Script UP Sprint

Amanda Keilholz, CPHQ

Program Manager

October 30, 2018

Sprint Details

No data submission required for the sprints

One hour initial webinar taking a deep dive into each UP Intervention.

One hour midway facilitated call discussing application of the interventions into practice.

Sprint Details

A single tollgate due at the end of each sprint that provokes thought around:

current policy

are changes needed

policy review processes

barriers

addressing drift.

Sprint Details

An estimated time commitment would be 4-12 hours per sprint.

Time commitment is really dependent upon how in-depth you choose to take the interventions throughout the sprint.

The sprints will give you tools to use and allow you to begin to think through the interventions and how the application may be within your facility.

Up Coming Sprints

Welcome

Steve Tremain, MD, FACPE

Cynosure Health

Missouri Hospital Assn HIINSCRIPT UPSteven Tremain, MD, FACPE

Cynosure Health

October 30, 2018

Optimize Medications

ADE Delirium Readmissions Falls Sepsis All HAI’s

S C R I P T - U P

Why It Matters

Adverse drug events are the most common cause of harm (AHRQ)

Overuse and inappropriate use of antibiotics is the key cause of antibiotic resistance (CDC)

Beers Criteria Medications are linked to poor health outcomes, including confusion, falls, and mortality (Am. Geriatric Society)

Risk of ADEs almost doubles with > 5 meds (Bourgeois, Shannon et al, 2010)

What It Means to YOU and YOUR Hospital

What It Means to YOU and YOUR Hospital

Joy of Work

Organizational Survival Avoid penalties

Avoid harms (that no one but you pays to fix)

Grows your image in the community

Reduces out-migration

Optimize Medications

ADE Delirium Readmissions Falls Sepsis All HAI’s

S C R I P T - U P

Understand Your Audience

Craft the message

Craft the messenger

Craft the modality

Who is this?

William Dawes

I’ll give you a hint…

WHAT DOES THIS STORY TELL US?

The messenger matters

The Tipping Point –

Malcolm Gladwell

The Message Also Matters

Know the

Score!

Customize the WAY You Communicate

SHAREINFORMATION

SHAPE BEHAVIOR

GeneralPublications

flyersnewslettersvideosarticlesposters

PersonalTouch

letterscardspostcards

InteractiveActivities

telephoneemailvisitsseminarslearning setsmodeling

PublicEvents

Road showsFairsConferencesExhibitionsMass meetings

Face-to-face

one-to-onementoringsecondingshadowing

Adapted from Ashkenas, 1995 (C) 2001, Sarah W. Fraser

The Modality Matters

SIMPLE

EASY

FUN

SCRIPT UP MUST DO's

SCRIPT UP MUST DO’s

Match the drug to the bug

Follow Beers’ age appropriate criteria if they're up in years

Use appropriate meds -- Less may be more Ask, “Does the patient needs any medication changes or

adjustments?”

Must Do #1 Match the Bug to the Drug

Implement antibiotic time outs at 48 or 72 hours to de-escalate and modify therapy

Verify the presence of a bacterial or fungal infection

Antimicrobial Stewardship Program (ASP)

A structured program that promotes appropriate use of antimicrobials by selecting:

the appropriate agent,

dose,

frequency,

duration, and

route of administration.

Goals of an Antimicrobial Stewardship Program

Improved patient outcomes

Reduced adverse events (e.g. C. difficile infection)

Improved rates of antibiotic susceptibilities to targeted antibiotics

Reduced length of stay

Reduced healthcare expenditures

Optimization of resource utilization across the continuum of care

Barlam TF et al. Clin Infect Disease. 2016:62;51-76.

Antibiotic Stewardship: Does it Work?

