Antimicrobial Stewardship Toolkit

93 Pages·2011·6.19 MB·English

Greater New York Hospital Association
United Hospital Fund
ANTIMICROBIAL STEWARDSHIP TOOLKIT
BEST PRACTICES FROM THE GNYHA/UHF ANTIMICROBIAL STEWARDSHIP COLLABORATIVE
ANTIMICROBIAL STEWARDSHIP PROJECT PARTICIPANTS
ACUTE CARE FACILITIES LONG TERM CARE FACILITIES
• Lutheran Medical Center • Lutheran Augustana Center for
• North Shore University Hospital Extended Care and Rehabilitation
• St. Catherine of Siena Medical • Stern Family Center for Extended
Center Care and Rehabilitation
• St. Catherine of Siena Nursing
Home
ANTIMICROBIAL STEWARDSHIP STEERING COMMITTEE
DAVID CALFEE, MD BERNARD J. NASH, MD, FACP
Chief Hospital Epidemiologist, NewYork- Diplomat, American Board of Infectious
Presbyterian Hospital/Weill Cornell and Diseases, Co-Chair Infection Control
Chairman, GNYHA/UHF Antimicrobial Committee, Member Antimicrobial
Stewardship Project Stewardship Program, Good Samaritan
Hospital Medical Center
HEIDE CHRISTENSEN, RPH, MS
Clinical Pharmacy Manager, Good Sa- BELINDA OSTROWSKY, MD, MPH
maritan Hospital Medical Center Infectious Diseases Physician, Montefiore
Medical Center and Assistant Professor
Medicine, Division of Infectious Diseases,
FRANCIS EDWARDS, RN
Albert Einstein College of Medicine
Director, Infection Control, Good
Samaritan Hospital Medical Center
RAFAEL RUIZ, PHD
Assistant Director, Clinical Practice and
MIRIAM ELLISON, PHARMD, CGP
Outcomes Research, GNYHA
Clinical Pharmacist, Good Samaritan
Hospital Medical Center
GINA SHIN, MPH
Project Manager, Regulatory and
LORI FINKELSTEIN-BLOND, RN-MA
Professional Affairs, GNYHA
Director, Performance Improvement,
The Mount Sinai Medical Center
ISMAIL SIRTALAN, PHD
Vice President and Executive Director,
CINDY FONG, PHARM D, BCPS
The Health Economics and Outcomes
GNYHA Pharmacy Consultant
Research Institute, GNYHA
KATE GASE, MPH, CIC
RACHEL STRICOF, MPH, CIC
Hospital-Acquired Infection Reporting
Bureau Director, Bureau of Hospital-
Program, Regional Representative,
Acquired Infections, NewYork State
NewYork State Department of Health
Department of Health
HILLARY JALON, MS
ROXANNE TENA-NELSON, JD, MPH
Project Director, Quality Improvement,
Executive Vice President, Continuing Care
United Hospital Fund
Leadership Coalition
CHRISTINE MARTIN, RPH, MS, CGP
MARIA WOODS, ESQ
Clinical Pharmacist, Good Samaritan
Vice President, Legal, Regulatory, and
Hospital Medical Center
Professional Affairs, GNYHA
WWW.GNYHA.ORG/ANTIMICROBIAL
PUBLISHED 2011
TABLE OF CONTENTS
I. WHY ANTIMICROBIAL STEWARDSHIP? 5
A. Introduction and Background
B. Overview of the GNYHA/UHF Antimicrobial Stewardship Project
C. Overview of the Toolkit
D. Toolkit Map
II. GETTING STARTED 9
A. Assessment of Current Practices
B. Establishing a Team
III. ANTIMICROBIAL STEWARDSHIP STRATEGIES 13
A. Planning and Implementation
B. Strategies
IV. SUSTAINING AN EFFECTIVE ANTIMICROBIAL STEWARDSHIP PROGRAM 17
A. Data Collection
B. Making the Business Case for an Antimicrobial Stewardship Program
C. Antimicrobial Stewardship Programs Support Infection Prevention Strategies
V. ADDITIONAL RESOURCES 21
VI. APPENDICES 23
1
2
PREFACE:
OVERVIEW OF THE TOOLKIT
CHAPTER I: WHY ANTIMICROBIAL STEWARDSHIP?
