Antimicrobial Stewardship: A System- Wide Approach at Carolinas HealthCare System

Transcription

1 Antimicrobial Stewardship: A System- Wide Approach at Carolinas HealthCare System Kelly Goodson, PharmD; Erin Roach, Pharmd; Susan Bear, PharmD; Lisa Davidson, MD Carolinas HealthCare System is one of the nation s largest healthcare systems serving patients throughout North and South Carolina. In 2012, Carolinas HeathCare System endorsed a system approach to antimicrobial stewardship to improve the use of antimicrobial agents across eight acute care facilities and four rehab facilities within the system, commonly referred to as primary enterprise facilities. This program, The Antimicrobial Support Network (ASN), was implemented under the direction of Kelly Goodson, PharmD, ASN pharmacy manager; Susan Bear, PharmD, CHS Associate Vice President of Clinical Pharmacy Services; and Lisa Davidson, MD, ASN Medical Director. The ASN utilized key concepts from the Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship as well as outcomes from an active antimicrobial stewardship program already initiated within the system. 1 Carolinas Healthcare System NorthEast (CHS- NorthEast), a regional 457- bed medical center implemented an antimicrobial stewardship program in 2010 due to increasing rates of antimicrobial resistance, increasing rates of clostridium difficile infection, and increasing antimicrobial expenditures. The program realized significant reductions in antimicrobial utilization leading to a 30% reduction in antimicrobial drug spend per adjusted patient day, an estimated cost avoidance of greater than $1,500,000, and a return on investment of 388% (see Figure 1). Figure 1. Antimicrobial Drug Spend per Adjusted Patient Days Table 1. Supplements to the core active antimicrobial stewardship strategies Aminoglycoside and vancomycin pharmacokinetic monitoring Renal dose adjustment protocols Prolonged infusion protocols (piperacillin/tazobactam and meropenem) Intravenous to oral conversion Empiric treatment guidelines Duration of therapy guidelines Formulary review of antimicrobial agents In 2013, prior to the launch of the ASN, a gap analysis performed illustrated that primary enterprise facilities had numerous elements considered as supplements to the core antimicrobial stewardship strategies (see Table 1). 1 Elements lacking included a system for targeted review of antimicrobial therapy, criteria for antimicrobial de- escalation, metrics for antimicrobial utilization and program monitoring, and information technology support and systems for enhancing antimicrobial review and data collection. Based on the success of the antimicrobial stewardship program at CHS- NorthEast and literature review, it was determined the core strategy of the ASN would be prospective audit with intervention and feedback in patients receiving target antimicrobials (see Table 2), patients receiving 3 or more antimicrobial

2 agents, and patients receiving any antimicrobial agent for 72 hours. A report utilizing the electronic medical record for the system was created to identify patients with the above criteria. The electronic medical record was also utilized to document interventions at the facility level and generate daily notes for the medical record. Table 2. Target antimicrobials Aztreonam Meropenem Doripenem Cefepime Ceftaroline Ertapenem Tigecycline Daptomycin Linezolid Amphotericin Caspofungin Voriconazole Posaconazole The ASN began the task of implementing stewardship programs across the remaining acute care facilities with a rolling implementation schedule from August, 2013 through January, In order to translate the success of the antimicrobial stewardship program at CHS- NorthEast on both a local and system- wide scale, the initial model for the ASN was designed as a hub and spoke model (see Figure 2). The ASN central office is staffed by a Medical Director and Clinical Pharmacy Manager who designed the roll- out, policy, education, training, and evaluation of metrics. The central office also serves as a system resource for coordinating all stewardship- related policies and clinical guidelines. University Figure ASN Mode ASN CENTRAL OFFICE The primary objective of the ASN during the first year was to Pineville Union establish a stewardship network for six facilities performing daily stewardship review and feedback to clinicians. This Mercy would be achieved by a multi- disciplinary team of pharmacists and physicians making recommendations to healthcare providers encouraging safe, appropriate use of antimicrobials and reduce overall antimicrobial resistance and expenditures. The following ASN goals were developed for both the system level and individual facilities: Goal 1: Decrease antimicrobial utilization (DOT) by 5% (stretch goal 10%) Goal 2: Decrease antimicrobial costs by 5% compared to Year 2013 Goal 3: Increase Intervention Acceptance Rate to 85% (stretch goal 90%) Goal 4: Adequately staff the program at each facility by greater than 90% The aforementioned goals are utilized to track the effectiveness of the program at both the system and facility level. The ASN central office generates the data on a quarterly basis which includes antimicrobial utilization (days of therapy (DOT) per 1000 patient days, antimicrobial purchases (expenditures per 1000 adjusted patient days), intervention acceptance rates, and self- reported facility staffing rates. The metrics chosen are in line with CDC- proposed national standards for monitoring antibiotic utilization. To adequately summarize, review, and illustrate success of the program, the ASN developed a score card to track metrics at both the system and facility level (see Figure 3). CMC NorthEast

