FHA Hospital Engagement NetworkInfection Prevention Roundtable

What’s New in Infection Prevention;What’s New in Infection Prevention;Updates, Challenges and Controversies

June 18, 2014

Agenda• Welcome• Key Points from the National APIC Conference:

What You Need to KnowWhat You Need to Know– Linda Greene, RN, MPS, CIC, Highland Hospital, NY

• Highlights from the Chasing Zero InfectionsHighlights from the Chasing Zero Infections Infections-Part 2 Meeting: Antibiotic Stewardship– Brian Mayhue, PharmD, Palm Beach Gardens Medical

Center– Suet-ping Lau, PharmD, Dr. Phillips Hospital

• Open Discussion / Q & A• Open Discussion / Q & A• Upcoming Events

2

Annual APIC Conference 2014Hi hli ht  Highlights 

Linda R. Greene, RN,MPS,CICManager of Infection Pre entionManager of Infection PreventionHighland Hospital Rochester, NY

University of Rochester Medical Centerlinda greene@urmc rochester edulinda_greene@urmc.rochester.edu

3

Overview of SHEA CompendiumCAUTI – May publicationSSI‐ JuneC difficile‐ JuneCLABSI – JulyMDRO – JulyVAE‐ AugustHand Hygiene ‐ August

4

CLABSI Update• Majority of CLABSIs are outside ICU• New independent risk factor‐ femoral lines• Transfusion of blood products in children• New : Reduced Risk‐ Antibiotic administration‐ Minocycline impregnated cathetersy p g

*CLABSI Update‐ presented by Lynn HadawayCLABSI Update presented by Lynn Hadaway

5

Current BundlesSuccessful in patient safety culture

Adherence to individual measures

Recent data suggests that adherence to all bundle components is not necessary

6

Basic PracticesEvidence based indications for CVC USERe‐educate staff when infusion components changeRe educate staff when infusion components changeUse checklist by someone other than inserter in ICU and non‐ ICUAvoid femoral in obese patients

7

Other PracticesPICC use is not a strategy to reduce CLABSI

Use ultrasound for internal jugular insertion

Vigorously scrub injection ports no less than 5 seconds

IV SETS‐ replace at intervals no longer than 96 hours

U     kl  i  h di l i   hUse tpa weekly in hemodialysis catheters

8

Barriers

Lack of infusion specialist

Maintenance checklist – no singe episode to be witnesses‐ reliability of self reported data

9

ChallengesOther Departments‐ Radiology, OR

Patients transferred from other facilities

10

Abstract‐ CLABSIDanielson et al. – Texas Health68% decrease in CLABSI rates with use of alcohol i d   impregnated port protector

Wawrzyniak et. al – Loyola U Medical Center      b i l  d  D  b  68% 2 year pre‐post observational study. Decrease by 68% overall with use of alcohol impregnated port prrotectorprrotector

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Hand HygieneAlcohol vs. soap and water‐ stress glove use

Antimicrobial soap‐ invasive procedures(Either is OK as long as gloves are used)

UNRESOLVED Issue – Hand Hygiene before donning  lgloves

* Presented by Janet Haas* Presented by Janet Haas

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VAEVAE• The limitations of VAP surveillance definitions hinder 

interpretation of the VAP prevention literature.

• Many interventions have been shown to reduce VAP rates but few interventions have been shown to improve objective p joutcomes such as average duration of mechanical ventilation or mortality

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UpdatesUpdatesBasic PracticesBasic Practices:  Interventions with little risk of harm that decrease duration of mechanical ventilation, length of stay, mortality, and/or costs.•Use non‐invasive positive pressure ventilation (NIPPV) whenever feasible• Minimize the use of sedation when possible.p• Interrupt sedation daily (spontaneous awakening trials) for patients without contraindications•Assess readiness to extubate daily (spontaneous breathing trials) in patients y ( p g ) pwithout contraindications•Maintain and improve physical conditioning•Minimize pooling of secretions above the endotracheal tube cuff ( Subglottic p g ( gsuctioning)•Elevate the head of the bed to 30‐45°•Change the ventilator circuit only if visibly soiled or malfunctioningg y y g