This chapter describes the burden of antimicrobial resistance and the rationale for an antimicrobial stewardship pro-
gram. An overview of the GNYHA/UHF Antimicrobial Stewardship Project and a Toolkit “roadmap” are provided.
CHAPTER II: GETTING STARTED
This chapter describes recommended preliminary steps for health care facilities to initiate a comprehensive antimicrobial
stewardship program. Specific ways to get started are highlighted, including assessing current practices and forming an
antimicrobial stewardship team.
CHAPTER III: ANTIMICROBIAL STEWARDSHIP STRATEGIES
This chapter describes essential elements and provides strategies used by health care facilities to plan and implement an
effective antimicrobial stewardship program. Common challenges encountered while implementing an antimicrobial
stewardship program and strategies to overcome them are also outlined.
CHAPTER IV: SUSTAINING AN EFFECTIVE ANTIMICROBIAL STEWARDSHIP PROGRAM
This chapter offers a list of process and outcomes measures that may be used to monitor and assess the impact of an
antimicrobial stewardship program. Recommendations on how to make the “business case” for antimicrobial steward-
ship programs and how to sustain an effective stewardship program within an institution are included. Additionally, the
relationship between antimicrobial stewardship programs and infection prevention strategies is discussed.
CHAPTER V: ADDITIONAL RESOURCES
CHAPTER VI: APPENDICES
This chapter provides tools developed by health care facilities and resources created by GNYHA/UHF for the Antimicro-
bial Stewardship Project.
3

CHAPTER I:
WHY ANTIMICROBIAL STEWARDSHIP?
A. INTRODUCTION AND BACKGROUND ment of cure, avoidance of toxicity, and other adverse
Despite widespread efforts to control the spread of mul- effects) and of the larger population (avoidance of
tidrug-resistant organisms (MDROs), the incidence of emergence or propagation of antimicrobial resistance).
infections attributed to MDROs among hospital patients Through ongoing monitoring and, when necessary, a
continues to rise. Infections caused by MDROs are associ- change in antimicrobial prescribing practices (e.g., op-
ated with a significant deterioration in clinical outcomes, timal selection, dose, duration, and route of therapy)
including an increased risk of death and significantly successful stewardship programs have improved patient
increased costs, mostly attributable to increased lengths care, decreased antimicrobial use and resistance, and
of stay. In a study done by Cosgrove, cephalosporin-re- reduced unnecessary pharmacy expenditures, in addi-
sistant Enterobacter infections increased mortality and tion to other direct and indirect hospital costs. In fact,
length of stay, and resulted in an average attributable Antimicrobial Stewardship Programs (ASPs) have the
hospital charge of $29,379.1 Further, antibiotic resis- potential to become financially self-supporting. Some
tance is strongly correlated with antibiotic prescribing programs demonstrated a 22% to 36% decrease in anti-
patterns. While antimicrobial usage has undoubtedly microbial use, which correlated to an annual savings of
reduced mortalities caused by infections, resistance to $200,000 to $900,000.5
these drugs has also increased.2 Studies show that up to
50% of antimicrobial use is inappropriate, which may Some of the problems health care institutions currently
include:3 face in implementing successful ASPs include communi-
1. Use of antibacterial medications for the treatment cating as a team about treatment plans and appropriate
of syndromes not caused by bacteria; antibiotic selection. Additionally, the burden of control-
2. Treatment for culture results that reflect ling infection rates has traditionally been the sole re-
colonization or contamination rather than sponsibility of infection control practitioners. However,
infection; realizing an effective and sustainable ASP necessitates a
3. Administration of broad spectrum antibiotics where culture change that shifts responsibility for controlling
narrow spectrum agents are equally effective; infection rates from one discipline to all members of the
4. Prescription of antibacterial therapy courses that health care team. This can only be achieved through
are longer than necessary; and active, multidisciplinary participation: infectious dis-
5. Prescription of antibacterial agents at inappropriate ease-trained physicians, clinical pharmacists, clinical
doses. microbiologists, hospital epidemiologists, senior institu-
tional leadership, and champion prescribing physicians.