3 Figure 3. Antimicrobial Support Network Scorecard Antimicrobial days- of- therapy, purchasing data, intervention data, and ASN staffing has been tracked since the beginning of the program. Upon completion through Q1 2014, the ASN central office reviewed the initial eight- month progress. Although significant declines in antimicrobial utilization and expenditures were seen, there was significant variability between facilities regarding staffing coverage. Facilities with dedicated, full- time ASN pharmacists were able to review more patients and perform more interventions. Facilities with pharmacists only partially dedicated to the ASN role were frequently reassigned to other areas of focus or were not as efficient in their daily review. With staffing levels averaging 71%, the actual number of patients reviewed and interventions made was only 52%. This translated to an additional 15-20% decrease in drug spending and an 8-11% decrease in DOTs not realized. Plans to bring on new facilities without pharmacists fully dedicated to the ASN role would widen this gap. Goals for 2015 included expanding the scope the ASN program to include patients with positive blood cultures, positive cultures for multi- drug resistant organisms, bug- drug mismatch, and early identification of patients with antibiotic- related nephrotoxicity. In order to improve ASN coverage at all facilities, increase efficiency in daily review, and expand the scope of practice, the ASN needed dedicated pharmacists 7 days a week. As the ASN continued to develop business plans and staffing models to justify expansion of the program, the Centers for Disease Control and Prevention (CDC) published national guidelines on the core elements of antimicrobial stewardship programs. 2 A second gap analysis for each primary enterprise facility, further justifying the need for program expansion. In recognition of the urgency of this growing national healthcare crisis, President Obama issued an Executive Order in September 2014 to develop a national plan to combat antimicrobial resistance. 3 A key component of this plan is to develop national antibiotic standards and require all acute- care facilities to have active antimicrobial stewardship programs. Based on the initial success of the ASN and the timely publishing of the Core Elements of a Hospital Antimicrobial Stewardship Program as well as the Whitehouse Executive Order Combating Antibiotic- Resistant Bacteria, Carolinas HealthCare Senior Leadership approved the expansion of the ASN. As of March 2015, the federal government is now proposing antimicrobial stewardship as a CMS Condition of Payment for

4 Figure ASN Model In January, 2015, the conversion to the new staffing model (see Figure 4), as well as recruitment for new infectious diseases/antimicrobial stewardship pharmacists began. Three ASN divisions were established: North, Central and South. Each of the teams is led by an ASN Clinical Team Leader with PGY 2 or equivalent training in Infectious Diseases and stewardship, together with one to two additional clinical staff pharmacists and an additional infectious diseases pharmacist. Pharmacists in these teams dedicate 100% of their time to stewardship activities including daily review of patients, clinician education, and development and implementation of system- wide initiatives. While these pharmacists are in a centralized location, they are dedicated to one to two facilities, thereby serving as the stewardship expert available to all clinicians in their respective facilities. Prior to conversion to the new ASN

5 staffing model, the ASN decreased antimicrobial utilization (days of therapy per 1000 patient days) by 8.4%. The ASN scorecard also illustrates the impact the initial ASN staffing model had on antimicrobial expenditures and intervention acceptance rates (see Figure 6). The new staffing model for the ASN has been very successful thus far. At the completion of quarter 2, all pharmacist positions were filled with ASN pharmacist orientation and training expected by the beginning of quarter 4, The new staffing model has led to significant growth for the system- wide ASN program as well as growth at the facility level. Hospital D experienced a modest decrease in antimicrobial utilization, a 3.8% decrease comparing 2014 utilization to 2013 (see Figure 7). Due to pharmacist staffing constraints throughout 2014, the program was staffed 40% of ASN eligible days with 635 interventions documented for the calendar year. After implementation of the new staffing model, ASN was staffed 100% of ASN eligible days with an 11.5% reduction in antimicrobial utilization (see figure 7) and a 2- fold increase in interventions documented comparing year- to- date 2015 to Figure 7. Hospital D Antimicrobial Utilization Hospital D Top Antimicrobial Agents Figure 5. Antimicrobial Utilization: 2014 vs DOT / 1000 palent days CHS Anlmicrobial Agents vs % Figure ASN Scorecard

6 Hospital G did not have the band- width within the current pharmacy staffing structure to implement ASN services prior in With the new ASN staffing model, the ASN was implemented at hospital D in January, This facility experienced a 17.8% reduction in antimicrobial utilization (see Figure 8) and a 28.9% reduction in antimicrobial expenditures comparing year- to- date 2015 to Figure 8. Hospital G Antimicrobial Utilization Hospital G Top Antimicrobial Agents vs % System- wide, the new staffing model has significantly impacted ASN goals and metrics. A reduction in antimicrobial utilization of 7.5% has been realized comparing year- to- date 2015 to 2014 as well as a 6.7% reduction in antimicrobial expenditures (see Figures 9 and 10). There has also been a 2- fold increase in interventions documented comparing year- to- date 2015 to 2014, with an 88% acceptance rate. In addition, the ASN has been launched at four rehab facilities in quarter 3, will be launched at three additional acute care facilities in quarter 4, and will expand coverage to weekends and holidays beginning in quarter 4. The goal by 2016 is to include all acute care and rehab facilities within the primary enterprise. In 2016, the ASN will expand to include Levine Children s Hospital. The centralization plan and use of virtual stewardship review will ensure adequate coverage of patients requiring Antimicrobial Support Network services. Figure 9. Antimicrobial Utilization: 2015 (YTD) vs CHS Top Antimicrobial Agents

7 1. Dellit TH, Owens RC, McGowan JE Jr, et al; Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44: CDC. Core elements of hospital antibiotic stewardship programs. Atlanta, GA: US Department of Health and Human Services, CDC; Available at elements.html press- office/2014/09/18/executive- order- combating- antibiotic- resistant- bacteria. Accessed April 15, Figure ASN Scorecard (YTD) resistant_bacteria.pdf. Accessed April 15, 2015