Role of Nurses & Consultant Pharmacist in Antibiotic Stewardship in long-term care

Role of Nurses & Consultant Pharmacist in Antibiotic Stewardship in long-term care


– [Tammi] So, after the presentation, hopefully you’ll be able to describe the role of long-term care nurses in an ASP program, or an ASP. Describe the challenges of implementing one in long-term care. Boots on the ground, the information that we all get, but the actual implementing it sometimes isn’t quite
so clear and easy to do. And then to outline the process of the consultant pharmacist antimicrobial assessment
in long-term care. So there’s three main roles of the nurse, communication is the first. And it seems like no matter
what you’re talking about, if something is going to fall through, it’s some level of communication. If you look at everything we do as nurses, sometimes the problems starts within the level of communication. Some barriers to communication, it has the definition there, I’m not gonna read it to you guys, you guys can read, is the education. There’s so many new things, so much new information out there. Making sure the education gets out to the people that really need it. The culture of antibiotic use. So many things that we
do in long-term care, we’ve been doing for a number of years and it’s ingrained into who we are, and it’s like our muscle memory. And so, reprogramming our thought process in how we use antibiotics. Also, in long-term care, especially in nursing, we tend to have limited resources. So, we’re asked to do more
with what we already have and sometimes it’s already stretched. So, as we do as nurses, sometimes we have to get creative. And then residents and visitors, families. Oftentimes, we can try to educate and sometimes it’s the family members because of information they have received or maybe other facilities they’ve gone to that are very assertive on what they want. And so, that can also be a barrier and looking at ways that we
can work with each other, how other people have
handled it can be helpful. Some opportunities. So we have these barriers, so what can we do to kind
of reduce the barriers? Or if we’re really lucky, eliminate them? Training, we can never train enough. Again, sometimes that’s also a barrier because if you’re already
dealing with limited resources, trying to get that training
out in an effective way, in a timely manner, sometimes can be a little difficult. So, thinking outside the box. Taking the resources that we have and using them more efficiently. So, working together as teams, working together multi-disciplinary
within our facility, and being able to delegate out other areas to other departments. As far as resources, the efficient use of
resources would be like, a number of presenters
have talked about today, the use of SBARs. So, the use of the SBARs will
give concise information, it will give what you
need in a quick manner and it’ll increase the
communication with the provider, it’ll also increase the communication between one shift to the next. Educating our families and our visitors and our residents about why, why we are making this decision, why not everything is treated
with an antibiotic anymore. Measurement, so as nurses, we take vitals, we assess the individual,
which comes next, but some barriers to that
might be documentation. Oftentimes, I always say, we do so much and we take
credit for so little. There’s a lot of things
that our nursing staff and nursing assistants that
are doing on a daily basis, but it’s not always
getting clearly charted, so then it’s not getting communicated. And then when chart reviews are done, it appears that these different
steps aren’t being taken. So that’s a barrier,
incomplete documentation. Also, as we’re looking at SBARs
and information like that, we’re looking at closer
observation longer. Many times in our
long-term care facilities, we know our residents,
we know who they are, and sometimes, maybe, that could also lead to the opposite if you’re used to somebody. So sometimes a fresh pair
of eyes can help that. Opportunities would be
the use of the SBAR. I know that we’ve said that a lot today but I think that that
really is going to be… It’s an invaluable tool that is going to help on multiple levels. Assessment, so we take the measurements, we take the vitals, and then we put our whole story together and we decide how this information is going to improve the quality of care for our residents that we take care of. So, how we’re looking at as far as looking at
these different things, Dr. Ashraf talked about
the SBAR as the UTI SBAR. So, they don’t meet the criteria, the individual might not need
criteria for a UA to be done. But we want to monitor them, it doesn’t mean that
they don’t qualify so, they must not have a UTI. That’s not necessarily what it’s saying. It’s saying that now we
want to monitor them closer and so that we will
catch something sooner. And all that would be
listed in the UTI SBAR. Also, another barrier is time. Like we said, so many things, especially with all the new regulations that came down for long-term care is expected to do a lot more with still the same amount of resources that you had before those
expectations came down. So again, it is going
to take out of the box, seeking out your resources. Other people you have in this room is phenomenal resources, your peers, kind of this, all in it
together type mentality. By doing all this, we’re
building on the quality of care. So, the SBAR is a standardized form between the nurse and the provider. It will answer a lot of questions that the provider will have and it’ll be right at their fingertips. And again, anything we’re doing is also improving the quality of care for our residents that