Consequently, unnecessary or inappropriate use of an-
tibiotics has increased rates of serious diseases or com-
plications such as Clostridium difficile– (C. difficile–)
associated diseases.4 To address these issues, health care
institutions are beginning to rely on stewardship pro-
1. Cosgrove, S.E., K.S. Kaye, G.M. Eliopoulous, et al. “Health and Economic
grams to manage antimicrobial usage with the goal of Outcomes on the Emergence of Third-generation Cephalosporin Resistance
in Enterobacter Species.” Archives of Internal Medicine (2002) 162: 185–190.
reducing the incidence of MDRO infections, improving
2. MacDougall C and R.E. Polk, “Antimicrobial Stewardship Programs in
patient outcomes, and reducing costs. Health Care Systems,” Clinical Microbiology Reviews (Oct. 2005) 638–656.
3. Gerding D.N. “The Search for Good Antimicrobial Stewardship.” Journal
on Quality Improvement (August 2001) 27(8): 403–404.
4. Dellit T.H., R.C. Owens, J.E. McGowan, et al. “Infectious Disease Society
Antimicrobial stewardship is a rational, systematic ap-
of America and the Society for Healthcare Epidemiology of America:
proach to the use of antimicrobial agents in order to Guidelines for Developing an Institutional Program to Enhance Antimicrobial
Stewardship.” Clinical Infectious Diseases (Jan. 2007) 44: 159–177
achieve optimal outcomes—those of the patient (achieve- 5. See note 4.
5
Chapter I: Why Antimicrobial Stewardship? cont.
B. OVERVIEW OF THE GNYHA/UHF ANTI- physician and/or a clinical pharmacist—team members
MICROBIAL STEWARDSHIP PROJECT communicated effectively and expressed enthusiasm to
Funded by the NewYork State Department of Health continue this work. When one or more well-respected
(DOH), from October 2009 to April 2010 the Greater clinical champions are committed to spearheading the
New York Hospital Association (GNYHA), in partner- ASP, it becomes easier to gain acceptance of the pro-
ship with the United Hospital Fund (UHF), assisted a gram from other clinicians. Along with these positive
small group of acute care and long term care (LTC) lessons learned, teams participating in the Antimicrobial
facilities in establishing ASPs within their institutions. Stewardship Project sometimes encountered challenges
Guided by a Steering Committee comprising expert as they pursued implementation, as explained below.
infectious disease–trained physicians, clinical pharma-
cists, hospital epidemiologists, senior leadership, and Faculty-Specific Challenges
representatives from DOH, as well as GNYHA affiliates While the interaction and communication between the
the Continuing Care Leadership Coalition (CCLC) and hospital and LTC facility teams was extremely effec-
The Health Economics and Outcomes Research Insti- tive, there were certain instances in which the contact
tute (THEORI), GNYHA/UHF developed this evidence- between partnering facilities could have been improved.
based toolkit to assist other health care facilities with Specifically, the acute care and LTC providers frequently
implementing an effective and sustainable ASP. spoke about the same subject matter in different ways.
For future initiatives similar to this one, GNYHA will
Recruiting Participants consider the fact that acute care and LTC facilities may
GNYHA identified three hospitals that had been suc- use different vocabulary and have different approaches
cessfully participating in the DOH-sponsored GNYHA/ to accomplishing their goals, and ways of communicat-
UHF C. difficile Collaborative and that also were in ing issues.
the early stages of implementing ASPs. These selected
facilities included representation from academic (major Staffing and Team Challenges
teaching), smaller teaching, and community (with most- Participants encountered challenges to team dynamics
ly voluntary physicians) hospitals. Additionally, selected and composition during this project. For example, one
facilities were required to each identify and partner with team relied heavily on one person to implement their
an LTC facility. Both acute care and LTC facilities were program. This initiative is a team effort which, to be
required to create a multidisciplinary team that included successful, needs administrative support and interdis-
representation from infection control, clinical phar- ciplinary involvement from infectious disease–trained
macy, clinical microbiology, epidemiology, and facility physicians, clinical pharmacists, and other clinicians.
leadership and operations. The reliance on one individual to manage the program
decreases the potential for a successful and/or sustain-
Lessons Learned able ASP. Moreover, senior leadership support is critical
Hospital and LTC facility teams produced impressive to achieving buy-in and interdisciplinary team involve-
accomplishments in a relatively short period of time ment.
during the GNYHA/UHF Antimicrobial Stewardship
Project. Not surprisingly, one of the most encouraging Engaging prescribing physicians was challenging for
lessons learned was that teams succeed when consis- some teams, but is a necessary component for success.
tently supported by active, committed senior leadership. Hospitals and LTC facilities that provided education
Senior leadership involvement is essential to ensure that about antimicrobial stewardship to physicians and that
the ASP is sustainable, and that the team remains moti- attained substantial support and commitment from clin-
vated to achieve the goals for the project. Further, when ical leadership and medical directors were able to effec-
the team functioned well—with a consistent champion tively achieve their goals with prescribers.
or team leader, such as an infectious disease–trained
6
Chapter I: Why Antimicrobial Stewardship? cont.