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U dUpdatesSpecial Practices:  Interventions that decrease duration of mechanical ventilation  length of stay  and/or mortality but insufficient data available on ventilation, length of stay, and/or mortality but insufficient data available on possible risks.• Decrease the microbial burden of the aerodigestive tractSpecial Practices:  Interventions that may lower VAP rates but for which there are Special Practices:  Interventions that may lower VAP rates but for which there are insufficient data at present to determine their impact on duration of mechanical ventilation, length of stay, and mortality.• Oral care with chlorhexidine• Prophylactic probiotics• Ultrathin polyurethane endotracheal tube cuffs• Automated control of endotracheal tube cuff pressureAutomated control of endotracheal tube cuff pressure• Saline instillation before tracheal suctioning

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Future Bundle Process Measure Date Y/N  CommentsContinuous Subglottic Suctioning

Assess readiness to extubate ( Spontaneous breathing trials)

Paired SBT’s and SATs.  Standardized process measures in development.

Interrupt sedation daily( S   k i   i l )

If contraindications – note here( Spontaneous awakening trials)

Ambulate according to protocol*  Note level

Regular Mouth care (without chlorhexidine )* chlorhexidine )  

Elevate HOB 35‐4000

Low Tidal Volume  Identify:

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Focus on MobilityFocus on Mobility

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MRSAHorizontal vs. Vertical approach to MDROsIsolation still recommended for colonized and infected 

ipatientsPerform a MRSA Risk assessmentU i l d l i i   f  d l  ICU  i   i h Universal decolonization of adult ICU patients with daily chlorhexidine bathingMupirocin ointmentMupirocin ointmentActive surveillance and targeted decolonization

* Presented by Julia Moody18

I t d d  d   i t d d Intended and non intended consequences of public reportingPublic attentionAdministration attentionAdministration attentionTransparencyThe Truth:e ut :Protect patientsKnow when something is wrong‐ interveneg gGet the help we need

* Susan Huang19

Response to GamingValidationIncreased visibility for IPs

What can we do:BelieveBe a voiceBe proactiveProve

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Trial to eliminate MRSA

• Chlorhexidine Matters:• Method• Method• ConcentrationC i• Consistency

• Safety

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DecolonizationMassage into skin for sustained 24 hour activityNo rinse

P lProtocol:Attention to high risk skin areasClean over non gauze dressingsClean over non gauze dressingsProximal 6 inches of lines catheters, etcPerineum and woundsPerineum and woundsMany soaps and shampoos inactivate

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Chlorhexidine

• 2% non rinse cloth most widely studied• 4% ‐ no rinse more adverse skin events• 4% rinse‐ shower or bath‐ lower concentrations• 2 min contact time before rinse• Mesh sponge works well for liquide application

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Consistency24 Hour Effect‐

Daily application

Assure all staff are trained

Night and weekends

C li   h kCompliance checks

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ANTIBIOTIC STEWARDSHIPSTEWARDSHIP

Brian Mayhue, Pharm D, CGPDirector of PharmacyDirector of Pharmacy

Palm Beach Gardens Medical Center

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Magnitude of Antimicrobial Use• Antibiotics are the second most commonly used class of

drugs in the United States• More than 8 5 billion dollars are spent on anti infectives• More than 8.5 billion dollars are spent on anti -infectives

annually200-300 million antimicrobials prescribed annuallyp y53% for outpatient use

• 30-50% of all hospitalized patients receive antibiotics• Studies estimate up to 50% of antibiotic use is either

unnecessary or inappropriate across all type of health care settingssettings

26

Unnecessary Use of Antimicrobials in HospitalizedUnnecessary Use of Antimicrobials in Hospitalized Patients

• Prospective observational study in ICU• 576 (30%) of 1941 antimicrobial days of therapy deemed

unnecessaryy

Most Common Reasons for Unnecessary Days of Therapy

192 187

94100

150

200

250

ys o

f The

rapy

Hecker MT et al Arch Intern Med

0

50

Duration of TherapyLonger than Necessary

Noninfectious orNonbacterial Syndrome

Treatment ofColonization orContamination

Day

Hecker MT et al. Arch Intern Med. 2003;163:972-978.

