Articles, Blog

2019 NHSN LTCF Training – Antibiotic Stewardship in LTCF

August 26, 2019

>>Next you will hear
from Dr. Kabbani.>>Good morning everyone. Thank you so much for being
here today and taking time out of your busy schedules
to spend three days with us, and thank you to NHSN
team for inviting me. I’m and adult infectious
disease physician, and I work in the Office
of Antibiotic Stewardship in the Division of
Healthcare Quality Promotion but work closely with
Dr. Thompson and Dr. Bell on all issues related
to antibiotic use and stewardship and
long-term care. So, what I’m going to be
doing today is expand on some of the concepts that
Dr. Thompson just talked about right now in terms
of antibiotic stewardship and implementation
in your facility. So, by the end of this
session, what I’m going to do is discuss ways to
track the core elements of antibiotic stewardship, but
the framework that I’m going to use is the facility survey
that you fill on a yearly basis where there are questions
that are pertinent to antibiotic stewardship
at your facilities and identify some
opportunities to improve use in UTI specifically using
the UTI module and how to monitor outcomes using
LabID event reporting. So, the work that Dr. Thompson
just presented on looking at antibiotic use in a prevalent
survey is antibiotic use on one specific day
in nursing homes, and our office has been doing
some work working with partners, whether electronic
health record companies or long-term care
pharmacies where we look at antibiotic use cumulatively
overall throughout the entire year. So, numbers we used
to quote in the past, as Dr. Thompson had said, were
based on very few studies, or we used to look at European
data and try to extrapolate some to the U.S. But we are learning
more and more through the work that Dr. Thompson and
her team are doing and the work that we are doing. And we’ve recently, this
work is still preliminary, but we’ve recently presented
this at a conference. We know that there’s
an estimated overall of 15 nursing home
residents over the year 2017 that were prescribed one or more
courses of antibiotic in a year. And facilities range, where you
have 44 percent at a facility over the entire year
to 58 percent. And there’s a lot of
variables that come into play, such as whether these
residents were short-stay or long-stay residents,
and we will be sharing more and more data on this
as we come along. So, we’re able to,
we’re learning and defining more
overall antibiotic use, but we know from previous
data that an estimated 40 to 75 percent of those
absolutely are inappropriate. You know, of course here
is a proportion of that that is unnecessary to
begin with, but when we talk about inappropriate,
we’re also talking about the drug selection, and
Dr. Thompson talked to you about fluoroquinolones and
whether they’re the best drug for a specific infection, whether the dosing
was appropriate, and we know from many studies that we frequently treat nursing
home residents for longer than they actually need
for a specific infection. So, why are we talking
anybody this, and I know you all have heard
this multiple times before, but we’re now becoming to
appreciate the adverse events that are associated with
antibiotics, both necessary and unnecessary use
more and more. Adverse events, such as
gastrointestinal disturbances and yeast infections, to
very serious adverse events that we’re learning more about, like the neurotoxicity
that’s associated with fluoroquinolones, especially in the
elderly population. And unique to the nursing home
setting is the multiple drugs that these residents are
on and the increased risk of adverse events
with drug interactions and just one small study into
a nursing homes were able to assign 13 percent of adverse
events to antibiotic use. You’ve been talking
throughout the past few days about Clostridioides
difficile infection, and one of the main
reasons is antibiotic use and microbiome disruption. And the resident population
you take care are not only that highest risk for
C. diff infection, but they also have the highest
morbidity associated with it and the highest mortality. Out of a study in Canada,
when looked at diarrhea, gastroenteritis, and
C. diff infection, that was the most common
antibiotic-related adverse event that was seen. And we are having more
and more evidence now that there are higher
rates of sepsis in people who have used antibiotics, and
this is very predominant data, and you have to assign
causation, but there has been some theories
that this could be secondary to microbiome disruption
and risk of infection. So, you know, as I say, we
continue to learn more and more about these drugs and
what they can cause in your vulnerable patient
population you take care of. I know all of you have
seen the definition of stewardship before, and
you know, we’ve been talking about this is new to the
nursing home community, but we’ve been talking
about it for a few years, and I didn’t think I needed to define what stewardship
was anymore. But just a few months ago I was,
we were doing a special session in the American Medical
Directors Association meeting earlier this year, and we asked
the community of providers who were there who were very
interested in stewardship and who have been doing this
for a while, what do you think, what is antibiotic stewardship? And the universal answer we get
was to decrease antibiotic use. And so I feel like we need
to talk about this again, antibiotic stewardship, decreasing antibiotic use is
a very small proportion of it. It is by definition the sets
of commitment and action to optimize the treatment
and infection and reducing adverse events. It’s an issue of safety and delivering high-quality
healthcare. Measuring antibiotic
use is stewardship. And we call it optimizing use. A proportion of that
is not giving them when they’re not needed,
but as we mentioned, it’s giving the right
drug at the right dose for the right duration is
what antibiotic stewardship is all about. So, Dr. Thompson, you
all have seen this before and Dr. Thompson told you
about the core elements of antibiotic stewardship that
