1. Antimicrobial Stewardship Program 2 nd Quarter May 19, 2016 Jill Hanson, WHA DeAnn Richards, MetaStar

2. Objectives for Today Hospital Highlight – UnityPoint Health - Meriter Status of the state Update on pilot program Available resources Next steps Educational rollout plan

3. Antibiotic Stewardship Update Steve Ebert, PharmD

4. Antibiotic Stewardship Activities at Meriter Initiation of antimicrobial therapy Decision to treat- serum procalcitonin Initial antimicrobial selection Infectious diseases order sets Antibiotic selection booklet Antibiogram Antibiotic “alternatives” at order entry Antimicrobial de-escalation Patients treated with vancomycin Patients treated with “Antibiotic Stewardship Target” drugs Daily culture reports Rapid diagnostic tests to detect infection/colonization

5. Antibiotic Stewardship Activities at Meriter Duration of antimicrobial therapy Procalcitonin Increasing body of evidence supporting shorter durations of therapy and/or objective measures to support discontinuation 48-72 hour “Time Out” Documentation of interventions in Rounding Navigator Other easily measured metrics of effort # Days of therapy for specific antibiotics #Serum antibiotic concentrations obtained

6. Antibiotic Stewardship Activities at Meriter Prevention of disease Immunizations- actively screen candidates for influenza and pneumococcal vaccine and order where appropriate Clostridium difficile Identify patients treated with broad spectrum antibiotics that may predispose to C difficile infection Recommend probiotic therapy (controversial) when initiating broad spectrum antibiotic therapy

7. Prescribing Protocols

8. Positive Cultures with the EMR

9. Common Drug/Bug Targets

10. Antibiotic Prescribing in EMR

11. IV to PO Protocol

12. EMR documentation for Antibiotics

13. Antibiotic Stewardship Metrics Many ASP’s were developed to reduce expenditures Many antibiotics are now generic Expenditures for high-cost items are still important More consideration of possible benefits of high-cost drugs Antimicrobial resistance- could be considered the ultimate outcome measure Others: Process Outcomes

14. Staphylococcus aureus Meriter Hospital

15. Escherichia coli Meriter Hospital

16. Klebsiella pneumoniae Meriter Hospital

17. Pseudomonas aeruginosa Meriter Hospital

18. Measuring Antibiotic Usage

19. Antibiotic Purchases

20. Days of Therapy

21. Days of Therapy Graph

22. Medications Days of Therapy

23. ID Interventions Recorded by RPhs

24. Questions for Steve

25. Status of the State

26. NHSN Annual Survey

28. January 2016 Polling Responses The following reflects the current state of my hospital’s Antimicrobial Stewardship Program: We have extensive experience and have impacted our antimicrobial resistance - 0% We have moderate experience and are making progress - 14% We have limited experience with an Antimicrobial Stewardship Program - 27% We have no experience with an Antimicrobial Stewardship Program - 18% No answer - 41%

29. Wisconsin’s Landscape What is your biggest hurdle with starting an Antimicrobial Stewardship Program in your organization? Other competing priorities - 31% We don’t have a champion to lead to the team - 12% Leadership support - 12% Drug expertise - 8% IT limitations - 8% No answer - 31%

30. Prescribing Approaches Which of the following interventions have you implemented related to antibiotic prescribing (select all that apply)? Broad (e.g., time out, “look back” for appropriate use) - 17% Pharmacy-driven (e.g., P&T Committee/governing body approving interventions to be implemented) - 24% Diagnosis and Infections Specific (e.g., UTI, MRSA) - 24% We don’t have any yet - 31% No answer - 21%

31. Results Input during teleconferences, written suggestions via e-mail to create a Targeted Assessment for Prevention (TAP) style tool. Draft tool was reviewed twice noting possible improvements after each attempt. The final tool provides additional considerations and strategies to consider during an initial gap analysis.

32. Draft Overall Results

33. Lessons Learned Collaboration resulted in valuable discussions, based upon experience and implementation barriers. As a result, additional questions and formatting changes to the original CDC document were made to allow all hospitals, regardless of size and resources, to implement or improve their current ASP.

34. Next Steps TimelineTask May 2016 Finalize TAP tool Revisions to Phase Two Testing (TAP tool next steps process) June 2016 Distribute and train on new Antimicrobial Stewardship tool Phase Two Testing continues July 2016Phase Two materials distributed

35. Accreditation Standard from The Joint Commission Late in 2015, The Joint Commission proposed an accreditation standard for antibiotic stewardship in all healthcare facilities. The standard has 8 performance elements. The determination if they are approved and will go into effect Jan 2017 will occur this week.

36. Accreditation Standard from The Joint Commission Element 1: Leaders establish antimicrobial stewardship as an organizational priority. Element 2: Educate staff and licensed independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and antimicrobial stewardship practices. Education occurs upon hire and annually thereafter.

37. Accreditation Standard from The Joint Commission Element 3: Educate patients, and their families as needed, regarding the appropriate use of antimicrobial medications, including antibiotics. Element 4: The organization has an antimicrobial stewardship multidisciplinary team that includes the following members, when available in the setting: Pharmacist(s) Infection disease physician Infection preventionist(s)

38. Accreditation Standard from The Joint Commission Element 5: The organization’s antimicrobial stewardship program includes the following core elements: -Leadership commitment Accountability Drug expertise Action Tracking Reporting Education

39. Accreditation Standard from The Joint Commission Element 6: The organization’s antimicrobial stewardship program uses organization-approved multidisciplinary protocols. Element 7: The organization collects and analyzes data on its antimicrobial stewardship program, including antimicrobial prescribing and resistance patterns Element 8: The organization takes action on improvement opportunities identified in its antimicrobial stewardship program.

40. Upcoming Webinar – National Quality Partners

41. Webinar registration link - http://nqf.commpartners.com/se/Rd/Rg.aspx?491704

42. Questions Thank you for attending DeAnn Richards (drichard@metastar.com) Jill Hanson (jhanson@wha.org)