we take care of everyday. So, a paper was put out by the, oops, went a little crazy there, sorry about that, touched the little pad there. The ANA and CDC, this is a paper they put together, not gonna read it all to you, don’t worry. So, this first slide talks about the nurse’s role at the time of admission. We want to use appropriate
triage and isolation, so that’s the communication
between the nurse and the IP, the infection preventionist,
infection control person, whatever the person is
called in your facility. That is the key component. If the infection
preventionist does not know about it as soon as possible, then there can’t be that collaboration. Communication with other
people within the facility and communication with whom you’re getting the information from. So, when they’re discharged
from the other facility and they’re coming to you, getting that information
as clear and concise and working with your other facilities. And then also, communication
from your admission staff, so the individuals that are bringing in the residents to your facility or when they’re being
readmitted to your facility. Making sure you have that
communication in place whether it’s stand-up meetings or that you’re getting involved in making sure that the
appropriate people know. Make sure the accurate
antibiotic and allergy history, so understanding that
if somebody’s allergic, knowing whether they’re
allergic to the antibiotic. We talked about one of the problems with overuse of antibiotics
is the adverse reactions. So make sure that that’s
clearly defined on the chart, if they received
antibiotics in the hospital or at other facilities
and they had a reaction, make sure that that is communicated. Complete the information for antibiotics. Complete information
about the antibiotics, sorry, I was checking my time, and if they’re on antibiotics. So make sure you have the dose, make sure you have how often
it’s supposed to be given, how long it’s supposed to go, so the duration of therapy
is really important. So when an infection is suspected, so you kinda think you have an infection but you’re not sure, the comprehensive evaluation. So, the detailed assessment where we’re looking for clues, we’re looking for what is causing this. A lot of our residents that we have aren’t always real verbal and so, again, you have
to be very perceptive. And making sure that gets documented so that when you’re looking at the history and you’re talking to the
physician or the provider that you can give them the
appropriate assessment. Communication with the
prescriber and the provider, that’s the SBAR. When you think you
might have an infection, making sure that’s completely filled out, every aspect of that SBAR is filled out before you contact the provider. Initiate management plan, the act of monitoring documentation. Look at the antibiotic order, the dose might need to
be revised, the timing. Connecting with your pharmacist, making sure that communication is open so that they’re gonna have
the updated recommendations before we will as nursing sometimes. Earlier appropriate cultures. So, again, not only getting the cultures before you start antibiotics, but make sure when you’re
getting the culture, that your technique that’s
being done is appropriate. So if what you’re doing is
contaminating the culture, you might as well not do the culture. So, working with staff and doing staff education on that too if your results are coming
back with a contamination. During management or suspected
or confirmed infection, progress reporting, so keeping in touch, is it getting better,
is it staying the same, is it getting worse? Antibiotic adjustments, deescalation was talked about just prior to our presentation based on the lab reports. So if you do a culture, if you’re treating before you
know what you’re dealing with, you do a culture, if it
comes back resistant to that, making sure that that’s
communicated quickly so that the appropriate
therapy can be initiated. Antibiotic dosing changes based on the drug levels and other lab reports. Again, keeping in contact with your lab and your pharmacy is important. Monitoring for adverse drug events. Again, we’re trying to use the antibiotics only when necessary but
when we do have to use them, just making sure that it’s appropriate. And then antibiotic time-outs, so 48 to 72 hours after
antibiotics are started, reevaluating, again, is it working? Is it consistent with
information that we now have? Are the cultures telling us that, yes, this is the appropriate therapy? At other times… So, our role at other times in nursing, question the medical necessity
for diagnostic testing. Oftentimes, making sure, it may not be your provider
within your building, it may be a specialist that is being seen, your residents are being
seen by a specialist and there’s been a change in behavior or maybe foul-smelling urine and they automatically wanna order a UA. So, looking at that and reassessing, do you have other symptoms that would lead you to believe that? So, you know the resident,
you know their history, and having a discussion with the provider or the provider with
your facility on that. Coordinate with the IP and the pharmacist on ASP activities. So, it’s important for
nursing to get involved with the antibiotic stewardship program because the nurses are the
boots on the ground people. Those are the individuals
talking with the families, talking with the physicians, so, getting them involved. And then, again, educating