Hospital Antibiotic Stewardship Programs have been shown to: Improve antibiotic resistance

Reduce C. difficile

Improve patient outcomes

Save $$$$$

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The Magnificent Seven

Leadership Commitment

Accountability

Drug Expertise

Action

Tracking

Reporting

Education

Add to That…

Pharmacy and Physician Champions

IP Champion

Nurse Champion

Strategies

CDC Gap Analysis Tool

Antimicrobial Management Program Gap Analysis Checklist, Centers for Disease Control and Prevention, 2010. Retrieved at https://www.cdc.gov/getsmart/healthcare/improve-efforts/resources/pdf/AMP-GapAnalysisChecklist.pdf

Key Strategies

Pre-Prescription Authorization

Post-Prescription Audit and Feedback

Target the high risk antibiotics

48 to 72 hour Antibiotic Time Out

Advantages ↓ initiation of antibiotics

↓ costs

Directly controls use

Preauthorization

Disadvantages Limited to restricted agents

Loss of prescriber autonomy

May delay therapy

Requires skill

Real-time resource intensive

Shifts to other agents that may be worse

Mother, May I?

Advantages ↑ visibility of ASP

↑ clinical data available

↑ flexibility in timing of recommendations

Les than daily

Educational

Prescriber autonomy

Promotes teamwork

Addresses de-escalation & duration

Post-Prescription audit and feedback

Disadvantages Compliance voluntary

Labor-intensive

Success driven by delivery

Fear of change; is patient doing well

May require IT/data mining

May take longer to achieve ↓ in targeted antibiotic use

Pre or Post?

Significant reduction in use of restricted agents and $$

Decreased antibiotic use

Decreased antibiotic resistance particularly gram-negative pathogens

Both have advantages and disadvantages

Unintended consequences

Seek Forgiveness not

Permission?

Antibiotic Time Out

1. Infected?

2. If yes, Bacterial?

3. If yes, source? Culture? Sensitivity?

4. Right drug?

5. Right dose?

6. Right frequency?

7. Right duration

8. Right route?

Measurement

Days of therapy (DOT)

True Costs based on prescriptions

The Math

Admitted tonight at 2300, given Amp + Gent before midnight

Receive 4 doses of amp and 3 doses of Gent tomorrow

Switched to Cephalosporin the next day and receives 3 doses, Amp + Gent both discontinues prior to dosing

4th day discharged before any abx dosing.

DOT = 2 + 2 + 1 + 0/4 days = 1.25 then X 1000 = 1250

Education and skill development for front line pharmacists

Barriers/Solutions

Staff development Bugs and drugs

Guideline familiarity

Provide resources Sanford Guide

John Hopkins Antibiotic Guide

Pharmacist Guide to ASP-ashp.org

www.mad-id.org

www.sidp.org

Metric for tracking

Barriers/Solutions

Internal IT involvement

External vendors

Software / data mining

Build into budget and seek approval Sentri7

Theradoc

Vigilanz

Don’ts and Do’s

Don’t: Talk about saving money

Start hammering outliers

Do: Talk about the 5 rights:

Antibiotic

Dose

Frequency

Duration

route

Next Steps…

Become Knowledgeable

Engage physicians and pharmacists

Guide structure

Oversee gap analysis

Provide necessary resources (does not need to be expensive!)

Seek monthly updates and data

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One Idea

Pharmacists focus review on patients with a fluoroquinolone order ≥ 48 hours if cultures are back

Review 7-10 patients daily

~50% require intervention

Antibiotic monitoring form is completed by pharmacists

Recommendations made during interdisciplinary rounds or by phone call

Stop Talking. Get Started.

Decide what antibiotic to target by considering: Potential risk

Volume used

High cost

Set up a review process

Monitor your results

Spread to other antibiotics when you can

Resources: HRET HIIN Change Package

http://www.hret-hiin.org/Resources/asp/17/antibiotic-stewardship-program-change-package.PDF

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http://www.hret-hiin.org/Resources/asp/17/antibiotic-stewardship-program-asp-case-study-large-medical-center-mississippi-baptist-medical-center.pdf

Resources:Case Studies – Large & Small Hospitals

http://www.hret-hiin.org/Resources/asp/17/antibiotic-stewardship-program-asp-case-study-critical-access-hospital-southwest-health-system.pdf

References

National Quality Partners Playbook: Antibiotic Stewardship in Acute Care, National Quality Forum. Retrieved at http://www.qualityforum.org/Publications/2016/05/National_Quality_Partners_Playbook__Antibiotic_Stewardship_in_Acute_Care.aspx . Last accessed May 16, 2017.

