1. Alaska Antimicrobial Stewardship Collaborative (A2SC)
Alaska division of public health
Alaska state hospital and nursing home association
Mountain-pacific quality health Alaska
Alaska native tribal health consortium
Alaska pharmacists association
LCDR Thaddus Wilkerson, PharmD, BCPS
Ryan Stevens, PharmD, BCPS
October 24, 2014

2. Objectives
Be able to list 3 goals of the Alaska Antimicrobial Stewardship Collaborative
Antimicrobial Stewardship Assessment Tool
Get Smart about Antibiotics
Spring Summit
Be able to discuss 2 successful strategies and 2 potential barriers when implementing an effective program
The PAMC and ANMC experiences
Be able to list at least 2 CDC Core Elements
Adaptation to small rural settings
Long Term Care Facilities
The purpose of this activity is to enable the learner to understand the benefits of participating in the Alaska Antimicrobial Stewardship Collaborative in developing your own ASP, accessing resources, sharing information and meeting regulatory requirements.

3. Antimicrobial Stewardship A Quality and Patient Safety Initiative
A combination of personnel and procedures that promote the wise use of antimicrobials
When providers prescribe broad-based antimicrobials for too long, or when they are not needed, it can lead to an increase in complications
Clinics can create a reliable system that optimizes outcomes through appropriate selection of:
Agent
Dose
Duration

4. The ASP Basic Framework
ASPs minimize antimicrobial use, thereby:
Reducing drug costs
Prevent hospital admissions
Decreasing hospital length of stay
Minimizing drug-resistant and nosocomial infections
Avoiding drug-related toxicity
CID 2003;37:
CID 1997;24:9-11.

5. Stewardship Interventions
Prospective audit & feedback
Restriction & preauthorization
Education
Guidelines & clinical pathways
Avoidance of combination therapy
Dose, frequency & duration
Streamlining tx / de-escalation
IV-to-oral conversion

6. A2SC Share Information Learn from Common Experiences Surveys Webinars
Workshops
Conference Calls
Statewide Strategic Planning
Reach the Public
Collaboratives
State health agencies worked with groups of facilities and other partners to share information and learn from common experiences. Specific activities undertaken by collaboratives included surveys, webinars, workshops, and conference calls.
- Audience: Collaborative members included a range of partners, such as state health agencies, acute care hospitals, long-term care facilities, long-term acute care facilities, hospital associations, quality improvement organizations, local health departments, and infection prevention associations.
- Topics: Most collaboratives focused on a range of antimicrobial resistance and stewardship issues. A few focused on C. difficile infections.

7. A2SC <akantimicrobialstewards@gmail.com>
Criteria for treating wounds
UTI diagnosis & treatment
Access to ID physicians
Patient education materials for abx use and appropriateness
Clinician education on bacteriuria
Create A2SC Educational Calendar
October 29, 2014
Leadership education
Cost
Utilization
Sustainability
1ST A2SC WEBINAR SEPTEMBER 19, 2014
Alaska Regional Hospital
Heritage Place
Norton Sound Health Corp
State of Alaska Section of Epi
Denali Center and Fairbanks Memorial Hospital
Alaska Psychiatric Institute
Yukon-Kuskokwim Health Corp
Petersburg Medical Center
Peace Health Ketchikan Medical Center
Providence Alaska Medical Center
Alaska Native Medical Center
Alaska State Hospital and Nursing Home Assoc.
Wrangell Medical Center
Alaska Pharmacist Association Board of Directors joined the Collaborative and sent the survey to its members on 10/17/2014
Education/training with subject matter experts on NHSN or clinically focused treatment for CAUTI, UTI, and wounds.
Discuss and pull together a list of ID physicians available to consult throughout state.  They are independent practitioners but may be open to resource list.
Lots available….what specifically do they want?
Dr Nimalie Stone from CDC did a presentation several years ago that did address this issue.  We can offer education/training on identification and treatment of bacteriuria.
Education/training for leadership buy-in, utilization and costs.
State ASP survey
CEO letter of commitment to stewardship

8. A2SC: Why now?
The rise of antibiotic resistant bacteria represents a serious threat to public health and the economy.
Antibiotic resistance is responsible for over 2 million illnesses and 23,000 deaths annually in the U.S.
A successful campaign will require collaborative efforts between public & private entities and is a national priority.
Executive order—Combating Antibiotic-resistant bacteria Sept 18, 2014
CDC “Antibiotic resistance threats in the United States, 2013.”

