Nursing

students from University of Nebraska and Creighton University

Antimicrobial Stewardship

• Centers for Disease Control and Prevention (CDC):– 3/2014; Published Core Elements of Hospital

Antibiotic Stewardship Programs(ASPs)• Leadership Commitment

• Accountability

• Drug Expertise

• Action

• Tracking

• Reporting

• Education

• President Obama:– 9/2014; Presidential Order mandating Task

Force and 5-Year Plan for combating antibiotic resistance

Antimicrobial Stewardship• Centers for Medicare and Medicaid Services(CMS):

– 12/2014; Updated checklist for infection control in hospitals

1.c.9 The hospital has written policies and procedures whose purpose is to improve antibiotic use (stewardship).

1.c.10 The hospital has designated a leader (e.g., physician, pharmacist, etc.)responsible for antibiotic stewardship outcomes.

1.c.11 Policy and procedures require practitioners to document an indication, dose, and duration for all antibiotics.

1.c.12 The hospital has a formal procedure for all practitioners to review antibiotics prescribed after 48 hours (e.g., antibiotic time out).

1.c.13 The hospital monitors antibiotic use (consumption) at the unit and/orhospital level.

Background

• Pre - ASP Operations – Decentralized pharmacists cover Critical Care, Progressive

Care, Medical, Oncology, and Burn Units– Pharmacokinetic Services by Pharmacy for select antibiotics– Infection Control Committee– Infectious Disease Physicians not employees of the hospital

– contract with provider group– Verigene

• Rapid detection of G+ and G- blood stream infections• Pharmacy occasionally called first; dependent on

microbiologist discretion– Yearly antibiogram

Pharmacist-Led Antimicrobial

Stewardship Program

• Recruit Committee – monthly meetings– ID Physician, 2 Internal Medicine Physicians, Infection

Control, Microbiology, Chief Medical Officer

– Pharmacy Clinical Coordinator attended meetings to assist in the handoff after the pharmacist completed residency

• Identify Goals– Cost reduction, clinical pathway optimization, success stories

• Process Implementation– Clinical Decision Support

– Quality and quantity metric development

– Provider education


Stewardship Program

What is Clinical Decision Support(CDS)?

“CDS systems link health observations with health knowledge to influence health choices by clinicians.” - Robert Hayward, Center for Health Excellence

Software that applies rules (e.g. if-then statements) to patient data.-Computerized alerts and reminders for providers-Clinical guidelines-Condition-specific order sets-Patient data reports and summaries-Documentation templates (interventions, etc.)

TheradocTM

ASP Pharmacist using Theradoc

Intervention period

• Pharmacy resident spent 1 to 3 hours/day for three months using a Clinical Decision Support (CDS) System report tailored to Antimicrobial Stewardship

– Process accelerated as pharmacist and hospital physicians grew familiar with process

• Pharmacy resident made interventions to providers based on daily report via face to face conversation or phone/pager

• The report was broken up by unit following the intervention period for clinical pharmacists to use

• Interventions during the 3 month period will be compared to baseline

ASP Pharmacist using Theradoc

Intervention period

Criteria that prompted alert:

-Antibiotic level, new

-Relevant culture: blood, respiratory

-Therapeutic Antibiotic Monitoring;

-drug-bug mismatch

-inadequate/no coverage

-overlapping therapy

-broad spec. de-escalation

-no positive cultures (72 hrs)

-redundant therapy

-IV to PO switch – anti-infectives

TIME INTENSIVE STEP


Stewardship Program

Example: Two separate providers providing overlapping empiric therapy

• Pharmacist documents all interventions • Cost savings assigned by Catholic Health Initiatives• Cost savings comparison of pharmacist interventions before and after ASP

Pharmacist implementation

Pre-ASP (Monthly Ave) ASP (Monthly Ave)Duplicate Therapy 3.25 9.3Narrow Spectrum 6.5 19.3No ABX Coverage 0.7 10.3No Indication 2 16Prolonged Duration 2.8 36.6Drug Optimization 0.5 15.6

Total Theradoc Antibiotic Stewardship Interventions 15.8/month 107.3/monthVancomycin Consult 156.8 229IV to Oral ABX 2.3 15

ABX Dose Adjust by Pharmacy 55.8 84

Non-Theradoc ABX Interventions 214.9/month 328/month

Total Antibiotic Interventions 230.7/month 435.1/month

$0.00

$2,000.00

$4,000.00

$6,000.00

$8,000.00

$10,000.00

$12,000.00

$14,000.00

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Antimicrobial Stewardship Interventions ($)

Duplicate Therapy Narrow Spectrum

No Abx Coverage No Indication

Prolonged Duration Drug Optimization

Project began September 1st

Goals

-Cost savings-Clinical pathway optimization

-Success stories

Cost savings (soft) from improved antibiotic use before ASP Pharmacist: $23,336/month

Cost savings (soft) from improved antibiotic use with ASP Pharmacist: $40,110/month

Worth noting; -Self reported-Costs are based on best available literature-Length of stay and ABX $$/Patient Day data is pending

Results-Cost savings

-Clinical pathway optimization-Success stories

Infectious Disease Physician suspected we were poorly treating empiric Urinary Tract Infection (UTI)

What could a stewardship pharmacist do?

