Antimicrobial Stewardship: The First Year at Holston Valley Medical Center. Brooke Stayer, PharmD Antimicrobial Stewardship Pharmacist

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1 Antimicrobial Stewardship: The First Year at Holston Valley Medical Center Brooke Stayer, PharmD Antimicrobial Stewardship Pharmacist

2 Antimicrobial Stewardship A system of informatics, data collection, personnel, and policy/procedures which promotes optimal selection, dosing, and duration of therapy for antimicrobial agents throughout the course of their use

3 Antimicrobial Stewardship An effective antimicrobial stewardship program will limit inappropriate and excessive antimicrobial use, but more importantly improve and optimize therapy and clinical outcomes for the individual patient Christopher Ohl, MD Wake Forest University School of Medicine

4 Why We Have to Improve Antibiotic Use A lot of in-patient antibiotic prescriptions are unnecessary or sub-optimal Antibiotics are unlike any other drug; their use in one patient can compromise their efficacy in another We are running out of antibiotics We won t get any new ones soon

5 5 Truths About In-Patient Antibiotic Use Antibiotics are misused in hospitals Antibiotic misuse is bad Improving antibiotic use can improve medical care There are many ways to improve antibiotic use Every facility can improve antibiotic use CDC

6 Example of Antibiotic Misuse C. difficile 85% of patients with C. Difficile have antibiotic exposure within 28 days before the infection Hospital acquired-hospital onset 165,000 cases; $1.3 billion excess cost; 9,000 deaths annually Hospital-acquired-post-discharge 50,000 cases; $0.3 billion excess cost; 3,000 deaths annually Nursing home onset 263,000 cases; $2.2 billion excess cost; 16,500 deaths annually Agency of Healthcare Research & Quality

7 Example of Antibiotic Misuse Extreme Drug Resistant (XDR) Bacteria Recent outbreak of an XDR bacteria has resulted in 19 infections and 7 deaths at an NIH hospital Caused by an extremely common organism, klebsiella pneumoniae, that has developed resistance to nearly all or all antibiotics, specifically carbapenems (thus called klebsiella pneumoniae carbapenemase or KPC)

8 Antimicrobial Use at HVMC At Holston Valley, antimicrobials account for nearly 20% of total drug expense 2 nd most costly class of drugs Need for improvement in antimicrobial use identified by pharmacy management, medical staff, and hospital administration

9 Antimicrobial Stewardship Program Official Opportunity Statement Antimicrobials are often inappropriately prescribed. By reviewing culture results, patients antimicrobial regimens can be tailored to the most efficient, safe, and cost-effective treatment. Improving antimicrobial use through multidisciplinary stewardship interventions and programs improves patient outcomes, reduces antimicrobial resistance, and saves money.

10 Timeline of Antimicrobial Stewardship Efforts March 2010 Acquisition of Theradoc software July 2010 Beginning of HVMC Pharmacy Residency Program July 2011 Full-time Antimicrobial Stewardship Pharmacist hired

11 Shewhart Cycle for Continual Quality Improvement Plan Do Act Check

12 Initial Plan & Implementation Actively review patient profiles and recommend changes to providers Intravenous (IV) to oral route switches Duplicate therapy De-escalation of therapy Changes in therapy based on culture results Evaluate trends in antibiotic resistance at HVMC to determine appropriateness in empiric therapy and make recommendations for changes physician order sets

13 Initial Plan & Implementation (cont.) Meet with microbiology lab and infection control to discuss changes in lab testing and reporting, trends in cultures/resistance, etc. Provide recommendations to Pharmacy & Therapeutics (P&T) committee regarding antimicrobial formulary changes Precept and educate pharmacy residents and students Provide education to physician groups regarding new antimicrobial therapies and guideline changes

14 Progress Check 1 st Month Month Recommendations Made Recommendations Accepted Recommendations Rejected Acceptance Rate Costs Avoided 2010 monthly average % $1,286 Jan-June 2011 monthly average July 2011 (first month with full-time pharmacist) % $3, % $7,890

15 Progress Check 1 st Month (cont.) Month IV to oral Switches Savings 2010 monthly average 24 $1,388 Jan-June 2011 monthly average 43 $2,918 July 2011 (first month with full-time pharmacist) 53 $4,100

16 Actions for Continual Improvement Continue to review patient profiles and recommend changes to providers Expand evaluation criteria to increase number of patient profiles reviewed Increase number of IV to oral conversions Send letter to all providers to increase awareness of program and provide contact information Find opportunities to educate providers Begin reviewing cultures for patients treated in the Emergency Department for appropriateness and make recommendations accordingly (Spring 2012)

17 Progress Check 1 st Year Month Recommendations Made Recommendations Accepted Recommendations Rejected Acceptance Rate Costs Avoided 2010 monthly average Jan-June 2011 monthly average July 2011 (first month with full-time pharmacist) Aug Jun 2012 monthly average % $1, % $3, % $7, % $14,292

18 Progress Check 1 st Year (cont.) Month IV to oral Switches Savings 2010 monthly average 24 $1,388 Jan-June 2011 monthly average July 2011 (first month with full-time pharmacist) Aug Jun 2012 monthly average 43 $2, $4, $8,553

19 Progress Check 1 st Year (cont.) Type of Intervention No. of Interventions/month Costs Avoided Microbiology Reviews 278 $19,629 Accepted Antimicrobial Recommendations 70 $14,292 IV to oral Switches 93 $8,553 Total 441 $42,474 (annualized cost avoidance - $509,688)

20 Progress Check 1 st Year (cont.) Education to providers Emergency Department, ETSU Internal Medicine residents Education to pharmacists, residents, and students Precepting, Pharmacy Grand Rounds Recommendations to P&T committee Formulary changes, protocol changes Recommendations to microbiology department Diagnostic testing, culture reporting

21 Future Plans Continue daily profile reviews and recommendations Continue working with Infectious Disease Service to recommend changes to provider order sets to match current guidelines as they change Continue meeting regularly with infection control and microbiology to share ideas and concerns and discuss new products and processes

22 Future Plans (cont.) Begin measuring effect of stewardship activities through patient outcomes such as treatment success, length of stay, cost avoidance, resistance, and C. difficile infection rates Find more opportunities to educate providers and other health care professionals regarding changes in guidelines and new therapies Form Antimicrobial Stewardship Committee with highly-visible physician champion to assist in overcoming any barriers

23 Antimicrobial Stewardship: The First Year at Holston Valley Medical Center Brooke Stayer, PharmD Antimicrobial Stewardship Pharmacist