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Antimicrobial Stewardship – the State Health Department Perspective Marion A. Kainer MD, MPH, FRACP, FSHEA Healthcare Associated Infections and Antimicrobial Resistance Program NIAA Antibiotic Stewardship: From Metrics to Management | Nov. 4, 2015
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Page 1: the State Health Department Perspective - Symp... · the State Health Department Perspective ... infrastructure ... Surveillance systems and informatics ...

Antimicrobial Stewardship – the State Health Department Perspective

Marion A. Kainer MD, MPH, FRACP, FSHEA Healthcare Associated Infections and Antimicrobial Resistance Program

NIAA Antibiotic Stewardship: From Metrics to Management | Nov. 4, 2015

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Acknowledgements • CDC

Funding support: ELC, EIP, CSTE HAI fellow

National Healthcare Surveillance Network [NHSN] infrastructure

Technical support

• Reporting partners: Laboratories, healthcare facilities, infection preventionists, pharmacists, clinicians

• Multidisciplinary Advisory Group on HAI & AMR

• Tennessee Department of Health [TDH]

Surveillance systems and informatics

Healthcare associated infections & antimicrobial resistance

No conflicts of interest

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Multidisciplinary Advisory Group on HAI & AR

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Every Infection/HAI Prevented, Represents:

http://www.tn.gov/health/topic/hai

One less episode of antibiotic use and thus one less opportunity for the development of resistance

One less exposure to a potentially resistant infection

CLABSI in Adult/Ped ICU, TN

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Standardized Infection Ratio (SIR): Risk Adjusted Summary Measure

• SIR > 1.0: # infections are HIGHER than predicted – SIR= 1.5: # infections = 50% HIGHER than predicted

• SIR < 1.0: # infections are LOWER than predicted – SIR= 0.4: # infections = 60% LOWER than predicted

Observed (O) HAIs Predicted (P) HAIs

To calculate O, sum the # of HAIs among a group

To calculate P, requires the use of the appropriate aggregate data (risk-adjusted rates) (e.g., national NHSN data for 2006-2008)

SIR=

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CLABSI* – Adult/Pediatric ICUs, TN 1/2008- 12/2014 Start CLABSI Collaborative: CUSP

HHS Goal

* Central Line Associated Blood Stream Infections [CLABSI]

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CLABSI – Adult/Pediatric ICUs, TN 1/2008- 12/2014 Start CLABSI Collaborative: CUSP

First report sent to hospitals with hospital specific data

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Hospital A: CLABSIs in Adult & Pediatric ICU

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Targeting facilities: TAP Strategy using the CAD (or Number Needed to Prevent)

CAD = Cumulative Attributable Difference = ObsFACILITY - (ExpFACILITY*HHS Goal SIR)

2013 HHS Goals

SIR=0.75 (SSI, CAUTI, MRSA) SIR=0.50 (CLABSI) SIR=0.70 (CDI)

See also: Soe, MM et al. A Mathematical Model to Prioritize Healthcare Facilities for High Prevention Impact on Healthcare-Associated Infections. CSTE Annual Conference 2013. https://cste.confex.com/cste/2013/webprogram/Paper2070.html Soe M, Gould CV, Pollock D, Edwards J. Targeted assessment for prevention of healthcare-associated infections: a new prioritization metric. Infect Control Hosp Epidemiol 2015 (in press). http://www.cdc.gov/hai/prevent/tap.html

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http://tn.gov/health/article/hai-prevention-calculator

TN HAI Prevention Calculator

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CLABSI – Neonatal ICUs, TN 7/2008- 12/2014

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Emerging Infections Program (EIP)

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183 hospitals in 10 States (EIP) [25 hospitals in TN] 11,282 patients; HAI prevalence: 4% Most common HAI pathogen: Clostridium difficile Extrapolation: estimate 721,854 HAIs in the US in 2011

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Overall Prevalence: 49.9% TN: highest: 56.3% [lowest state: 43.9%]

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• ICUs • Medical • Surgical • Med/Surg • Hem/Onc

AU Prevalence in Different Hospital Locations

Overall: 49.9%

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Lower Resp tract UTI Skin, soft tissue GI Empiric BSI

Infection Sites for Which Patients Received Antimicrobial Treatment

34.6% 22.3% 16.1% 12.6% 8.5% 9.4%

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5 Most Common Antibiotics: Community Onset (CO) vs Healthcare Facility Onset (HO)

CO HO

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63.4%

52.4% 54.6%

Small Medium Large

Slide shown at TN MDAG, March 27, 2012; TN provisional data

Proportion of Patients on Antibiotics, by Facility Size, TN, 2011

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88.8% 83.6%

67.9%

10.9% 16.1%

31.7%

Small Medium Large

IV/IM Oral Enteral

Slide shown at TN MDAG, March 27, 2012; TN provisional data

Route of Administration by Facility Size, TN, 2011

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Rationale for Antimicrobial Administration at Patient Level, TN, 2011