provide the framework for how to you assess current
activities and how to identify new stewardship
activities. And so I’m going to be
going over the questions and the yearly facility
survey that you fill to discuss these
different core elements. So, the first one is
leadership commitment. And you have two questions
in the facility survey on how to identify leadership
commitment at your facility. And we know that without nursing
home leadership commitment you cannot implement
antibiotic stewardship. You need that support and that
commitment whether, you know, it’s moral support or financial
support or the training support that comes along with it. And data that Dr. Thompson
showed you that this wasn’t one, it was around, around 60
percent, and you know, it’s the first step is that
commitment, and it can be through written statements that
support improving antibiotic use that you share, that the
leadership shares with staff, with residents, and
their families. And, you know, here’s
an example of a letter that the leadership can adopt
to choose at their facility that spells out some
of, a broad overview of what they’re going to do. And, reviewing antibiotic
use and resistance data and the quality improvement
meetings can also be a way of demonstrating
leadership commitment. So, the second core
element we’ll talk about and the question that
addresses here is at the bottom of the page is identifying
those individuals how will lead stewardship implementation. If there’s no, you know,
specific person is responsible, no one is really responsible. And different people can support
stewardship in different ways. And I’m going to talk a
little bit about the role of the medical director,
because there’s a lot of different ways your medical
director can support stewardship even if they’re not doing this
hands-on on a day-to-day basis. You know, first is
just role modelling. If they are using
stewardship principles in the way they evaluate
residents, treat them, you know, that alone is very,
very helpful. They can help with
policy development, with providing education not
only to your staff but also to your residents
and your family. And they do have a critical role that not many other people
can play, is providing some of that feedback when we talk
about reporting to providers on their prescribing practices. It’s a difficult position for a
director of nursing or an IP put in that position, you know,
to call different prescribers and tell them about this. And the medical director
plays a critical role in providing support in that
process and in that followup. And, you know, the director
of nursing, of course, has a role to play in
providing of education and implementing of practices. I will talk a little bit about
the consultant pharmacist later, but also the IPC
coordinator, she has, sorry, he or she have key expertise and
data to improve antibiotic use but require some training,
some dedicated time, and the resources to help
implement stewardship activities properly. So, we’ll move on
now to drug expertise and establishing
access to individuals with antibiotic expertise. And more and more, and I know
there’s a lot of variability around the country, and we
hear that anecdotally for many of our partners, about the
extent that long-term care or consultant pharmacists play in supporting stewardship
activities, but there are several ways
that that can be done. They can help you review
your antibiotic use data or even support tracking
of antibiotic use, because they have access to a
lot of the prescribing data, and they do this in their own,
on their own, on their own role as they review medications. Dr. Thompson talked to you
about the documentation of prescribing elements. So when pharmacists review
orders, they can ensure that documentation of
prescribing elements, and it is one of the
interpretive guidance of the CMS requirements
documenting a dose indication and duration for
every single dose, for every single antibiotic
prescribed is in there. So, pharmacists,
when those elements of documentation are
missing, calling providers and asking them about this,
it’s part of their, you know, it’s going to be
part of their job to make sure these data
elements are documented. I know it’s tricky because in
the long-term care setting, pharmacists play a different
role than for example in the hospital setting. The hospital setting, you
have your pharmacist there. She’s seeing order as
soon as it’s placed. She can adjust it,
adjust the dose. He or she can adjust
it, adjust the dose, call the provider back. Whereas in the long-term
care setting, especially your consulting
pharmacists, their role is somewhat
more sometimes in review or in retrospect, but
that said, they can help in limiting antibiotic duration. For example, if they are looking
at the prescribing of UTI over a course of a
month and let’s say most of the residents ended up
getting 10 days for a UTI, which we know, you know, especially for uncomplicated
urinary tract infections that’s too long. They can provide feedback to
the providers, and you know, we are seeing these practices,
and you should consider ABC, and look back at our protocols
and see how we can do better. So, other than duration,
they can also help with improving prescribing
practices, as we said, in protocol development and
providing education for staff as they have that
expertise that many of your [inaudible]
staff needed. And ASB treatment, so when
they are doing that review, if there’s no documentation
of signs and symptoms and this UTI event looks like
more asymptomatic bacteriuria, providing that feedback
can help. You know, it’s not going to help
that resident there and then, but it’s going to help as
we move along down the line to prevent those
inappropriate practices. Dr. Thompson mentioned the use
of prophylaxis in this setting. So, even identifying
those residents who are on prophylactic use and
having a conversation with the prescriber, you know,
do you think this is necessary? How long do you think
we should continue? Do we think this really helps? As the evidence for this
practice is not very, very strong and there is a lot