9. Executive Order Combating Antibiotic-Resistant Bacteria
Sec. 5. Improved Antibiotic Stewardship
“By the end of calendar year 2016, HHS shall review existing regulations and propose new regulations…that require hospitals and other inpatient healthcare delivery facilities to implement robust antibiotic stewardship programs…”
“HHS shall also take steps to encourage other healthcare facilities, such as ambulatory surgery centers and dialysis facilities, to adopt antibiotic stewardship programs.”
“Task force agencies shall…define, promulgate, and implement stewardship programs in…office-based practices, outpatient settings, emergency departments, and institutional and long-term care facilities…nursing homes, pharmacies, and correctional facilities.”

10. CDC’s Core Elements Complement existing guidelines on ASPs
No single template
Flexibility in implementation
Experience in a wide variety
Success depends on
Defined leadership
Coordinated multidisciplinary approach
In 2014 the CDC recommended that all acute care hospitals implement Antibiotic Stewardship Programs
Core elements of success complement existing guidelines on ASPs from organizations including the Infectious Diseases Society of America in conjunction with the Society for healthcare epidemiology of America, American Society of Health System Pharmacists and the Joint Commission.
There is no single template for a program to optimize antibiotic prescribing in hospitals and a great deal of flexibility is required in implementation.
Experience demonstrates that antibiotic stewardship programs can be implemented effectively in a wide variety of hospitals and that success is dependent on defined leadership and coordinated multidisciplinary approach.

11. Core Elements in Summary
Leadership Commitment
Dedicating necessary human, financial and information technology resources.
Accountability
Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective.
Drug Expertise:
Appointing a single pharmacist leader responsible for working to improve antibiotic use.
Action:
Implementing at least one recommended action, such as an “antibiotic time out” after hours.
Tracking:
Monitoring antibiotic prescribing and resistance patterns.
Reporting:
Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff.
Education:
Educating clinicians about resistance and optimal prescribing.

12. State Strategies to Address Antimicrobial Resistance – Survey Results
ASTHO conducted a survey to better understand current state health department strategies
HAI coordinators from the states, DC and Puerto Rico in July 2013 with a response rate of 69% (36/52)
25 states (69%) reported antimicrobial stewardship activities
11 states (32%) considered policy, 5 developed/implemented
Suggested incentives: trainings, certification, awards, physician leadership, demonstration of benefits, public reporting
States conducting surveys
Data gathered used to inform state stewardship activities
Acute & long-term care facilities
Range of targeted audiences
ASTHO conducted a survey to better understand current state health department strategies to address antimicrobial resistance
Antimicrobial stewardship programs (ASPs) can ensure judicious use to improve individual patient outcomes, prevent death from resistant infections, slow resistance, and reduce healthcare costs.
ASTHO conducted a survey of healthcare-associated infections (HAI) coordinators from the states, DC, and Puerto Rico in July 2013, with a response rate of 69 percent (36/52). The survey’s purpose was to identify (1) what activities and policies the health agencies are using to promote antimicrobial stewardship; (2) what incentives and tools the health agencies need; and (3) promising practices to share with other states and territories.
(69%) reported conducting antimicrobial stewardship activities including education or training, communications, surveys, collaboratives, demonstration projects
Eleven states (32%) have considered policy on antimicrobial stewardship, and in 5 of those the policy has been developed/implemented. Some suggested incentives that would motivate implementation of antimicrobial stewardship activities include: trainings, certification, awards, physician leadership, demonstration of benefits, and public reporting.
Education/Training
Several states held day-long conferences, one-time live trainings, or webinars. Several held webinar series or conference calls. Almost half provided printed materials.
- Audience: States mainly targeted healthcare providers in acute care hospitals and long-term care facilities.
Topics: Education or training often covered an overview of stewardship, suggestions or considerations for implementing stewardship activities or ASPs, or targeted stewardship topics
©Association of State and Territorial Health Officials

13. Alaska Antimicrobial Stewardship Assessment Tool
Adopted from the CDC Checklist for Core Elements
Released on October 1st to members of ASHNA
Released on October 17th to members of AKPhA
31 responses to date
19 facilities represented from throughout the state including:
Anchorage, Barrow, Fairbanks, Homer, Juneau, Ketchikan, Sitka, Soldotna, Valdez and Wrengell
Various responder titles including:
Nurses, pharmacists, clinical resource coordinator, coordinated care managers, infection preventionists, hospital education coordinator
Alaska Native Medical Center
Alaska Psychiatric Institute
Alaska Regional Hospital
Alaska VA Healthcare System
Bartlett Regional Hospital
Central Peninsula Hospital
Chief Andrew Isaac Health Center
Denali Center
Fairbanks Memorial Hospital
Heritage Place
JBER DoD Joint Venture Hospital
Ketchikan Medical Center
Providence Alaska Medical Center
Providence Valdez Medical Center
Samuel Simmonds Memorial Hospital
Sitka COmmunity Hospital
South Peninsula Hospital
Wildflower Court
Wrangell Medical Center

