1. Program Overview Hosts: – Jan Ratterree, RN, CIC, Georgia Hospital Association – Jesse Jacob, MD, MSc, Emory University Hospital Midtown – Jeanne Negley, MBA, HAI Surveillance Director, DPH Stewardship Story: – Lisa Ferraro, PharmD, Mountain Lakes Medical Center Advancing Antimicrobial Stewardship in Community Hospitals in Utah – Edward Stenehjem, MD, MSc, Intermountain Healthcare Thank You California Department of Public Health Illinois Department of Public Health

3. Advancing Antimicrobial Stewardship in Community Hospitals in Utah May 6, 2015 Edward Stenehjem, MD, MSc Division of Infectious Diseases, Intermountain Healthcare Medical Director of Antimicrobial Stewardship, IMC Co-Chair Intermountain Healthcare Antimicrobial Stewardship Committee

4. Advancing Antimicrobial Stewardship in Community Hospitals in Utah Eddie Stenehjem, MD MSc Infectious Diseases and Antimicrobial Stewardship May 6 th, 2015

5. Objectives Describe how antimicrobial usage in small, community hospitals compares to large urban centers Understand the basic concepts of Intermountain’s SCORE study and how it can apply to your hospital

6. What is Antibiotic Stewardship? Systematic efforts to optimize the use of antibiotics to maximize benefits, minimize resistance and decrease adverse events

7. Core Elements Antibiotic Stewardship Program Leadership commitment from administration Single leader responsible for outcomes Single pharmacy leader Antibiotic use tracking Regular reporting on antibiotic use and resistance Educating providers on use and resistance Specific improvement interventions http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

8. Improvement Interventions Antimicrobial Stewardship Prospective Audit with Feedback Formulary Restriction Antimicrobial Indications Guidelines and Clinical Pathways Education Dose optimization IV to PO conversion Rapid Diagnostics Decision Support

9. What is Antibiotic Stewardship? Antimicrobial Stewardship Prospective Audit Formulary Restriction Antimicrobial Indications Guidelines and Clinical Pathways Education Dose optimization IV to PO conversion Rapid Diagnostics Decision Support Structured mechanism of optimizing antibiotic use This isn’t a new topic

10. Sir Alexander Fleming June 26, 1945 The public will demand [the drug and]…then will begin an era… of abuses….In such a case the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with penicillin-resistant organism. Fleming A. Penicillin’s finder, assays its future. New York Times. 1945; 21

11. Why Stewardship? 1. All Antibiotics Fail 2. Rising Resistance 3. Dry (damp?) pipeline 4. It is the right thing to do

12. Why Stewardship? 1. All Antibiotics Fail 2. Rising Resistance 3. Dry (damp?) pipeline 4. We will have to

13. Presidential Report

14. National Action Plan 1.Slow the emergence of resistance bacteria 2.Strengthen National One-Health Surveillance 3.Advance development of rapid dx tests 4.Accelerate research and development of new abx 5.Improve international collaboration

15. Goal 1 Within three years: –All hospitals that participate in Medicare and Medicaid programs must comply with Conditions of Participation (COP). The Centers for Medicare Medicaid Services (CMS) will issue new COPs or revise current COP Interpretive Guidelines to advance compliance with recommendations in CDC’s Core Elements of Hospital Antibiotic Stewardship Programs. All acute care hospitals governed by the CMS COP will implement antibiotic stewardship programs.

16. SCOPE 2005 United State Hospitals 4935 Registered Hospitals 72% have < 200 beds Most of these are without antibiotic oversight All will be included in National Action Plan Very few studies of stewardship in these settings AHA Statistics http://www.aha.org/research/rc/stat-studies/index.shtml

17. Since 1975 22 hospitals 2,784 licensed beds Since 1983 Health plans 700,000+ members Since 1994 1,200 employed physicians 558 advanced practice clinicians Since 1997 10 key service lines Intermountain Healthcare Highly-Integrated Health System Hospitals SelectHealth Medical Group Clinical Programs

18. Intermountain Antibiotic Stewardship Increased emphasis in the past 5 years at our large facilities Corporate AS Committee –Subcommittee of Infection Control Guidance Council Corporate Outpatient AS Committee –Subcommittee of Primary Care Clinical Program Individual ASP Committees at our large sites NO FOCUS ON OUR SMALLER HOSPITALS

