QAPI and Antimicrobial Stewardship Paul Mulhausen, MD Nell Griffin, Sr. QIF Telligen QIN-QIO Employee-Owned Employee-Owned
Program Objectives • You will recognize the challenges and practice patterns in LTC that uniquely inform improvement opportunities for antimicrobial stewardship. • You will bring best practices in antimicrobial stewardship to inform a QAPI Project Plan and Monitoring Tool. • You will implement a QAPI PIP that enhances antimicrobial stewardship in your setting. 2
Presentation Organization • Brief Review of the Problem and Opportunity • The nature of antimicrobial use in long term care institutional settings • Highlight similarities of antimicrobial stewardship core elements and QAPI – integrating antimicrobial stewardship into your QAPI program • Discuss unique challenges to stewardship in LTC settings • Highlight bacteriuria management using resources from the AHRQ NH Stewardship Guide as a QAPI PIP opportunity for antimicrobial stewardship. 3
Review of the problem • Antibiotic resistance is one of the three greatest threats to health in the US! – 23,000 deaths each year from resistant infection – 250,000 C. difficile infections (CDI) each year – 75% of CDI occur in nursing homes and other community settings • Antibiotic resistance is one of the greatest threats to health in the world! • 700,000 die of resistant infection • Predictions rise to 10-million by 2050 4
Fighting Antimicrobial Resistance Prevent Infections and 1. Prevent Spread Track antibiotic-resistant 2. infections 3. Antimicrobial Stewardship Develop New Drugs and 4. Diagnostic Tests 5
Fighting Back in LTC • Huge opportunities for stewardship • 43% of residents are colonized with resistant microorganisms • Every six months 42% of residents receive an antibiotic. • 25% to 75% of the antimicrobial prescriptions may not meet guidelines 6
Core Elements of an Antimicrobial Stewardship Program • Leadership commitment • Accountability • Drug expertise • Action • Tracking • Reporting • Education 7
Antimicrobial Stewardship and QAPI 8
Unique Challenges in LTC • The antibiotic prescribing process in nursing homes is complex and differs from the prescribing process in hospital and clinic settings. – A process – Family preferences are influential – Often a telephone consultation Influenced by nursing staff input Influenced by inter-professional communication – Limited clinical and laboratory information • Vulnerable population • Challenging symptom communication 9
What works in Long Term Care Institutions? • Educational Materials for clinicians, staff, and residents • Education Materials for prescribing clinicians with prescribing pattern feedback • Locally developed guidelines for clinicians • Help staff and prescribers avoid over-diagnoses of urinary tract infections • Antimicrobial stewardship tool for staff • Post-prescribing Review and de-escalation 10
UTI Overdiagnosis: A place to start • Suspected UTI accounts for 30%-50% of antibiotics prescribed in LTC • Up to one-third of antibiotics used for UTI are for asymptomatic bacteriuria (ASB) • Half of LTC residents have ASB • ASB is benign in LTC residents • Treating ASB does not improve outcomes • Treating ASB with antibiotics causes ADEs • Preventing the overtreatment of ASB holds promise for a QAPI Process Improvement Process (PIP) 11
Choosing Wisely: AMDA & AGS • “Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract.” • “Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.” 12
Preventing UTI Overdiagnosis • Practice Guideline: The Loeb Criteria • Communication Tools: The Suspected UTI SBAR • Staff education: Asymptomatic bacteriuria • Resident and Family Engagement: – Asymptomatic bacteriuria – Educate about role of “culture for cure” • Tracking Measures – UTI by Loeb or McGeer Criteria – Antibiotic use rates for UTI 13
Suspected UTI SBAR https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T1-SBAR_UTI_Final.pdf 14
Staff Education: Not all infections need antibiotics! https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T3-Not_all_Infections_need_antibiotics-_final.pdf 15
Patient and Family Engagement https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T5- Suspect_a_Urinary_Tract_Infection_brochure_MA_Coalition_final.pdf 16