14. Alaska Antimicrobial Stewardship Assessment Tool
Facility Size:
< 50 beds: 7
beds: 9
> 100 beds: 3
Alaska Antimicrobial Stewardship Assessment Tool
Alaska Native Medical Center
Alaska Psychiatric Institute
Alaska Regional Hospital
Alaska VA Healthcare System
Bartlett Regional Hospital
Central Peninsula Hospital
Chief Andrew Isaac Health Center
Denali Center
Fairbanks Memorial Hospital
Heritage Place
JBER DoD Joint Venture Hospital
Ketchikan Medical Center
Providence Alaska Medical Center
Providence Valdez Medical Center
Samuel Simmonds Memorial Hospital
Sitka COmmunity Hospital
South Peninsula Hospital
Wildflower Court
Wrangell Medical Center

15. Alaska Antimicrobial Stewardship Assessment Tool
About half of facilities surveyed (10/19) have a multidisciplinary committee focused on appropriate antimicrobial use?
Those that do have an ASP meet regularly.
5 facilities receive budgeted financial support for antimicrobial stewardship activities.
7 facilities have supported training on appropriate antimicrobial use within the last year.
Only 6 facilities have access to clinical infectious disease consultation on the same day as requested?
There is a physician identified as a leader for stewardship activities in 8 facilities.
Half of these physicians receive funding specific for ASP activities.
Alaska Native Medical Center
Alaska Psychiatric Institute
Alaska Regional Hospital
Alaska VA Healthcare System
Bartlett Regional Hospital
Central Peninsula Hospital
Chief Andrew Isaac Health Center
Denali Center
Fairbanks Memorial Hospital
Heritage Place
JBER DoD Joint Venture Hospital
Ketchikan Medical Center
Providence Alaska Medical Center
Providence Valdez Medical Center
Samuel Simmonds Memorial Hospital
Sitka COmmunity Hospital
South Peninsula Hospital
Wildflower Court
Wrangell Medical Center

16. Alaska Antimicrobial Stewardship Assessment Tool
11 sites have a pharmacist or nurse identified as a leader of stewardship activities.
This role is included in the job description and annual review in only 6 facilities.
Similarly, 6 of these individuals have received specialized training in ID or antimicrobial stewardship.
What staff contribute to assuring appropriate antimicrobial use at your facility?
Infection Preventionist 9
Microbiologist 8
Pharmacy 4
Quality officer 3
Hospital Epidemiologist 2
Informatics 1
Only 5 facilities require an indication for an antimicrobial Rx
10 sites have facility-specific guidelines, based on national guidelines and local susceptibility, to assist with antimicrobial selection for common infections.
Less than half (4) make these easily accessible on all wards and to prescribers (e.g., printed 'pocket guide' or electronic summaries on appropriate networked computers)
Alaska Native Medical Center
Alaska Psychiatric Institute
Alaska Regional Hospital
Alaska VA Healthcare System
Bartlett Regional Hospital
Central Peninsula Hospital
Chief Andrew Isaac Health Center
Denali Center
Fairbanks Memorial Hospital
Heritage Place
JBER DoD Joint Venture Hospital
Ketchikan Medical Center
Providence Alaska Medical Center
Providence Valdez Medical Center
Samuel Simmonds Memorial Hospital
Sitka COmmunity Hospital
South Peninsula Hospital
Wildflower Court
Wrangell Medical Center