27

Antibiotic Misuse• Given when they are not needed• Continued when they are no longer necessary-

duration• Given at the wrong dose-renal and weight-based

dosing• Broad spectrum agents are used to treat very

ibl b isusceptible bacteria• The wrong antibiotic is given to treat an infection

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Guidelines to develop an institutionalGuidelines to develop an institutional Antimicrobial Stewardship Program (ASP)

• Antimicrobial Stewardship committee• Computer surveillance and decision support

software• Proactive microbiology lab• Monitoring of process and outcomes

measures• Elements of an ASP

– Active Strategiesg– Supportive Strategies

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Goals of AntimicrobialGoals of Antimicrobial Stewardship Programs

Optimize Patient Safety

Decrease or Control Costs

Reduce Resistance

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Antimicrobial StewardshipAntimicrobial StewardshipGoals

• Improve patient outcomes• Optimize selection, dose and duration of Rx

R d d d i l di d i f i• Reduce adverse drug events including secondary infection (e.g. C. difficile infection)

• Reduce morbidity and mortalityReduce morbidity and mortality• Limit emergence of antimicrobial resistance• Reduce length of stay• Reduce health care expenditures

MacDougall CM and Polk RE. Clin Micro Rev 2005;18(4):638-56.MacDougall CM and Polk RE. Clin Micro Rev 2005;18(4):638 56.Ohl CA. J. Hosp Med. In press.

Dellit TH, et. al. Clin Infect Dis. 2007;4

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PBGMC C. Diff Rate

• Rate based on cases per 10000 admissions

4 55

33.5

44.5

22.5

320122013

0.51

1.5

0Rate

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Challenges• Literature often not clear in Infectious Diseases• Everyone thinks they know how to use antibiotics

P id i i l• Providers perceive autonomy is lost• Difficulty proving impact (no national measures)• Financial pressures dictating decisions• Financial pressures dictating decisions

– Pharmaceutical manufacturers– Hospitals p– Insurance companies– Patients

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Getting StartedMultidisciplinary team

– Physician champion– Clinical pharmacist (with ID training)

Decentralized (on the units)Additi l– Additional

– clinical microbiology– Information systems specialist– Infection prevention professional/ hospital

epidemiologist

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Multidisciplinary TeamMultidisciplinary Team Approach

*HospitalHospitalEpidemiologistEpidemiologistHospitalHospitalEpidemiologistEpidemiologist

I f tiI f ti

InfectiousInfectiousInfectiousInfectiousDiseases Diseases

DirectorDirectorDirectorDirector

Hospital and NurseHospital and NurseAdministrationAdministrationHospital and NurseHospital and NurseAdministrationAdministration

InfectionInfectionPreventionPrevention

MedicalMedicalMedicalMedicalInformationInformation

Director,Director,QualityQuality

Chairman,Chairman,Chairman,Chairman,P&TP&T

AMP Directors•• Cl. PharmacistCl. Pharmacist•• Physician ChampionPhysician Champion

SystemsSystemsSystemsSystems

MicrobiologyMicrobiologyMicrobiologyMicrobiologyLaboratoryLaboratory

CommitteeCommitteeCommitteeCommitteePartners in Partners in OptimizingOptimizingPartners in Partners in OptimizingOptimizingAntimicrobial Use such asAntimicrobial Use such asED, hospitalists, ED, hospitalists, intensivistsintensivists

y py p

ClinicalClinical

SpecialistsSpecialists

ClinicalClinicalPharmacyPharmacySpecialistsSpecialists , p ,, p ,

and surgeonsand surgeons, p ,, p ,

and surgeonsand surgeonsDecentralizedDecentralized

SpecialistSpecialist

DecentralizedDecentralizedPharmacyPharmacySpecialistSpecialist *based on local resources

Modified: Dellit et al. ClD 2007;44:159-177.