families and residents on appropriate antibiotic use because sometimes that is the issue. Maybe they go to the hospital and they get put on something, and then they came back to us and we’re saying, you know, really, we don’t have the
documentation, let’s try this. And they may not want to
not be on antibiotics. So, the communication
with the family on why is in the best interest of the resident. Just some questions about, when we look at what the role of the long-term care nurse, or what activities can
a nurse participate in to decrease the
unnecessary antibiotic use? So, the options are help develop an SBAR, use the SBAR, clear communication with physicians, assess all other causes of symptoms, or all of the above? You can just say it out loud. All of the above. So, they need to be
involved in all of those. And then the potential barriers to implementing a program
of ASP nursing activities. We had talked about… It’d be A and B, the
culture and the resources. So, just changing our way
of thinking a little bit, what it’s been to what
we’re heading towards. And then also, again,
the limited resources that aren’t available to many facilities. So I will pass it on to Rebecca now. (audience clapping) – [Rebecca] Thank you, Tammi. It was really appropriate in my mind that they asked the
nurse and the pharmacist to speak together because we really are doing a lot of collaborating on this ASP. As several people have mentioned, it’s not just a one-person’s
job, a one man show, it’s a team effort. I’m gonna speak a little bit about the consultant pharmacist
role in stewardship, in my experience. So, as was mentioned earlier, the CDC core elements recommend that the consultant pharmacist is a
part of the stewardship team. Like Dr. Ashraf mentioned, we do bring that drug expertise. We’ll talk about that a little bit more in the presentation. The pharmacist has access to pharmacy data a lot of the time. And we are already reviewing each resident’s chart every month. So why not pay a special
attention to those antibiotics? So, assessing appropriateness
can be a challenge. We’ve talked a lot about obtaining duration and dose and indication, but how do we determine
if it was appropriate? Consultant pharmacists are accustomed to assessing appropriateness,
we do that on a daily basis, whether it’s with psychotropics
or antihypertensives. That’s kind of what we’re used to doing. If your pharmacist does not
have a baseline knowledge, as Dr. Ashraf mentioned, there’s lots of resources. ASCP has training available. We also are already reviewing charts and sending letters to prescribers. So, at the time of our monthly review, we can send letters to prescribers if things are inappropriate. Now, that could be current therapy and it could be a retrospective review. Either way, we are viewing it as it’s still as an opportunity to educate. If any of you have ever
heard providers complain about the amount of letters
they received from a consultant, you will know that that will motivate them to make better choices. By doing that, we’re giving physicians a recommendation for future prescribing. Easier when they are an in-house provider. As it’s been mentioned, it’s definitely more challenging when they are not someone
that is affiliated with us. It’s hard to affect those ER docs, urgent care, that kind of thing. So, your consultant
pharmacist may have access to pharmacy dispensing data which can provide the
facility with some assistance in obtaining all of the data. Things that we are monitoring for, our total number of
residents on antibiotics during a given month, new antibiotic starts,
and total days of therapy. While we are performing the chart review, we can review the percent
of new antibiotic orders, where the SBAR was used, if that’s something you’ve implemented, we can be that double check for you to see if staff is following through. And then as far as appropriateness, we are using McGeer
criteria or Loeb criteria to assess inappropriate
versus appropriate. Now, a barrier that we’ve been seeing is, like Tammi had mentioned, documentations. We are going to deem it as inappropriate if we don’t see the symptoms documented but sometimes that’s not the case, it just wasn’t documented properly. So, again, stress the
importance of that to staff. Other things we are looking for is total number of adverse events reported with antimicrobial therapy. And lastly, which prescribers are consistently prescribing inappropriately. Again, something that
was mentioned earlier is giving providers feedback. I think that is really important. As we’re looking at trends in our data, we’re going to be implementing some reward system type thing, a recognition for being a good prescriber. Drive that competition, kind of. Okay, so to get a program up and running, what I have done with my team is we were fortunate enough to work with the UNMC infectious disease experts. So we were trained in ASP
implementation programs to help our facilities. We have been out there,
kind of doing our thing in long-term care facilities, helping them get started with antimicrobial stewardship programs, providing them tools and templates and guidance obtained from our sessions. And like Dr. Ashraf mentioned, a lot of that is available
to you on the ASAP website, so no worries if you’re
just getting started. And as Tammi mentioned, there are so many barriers
sometimes for the IP. Not that we have all
the time in the world, but with the two of us together, we can kind of conquer that effectively. And again, it shouldn’t have to be just the IP driving the program, we need the involvement on everybody. That slide, the cartoon that Dr. Crnich said before of the men in the boat, if your pharmacist is that