OVERVIEW OF THE TOOLKIT
This toolkit is based on published guidelines and the experiences of the six facilities that participated
in the GNYHA/UHF Antimicrobial Stewardship Project. As you will see through the examples provided,
ASPs vary from facility to facility.6 The resources included are intended to provide a basic framework that
can be tailored to suit other institutions irrespective of the facility’s size, academic teaching status, staffing
model (voluntary vs. staff physician models), formulary, prescribing practices, patient population, level of
implementation, or available resources. Although each institution is confronted with unique challenges,
this toolkit is designed to provide individual institutions with a general guide to the implementation of a
successful ASP. (See Toolkit Map on Page 6.)
Suggestions for Use
Please read this toolkit in its entirety prior to program development.
Limitations of the Toolkit
The six participating facilities may not be representative of “typical” facilities. The three hospitals had
prior experience with the GNYHA/ UHF Collaborative model and were affiliated with the partnering LTC
facilities. Also, the project’s limited timeframe prohibited formal data collection, although some facilities
implemented their own data collection strategies. While quantitative data is not available, this project
appears to have significantly impacted the antimicrobial stewardship processes and operations at the
participating facilities.
6. Weber S, et al. “The Cost of Antibiotic Resistance.” Joint Commission Resources. 2009.
7
Chapter I: Why Antimicrobial Stewardship? cont.
GNYHA/UHF ANTIMICROBIAL STEWARDSHIP TOOLKIT MAP
ASSESSMENT OF ESTABLISH PLANNING AND IM- OUTCOMES AND
CURRENT PRACTICES CORE TEAM PLEMENTATION BUSINESS CASE
• Pharmacy: Review ag- • Infectious disease–trained • Identify 1 to 2 target areas • Identify data sources and
gregate antibiotic use and physician for intervention. develop ongoing data col-
patterns of use. • Clinical pharmacist u Common clinical infec- lection strategies.
• Clinical microbiology: • Clinical microbiologist tious syndromes treated • Consider usage, clinical,
Review rates of resistance in • Infection control representa- at the facility (e.g., UTI, microbiologic, and costs.
common pathogens. tive CAP, “fever”) • Present program’s clinical
• Identify common clinical in- • Epidemiologist u Specific pathogens outcomes and business
fectious disease syndromes. • IT Representative u Specific antimicrobial case (e.g., impact on costs)
• Identify whether an antibio- • Senior leadership agents to leadership.
gram is currently developed • Identify group of champion • Strategize rollout.
and disseminated to all de- prescribing physicians u Consider:
partments and prescibers. • Hospital-wide vs. Unit
• Identify IT infrastructure • Resources
(e.g., CPOE, computer- • Timeline
based surveillance for u Determine which
antibiotic use). strategies may be most
• Administer baseline survey feasible and effective for
to assess clinicians’ baseline your institution (Figure
knowledge and perception A).
of antimicrobial resistance, u Develop materials to
prescribing and steward- educate facility staff.
ship.
FIGURE A - STRATEGIES
FIGURE B - SCENARIOS
1. Develop or update antibiogram.
AND STRATEGIES USED
2. Develop guidelines (e.g., care path) for diagnosis, treatment, and duration
• Overtreatment of asymptomatic
of antibiotic therapy and other interventions to treat infections.
bacteriuria—Strategies 2, 7, 8
3. Identify dose optimization strategies.
and 9
4. Provide guidelines for parenteral to oral conversion.
• Patients on broad-spectrum
5. Create formulary decisions, including antibiotic restrictions.
antibiotics—Strategies 2, 6, 8,
6. Develop policy/guidelines to streamline/de-escalate therapy.
and 9
7. Develop antimicrobial order forms with algorithms for common entities.
8. Provide continuous prospective review with feedback and interventions.
9. Communicate recommendations via chart stickers, notes, or face-to-face.
8