of concerns of adverse events with prolonged use
of antibiotics, and fluoroquinolones
specifically, and this is becoming more and
more priority in this setting as it was the most commonly
prescribed antibiotics. You know, discussing
what are alternatives, making sure the emergency box
on your floor has alternatives, you know, nitrofurantoin
is in there, and there are alternatives to
fluoroquinolones on the floor that you can use as an
emergency so you’re, you know, so that you can avoid
the use of those agents. Many facilities are looking
into developing partnerships with antibiotics stewardship
hospitals, and there’s a lot of work you’re doing right
now on preventing readmissions and so you can leverage those
partnerships as you work with hospitals for educational
resources for your staff and expertise and making
sure the communication across transitions includes
information on antibiotic use. So, we’ll move on
now to actions, and there are several questions
in your facility survey that reviews the actions on
policies and practices that aim on improving antibiotic use. And I will discuss
a few of them. So, we talked about
improving the documentation of indication, dose,
and duration. There’s a lot of effort going
on around that right now with pharmacists trying to
get all that information with some electronic health
record companies mandating that you enter an indication
for every antibiotic order and making sure there’s
adherence to this documentation policy. The development of the facility-specific
treatment guidance for common infections
can be helpful. You know, as you provide
feedback to prescribers, you know, for UTI our
first-line agent is, you know, it’s nitrofurantoin,
it’s Bactrim, it’s not ciprofloxacin anymore. Having those documents
to support you, having those documents develop, a long with those different
prescribers [inaudible] use them to provide education
can help you not only in tracking those practices
but providing feedback on them. You talked a little bit about
providing the antibiotic timeout or that antibiotic review. It does have some challenges,
as Dr. Thompson was saying, in working those and building
those into the workflows as, you know, you don’t have this
prescriber on site except for once a week for that, identifying that designated
person who is going to go see, you know, Mr. X was
provided that drug, and this is the plan for it. How are they doing? Are they responding? Do we really think
they have an infection? Should we continue this or not? How long are we going
to continue this? Is there a culture
we need to check. You know, building in
into the work process that designated person
who is there, who can review all
those data elements and do this has been
a little bit tricky. You know, some pharmacists
have access to that information but not all of them
have the culture data. Sometimes, the IP or the
director of nursing have access to that information
but may not, you know, frequently don’t have the
time and energy to dedicate to this activity on a regular
basis, and doing it, you know, only once a week or only once
every two weeks is not going to be very effective to
provide residents care. So, we are doing a lot of
thinking and discussion on how best to integrate
this practice into the nursing home setting. I’ll move on now to tracking and
reporting of process measures and measures of antibiotic use,
and there are several questions that address, you know, and
there are a few questions in your facility survey that can
address multiple core elements. So, you know, if you go back
and look at this slide later, you’re going to see some
questions are mentioned under several core elements,
because sometimes sub questions, one question can address one, and a sub question
can address another. So, tracking of antibiotic use
can help guide practice changes. Frequently when people
come and ask us, you know, I want to do stewardship, and
I don’t know where to start and what’s the best way
for me to approach this? And we, you know, the common
answer we give back is you start from your own data. You need to look at your
own prescribing practices, what are you prescribing
antibiotics for, and this is where you identify
opportunities for improvement. Do you have a large
subset of your residents who are taking prophylaxis
for prolonged periods of time, and those can be, you
know, that can be improved. Is UTI the primary driver in
your facility, and you need to address, you know,
improved testing and treatment practices
for that. Is there a lot of empiric
testing on admission? But some facilities
still engage, and that drives prescribing, and maybe we need
policies around that. Are we doing a lot
of tests of cure? Let’s say we treat someone with
C. diff and then test them again at the end of therapy and
end up giving more and more for not a real infection. So, looking at your
own practices, what you’re prescribing and
what you’re doing is, you know, it’s not an easy answer,
but it’s where a lot of the facilities need to start. And, I know there’s a lot
challenges and data sources in this setting, but many
facilities are looking at their, getting their antibiotic use
data from different sources. So, long-term-care pharmacies, some of them now
provide dashboards that can give you
antibiotic use reports that provide you an overview that can be reviewed
that can help. They dispense and
deliver medications. They provide drug
regimen reviews, and so some of them can
provide those reports and some long-term care
pharmacists can help you interpret them and know
what to do with this data. We know that EHR
implementation is very variable across the country. You know, whether facilities
have an electronic health record system, what they’re using it
for, whether they’re using it to order drugs or not, there’s
a lot of variability over that, but we know the uptake is
increasing slowly, and you know, we’re not at the level
where hospitals are, where you have an EHR
record in every hospital, but things are moving
slowly into that direction. So, some EHR records, EHR
systems can provide you with antibiotic use
reports for your residents. But in many places similar