person sitting in the back, you should come talk to me. That’s not okay. (all laughing) Okay, so our process
that our consulting group has taken is we’re reviewing
every antibiotic order for appropriateness on a monthly basis. Like I said before, that could be current, it could be retrospective. And then we are providing written feedback to prescribers for
inappropriate prescriptions. We are reviewing use of the SBAR tool, if it was filled out correctly, if it was or was not filled out, and reporting that back
to director of nursing. And then kind of having a chit-chat with the infection
preventionists every month to identify barriers or
what still needs to be done. Kind of just helping keep them on track and working together. So this was kind of mentioned earlier too, tracking is a big part of stewardship. Lots of different things we can track, which is very helpful if
we have the pharmacy data. So, number of antibiotic
starts per 1000 resident days, again, your pharmacist
will need some of your help obtaining that information. Whatever your billing department
is using for resident days, we would need that information. Days of therapy of antibiotics, number of antibiotics
reviewed in each month, or each quarter, whichever way. We are just now at the six month mark from when the regulation began, so we’re all still learning this together. We’ve been tracking
the data for six months and actually putting it in an app to be able to get our results. And our facilities have
been waiting patiently for some of those results. And I am really excited to be
able to present it to them, I think it will be very eye-opening. Once we are able to look
at all that app data, we will be able to assess
what the most common reasons for inappropriate prescribing were, and just the proportion of
appropriate versus inappropriate. And like was mentioned earlier, in addition to that, you could also be looking
at duration of therapy. That might be another target
that we can try to affect, which we are sending
letters to prescribers for that as well. So also as mentioned earlier, your consultant pharmacist can attend your quarterly QAPI meeting and maybe have a stewardship
meeting on top of that, or in addition, while the
medical director is on site. That’s worked pretty well
for some of our facilities. Working with the infection preventionist to develop reports, kind of being their support system. Assisting the ASP community in providing templates and reports for prescribers. And regional benchmarking data is something we can also provide. Currently, we are working
with Dr. Ashraf’s group and have 32 facilities enrolled. And a lot of people do like to see where they compare to their peers, we’re able to break that
down by facility size and skilled versus nonskilled population. So that’s been really
interesting to see that form. Here is one of those baseline
of what we started with. I think someone mentioned earlier how you’re not gonna know if you’ve improved unless you have your baseline established, and that has been a challenge because prior to November of
2017, when the reg started, a lot of people weren’t
tracking these things. So we don’t know where we
started before November. But it’s a process and we’re doing it, and we’re working on it, so we are confident we will
be able to show improvement. Education is another thing
your consultant pharmacist can provide. As they mentioned before, we had some training
from Dr. Ashraf’s group. And for those who haven’t
done training yet, there’s training available through American Society of
Consultant Pharmacists, and even just a lot of the
resources that Dr. Ashraf has mentioned for facility staff. So we can help facilities with resources for educating staff and families, inform facilities about
opportunities like this Summit, and then one-on-one or group education. Sometimes I feel like the IP or the DON, they think their staff needs to hear it from an outside source what they are doing incorrectly or should be doing better. So we are happy to step
in and give our insight. It’s always better for us to point out areas that are lacking before
the survey team comes in. So, utilize your pharmacists. Okay, so there we are to the end already. An effective antimicrobial
stewardship program should include the
collaboration of the team, like has been stressed
several times today, communication between
nursing and the prescriber is essentially in improving appropriate antimicrobial
prescribing, like Tammy mentioned. We are really pushing
the use of the SBAR tool because it’s been studied and
proven to have good outcomes. As Salman mentioned,
providers would rather receive all the information so
they can make good choices. Nursing is their eyes and ears, they are reporting to the
physician in a lot of cases, where the physician is not in the facility to see the resident. So they need the most
accurate information. Consultant pharmacists can help facilities identify inappropriate antibiotic use and to help track trends. Like I mentioned, if your pharmacist is
the one sitting in back, should not be doing that
at this point in time. And long-term care
facilities should involve all their nursing staff. We need to incorporate
everything we’re learning to the people on the floor because if we’re keeping it to ourselves, then we’re really not going
to see a greater improvement. We are not always there
to monitor these things, we really have to empower our team, get everybody on board. That is it. Thank you so much for attending and we’ll take any questions. (audience clapping)

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