AHRQ tools to support tracking 17 https://www.ahrq.gov/nhguide/toolkits/implement-monitor-sustain-program/toolkit2-monitor-sustain-program.html
AHRQ NH Stewardship Guide • https://www.ahrq.gov/nhguide/index.html 18
Resources to Get You Started • https://www.cdc.gov/getsmart/ • https://www.cdc.gov/longtermcare/prevention/antibi otic-stewardship.html • https://www.ahrq.gov/nhguide/index.html • https://www.cdc.gov/getsmart/healthcare/implement ation.html 19
Get started with QAPI for antimicrobial stewardship • LTC settings present great opportunity to fight antimicrobial resistance and CDI. • Antimicrobial stewardship presents one of the largest opportunities for LTC settings • Antimicrobial stewardship structure is nicely supported by QAPI framework. • Resources are available to support your antimicrobial stewardship PIPs. 20
What is Antibiotic Stewardship? A set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. • Recommend all nursing homes improve antibiotic prescribing practices • Recommend all nursing homes reduce inappropriate antibiotic use 21
Why QAPI? Quality Assurance Performance Improvement (QAPI) is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI: • involve members at all levels of the organization • identify opportunities for improvement • address gaps in systems or processes • develop and implement an improvement plan • continuously monitor effectiveness of interventions . 22
Why Antibiotic Stewardship for Nursing Homes? • Among the most commonly prescribed medications • 40%-75% are prescribed incorrectly – For prevention – Before infection is confirmed – For colonized bacteria • Poor communication during transfers • Antibiotic harm such a C. difficile can be severe. 23
Why Antibiotic Stewardship and QAPI? To protect residents and reduce the threat of antibiotic resistance which will improve the quality of care and services. • Both included in the Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities • Both advocate for the residents • Both involve process improvement 24
QAPI Resource • Guidebook to assist with QAPI – Implementation – Sustainment • 12 Action Steps https://www.cms.gov/Medicare/Provider-Enrollment-and 25 Certification/QAPI/Downloads/ProcessToolFramework.pdf
Antibiotic Stewardship Resources https://www.cdc.gov/longtermcare/prevention/ant 26 ibiotic-stewardship.html
QAPI Process Tools • Checklist • Worksheet • Templates • Flow charts and process maps • Reporting forms or outlines 27
Checklist for Core Elements of Antibiotic Stewardship in Nursing Homes • Leadership Support • Accountability • Drug Expertise • Action to Improve Use • Tracking Monitoring Antibiotic Prescribing, Use, and Resistance • Reporting Information to Staff on Improving Antibiotic Use and Resistance • Education 28
Antibiotic Stewardship Checklist: Guiding Questions & QAPI Action Steps • Q 1 Leadership Support: Can your facility demonstrate leadership support for antibiotic stewardship? – QAPI Step 1: Leadership Responsibility & Accountability – QAPI Step 5: Develop Your QAPI Plan • Q 2 Accountability: Has your facility identified a leader for antibiotic stewardship activities? – QAPI Step 1: Leadership Responsibility & Accountability – QAPI Step 2: Develop a Deliberate Approach to Teamwork – QAPI Step 4: Identify Your Organization’s Guiding Principles – QAPI Step 5: Develop Your QAPI Plan 29
Antibiotic Stewardship Checklist: Guiding Questions & QAPI Action Steps • Q 3 Drug Expertise: Does your facility have access to individual(s) with antibiotic stewardship expertise? – QAPI Step 2: Develop a Deliberate Approach to Teamwork – QAPI Step 9: Prioritize Quality Opportunities and Charter PIPs – QAPI Step 10: Plan, Conduct and Document PIPs – QAPI Step 11: Getting to the “Root” of the Problem – QAPI Step 12: Take Systemic Action • Q 4. Actions to Improve Use: Does your facility have policies to improve antibiotic prescribing/use? – QAPI Step 1: Leadership Responsibility and Accountability – QAPI Step 4: Identify Your Organization’s Guiding Principles – QAPI Step 5: Develop Your QAPI Plan – QAPI Step 7: Develop a Strategy for Collecting and Using QAPI Data 30
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