to what facilities use to collect infection data
with their infection log, the only way they can
collect antibiotic use data is by keeping a log. And that, you know, if
that’s the only way to do it, that’s the only way to do
it, and you know, not ideal. It’s labor intensive, but it
can provide you with information on what you need to do. So, in terms of looking at
antibiotic use measures, there’s many nursing
home programs that track new antibiotics
as part of their infection
surveillance activity. On a day-to-day basis, that
can help you with, you know, identifying the subset
of your residents on what antibiotics there are
and what the indication is, and more and more, the
antibiotic use reports that you’re getting are based
on antibiotic base of therapy. And this is what’s
being used in hospitals to track antibiotic use, where you identify
different residents, what drugs they’re one, how
many days where they are on antibiotics, and those are
added and to provide a measure over time of what you’re using. This may be more accurate when
using EHR systems or pharmacy, and this form of
tracking is more useful when you’re looking sort
of like at the big picture, when you’re in your [inaudible]
meetings when you’re looking at your quarterly use
and your yearly use and you’re comparing
different time periods to see what happens. So, you know, tracking
antibiotic use on a day-to-day basis looks
a little bit different than what you’re doing
when you’re reviewing, when you’re reviewing, you
know, quarterly or yearly. Dr. Thompson talked to you
about urinary tract infections, and this is commonly an
opportunity for improvement, because we know asymptomatic
bacteriuria is– sorry, I moved onto
another slide. Yeah. So, another way to look at
antibiotic use rates is looking at it by class, to look at
your fluoroquinolones use, specific resident type, you
know, your short-stay population and your long-stay
population have different needs and different requirements. Documenting indication when
it’s available, it’s helpful, and sometimes the location
within the nursing home and the unit can be helpful. And prescribers, to identify
those negative deviants or those individuals who, you
know, you need, who you need to sort of follow
up more closely with or keep a closer eye
on, sometimes can help. There are challenges in
that, and we recognize that, but getting this data
over time can help. And providing that
feedback is helpful. You know, there is a
subset of prescribers that no matter what you do,
it’s just, there’s, you know, they are, they have a
specific way of doing this, and they may not respond. But overall, and, you
know, we’ve been doing this for a while, people want
to do the right thing. Nobody wakes up in the morning
and says, today I’m going to prescribe, give a resident an
antibiotic that they don’t need. You know, they’re doing this
because of a lot of limitations and difficulties and challenges. And facilitating stewardship
implementation and facilitating, you know, a review and giving
them feedback and tools so they make sure that
the residents are safe and they’re being followed up
appropriately is what’s needed. Now, I’ll move onto
urinary tract infections. So, you know, asymptomatic
bacteriuria is common in this population, and there
are studies that have shown that in your nursing home
residents 15 to 35 percent of asymptomatic men,
we check their urine, they have bacteria in the urine. Twenty-five to 50 percent
of women and everybody on a catheter has
bacteria in the urine. So that over testing and testing
that culture without, you know, a good index of suspicion for
a urinary tract infection leads to unnecessary treatment, risk
of adverse drugs and events, and delays in diagnosis. As a lot of times that
testing is triggered by a change in condition. So, you know, we have a
lot of anecdotal cases, and I think every one of you
have learned, have seen a case where they were treated for a
UTI and it turned out they had, you know, a TIA or a stroke or
something or an adverse event from a different drug or
something else or dehydration or something else
completely going on. We know from some
data that up to half of the antibiotics
prescribed to treat each UTI in older adults is either
unnecessary or inappropriate, such as, you know, you give them
quinolone as a first-line agent. So, when, and you
talked about the use of the urinary tract infection
module, and I just want to highlight how the use of this
module can help you track some of your practices around testing
of UTI, about antibiotic tracks that you provide, and
about those UTI events that help meet surveillance
definitions. And this can help
you track the testing and treatment practices
at your facility. And you can look at
your antibiotic use through the antibiotic starts
for that specific infection. As we said, the CMS regulatory
guidelines, you know, tell you, you need a system to track
antibiotic use at your facility. And, you know, but they
don’t really specify where that data is coming
from, what the focus of it is. You need to have a system
where you’re collecting data, where you’re looking
at this data, and where you’re
acting on this data. You’ve seen, again, you’ve
seen those slides before, but I’m just, I’m
just bringing this in. You can have, you can look at
a line list, and a rate table from that module to
look at your practices. And the line list shows you
all those different UTI events that meet surveillance
definitions, and you also have all the events that you’re treating regardless
whether they need definitions or not and that helps you
calculate the total rate for your facility. So, other than monitoring what
we call a process measure, which is antibiotic use, which
is where you need to start when you implement stewardship. Also, monitoring health
outcomes can help you guide practice change. And we talked a little bit about antibiotic susceptibility
profile and microbiomes and some of the challenges that you
have in getting that data. You know, antibiograms can be
helpful in many different ways. When antibiogram data is
available to your facility, it can just by showing