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Physician Champion• Basic knowledge of antibiotics*(does not have to

be an infectious disease MD but helps)M t h i t t i t ki l d hi l i• Must show interest in taking a leadership role in the hospital

• Respected by his or her peers• Respected by his or her peers• Good interpersonal skills• Good team playerp y• Basic understanding of human factors and culture

transformation

36

PBGMC Antibiotic StewardshipPBGMC Antibiotic Stewardship Program

• Prospective audit with intervention and feedback

• Streamlining or de-escalation of therapy• Dose optimization• Dose optimization• Formulary restriction and pre-authorization

l l i• Parenteral to oral conversion

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Prospective Audit and FeedbackProspective Audit and FeedbackBack-end Approach

Physician writes order

Antibiotic DispensedAntibiotic Dispensed

At a later date, time antibiotics reviewed

Prescribing physician contacted and recommendations maderecommendations made

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Prospective Audit and FeedbackProspective Audit and Feedback

• Advantages– Prescriber autonomy maintainedy– Educational opportunity provided– Patient information can be reviewed before

interaction– Inappropriate antibiotic use decreasedpp p– De-escalation

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Prospective Audit and Feedback

• Disadvantages– Voluntary compliancey p– Identification of patients require computer

support (IT pharmacist helpful)– Prescribers reluctant to change if patient is

doing well– Some inappropriate antibiotic use permitted

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Dose Optimization• New evidence for duration of therapy

– Uncomplicated urinary tract infection: 3-5 days1

– Community-acquired pneumonia: 3-7 days2

– Ventilator-associated pneumonia: 8 days3

– CR-BSI Coagulase-negative staphylococci: 5-7 days4

– Acute Hem Osteomyelitis in children-21 days5

i l i i i d 6– Meningococcal meningitis-7 days6

– Uncomplicated secondary peritonitis with source control: 4-7 days7

• Avoid 10-14 day course of antibioticAvoid 10 14 day course of antibiotic therapy

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Dose Optimization

• Other steps taken at PBGMC– Implementation of extended infusion of p

Pip/Tazo (started in Feb 2013)• Dosing based on renal function (either Pip/Tazo

3 375 IV 12h 8h 4 h i d)3.375g IV q12hrs or q8hrs over 4 hr period)

Renal Dosing Policy– Renal Dosing Policy• Allows pharmacist to change dose/ frequency based

on renal function

42

Pip/Tazo purchases

100000

120000

60000

80000

2012

20000

400002013

0

20000

Pip/TazoPip/Tazo

43

Formulary Restriction

• Restrict high cost antibiotics to infectious disease physicians– Examples: daptomycin, linezolid, tigecycline

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IV to PO Conversion

• Develop a policy specifically targeting antibiotics which have same bioavailability to change to oral if certain criteria are met.– Azithromycin

Fluconazole– Fluconazole– Fluoroquinolones (ciprofloxacin, levofloxacin)– Metronidazole

Li lid– Linezolid– Clindamycin– Doxycycline

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IV to PO Conversion

• Inclusion Criteria (must meet one)– Tolerating a regular or modified diet for at least g g

24 hours– Tolerating enteral nutrition for at least 24 hours– Receiving other scheduled medications by the

oral route– Signs and symptoms of infection have resolved

or are improving

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IV to PO Conversion

• Exclusion criteria (must have none)– Unable to swallow, NPO, high risk for aspiration

A ti N/V/D GI b t ti IBS l b ti il– Active N/V/D, GI obstruction, IBS, malabsorption, or ileus– Signs and symptoms of infection have not improved– Experienced severe trauma within last 72 hrs

A ti GI bl d– Active GI bleed– Neutropenia (ANC<5000– Documented CNS infection or endocarditis

P i ith AIDS l i i d– Pneumonia with AIDS or severely immunocompromised– Pseudomonas infection and on antibiotics <24 hrs– Candidemia treated <7 days

Oth i f ti h IV th i th f d t d d f– Other infections where IV therapy is the preferred standard of care (osteomyelitis)