46.0%

9.6%

1.6% 0.3% 2.4%

Treatment ofActive Infection

Surgicalprophylaxis

Medicalprophylaxis

Non infection Nonedocumented

Slide shown at TN MDAG, March 27, 2012; TN provisional data

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Most Common Antimicrobial Agents Given for Active Infection, TN, 2011

0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00

VancomycinCeftriazoneLevoflaxin

Pip/tazoAzithromycinMetronidazole

CiproflaxinFluconazoleClindamycin

LinezolidMoxifloxazine

DoripenemMeropemen

Proportions of Antimicrobials Given

Slide shown at TN MDAG, March 27, 2012; TN provisional data

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Assessment of Appropriate Antimicrobial Use Among Patients in Acute Care Hospitals in Tennessee (EIP Pilot)

High proportion • Inadequate

microbiology testing

• Inappropriately tailored antimicrobial therapy

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Antimicrobial Stewardship Annual

Hospital Survey 2014

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http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Core Elements of Hospital Antimicrobial Stewardship Programs

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7 Core Elements of Antimicrobial Stewardship • Leadership commitment: Dedicate necessary human, financial, and IT

resources • Accountability: Appoint a single leader responsible for program

outcomes. • Drug expertise: Appoint a single pharmacist leader to support

improved prescribing • Act: Take at least one prescribing improvement action, such as

requiring reassessment after 48 hours to check drug choice, dose, and duration

• 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

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Core Elements: TN vs US (national), 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Accountability Action Drug-expertise Education Leadership Reporting Tracking

The seven elements of antibiotic stewardship in TN compared to the US.

Nationwide(N=4,091)

Tennessee(N=112)

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Aggregate Core Elements: TN vs US, 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4 or less 5 or more

Aggregated number of core elements

Nationwide (N=4,091)Tennessee (N=112)42%

70%

30%

58%

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Tennessee Healthcare Coalitions/EMS Regions and Number of Acute Care Hospitals, 2014

EMS 1 Northeast/Sullivan N=11

EMS 2 Knox/East N=20

EMS 4 Upper Cumberland N=10

EMS 3 Southeast/Hamilton N=13

EMS 5 Highland Rim N=20

EMS 6 South Central N=9

EMS 7 Region 7 N=14

EMS 8 Mid South N=15

8 EMS regions, numbered from East to West 9 to 20 hospitals per EMS Region

TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1

112 15 14 9 20 10 13 20 11

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>5 Core Elements of Stewardship by EMS Region, 2014

TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1

58%

47%

50%

44%

60%

50%

61%

100%

18%

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Leadership: Salaried Support TN, 2014

23% (N=26)

77% (N=86)

Facilities with salaried support for antibiotic stewardship activities (N=112).

YesNo

Q26. Does your facility provide any salary support for dedicated time for antibiotic stewardship activities?

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Leadership: Written Support TN, 2014

45% (N=50) 55%

(N=62)

Facilities with a written statement designed to improve antibiotic use

(N=112).

YesNo

Q23. Does your facility have a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship)?”

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Action as a Component of Antimicrobial Stewardship , Hospitals, TN, 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Policies present Treatmentrecommendations

Review oftreatments

Antibioticapproval by a

physician

Antibiotic reviewby a physician

The five components of action towards antimicrobial stewardship.

Document Indication “Time out”

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>3 Core Elements of Action by EMS Region, 2014

TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1

50% 40% 64% 33% 55% 50% 31% 65% 45%

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Action-Policies: Indication Documented, 2014

27. Does your facility have a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry?

TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1

21% 53% 36% 11% 5% 10%

100% 30% 18%

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Action-Treatment Review (“Time-Out”), 2014

29. Is there a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g. antibiotic time out)?

TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1

22% 13% 29% 33% 25% 10% 23% 30% 9%

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Antimicrobial Stewardship Recommendations, THA Board Adopted (October 2015) 1. Hospital demonstration of commitment to

antibiotic stewardship via a written statement of support and consideration of dedicated pharmacy, clinician and IT staff time for antibiotic stewardship activities.

2. All hospitals commit to reporting to the National Healthcare Safety Network antimicrobial use and resistance modules within specified timeframes.

3. All hospitals commit to a policy requiring documentation of indications for antibiotic therapy.

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Antimicrobial Stewardship Recommendations, THA Board Adopted (October 2015) 4. All hospitals commit to implementing a policy

requiring an “antibiotic review” at 48-72 hours to allow for appropriate review of clinical indication of need, response and any therapeutic revisions that might be appropriate.

5. Participation by hospitals in an antibiotic stewardship collaborative to encourage best practice / lessons learned sharing, and development of appropriate educational programing, as well as any other steps or activities that would assist with antibiotic stewardship.

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National Healthcare Safety Network (NHSN) NHSN is a surveillance system that serves multiple

users and uses NHSN is used by >17,000 healthcare facilities to track HAIs,

antimicrobial use and resistance, and adherence to prevention guidelines; guide prevention efforts; submit data for public reporting and quality measurement purposes

Health departments for surveillance, prevention, and public reporting

CMS for quality measurement and reporting, reimbursement, and prevention

HHS to measure national progress

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NHSN Antimicrobial Use & Resistance Module

• Only electronic data submission using CDA (clinical document architecture).