your prescribers the rates of resistance that you have. For example, for example for
E. coli and UTI and, you know, from data we’ve looked
at universally, those rates of resistance
for quinolones are high. Just by telling them, you know,
what we’ve tested, 70, 80, or whatever number of samples
are resistant to quinolones, you know, we shouldn’t be
prescribing that as first line for a UTI can help you
with improving practice. It can help inform your
guidance for treatment of UTI and identifying your
first-line agents for treatment. With that said, we frequently
hear from some nursing homes, it’s, you know, I
have a small facility or my lab cannot get me an
antibiogram, so I’m sorry, but we can’t do stewardship
here. And there’s a lot of
other ways, you know, antibiograms are important. They can help you, you know,
they can help you with practice, but we also know that,
you know, not many people, not many people know what
to do with it, you know. I’ve also heard anecdotally
from a DO, and she said, I spent nine months to get an
antibiogram for my nursing home, and I was on the phone every
other day, and I talked and sent letters and emails
and then finally I got it, and I got this paper, and I
don’t know what to do with it, and I put it in a file,
and it’s on my shelf. So, you know, getting
that data is helpful, and it can guide practice
change, but there’s a lot of other things you can
do to improve practices and another thing to
track is what you’re doing through the CDI module
is the rates of C. difficile infection
at your facility. I want to emphasize that although improving
use is a priority, improving infection
control practices and vaccination rates can
prevent those infections, and you wouldn’t need an
antibiotic to begin with, and a lot of the conversations
and what we’ve been talking about the past few days
in terms of surveillance of infections all feed into you
want to prevent these infections to occur from the, you
know, in the first place. And all of you struggle with
a lot of limiting resources, and we’ve been having a lot
of different conversation with partners how can we
integrate quality improvement practices together? How can we make sure that
stewardship practices and infection prevention? What stewardship and the
regulatory guidelines fall under and early sepsis
detection and how all of these things fit together
so you’re not doing, you know, different quality
improvement initiatives but all these principles
are working together to improve resident care. And we know, you know,
education alone is not enough, but education is where
you need to start, and we know that your frontline
nursing staff are critical in building a team that are
working to improve communication and implement any quality
improvement initiatives. You know, many times
we hear, you know, we talked to the providers. We implemented practice
change, but then, you know, someone on the staff walks
in and tells the, you know, tells the resident, oh,
that urine smells nasty. I think you have a
urinary tract infection. So, making sure that
everybody is on the same page and everybody, you know, is part
of this process is critical. And education for residents and families is part
of the core elements. And it’s important to set
those expectations early. And this is not a conversation
you have with a resident and family when mom is confused. This is a conversation that
should be had, you know, on admission, on
an ongoing basis through resident counsel
meeting, through letters and education that’s provided. You know, and part of it
is for us to say, you know, we’ve been doing this
[inaudible] for a while. Residents and families didn’t
learn about UTI and antibiotics from TV or from an ad. They learned about it from us, and we’ve been doing
this [inaudible], any time something happens,
or this is probably a UTI, and some Cipro will
clear it right back up. And, you know, and it’s okay
to say, we now know more, and we know many adverse events that we didn’t appreciate
before, and just in case is not
good enough anymore. You know, we need to
keep a closer eye on this and do the right
thing for your family. So, having those conversations
early and having, you know, and of course personalizing it
to every specific situation. These are meant to be
guidance, and this is not meant to tell you, you know, what to
do in your clinical practice when you take care of
your own residents. At the end of the day,
you know, you’re there. You’re seeing them,
and you know best. I want to talk a little bit
about effective communication with residents and families
and a lot of the work that our office does is
exploring and looking at different ways to
improve antibiotic use. And we know that a lot of the
antibiotic use is a behavioral, you know, it’s a
behavioral issue. Not every single antibiotic
prescribing decision is a thoughtful, you know, thoughtful
decision that you make. A lot of it has been built
over time with practices and has an impulsive
component to it, and changing behavior
is not very easy. So, we have been looking at
ways to improve communication between providers and their
patients to, you know, to improve the uptake of those
treatment recommendations and make sure they
are satisfied. You know, a lot of us, and
I know for myself, you know, I don’t want to take
care of a patient and have them leave
unhappy with the care that I provided for them. You want them to trust you. You want them to feel confident
in the care that you provided. So, you know, with
all the caveats of patient satisfaction survey, which a whole other discussion I
can talk about for a full hour, you want, you know, we
want, we are human beings, and we want that positive
reassurance that, you know, their confident in us and
they’re happy with our care. So, how can we deliver
that information and that necessary care, which is sometimes not
giving an antibiotic when they want it
in an effective way. And a lot of this work has been
done in outpatient clinics. So, you know, extrapolating it to other nursing home
residents is really tricky and it’s something we’re
exploring right now and working on. But I want to review with you