17. Alaska Antimicrobial Stewardship Assessment Tool
Only 3 facilities have IV to PO protocols in place.
Only 1 facility reported having a formal protocol in place for de-escalation of therapy based on microbiology results.
5 sites have protocols for antimicrobial dose adjustment in patients with renal or hepatic insufficiency.
4 facilities have a clinician guide for ordering or collecting cultures appropriately.
At 5 sites specified antimicrobial agents need to be approved by a physician or pharmacist prior to dispensing.
Prospective audit and feedback is actively performed at 10 facilities surveyed.
An “antibiotic time out” is formally implemented in 3 facilities.
Alaska Native Medical Center
Alaska Psychiatric Institute
Alaska Regional Hospital
Alaska VA Healthcare System
Bartlett Regional Hospital
Central Peninsula Hospital
Chief Andrew Isaac Health Center
Denali Center
Fairbanks Memorial Hospital
Heritage Place
JBER DoD Joint Venture Hospital
Ketchikan Medical Center
Providence Alaska Medical Center
Providence Valdez Medical Center
Samuel Simmonds Memorial Hospital
Sitka COmmunity Hospital
South Peninsula Hospital
Wildflower Court
Wrangell Medical Center

18. Alaska Antimicrobial Stewardship Assessment Tool
Only 3 sites utilize an order entry system with embedded clinical decision support for prescribing antimicrobials.
Results of antimicrobial audits or reviews are provided directly to prescribers through in-person, telephone, or electronic communication at 4 sites.
4 have time-sensitive automatic stop orders.
Just over half (10) monitor antimicrobial consumption on a regular basis.
Pharmacy purchasing data 5
Days of Therapy (DOT) 4
Reports on antimicrobial use is provided to prescribers in 5 facilities
Adherence to facility-specific policies, guidelines or protocols to assist with antimicrobial selection is monitored at least annually at 3 sites.
If antibiotic recommendations are routinely provided, acceptance by the primary prescriber is tracked at 3 facilities.
Alaska Native Medical Center
Alaska Psychiatric Institute
Alaska Regional Hospital
Alaska VA Healthcare System
Bartlett Regional Hospital
Central Peninsula Hospital
Chief Andrew Isaac Health Center
Denali Center
Fairbanks Memorial Hospital
Heritage Place
JBER DoD Joint Venture Hospital
Ketchikan Medical Center
Providence Alaska Medical Center
Providence Valdez Medical Center
Samuel Simmonds Memorial Hospital
Sitka COmmunity Hospital
South Peninsula Hospital
Wildflower Court
Wrangell Medical Center

19. Alaska Antimicrobial Stewardship Assessment Tool
The majority of facilities (12) perform routine microbiology tests on site (urine, blood, sputum cultures).
Most (13) produce and distribute an antibiogram (cumulative antimicrobial susceptibility report) at least annually.
Healthcare information technology is utilized frequently.
Electronic medical or health care record 17
Computerized order entry 13
Electronic medication administration 13
When asked if the facility has received feedback and/or penalty for presence or absence of policies or procedures regarding antibiotic surveillance or stewardship, 4 replied yes.
Alaska Native Medical Center
Alaska Psychiatric Institute
Alaska Regional Hospital
Alaska VA Healthcare System
Bartlett Regional Hospital
Central Peninsula Hospital
Chief Andrew Isaac Health Center
Denali Center
Fairbanks Memorial Hospital
Heritage Place
JBER DoD Joint Venture Hospital
Ketchikan Medical Center
Providence Alaska Medical Center
Providence Valdez Medical Center
Samuel Simmonds Memorial Hospital
Sitka COmmunity Hospital
South Peninsula Hospital
Wildflower Court
Wrangell Medical Center

20. Alaska Antimicrobial Stewardship Assessment Tool
Additional Comments regarding educational needs, challenges, or perceived barriers to implementation:
The biggest barrier to implementation is a lack of pharmacist training. Additional funding and creating training opportunities is essential for success.
We are just now starting an ASP, hope to create a standing committee, and are looking to collaborate with a hospital in town.
Examples of other ASPs in small hospitals would be helpful to start a program here.
There might be resistance from prescribers.
We would need help with pharmacist and provider education.
We are hindered by limited staffing and software.
Challenges for our program include: lack of quick and easy data extraction from the EHR for tracking abx use, interface issues between electronic systems, and lack of staffing for epidemiologic data analysis.

21. Alaska Antimicrobial Stewardship Assessment Tool
Additional Comments (cont…)
Plans underway to discuss newly developed outpatient antibiogram, however, providers often have a misperception that antibiotic resistance is less of a concern.
Ambulatory providers often prescribe the same antibiotics over and over for the same patient.
Lack of an in-house microbiology lab complicates our ability to track resistance trends.
We hope our new electronic health record will provide more comprehensive reporting.
Our ASP just started a few months ago and we need guidance on what to do in an outpatient facility.
Our program needs administrative support and an ID physician.
Although there is no formal ASP, there is a stewardship pharmacist who conducts most of the activities using national guidelines and has demonstrated positive outcomes.