• NO MANUAL data entry • Antimicrobial Use [AU]

– eMAR (electronic medication administration record) or

– BCMA (bar code medication administration system – ADT (admission, discharge, transfer) or registry data

• Antimicrobial Resistance [AR] – LIMS (laboratory information system) – ADT (admission, discharge, transfer) or registry data

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Reporting Data to NHSN AUR Module

• Stakeholder Meeting March, 2015: – THA (Tennessee Hospital Association) – CMO Society (Chief Medical Officer) – TN Pharmacy Coalition – TDH (Tennessee Dept of Health)

• Objective: Prepare hospitals and health systems for the

expected state and federal reporting requirements on antibiotic use and resistance (AUR) to NHSN. – Data submission to NSHN is electronic only and involves

multiple sources of data (ADT, LIMS, eMAR/BCMA). – Requires lead time

• time and resources

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Facilitating Reporting to NHSN AUR Module

• Sharing lessons learned from two TN hospitals reporting data to the NHSN AU module – Holston Valley Medical Center (major teaching hospital) – Maury Regional Medical Center (medium size)

• Inventory of electronic systems in use at TN healthcare facilities: – ADT – BCMA – eMAR – LIS – 3rd party software

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Interim Measurement Solution Until More Facilities Report to NHSN: Serial Point Prevalence Surveys

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Facility AV: Reduction in Antimicrobial Use

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Example Report: Facility vs Collaborative All Antibiotics and Quinolone use

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Distribution of Patients on Quinolones TN, 2014-15

4% 12% 20% 28% 36%

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Outpatient Antibiotic Use Rates (2010)

Center for Disease Dynamics, Economics & Policy <http://www.cddep.org/node/4933> Hicks et al. U.S. Outpatient Antibiotic Prescribing, 2010. N Engl J Med 2013; 368:1461-1462

Number of dispensed outpatient antibiotic prescriptions per 1,000 inhabitants

Tennessee =1,159 per 1,000 inhabitants

Alaska =511 per 1,000 inhabitants

California =555 per 1,000 inhabitants

U.S. Average =801 per 1,000 inhabitants

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http://www.tnpca.org/?Connections1015

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CSTE PS 14-ID-01 Recommendations for Strengthening Antimicrobial Stewardship in the US, including Role of State and Local Health Departments 1. CSTE recommends all state health departments evaluate and incorporate

stewardship activities across healthcare settings into their HAI programs. The degree to which health departments can include these programs depends upon the resources, including training and access to subject matter. Examples of activities that can be conducted with current and with expanded funding levels are presented in Appendix 1.

2. CSTE recommends that CDC identifies a standardized metric for measuring inpatient antimicrobial use to facilitate risk-adjusted benchmarking and evaluation of national trends of antimicrobial usage over time using data reported to the National Healthcare Safety Network’s Antimicrobial Use and Resistance (AUR) Module and train health departments on the use of these metrics. These data can then be used by state and local health departments in their antimicrobial stewardship efforts.

3. CSTE recommends that CDC evaluates existing measures for monitoring outpatient antibiotic prescribing practices and determine whether expansion of existing measures or development of new measures are needed.

http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2014PS/14_ID_01upd.pdf

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Appendix 1: Sample Antimicrobial Stewardship (AS) Activities 1. Convene a State Workgroup on AS 2. Assess AS Activities and Needs

– Surveys and Assessment Tools – Focus Groups

3. Support Interest and Efforts to Collect and Evaluate Antimicrobial Use Data: Encourage NHSN AUR module – Interim options (acknowledging delays in all HCFs

submitting data to NHSN AUR module): • Point prevalence surveys • Days of Therapy (DOT ) per 1,000 days present • Behavioral Risk Factor Surveillance System

4. Educate and Provide Tools for AS 5. Support, Coordinate and/or Participate in State and

Local Prevention Collaboratives on AS

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Appendix 1: Sample Antimicrobial Stewardship (AS) Activities 1. Convene a State Workgroup on AS 2. Assess AS Activities and Needs

– Surveys and Assessment Tools – Focus Groups

3. Support Interest and Efforts to Collect and Evaluate Antimicrobial Use Data: Encourage NHSN AUR module – Interim options (acknowledging delays in all HCFs

submitting data to NHSN AUR module): • Point prevalence surveys • Days of Therapy (DOT ) per 1,000 days present • Behavioral Risk Factor Surveillance System

4. Educate and Provide Tools for AS 5. Support, Coordinate and/or Participate in State and

Local Prevention Collaboratives on AS

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Position Statement 15-ID-02

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CDC & State Health Departments Consider for Implementation Any Number of Strategies Below as Resource Allow (Appendix)

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Thank You!

Contact: (615) 741-7247 (24/7, 365) [email protected]

http://tn.gov/health/topic/hai