effective ways of communication that were found to work
in the outpatient setting, and they were found
in multiple studies to improve antibiotic
prescribing, and they were found to be a very low cost,
sustainable intervention that when you train providers on
effective communication skills, it not only it works
but it also, a lot of the interventions
we do, such as education and, you know, EHR modules,
they work for a while. The intervention is there,
but when you stop looking, people usually revert
back to practice. Communication was one of the
few interventions that were, improving communication
is the few interventions that were found to
be sustainable. So, those principles are,
and they reviewed them in that specific way,
start with, you know, making a case for a diagnosis. And many of you have been doing
this for a while and integrate, already do this in some of the
ways when you talk to residents, but, you know, having
that formal way, especially for your
providers can be helpful. So, making the case for your
diagnosis, like, you know, reviewing your findings. So, for example, Mrs. Jones may
be sleepier than usual today. But she does not have a fever. She does not report burning
on urination, urgency, or any other symptoms that suggest she has a
urinary tract infection. Although her urine does
seem darker but it seems like dehydration
and not really UTI. And then, you move on to explain
why an antibiotic is not needed, and you combine it with a,
sorry this is written wrong, it’s combined with a negative
recommendation followed by a positive one. So, you need to start
with, you know, I don’t think she
needs an antibiotic, and I think it’s going to
cause her more side effects like diarrhea rather
than help her. And then follow with a
positive recommendation. Instead, we would initiate
a hydration protocol with IV fluids to
address her dehydration. And it’s very important
at the end that you give people
a contingency plan, that if I’m doing doesn’t work, what’s going to happen
at the end. So, yeah, we will
continue to monitor her, and if she does not improve,
we will reassess her, do cultures if they’re
necessary, and start therapy if she has a fever or if
there’s any signs of infections. And as I said, these
principles have been tested in the outpatient
setting, and I’m curious to hear your thoughts, whether
training people around trying to improve their
communication could help. So, and we’ve been talking
a little bit about education and improving communication, and there are several training
resources that are available to you and your staff, and
you’ve heard about them before. I’m going to focus on the
stewardship components. So, CDC has a training
on antibiotic stewardship that includes the
module on the treatment of urinary tract infections,
and although that is meant for the outpatient setting,
a lot of the principles in it on asymptomatic bacteriuria
apply to the nursing home settings. And we were very mindful when
we were developing it to focus on older adults in it. And there’s another
one that is focused on stewardship in nursing homes. You know, this module
is a good module to provide an overview
of, you know, what is stewardship,
why is it important. It goes over stewardship
into different settings and some specific infections like respiratory
tract infections and urinary tract infections
and all of those are available with free CE credit online. And I know you’ve heard about
the infection prevention and control training course that
was developed in collaboration with CMS, and there is
a module in that also on antibiotic stewardship. So, Dr. Thompson
reviewed with you from their own prevalent survey
work what they’ve seen in terms of implementation for
nursing homes for stewardship. So, the data you report to
us, we learn a lot from it. Not only the infection
and the surveillance but also the facility survey
you fill on a yearly basis and all those questions
I’ve been going over with you right now. You know, we look at the data,
and we analyze it and see, you know, what’s
happening out there and what are facilities doing. So, we looked at 2016 annual
survey data and facilities that reported their stewardship
practices, and we looked, and we found that
there were 42 percent of facilities reported
implementing all seven core elements. And as Nicholas, as Dr. Thompson
was saying, this is, you know, this is reported data. So what you say, yes I have
leadership commitment can be very, very different from when
you say I have leadership. And some of it may be true,
and some of it may be not. That said, the way we look at this data is we
look at the gaps. So, when someone says,
no, I don’t have it, we know for a fact that they
don’t have it, and figuring out where nursing homes are
struggling most and trying to provide resources
and work with partners to help implementing that core
element specifically is helpful to us, and also for us to track
that implementation over time and see, you know, where
people are doing better. For example, leadership are
identifying its priority within CMS regulations and
writing commitment letters and reviewing data
whereas reporting remains to be a challenge for everybody. It helps us also figure
out what we need to do and how we can support
stewardship implementation. And, so we found that both
reporting and education are, you know, big areas where
facilities struggle with most. So, in summary, you know, we
defined antibiotic stewardship and talked about
specific actions that can help you optimize
the treatment of infections. We went over the annual
facility survey, you know, and also when you
fill this data, you can identify opportunities where to implement
the core elements. So, when you say no to
a specific question, this is something
you can look into. It’s like the checklist
that’s under the core elements that let’s you look
at every core element and identify what you can do. Looking at that facility
survey every year is also an opportunity for improvement. And looking at the urinary
tract infection modules to test your testing
and treatment practices for UTIs can help you also
improve antibiotic use. I’d like just to