20. HospitalStaffed Bed Count Intermountain Medical Center472 Utah Valley375 McKay-Dee300 Primary Children's289 Dixie Regional245 LDS243 Logan Regional128 American Fork89 Riverton88 Alta View66 Valley View48 Park City Medical Center30 Cassia Regional25 Sevier Valley24 Orem Community18 Bear River Valley16 Heber Valley16 Delta Community15 Garfield Memorial14 Sanpete Valley13 Fillmore Community7 Large Urban Hospitals -ASP focused -Formal ID consultation available Small Community Hospitals -15 Hospitals -597 Beds -25% of IHC Beds -No formal ASPs -No Infectious Diseases MD support -All with full time pharmacy staff

21. Antimicrobial Use in Small Hospitals Antibiotic Usage Using NHSN AU Data How does usage differ across our system? –Small vs Large Hospitals –Usage and Case Mix Index (CMI) –Usage and Spectrum

22. Small vs. Large Hospitals 3 year average 15 Small IHC Hospitals 3 Large IHC Hospitals

23. Usage and Spectrum

25. Need for Stewardship 63%

26. Usage Conclusions SCHs have similar antibiotic usage rates as large, urban hospitals. There is significant variation in antibiotic selection in SCHs. Antibiotic Stewardship in SCHs is critical

27. SCORE Stewardship in Community Hospitals: Optimizing Outcomes and Resources (SCORE) Funded by: Pfizer Independent Grants for Learning and Change The Joint Commission

28. Project Aim: SCORE Stewardship in Community Hospitals Optimizing Outcomes and Resources Define an antibiotic stewardship strategy for Intermountain’s smaller hospitals that optimizes outcomes while maximizing resources

29. Study Design: Cluster Randomized Clinical Trial Study sites: 15 small hospitals Intervention: Low Resource Utilization – 5 hospitals Medium Resource Utilization – 5 hospitals High Resource Utilization – 5 hospitals

30. ALL Sites – Antibiotic Best Practices IV to PO Conversion Antibiotic Indications 48 hour Antibiotic “Timeout” Access to: ID clinicians and pharmacists Monthly Hospital Antibiotic Utilization Report Low Resource Medium Resource High Resource Education Initiative - Pharmacy Topics Covered:  Stewardship Basics  Antibiotic Time Out  IV to PO  Antibiotic Indications  Bug-Drug mismatch  When to call ID KAP Survey Education Initiative - Pharmacy Topics covered (in addition to low group):  De-escalation - mylearning  Anaerobes - mylearning  Restrictions - mylearning  Allergy Verification  Stewardship Pearls / Q and A KAP survey Education Initiative - Pharmacy Topics covered (in addition to low group):  De-escalation - mylearning  Anaerobes - mylearning  Restrictions - mylearning  Allergy Verification  Stewardship Pearls / Q and A KAP survey PAF – lite: Audit a limited number of antimicrobial agents* and provide feedback Restriction (local pharmacy review) of selected antimicrobials*** * Vancomycin, carbapenems, piperacillin/tazobactam, and cefepime PAF: Audit an expanded list of antimicrobial agents** and provide feedback Restriction (Infectious Diseases review) of selected antimicrobials*** ID study staff to review positive blood culture results and all cultures with MDROs. ** Vancomycin, carbapenems, piperacillin/tazobactam, cefepime, aminoglycosides, ciprofloxacin, levofloxacin, ceftriaxone, and ampicillin/sulbactam *** Restricted agents: Meropenem, linezolid, daptomycin, ceftaroline, tigecycline, antifungals.

31. Antibiotic Best Practices IV to PO Conversion Antibiotic Indications 48 Hour Antibiotic “Timeout” Monthly Antibiotic Report Access to ID Consultation

33. Antibiotic Time-Out

34. Usage Reports

36. Access to ID Clinicians Adults and Pediatrics One number: 1-801-50-SCORE Call: Anytime –Adults: Stenehjem –Pediatrics: Attending on call at PCMC

