STRATEGIC INFORMATION SYSTEMS PLAN
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Transcript STRATEGIC INFORMATION SYSTEMS PLAN
Pharmacist Monitoring Tools
for Antimicrobial
Stewardship
Dianna Gatto, Pharm.D., BCPS
Pharmacy Clinical Manager
Chris Beuning, Pharm.D., BCPS
Pharmacy Clinical Analyst
MultiCare Health System
September 10, 2012
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MultiCare Health System
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MultiCare Health System
Not for profit organization in
the greater Tacoma, East
Pierce and South King
County regions in
Washington state
879 licensed beds
Tacoma General – 402 beds
Good Samaritan – 275 beds
Allenmore – 130 beds
Mary Bridge Children’s –
72 beds
Specialized Services
Level II trauma at TGH and
Mary Bridge Children’s
Level III NICU at TGH
Rehabilitation program at Good
Samaritan
Primary Care Clinics
Urgent Care Centers
Free standing Emergency
Department
Employed Providers
HIMSS Davies Award winner
2009
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Objectives
Be familiar with antimicrobial stewardship
Understand key pharmacist workflows
Identify tools for patient monitoring
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Outline
Overview of MultiCare Health System
What is Antimicrobial Stewardship
Pharmacist tools
Key pharmacist workflows
Challenges
Future directions
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Outline
Overview of MultiCare Health System
What is Antimicrobial Stewardship
Pharmacist tools
Key pharmacist workflows
Challenges
Future directions
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What is Antimicrobial Stewardship
Antimicrobial Stewardship (AMS)
Systematic, multi-faceted approach to the use of
antimicrobial agents, to optimize clinical outcomes while
minimizing unintended consequences
Goals of programs
Achieve the best clinical outcomes
Reduce emergence of resistant organisms
Decrease costs
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Antimicrobial Stewardship at MHS
Specialized ID pharmacist
Prospective
audit of targeted hospitalized patients
receiving antimicrobial agents and/or diagnosis of
infection
Patient identification based on the following:
Selected
antimicrobials
Bug-drug mismatches
Inappropriate durations of therapy
De-escalation opportunities
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Role of Decision Support in AMS
Efficiently identify patients who need to be reviewed
Pharmacists spend time assessing patient therapy versus
report generation and data mining
Easily generate daily reports in a timely manner that
pharmacists can utilize
Target patients by running reports based on flexible
criteria
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Outline
Overview of MultiCare Health System
What is Antimicrobial Stewardship
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Key Pharmacist Workflows
Order entry and order verification
Prescriptive authority (dosing) protocols
Pharmacist Inbasket message review
Consults
Medication messages
Best practice alerts
Intervention documentation
Ongoing drug monitoring
Microbiology results
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Outline
Overview of MultiCare Health System
What is Antimicrobial Stewardship
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Tools
Need specialized tools that drill down to
increase the number of patients served,
focusing on outcomes and decreasing costs
Selected antimicrobials
Bug-drug mismatches
Inappropriate durations of therapy
De-escalation opportunities
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Tools – Order Entry/Verification
Order sets
Appropriate
agents and doses
Links to guidelines from order sets
Targeted medication build
Appropriate
defaults
Linked
labs
Order instructions
Reference Links
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Tools – Microbiology Results
Best Practice Advisories - General
New properties allow creative rules based on culture results
Rules can be used in BPA criteria
Do not fire to end user
Trigger Inbasket message to pharmacists or pools
Pharmacists can monitor messages based on workflows and
time
Custom Inbasket message created to provide patient
specific information within message
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Tools – Microbiology Results
Best Practice Advisories – Applications
Updated
micro results available
Positive blood culture and no antimicrobial
Resistant culture
Duplicate anaerobic coverage
Duplicate C. difficile coverage
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Tools – Microbiology Results
Best Practice Advisories – Properties
(Vendor specific screen capture removed)
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Tools – Pharmacist/Physician Rounding
Accordion Reports
General
Medication
administration visual
Culture information
Lab data, Vital information
Pertinent drug levels
Allow changes to time view
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Tools – Pharmacist/Physician Rounding
Antimicrobial Accordion
Challenge – complicated patients, multiple antimicrobial
orders, changes in regimen over time
Visual timeline of all antimicrobial administrations
Vancomycin Accordion
Challenge – vancomycin often non-continuous therapy with
stops, starts and dosing changes
Visual timeline of vancomycin administrations
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Accordion Reports - Antimicrobial
(Vendor specific screen capture removed)
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Accordion Reports – Vancomycin
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(Vendor specific screen capture removed)
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Tools - Pharmacist Rounding: Scoring
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System Lists and Patient Scoring Tools
Utilize
same BPA properties to create rules
Ability to sort columns and relative overall score to
identify key patients
Rules/Columns in Antimicrobial Stewardship Scoring
Patient
specific information: location, name, age, primary
problem, weight, height and creatinine clearance
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Tools - System Lists and Patient Scoring
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Rule based columns
Score
Creatinine clearance (CrCl)
Value of 0 to 1 based on
level of renal dysfunction
(0 = >70 mL/min; 1 = < 10 mL/min)
On antimicrobial
AMS target medications
Aminoglycoside/Vancomycin
Value of 1 for each
antimicrobial
Value of 1 for each target
antimicrobial
Value of 1 if on either
On 3 or more antimicrobials for 2 Value of 1 if true
or more days
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Tools - System Lists and Patient Scoring
Rule based columns
Score
On quinolone, vanco or imipenem
Value of 1 if true
for 3 or more days
On ceftriaxone and azithromycin IV Value of 1 if true
for 5 or more days
On nitrofurantoin and
CrCl < 60 mL/min
Open I-Vents
Value of 1 if true
Rx Protocol
Value of 1 for each open
protocol
Value of 1 for each open
I-Vent
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Tools - System Lists and Patient Scoring
(Vendor specific screen capture removed)
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Tools - Surveillance/Effectiveness Reports
Drug Usage
By
patient, location, physician and drug
Days of therapy
Individual
drug per 1000 patient days
Entire patient hospitalization per 1000 patient days
IV compared to PO
Track
antibiotic use and days of therapy by
provider and specialty groups
Antimicrobial cost per patient day
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Tools - Surveillance/Effectiveness Reports
Process/Outcome Measurements
Antimicrobial
use and impact on Clostridium difficile
infection rates
Intervention
acceptance rate by physicians
Direct antimicrobial expenditures
Track discharge antibiotic trends
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Outline
Overview of MultiCare Health System
What is Antimicrobial Stewardship
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Challenges
Identifying specific interventions
Incorporating tools into pharmacist workflows
Quirky BPA behavior based on free text
Lacking interfaced lab system
Free text data sent for microbiology results from lab
system
Competing requests for reporting resources
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Mitigating Challenges
Creative use of BPA’s and searching for free text
strings
Use of reports with data already in the Enterprise
Data Warehouse (EDW) for other initiatives (sepsis
metrics)
Leverage expertise from outside the pharmacy team
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Outline
Overview of MultiCare Health System
What is Antimicrobial Stewardship
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Future Directions
Introduction of QlikView for reporting from Epic
AMS program outcomes
Antimicrobial
usage trends
Drug use patterns related to infection control data
Comparative reports by drug, facility and prescriber to
identify improvement areas
Financial impact
Expand AMS to all hospitals in system
Consideration of changes to lab system
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Conclusion
What is Antimicrobial Stewardship
Pharmacist tools
Key pharmacist workflows
Pharmacist tools
Challenges
Future directions
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Questions
[email protected]
[email protected]
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