make a quick plug for U.S. Antibiotic
Awareness Week in November. This is, you know, our
yearly, a weekly event that we do every year around
November where there’s a lot of social media activity
and education activities around the improvement
and antibiotic stewardship and improving antibiotic use across the spectrum
of healthcare. And many times, there’s very
specific nursing home materials that are released at the
time or, you know, interviews and studies and educational
content that we post at that time. So, mark your calendars. Many state health departments where you are participate
actively in that, so you may be hearing
and getting email and participation is welcome. So, this is all I have. Any questions can be
addressed to antibiotic use at and, you know, maybe
with a version that we share with you I’ll also
add my email to that, so if you have any
questions, you can refer to me, and I’m happy to take
any questions now. [ Applause ]>>So, I have two comments. One, I’m very excited to hear about you addressing
patient family– I’m glad to hear about the
patient family education. As I travel around the country at our medical director
meetings, what I consistently
hear over and over from our medical directors
and providers is the family and patient pressure that,
you know, they’ll go in, they’ll have those discussions about why they don’t
feel it’s needed, but you have a family member
who’s well intentioned, that says, you know, my
mom, when she has a UTI, she’s always this way, and if
you don’t give her an antibiotic and something happens and
almost becomes threatening>>Yep.>>And they, after
a while we give up. You know, we bang our heads
against the wall, and sooner or later we just give up
even though we know it’s not best practice. So, I’m glad to hear
about that education. And then the second is, when I’m
at these meetings educating them on stewardship, it would be
great if I could have written from a physician perspective a
one-page with some really key, written in their language
bullets that might be able to derive things home
better for their education. You know, we talked a lot about
the things that you mentioned on your slides, but I don’t know if I’m not using the right
language or whatever. Maybe if written in physician
language it might be better, but maybe that might also
be helpful for centers when they’re working and educating their
providers some key points from a physician
perspective on what to say.>>So, you’re saying sort
of a script to communicate with providers better. You know, we can certainly
talk, you know, talk about that and think about that, and
you know, part of it is, like we were talking,
education is not a, you know, it’s not a one-time
thing you do once and check the box and move on. Changing practices that you’ve
been doing for years and beliefs that your residents and
families have, it takes time, and it’s an ongoing
conversation, and you start, and you know, you go on. But a lot of the educational
content I refer to is meant, you know, for clinicians and
highlights those practices and issues of adverse
events with those. So doing those modules that
are, you know, that are free, that are available for
CE credits very easily, and you know, you don’t
have to do the full thing. You know, you don’t have
to do the full thing. You can pick and choose. There are several
modules, and you can pick and choose each one you want,
and so sometimes prepping, some of the talks and we
found that to be effective when we give talks in webinars. You know, we prepare for it
with one of those modules that we send people
to do ahead of time. So we’re not going and starting
that conversation from scratch, and that’s been, you know,
we’ve received feedback that that could be helpful,
where you sort of plant the seed and highlight those
principles before, and then you start building on
them and having a conversation.>>Too, just one point, I
appreciate what the woman that just spoke said, and
I appreciate what you said about kind of following
the negative by a positive. There was some work done. I watched some webinars on
work in this area with parents with children in
pediatric settings also. But also, your point
that it’s not about necessarily taking away
the antibiotics but looking at the right, you know,
drug, the right dose for the right amount of time. So, if we could really
promote that message, because I know even as a
healthcare professional for many years, when
I first heard about antibiotic
stewardship, that was kind of my first thought too. Like, oh, we just don’t
care about people. We’re just going
to let them die. It kind of, I mean that’s
kind of what I heard and what, you know, was kind of in
the back of my mind too. And especially with the elderly,
you know, do we really care about those that are aging? Maybe we’re just
thinking, you know, well, what are they really worth? Will this, you know, not
take care of them well? And so I think there’s
some really huge issues, especially in nursing homes
with trust and, you know, many people, if you talk
to them, will not want to go to a nursing home. Most people I know do not want
to end up in a nursing home, so I think we really
need to think about that, and so when you’re coming,
you know, when you’re caring for someone and you have
an excellent relationship with them, and they trust you,
and what are you offering them? What are your protocols
within your facility? Like if I’m laying there,
and you’re telling me that you’re not going
to give me an antibiotic but I’m having these discomfort,
what are you offering me.>>Exactly, and that’s what
I meant when I emphasized when you’re talking, you know,
it’s not only for communication but having it in practice,
having that contingency plan. That, you know, you have
a, there is a complaint, there is a change in condition
that prompted that thought, is this infection, do
I need to treat it. And what we are seeing in
your complicated patients, this is not always
and infection, and sometimes antibiotics
give you that false sense of security, and you’re missing
what’s actually going on. So, knowing what’s, you know,
having a contingency plan, having an active