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Other Interventions

• Post antibiogram on line through our physician portal

• Work with Pharmacy Informatics to get computer generated reports to help clinical p g p ppharmacists identify opportunities

• Future opportunities (procalcitonin) toFuture opportunities (procalcitonin) to identify sepsis

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PBGMC Antibiotic Spending

80000

100000

120000

40000

60000

80000

2012

0

20000 2013

49

Lessons Learned

• Physician push back was a huge problem– Education does not always work- because they y y

“know” better– A peer (trusted colleague/ physician champion)

is the key to success– Showing physicians financial data vs their peers

does work

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Lessons Learned

• One ID physician changing prescribing habits can make all the difference

• Getting simple policy and procedures thru P&T is not always simpley p

• Whatever is the driving force for starting an ASP it can be successful and can helpASP it can be successful and can help substantially cut medication costs

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Conclusion

• Effective empiric antimicrobial selection based on your particular hospital (antibiogram)

• Optimize dose and route of administrationp• Administer for the shortest duration

possiblepossible• De-escalate once susceptibility known

S if i f i id ifi d• Stop if no infection identified52

Overview: A ti i bi lAntimicrobial Stewardship Program at DPH

S t i L Ph DSuet-ping Lau, Pharm.D. Infectious Diseases Clinical PharmacistDr P Phillips HospitalOrlando Health

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Before ASP ……• The highest utilization of broad & costly abx at OH:

• Meropenem, linezolid, daptomycin… etc

• The highest abx Cost / PDE at OH:• $33.6 at DPH vs. $22.9 at OLM

• The usage of meropenem was above the national average• The usage of meropenem was above the national average

DPHDPH

OLMSSHSSH

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Overview Antimicrobial Stewardship Program (ASP)• Daily antimicrobial agents monitoring & surveillance:

• IV to PO switch • Bug-drug Mismatch• Possibility de-escalation per culture resultsPossibility de escalation per culture results • Decrease the duration of antimicrobials• Formulary alternatives per culture results, allergies, pharmacotherapy

D i i i l / h i f i• Dose optimization per renal / hepatic function• Discontinue surgical prophylaxis antimicrobial agent(s)• Allergies investigation (Antimicrobial Allergy Team)• Monitor high cost / broad spectrum / high toxicity / national shortage

agents: • Meropenem, tigecycline, linezolid, daptomycin, colistin, aminoglycosides, ampho-B,

IV acyclovir

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Meropenem Utilization at DPH vs. ORMC

Use of Meropenem DPH vs. ORMC in 2010-2011

2500

3000

1500

2000

500m

g vi

als

500

1000# of

5

0 Jan-10

Mar-10

May-10

Jul-10

Sep-10

Nov-10

Jan-11

Mar-11

May-11

Jul-11

Sep-11

Nov-11

ORMC

DPH

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Antimicrobial Agent Cost Saving at DPH (Before vs After ASP):DPH (Before vs. After ASP):

Antimicrobialagents yearly

Cost reductionfrom year of

Cost Reduction

Cost Reduction from the

Year

agents yearly expenditure

from year of 2009 without ASP (baseline)

Reduction from the previous year

from the previous year (%)

20092009$1,630,546

2010$1,374,318 $256,228 $256,228 -16.0%

2011$863,932 $766,614 $510,386 -37.0%

2012$788,461 $842,085 $75,471 -9%

2013$550,106 $1,080,440 $238,355 -30%

Potential Cost Saving in 4 years: $2,945,36557

Overall Intervention Acceptance Rate

Therapy recd accepted

Type of Interventions in 2013 (N=1217)

96%

Formulary Alt Accepted

Therapy recd accepted

96%

96%

Dose Optimization Accepted

Cut Duration of abx Accepted 95%

IV to PO Accepted

Dose Optimization Accepted98%

100%

0 50 100 150 200 250 300 350 400 450 500

De-Escalation Accepted94%

Overall Acceptance Rate: 96%0 50 100 150 200 250 300 350 400 450 500

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1st CAUTI Rounds at DPH• Established the FIRST CAUTI prevention Rounds at DPH

with the Infectious Diseases Physician • Weekly rounds with ID physician• Educated Staff and family member to remove unnecessary Foley

catheter

• Developed electronic CAUTI Progress Note • Assisted other OH sites to establish site wide CAUTI rounds• Successfully reduced the CAUTI rate at DPH since 2012

