Antimicrobial Stewardship: VUH Program started in 2009 Program - PDF document

11/14/2016 Antimicrobial Stewardship (ASP) at VUMC Antimicrobial Stewardship: • VUH Program started in 2009 Program Overview • MCJCH Program started 2012 Vanderbilt University Medical Center • VUH Currently staffed by: – ID physician: George Nelson, MD (Director) – ID physicians: Patty Wright, MD; Matthew Greene, MD; November 17, 2016 Tennessee Hospital Association Medication Safety Summit on Gowri Satyanarayana, MD (Associate Directors) Antibiotic Stewardship – ID pharmacist: Whitney Jones, PharmD George Nelson, MD – Therapeutic drug monitoring pharmacist: Pratish Patel, Director Vanderbilt Antimicrobial Stewardship Program PharmD Whitney Jones, PharmD Vanderbilt Antimicrobial Stewardship Pharmacist Bring Everyone to the Table Major ASP Activities at VUMC • We created a multidisciplinary approach • Oversight of restricted high risk, high cost antimicrobials – 25 restricted antimicrobials requiring pre-approval – Pharmacy – Infection Prevention • Limited post-prescription review of antimicrobials – Quality Department • Focused interventions in selected areas – Laboratory – Heme/Onc, surgical subspecialties, etc. – Infectious Diseases • Manage antimicrobial shortages/formulary – Nursing • Review of protocols/policies/order sets – Patient Education – IT/Analytics • Provision of education and training – Evidence based medicine • Algorithm development/Quality initiatives – Many others…. • Ensure compliance with CDC, CMS, TJC guidance Cellulitis Pathway to Reduce Short VUH ASP Quality Initiatives Stay Admissions • Staphylococcal bacteremia treatment algorithm • Cellulitis recognized as a top diagnosis for admissions • Reduce unnecessary testing via advisors with LOS <2 days – Diarrhea and Respiratory Viral Infections • Collaboration between VASP, ED, Pharmacy, and • Pharmacokinetics monitoring service Quality Council – Vancomycin and Aminoglycosides • Algorithm identified patients who could be safely • Clostridium difficile initiatives managed as outpatients with options for therapy • Partner with lab for rapid diagnostics • Started Feb, 2016 – Ex: BUGZ pager for Verigene results • Prior to pathway ~ 50% of cellulitis presentations • Algorithms for unnecessary short stay admissions were admitted; after ~ 30% 1

11/14/2016 Improving Antibiotic Staphylococcus Bacteremia Safety Algorithm Appropriateness Reduces C. diff • Ensures appropriate management • Increase in C. difficile infections on select – TTE/repeat BCx/etc, treatment (duration/agent) inpatient units, FY2015 • Implemented at VUH August 2015 – After several patient-specific opportunities for improvement noted • Task Force convened – Elevated need for quality improvement • 82 interventions on 68 distinct patients – Antibiotic misuse identified – Only 2 elevations to supervising MD • Rounding tool created on target unit (MICU) – No elevations to Chief of Staff • 15 patients had adverse events averted (not mutually exclusive): – Based on validated CDC assessment tool – No treatment (or suboptimal)  treatment n= 9 – • 650 patients enrolled in quality improvement Escalate from PO to IV therapy n= 5 – Increase duration of therapy n=1 project – Obtain TTE n= 9 – Repeat BCx n=7 C. diff Rates Improved Quality vs Cost • We have found that it is important to partner with Quality department – Resonates with providers – Longer lasting – Quality/safe care is goal – Patient level concerns drive point home Task Force convened • Cost effectiveness remains important goal Rounding Tool Started – Easier to quantify – Leverage in administration • Collect data on interventions to demonstrate value Antibiotic Utilization Reporting Unrestricted Antibiotics Restricted Antibiotics -Lack of restriction -Restrictions can • Mandatory external reporting anticipated demonstrates stable drive improvement • Internal reporting to leverage change within units, use divisions, departments and beyond • Build upon success of hand hygiene feedback program • Use data as agent of change • Have developed dashboard to capture the above 2

11/14/2016 AU Dashboard Gap Analysis • Start with a program review • CDC Core Elements of ASP – Good starting place • Write down what you have – Resources, interests, programs, champions who could represent other areas • We performed Gap Analysis recently – Really helpful to define next steps and opportunities we had Conclusion Questions? • ASP is hard, but worth it • Impossible to do everything all at once • Have to bring everyone to table • When possible link to quality outcomes – Use patient specific examples for need • Leverage data to inform your next steps (and results of your projects) • THANKS!!! 3