1. Communities of Care Antimicrobial Stewardship Collaborative 2014 Project Overview Carol Dietz RN, MBA, BSN, CPHQ

2. The Problem 2 “Growing concern about antimicrobial resistance and the need for practical strategies to manage antimicrobial use effectively has reached a global scale, and demand for education, tools and expertise has increased both in the U.S. and internationally. There is a need for a multifaceted strategy to increase the number of effective antimicrobials available, to reduce resistance to available antibiotic treatments, and to put existing research on this important topic into practice.”

3. Project Goal 3 To assist hospitals and their community partners to work together from April through July, 2014 to develop and implement antimicrobial stewardship programs based on their community- specific needs. needs.

4. Participant Expectations 4 Commit to appropriate antibiotic usage at your facility Commit to be the AMS champion in your facility Attend community meetings with your community partners Participate in monthly conference calls with Qualidigm Confer rights to NHSN data to Qualidigm (hospitals only) Complete the appropriate Antimicrobial Stewardship Environmental Scan for your facility

5. Participant Expectations continued….. Submit a copy of your facility's antibiogram to Qualidigm at kick-off session Collect monthly data and submit to Qualidigm for analysis Participate in kick-off and wrap-up collaborative face-to-face sessions

6. Community Expectations Community leader/Stewardship leader will sign the participation agreement Select one or two antimicrobial stewardship interventions to be implemented and monitored in your community Discuss data and other related issues at monthly community meetings Present findings/lessons learned at the wrap-up session

7. Project Timeline 7 Kick-off April, 2014 Knowledge transfer/reinforcement Complete AIM statement Draft work plan Monthly activities Regular meetings with your community partners to discuss progress and opportunities Qualidigm representative will attend as a resource Data collection as determined by each community Monthly conference calls with all Communities hosted by Qualidigm for peer-to-peer learning Monthly NHSN data entry by hospitals Technical assistance by Qualidigm as needed Wrap-up July, 2014 Celebration of wins Presentation by each participating Community

8. Antibiograms Used by clinicians (hopefully) to: – Assess local susceptibility rates – Aid in selecting empiric therapy – Monitor susceptibility and resistance trends

9. AMS Program Resources 9

10. AMS Checklist (CDC)  Leadership commitment: Dedicate necessary human, financial, and IT resources.  Accountability: Appoint a single leader responsible for program outcomes; physicians have proven successful in this role.  Drug expertise: Appoint a single pharmacist leader to support improved prescribing.  Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check antibiotic choice, dose, and duration (antibiotic timeout).  Track: Monitor prescribing and antibiotic resistance patterns.  Report: Regularly report to staff prescribing and resistance patterns, and steps to improve.  Educate: Offer education about antibiotic resistance and improving prescribing practices.

11. Breakout Session #1 Opportunity to discuss Barriers to implementing an AMS program as well as Best Practices that have been implemented as Antimicrobial Stewardship interventions. Breakout in specific settings: – Hospital – Nursing Home – Home Health There is a flip chart and facilitator assigned to your community group

12. Break-out Session #2 12 Opportunity to kick-start your antibiotic stewardship project within your community Break out into your “Community of Care” Develop a SMART AIM statement Create a Work Plan Identify missing community members and decide how to bring them up to speed Propose next meeting date to refine work plan, including those performance measure(s) that make the most sense Select a spokesperson to provide progress report to group at large

13. SMART AIM Statement (in Handouts)  S pecific – What is the goal or intent  M easureable – Defines the acceptance criteria against which the requirement can be evaluated  A ctionable – The actions the team can take to overcome any known barriers to achieving the proposed measurable results  R ealistic – Ensures that there are sufficient resources and time to achieve the aim statement  T imely – The goal has a target date

14. Create an AIM Statement using all the elements from your SMART outline

15. Develop a Work Plan Name of community Name of recorder Name of each facility AIM statement Others to recruit How workgroup fits into current community meeting Short term goals Performance measures – Process measures – Outcome measures Action Items

16. Sample Performance Measures 16 MRSA Bacteremia rate CDI rate Number of antibiotics reviewed concurrently, number of changes recommended by concurrent reviewer, number of recommended changes approved by treating MD, and resulting potential and actual cost savings All antibiotic orders have an indication and therapy is reassessed within 72 hours “Measure something!” - Dale Bratzler DO

17. Sample Performance Measures (continued) Cultures obtained before antibiotics administered for sepsis or systemic inflammatory response syndrome Patients who can be switched from intravenous to oral antibiotics are switched Review of all positive blood cultures for bug/drug mismatch

18. Sample Performance Measures (continued) Non-treatment of asymptomatic bacteriuria Compliance with SCIP antibiotic measures Antibiogram resistance Defined Daily Dose of antibiotic (DDD) per 1000 patient days Days of Therapy (DOT) per 1000 patient days 18

19. The New Model: A Spectrum of Activities Many approaches in between Bottom Line: Function Trumps Structure Comprehensive program led by ID trained physician and pharmacist Individual interventions based on goals of institution led by interested individual(s)

20. Community Focus Areas – Last Year Asymptomatic bacteriuria Handoff communication: hospital nursing home, HHA

21. Asymptomatic Bacteriuria Toolkit available on Qualidigm web-site http://www.qualidigm.org/index.php/current- initiatives/antimicrobial-stewardship- collaborative/asymptomatic-bacteriuria-tookit/ http://www.qualidigm.org/index.php/current- initiatives/antimicrobial-stewardship- collaborative/asymptomatic-bacteriuria-tookit/ Antibiotic order form Poster: “Ask me” campaign Handout for residents and family members Masonicare sample handout Handout for staff Monitoring tool Staff training curriculum outline Staff training scenarios

22. Lessons Learned by Participants Availability of tools in the public domain e.g. CDC The significant impact of antibiotic use and serious sequellae to residents/patients ASPs are worthwhile but challenging to get to work optimally; but any progress is better than none Increase use of urine dipsticks leads to increase in antibiotics. Need to eliminate use of dipsticks, need to education MD’s, APRN’s and nursing staff. Need to include antibiotic stewardship in nursing orientation program. How important it is to have open communication with families and physicians Some practical approaches to stewardship (much data on stewardship emphasizes the “why” but not the “how” to go about it) Multidisciplinary participation is essential That good, data-based, evidence-based answers are being developed Antimicrobial stewardship program represents an opportunity to improve patient safety I’ve learned a lot about the barriers to implementing antimicrobial stewardship programs in health care facilities

23. Lessons Learned (cont.) Decrease antibiotic use, decrease infections, increase staff/family awareness How important it is to decrease the use of antibiotics Obtain lab test before treating resident One step at a time; this has been very informative The need to educate staff, families and residents The need to utilize antibiograms Commonalities among hospital systems Don’t forget CNAs Value of communication Utilize other Communities of Care to assist our current program The power of data to measure success/progress

24. 24 Tools Implementation Strategies Support Structure Networking Peer-to-Peer Learning

25. Questions? 25