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

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

August 8, 2019 0 By William Morgan


– [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)