37. https://my.intermountain.net/qpsafety/Pages/SCORE.a spx

38. ALL Sites – Antibiotic Best Practices IV to PO Conversion Antibiotic Indications 48 hour Antibiotic “Timeout” Access to: ID clinicians and pharmacists Monthly Hospital Antibiotic Utilization Report Low Resource Medium Resource High Resource Education Initiative - Pharmacy KAP survey Topics Covered:  Stewardship Basics  Antibiotic Time Out  IV to PO  Antibiotic Indications  Bug-Drug mismatch  When to call ID Education Initiative - Pharmacy KAP survey Stewardship Basics – all of those in Low, plus  De-escalation - mylearning  Anaerobes - mylearning  Restrictions - mylearning  Allergy Verification  Stewardship Pearls / Q and A Education Initiative - Pharmacy KAP survey Stewardship Basics – all of those in Low, plus  De-escalation - mylearning  Anaerobes - mylearning  Restrictions - mylearning  Allergy Verification  Stewardship Pearls / Q and A PAF – lite: Audit a limited number of antimicrobial agents* and provide feedback Restriction (local pharmacy review) of selected antimicrobials*** * Vancomycin, carbapenems, piperacillin/tazobactam, and cefepime PAF: Audit an expanded list of antimicrobial agents** and provide feedback Restriction (Infectious Diseases review) of selected antimicrobials*** ID study staff to review positive blood culture results and all cultures with MDROs. ** Vancomycin, carbapenems, piperacillin/tazobactam, cefepime, aminoglycosides, ciprofloxacin, levofloxacin, ceftriaxone, and ampicillin/sulbactam *** Restricted agents: Meropenem, linezolid, daptomycin, ceftaroline, tigecycline, antifungals.

39. Prospective Audit and Feedback Pharmacy will review the following medications after 48 hours of administration Vancomycin Carbapenems Piperacillin/tazobactam Cefepime Fluoroquinolones Aminoglycosides Ceftriaxone Ampicillin/sulbactam

40. Restrictions The following drugs are restricted –Daptomycin, linezolid, ceftaroline –Imipenem/meropenem, tigecycline –Amphotericin, vori/posaconazole, micafungin Medium group – local pharmacy control High group – ID pharmacist control

41. High Group Infectious diseases involvement –Positive blood cultures –S. aureus bacteremia –CNS infections –MDRO –Home IV antibiotic therapy

42. SCORE Outcomes Primary Outcome: –Antimicrobial use Secondary Outcomes: –Stratified antimicrobial use –Incidence of C. difficile infection –Incidence of MDRO infections (VRE, ESBL, CRE, MRSA, FQ R E.coli) –Feasibility –Cost

43. Significance One of the largest AS studies ever done First AS study to evaluate effectiveness of different intervention levels First randomized AS study done in small, community hospitals

44. Timeline Jan/Feb 2014: Education March 2014 – June 2015: Intervention July 2015 – Aug 2015: Analyze Data Sept 2015: Present Intermountain Plan

45. Conclusions 70% of US hospitals have < 200 beds, most don’t have ID specialists/pharmacists SCHs use antibiotics at a similar rate compared to larger facilities Stewardship is feasible in SCHs, hopefully SCORE will tell us more

46. Thank You eddie.stenehjem@imail.org

47. Webinar Contact: Jeanne Negley (Jeanne.Negley@dph.ga.gov) Questions? Advancing Antimicrobial Stewardship in Community Hospitals in Utah

48. Upcoming Best Practice Power Hour Webinar’s: Wednesday, May 13 th at 11:00 a.m. – Redmond Regional Medical Center “Improving Patient Flow in an Emergency Department, a Hospital-wide Initiative” Wednesday, May 20 th at 11:00 a.m. – Grady Health System/Grady Memorial Hospital “Heading Toward Zero: Falls Reduction Patient Safety Program”

49. Angelina Davis, PharmD, MS, BCPS (AQ-ID) and Daniel Sexton, MD Duke Antimicrobial Stewardship Outreach Network Next Antimicrobial Stewardship Series Webinar: June 3, 2015, 12 – 1 pm (ET ) Webinar: https://gharef.webex.comhttps://gharef.webex.com Webinar Password: Gha060315 Teleconference: 877-443-9072 Effective Communication between Physicians and Pharmacist for Stewardship

50. THANK YOU! Thank you Dr. Stenehjem, Lisa Ferraro, and all of our participates from Georgia, California, Illinois. Copy of the slides and webinar recording will be available within one week.