MS-DRG Custom Groups (ICD-9)

Anti-Infective % Use Quantity/Resource Case

Urinary Tract Infection

LEVOFLOXACIN 64.76% 2.65


PIPERACILLIN/TAZO 32.15% 3.29


CEFTRIAXONE 28.57% 0.70


VANCOMYCIN 11.90% 3.00


CEFAZOLIN 5.12% 5.88


CIPROFLOXACIN 4.76% 1.38


CEPHALEXIN 3.90% 1.33


CEFEPIME 3.57% 2.67

Presented at December Meeting;Baseline data (3 month average) from PremierTM

Per Johns Hopkins Antibiotic Guide*:

• Empiric Inpatient Treatment for Acute Uncomplicated Cystitis– “Fluoroquinolones are no longer considered first line treatment and should be

reserved for special situations such as allergy or intolerance to other agents”

• Empiric Inpatient Treatment for Acute Uncomplicated Pyelonephritis– “Use local antibiotic susceptibility data to guide initial empiric therapy”

Ciprofloxacin 400 mg IV q12h (if local fluoroquinolone resistance rates < 10%)

Levofloxacin 500 mg IV once daily (if local fluoroquinolone resistance rates <10%)

• Complicated– “Fluoroquinolones (FQ) are reasonable empiric choices if patient has not

received an FQ in recent past, is not from a long-term care facility, and FQ resistance is low.”

*Guide preferred by internal medicine service

% Urine Isolates

Sulfamethoxazole/ TrimethoprimNitrofurantoin Cephalexin Levofloxacin

E Coli 58% 76% 98% 92% 76%Klebsiella 12% 94% 57% 98% 98%

Enterococcus faecalis 8% NI 100% NI 63%

Proteus 7% 74% 74% 84% 70%

Pseudomonas 5% NI NI NI 72%

Citrobacter 4% 75% NI NI 88%

MSSA 3% 100% 100% 100% 66%

MRSA 2% 100% 100% 0% 16%

Hospital Urine Antibiogram minus Emergency Department*

*Emergency Department urine E. Colisusceptibility to Levofloxacin: 86%** NI = Not indicated

Situation: We regularly use a fluoroquinolone for UTI treatment despite local resistance rates

Action: ASP Pharmacist -Targeted patients being empirically treated for UTI with FQ -Provider education

64%

71%75%

17%14%

11%

October November December January February March

Levofloxacin usage for UTI

% of UTI cases

“UTI” Stewardship Meeting; December 16th

Result: Levofloxacin usage for UTI decreased

Results-Cost savings

-Clinical pathway optimization

-Success stories

KJ admitted for Sepsis (unknown source-respiratory?) at 0115

• From LTC -> admitted to critical care unit(CCU)

• Medical Resident empirically selected Piperacillin-Tazobactam, Vancomycin, and Levofloxacin

• ESBL Klebsiella

– Microbiology left message with nurse at 0430

• Alerted via Theradoc – seen in morning review @ 0800

– Needed carbapenam – contacted attending MD

• Pt. switched by 0830

Clinical Decision Support (cont’d)

Other functionalities of Clinical Decision Support that an ASP Pharmacist could use

• Patient flags

• Antibiogram

• Estimated doses for antibiotics• Frequency * number of days• 741 doses of levofloxacin during December vs. 624 during

February (~5 minutes to run this report)

Obstacles• Non-residency/infectious disease trained pharmacist using unfamiliar

software to make infectious disease interventions

– Providers not always receptive

• Initial Theradoc reports took entire day to sift through

– No expert on site

• Data not readily available (usage, etc.)

• Wide variation on what antimicrobial stewardship looks like across and within academic and non-academic medical centers

– Differing metrics, process, medication use systems

Pharmacist-led Antimicrobial Stewardship




Conclusions

• A pharmacist can lead an antimicrobial stewardship program at a 260-bed community hospital

• Clinical Decision Support(CDS) can identify intervention opportunities for pharmacists with little/no specialty training

• Minimal daily activity on CDS alerts is financially lucrative and benefits patients and institutions



Future• Skin/soft tissue order set

• CAP/HCAP order set

• Provider eduction

• Reporting– ABX $/1000 patient days

– Length of stay for sepsis, pneumonia

– Monthly reports of antibiotic usage for sepsis, pneumonia, and UTI

• FTE Request submitted using stewardship and intervention data– Approved by position control and facility

Questions/Concerns Comments

Nathan Peterson, Pharm.D.

CHI-St. Elizabeth, Lincoln, Nebraska

[email protected]

mailto:[email protected]

Documents

Stewardship Presentation MRPRC