Fiscal Year # of CAUTI2010 262011 252012 152013 112014 0 (till April)

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C.diff PreventionD l d C diff I f i Q li M i i F• Developed C.diff Infection Quality Monitoring Form • Review each HACDI with the attending• Review all HACDI cases monthly (CQO, ID physicians, Infection y ( Q , p y ,

Preventionist)• C.diff task force: launched hand-washing Champaign

• Reduced unnecessary antimicrobial usage• Reduced unnecessary antimicrobial usage• Floroquinolones restriction at Orlando Health

• Reduced proton pump inhibitor (PPI) usage

Fiscal Year # of HACDI

2010 53

2011 82

2012 64

2013 752013 75

2014 22 (Till April)

60

DPH Antibiogram (2009-2013)

Pseudomonas aeruginosa

2009 2011 2012 2013aeruginosa

Amikacin 95 95 96 96Cefepime 64 83 85 90Ciprofloxacin 57 71 75 8857 71 75 88Pipercillin-Tazobactam

75 89 92 92Meropenem 64 79 86 89

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DPH AntibiogramsComparison DPH antibiogram (2009 – 2013)

MDR Rate 2009 2010 2011 2011 2012 2012 2013MDR Rate 2009 2010 – 2011 2011 – 2012 2012 – 2013

MRSA 55% 55% 50% 50%

VRE 17% 13% 19% 17%VRE 17% 13% 19% 17%

ESBL:• E. Coli 8% 5% 6.6% 4.4%•K. pneumoniae 15% 12% 9% 8.1%

CRE:• KPC 2.4% 1.8% 1.6% 0.6%

(No other CRE cases!!)

•MRSA i

No reported 2.5% (N=6) 4.5% (N=9) 0% (N=0)!!! vancomycin MIC ≥ 2

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Sharing ASP Experience

• It was tough to start but it is rewarding with the accomplishments!accomplishments!

• NEVER EVER give up!• Remember: we are the physicians’ teammates NOTRemember: we are the physicians teammates NOT

enemies! • We can be a “police” but we have to be friendly!We can be a police but we have to be friendly!• Be SMART and SWEET!• Find out what are the problems then tackle each one!Find out what are the problems then tackle each one!

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Questions?Questions?Preguntas?

Th k !Thank you! 64

Open Discussion / Questions?

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Upcoming EventsJune 19 VAE Office Hours (12-1pm)June 19 Role of Pharmacists in Transitions of Care Services (1-2pm)June 20 Data Coordinator Webinar – Live Encore (11:30am-2pm)June 23 OB & Failure to Rescue Webinar (11:30am-2:30pm)June 23 Patient & Family Engagement Master Class (3-4pm)June 24 Junior Fellows Open Office Hours (11am-12pm)June 24 Patient & Family Engagement Office Hours (12-12:30pm)June 24 Care of Children in General Hospitals (3-4pm)June 25 Florida CAUTI Coaching Call (11am-12pm)June 25 Monthly OB Coaching Webinar (1-2pm)June 25 HAI Affinity Group Meeting (1-2pm)June 25 ILF Virtual Meeting (2-4pm)June 26 Falls & Procedural Harm Webinar (11:30am-2:30pm)June 26 NPLH Readmissions Office Hours (12:15-1pm)Sept 16-17 TeamSTEPPS Master Trainer Class (Deerfield Beach, FL)

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We are here to help!FHA ContactsFHA Contacts

Sally Forsberg RN Director of Quality & Patient Safety

(407) 841-6230, sally@fha.org

Kim StreitVP/Healthcare Research & Information Services

(407) 841-6230, kims@fha.org( ) @ g

Phyllis Byles RNQuality Coordinatory

(407) 841-6230, phyllisb@fha.org

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