On the Front Lines of Antimicrobial Stewardship (Marci Drees)

On the Front Lines of Antimicrobial Stewardship

Marci Drees, MD, MS, FACP

Hospital Epidemiologist

Hospital of Tomorrow Summit

19. October 2015

Disclosures: None to report.

Dela-where?

Setting

Two-hospital, 1100-bed private not-for-profit community-based academic health care system

>50,000 admissions, 185,000 emergency visits annually 21st in U.S. for admissions and ED visits

Level 1 trauma, level 3 NICU

> 11,000 employees

~1600 Medical-Dental staff (400 employed)

Largest teaching affiliate of Sidney Kimmel Medical College at Thomas Jefferson University

~450 employed or rotating residents/fellows (No ID)

~12,000 rotating students annually

Evolution of Stewardship at CCHS

Pre-2009: 1 ID-trained PharmD, working with 1 private ID physician

~2009-10: different ID-trained PharmD hired, stewardship “committee” formed

2011: current ID-trained PharmD hired

2013: 2nd ID-trained PharmD hired

2014: Revamped ASP committee launched

Co-chaired by ID PharmD and private ID physician

3rd ID-trained PharmD hired (left after 6 mo.)

2015: replacement 3rd PharmD hired

Early Accomplishments

Series of guidelines developed for front-line staff

Pneumonia, skin/soft tissue infections, sepsis, UTI

Duration of therapy

Vancomycin dosing by pharmacy protocol

Procalcitonin guidelines

Working with microbiology lab to adopt and implement Verigene® as a stewardship tool

Identification of blood culture organism within hours

Discussion Points

Engagement

“Culture/testing stewardship”

Clinical Decision Support

Metrics

Engagement ASP committee revamped early 2014

Co-chaired by David Cohen, MD

Private practice (inpt/outpt)

Chair of ID Division

Force of personality

Membership expanded

Pharmacy, ID docs, microbiology, infection prevention

Hospitalists, residents, surgery PAs, students, ED, family practitioners, critical care PAs

Strong educational/outreach component

“Staphylococcupalooza”

Culture/Testing Stewardship

Recognition that positive cultures/tests very difficult NOT to treat C. difficile colonization Asymptomatic bacteruria

Interventions Laxative alert Previous C. difficile alert

Future: Urinalysis with reflex to urine

culture Requirement for symptom

documentation when ordering urine cultures


“Forcing function”

Or, making the right thing to do the EASIEST thing to do

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Metrics

Intra-facility Internal benchmarking for

targeted antibiotics

Evaluate effect of interventions

Compare antibiotic use between similar units

Compare individual providers

Inter-facility Benchmarking to similar

institutions

What is the “right” amount of antibiotic use?

Possible metrics Resistance rates:

Annual antibiogram

Pharmacy interventions

ASP pharmacist

Unit-based pharmacists

Utilization (DOT)

Safety Surveillor® (Premier)

Power Insight (Cerner®)

University Health System Consortium (UHC)

Outcomes (?)

Measuring Utilization

Data mining program (SafetySurveillor®)

Pro: pulls in micro and pharmacy data (bug/drug mismatch)

Con: orders, not actual administration; labor intensive

SAP Business Objects software (Power Insight)

Pro: anything in PowerChart available for query (barcode)

Con: labor-intensive, slow

UHC

Pro: ability to benchmark nationally to similar institutions

Con: based on charges; 3-month delay

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Utilization Data (UHC)

External Benchmarking (UHC)

On the Front Lines…

Engagement is key…

Private ID docs

Employed and private hospitalists

Many, many others who prescribe antibiotics (or obtain the tests that prompt antibiotics)

Measurement is hard…

Interventions should make less work, not more, for frontline providers.

Acknowledgments

Nicole Harrington, PharmD

David Cohen, MD

Jennifer Lukaszewicz, PharmD

Julianne Gardner, PharmD

Donna Walsh, PharmD

Kim Taylor, BSN, RN

Sharon Kleban, MA

Steve Eppes, MD

Paul Sierzenski, MD, MS-HQS

On the Front Lines of Antimicrobial Stewardship (Marci Drees)

Health & Medicine

Transcript of On the Front Lines of Antimicrobial Stewardship (Marci Drees)