monitoring protocol in place where I’m going to recheck
you in a couple of hours, for the next 24 to
see what’s going on. I’m going to evaluate
you for other causes. I’m going to give
you some fluids and having that conversation. And I want to emphasize
again what you said. There is that distrust,
and we’re moving, especially in the elderly
population, emphasizing safety and emphasizing that this is not
about taking an antibiotic away. It’s about giving it properly. And that also is, and I
don’t know if you’ve seen, it’s changed the
communication that we do about stewardship in general. Early in the days of
stewardship all we did was talk about resistance at
the population level. And I know from my own practice,
when I’m sitting there, talking to a patient, and I’m
worried whether they have an infection or not, and they’re
going and who’s going to check on them and whether they’re
going to die from sepsis at home because I missed something. I really don’t care
about resistance at a population level. I care about the person
right there in front of me. So, the emphasis of talking
about stewardship in terms of resident care, in terms of
giving them the right drug, and even when we talk
about resistance, it’s a resistant infection
that you’re going to get in the future, not that somebody
is going to get, you know, maybe in another
hospital or, you know. And we talk about resistance
in nursing homes as a threat to other places, but it’s not. It’s resistance as a threat to the residents
that we take care of. So, making it individual,
making it about the resident, about their safety, about the
risk of resistant infections in them in the future is how
we communicate around this. And, you know, we all have
been very mindful of this, and it’s been directing
our policies , our communication material. So, it’s about, you know, making
it a safety issue, not taking, you know, stewards are told, like we’re the antibiotic
police, and we’re taking your
antibiotics away, and I don’t want that title. And, you know, I don’t
think anyone else does.>>Just one more, I
just wanted to share, just a couple things
I wanted to share. I’m from Fairfield, California,
and I just wanted to say that it’s, our building or
our area is very fortunate, and I appreciate the HA, the
HSAG, H-S-A-G, because they did in the past, they did have a
series of training or a webinar about antibiotic stewardship. And so, and my administrator
and my director of nurses, they’re very supportive on this. So, in my facility, we do
have a quarterly meeting. My administrator hired infection
MD from the acute hospital, and we meet with the
infection MD and the doctors, providers in our nursing home, and then on this antibiotic
stewardship I had expressed to the doctor that if the nurse
has spoken to you let’s wait for the three days when
the culture comes back and we’re going to monitor
the patient and we’re going to provide fluids and
everything, we probably started on antibiotic, please
don’t get offended. So, that alone can improve the
communication in [inaudible] between the doctor
and the nurses. But then, when you said
about the communication and that is very important,
but I wanted to add too, that documentation
comes along with this.>>Yes.
>>Because you know why? We just had a survey last month. You think we did good? No. And this is the first time, because I’m in northern
California, this is the first
time we had a surveyor from southern California,
from Orange county, because there’s not enough
[inaudible] surveyors, so they sent these
folks to our building. And this is the first,
every year I get interviewed by infection prevention,
from the infection control, and we always do good,
but this year, this lady, she has some career guidelines
in front of her, and she will go through by, you know the
symptoms, and she asked me to look at the records and
showed me these symptoms, and if the symptoms is not
in there, she asked me, now can you show me
the documentation that the nurse has attempted to call the doctor
and documented that. Look, doctor, there’s
no symptoms. The culture is negative. Can we stop the antibiotic? And unfortunately there
was no documentations. That’s why I want to say,
they go hand in hand. And we’re all are long-term-care
facility, and I don’t want that, I don’t want you to be on that
[inaudible] like what happened to me, and I just felt like,
I don’t know what to say. So, I just wanted to share that.>>Well, thank you so much. And I want to emphasize,
you know, monitoring whether
you give antibiotic or you don’t give an antibiotic,
in either it’s critical. And as you said in
documentation, for surveyors, for litigation purposes, you
know, whatever you end up doing, it’s really important. I don’t know with
time how we’re doing?>>I’m from Washington,
DC, and my question is, the information clearly is
being disseminated and shared with the IPs throughout. My question is, is it being
shared as much with the NPs that are coming into
the facilities, that are independent prescribers
and are prescribing antibiotics without following up, pausing
just because they can bill because they’re able
to prescribe.>>It is a difficult
issue, and we know from, not from the nursing home
setting, although we’re trying to look at that, but from
the outpatient setting that there is a tendency for
advance practice providers like NPs and, you know,
and assistant physicians, they tend to have slightly
higher prescribing rates in terms of antibiotic, and
there are several reasons that could drive that. It is an issue, and you know,
we are currently doing a lot of focus group testing with this
group of provides specifically and try to identify, you know,
what are the causes of this, the drivers of this, and how
can we focus our material better and our messaging better to address this provider
population specifically. You know, there’s a
lot of work to be done, and I’m with you on that. And so, in closing, thank you
so much for being here today and thank you so much
for your feedback. And you all do the hard
work, so thank you. [ Applause ]

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