Antimicrobial Management Program Gap Analysis Checklist, Centers for Disease Control and Prevention, 2010. Retrieved at https://www.cdc.gov/getsmart/healthcare/improve-efforts/resources/pdf/AMP-GapAnalysisChecklist.pdf . Last accessed June 2, 2017.

Barlam, T. F., Cosgrove, S. E., Abbo, L. M., MacDougall, C., et al, Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society and the Society for Healthcare Epidemiology of America, Clinical Infectious Diseases, 62:e51-77, 2016. Retrieved at https://www.ncbi.nlm.nih.gov/pubmed/27080992 . Last accessed May 16, 2017.

Doron, S., and Davidson, L. E., Antimicrobial Stewardship, Mayo Clinical Proceedings, 86:1113-1123, 2011. Retrieved at https://www.ncbi.nlm.nih.gov/pubmed/22033257 . Last accessed May 16, 2017.

Approved: New Antimicrobial Stewardship Standard, Joint Commission Perspectives, 36:1-4, 2016. Retrieved at https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf . Last accessed May 15, 2017.

Antimicrobial Stewardship, American Hospital Association’s Physician Leadership Forum. Retrieved at http://www.ahaphysicianforum.org/resources/appropriate-use/antimicrobial/ . Last accessed May 16, 2017.

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Must Do #2 Follow Beers’ age appropriate criteria if they're up in years

Flag, stop and replace medications on the Beers’ list

If needed, switch to a safer agent

If not needed, discontinue medication

Classes of Medications to Avoid

Provide Alternatives

Drug Class Preferred Alternative Special dosing considerations for the elderly

Benzodiazepines - For insomnia: - emphasize sleep hygiene- treat for underlying disrupters- evaluate timing of other medications and

alcohol- For chronic anxiety:

- consider buspirone or SSRIs or SNIRs- consider psych referral

- Risk of fall doubled if used more than 14 days

Opioid analgesics Avoid meperidine

Provide Alternatives

Drug Class Preferred Alternative Special dosing considerations for the elderly

Cardiovascular agents - For HTN alone- ACE inhibitors,

betablockers, or calcium channel blockers preferred

Most significant risk is orthostatic hypotensionMonitor closely and educate patient Slowlyincrease to full dose

Skeletal muscle relaxants Monitor length of use and discontinue as soon as no longer indicated; recommended for short use only

Help your physicians by

providing guidelines about alternatives and

any special dosing or monitoring

considerations.

Must Do #3

Use appropriate meds -- Less may be more

Ways to Start

Consider shortening med lists, especially PRN medications When adding a med, ask “What can I discontinue?”

Why less may be better

There is no set number of medications defining polypharmacy –The CDC uses 6

Concerns Increased ADE

Increased drug interactions

Increased costs

Prescribing cascade

Associated with Decreased quality of life, mobility and cognition

Take Action

Set a threshold number for review Consider the volume of patients who are

at or above the threshold and the amount of pharmacist time that can be dedicated

Have pharmacist review and consult with physician

Monitor the impact of your intervention

Let’s Combine #2 and #3

Deprescribe medications that have high harm:benefit ratio

PFE Is critical!

Involve patients and families in the discussion

Find out why the medication was started and how long they have been taking it

Find out if they have current concerns about the medicine

PFE Is critical!

Understand what benefit the patient or family believe the medication is providing

Understand what fears the patient or family have about stopping a certain medication

Segment….

See if medications can be listed by class

Look for duplicates

Target one class

One area (clinic, unit)

Follow up!

2-3 day phone call

30 day check

What’s Next

Midway Interactive Discussion

Tuesday, November 13 10:00 a.m.

Register

Tollgate Due

Friday, November 30

Amanda Keilholz, CPHQ

Program Manager

573/893-3700, ext. 1405

akeilholz@mhanet.com

Contact Information