Transcript [Poster title] - Health Systems Renovators, LLC

A NOVEL APPROACH TO ANTIBIOTIC STREAMLINING
Kevin D. Mills, Pharm D1; Marisa Rahn, Pharm D, BCPS2; Corstiaan Brass, MD3 James Fenner, B. Sc., Pharm D, BCPS4; Salvi Parpia, B. Sc., Pharm D, MRCF5
1Clinical
Pharmacy Coordinator, Kaleida Health/DeGraff Memorial Hospital; 2Assistant Professor of Pharmacy Practice, Albany College of Pharmacy; 3Clinical Associate Professor, SUNY at Buffalo School of Medicine;
4Clinical
Pharmacy Coordinator, Kaleida Health/Millard Fillmore Suburban Hospital; 5Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, University of British Columbia
INTRODUCTION
The implementation of antibiotic management programs
utilizing multiple strategies for improvement in antibiotic use
and demonstration of cost savings have been described in a
number of different studies and evaluations, primarily at large
teaching institutions.
 Unfortunately, savings for the pharmacy department have
been variably reported.
 A 3-week prospective evaluation conducted at a community
hospital identified the extent of inappropriate and non-focused
use of antibiotics and estimated the potential cost savings if an
antibiotic management program was implemented.
PURPOSE
 On the basis of our prior 3-week feasibility study, an
implementation protocol as a quality improvement initiative for
antibiotic management was proposed and implemented to
determine the accuracy of our methods for determining the
potential cost savings.
The goal of this initiative is to decrease inappropriate and nonfocused antibiotic use and decrease both direct and indirect
hospital costs through the collaboration of a team consisting of a
clinical pharmacist, ID consultant, nurse case managers and
administration.
METHODS
METHODS (CONT.)
Collaborative Approach
Data Collection
 Customized ACCESS® Database
 Data collected
• Demographic and clinical data, antibiotic regimen,
length of stay
• Interventions, date and reasons
• Cost of regimen and interventions
 Hospital Data Utilized
• Admission, Discharge and Transfer System
• DRG
• Pharmacy Purchasing
• Hospital Billing
Male sex (No, %)
Infection syndrome
Antibiotic Management Strategies Implemented





Therapeutic Interchange
Automatic Dose Adjustment
Antibiotic Restriction Policy
Automatic IV to PO Policy
Post-Prescribing Evaluation
Post-Prescribing Evaluation
124
88
56
46
34
17
13
35
7
209
Upper respiratory tract
Pulmonary
Skin or soft tissue
Intra-abdominal
Urinary
Diarrhea
Bacteremia
Other or unknown
Bone/ joint
(Patient not seen)
 Residency-Trained Clinical Pharmacist
 Antibiotic orders on two medical/surgical floors and the ICU were
reviewed daily
 Evaluation and assessment of antibiotic use was conducted as
described in the 3-week feasibility study
 Recommendations were:
• recorded in the progress notes of medical charts
• verbally communicated to physicians
• any questions regarding appropriateness was reviewed with
ID consultant prior to intervention
Result
No. of patients evaluated and
followed during study period
No. of instances of inappropriate
antibiotic therapy
No. of instances of redundant
antibiotic therapy
22
YTD
152
$20.00
Inpatient Length of Stay: Infectious DRG’s
Infection DRG
Time
Period
Mean LOS +/St. Dev.
7.88 +/- 8.19
n
ALL
1st qtr 2004
248
1st qtr 2005
328
6.41 +/- 5.66
89- Simple pneumonia w/ 1st qtr 2004
complication or
1st qtr 2005
comorbidity
88- COPD Exacerbation 1st qtr 2004
61
8.61 +/- 7.48
77
6.39 +/- 5.29
45
5.09 +/- 2.99
1st qtr 2005
81
4.89 +/- 2.65
1st qtr 2004
29
12.03 +/- 14.15
1st qtr 2005
43
8.49 +/- 8.48
79- Resp. infection w/ 1st qtr 2004
inflammation (Bronchitis) 1st qtr 2005
21
10.0 +/- 8.27
12
15.58 +/- 10.55
1st qtr 2004
10
11.0 +/- 7.92
1st qtr 2005
13
5.92 +/- 2.96
Top 5 Infection DRG's:
900.00
Vancomycin
Quinolones
700.00
Penicillins
600.00
Misc.
Macrolides
400.00
Cephalosporins
300.00
Carbapenems
Dose change
4
100.00
Antifungals
% of recommendations accepted:
83.6%
Quinolones
Penicillins
$66.56
Misc.
Macrolides
Cephalosporins
Carbapenems
Anti-VRE
Antifungals
Anti-anaerobic
Aminoglycosides
1st QTR 2005
Antibiotic Cost Validation of 3-week Feasibility Study in May 2004
4.90
Anti-anaerobic
0.00
1st QTR 2004
DDD/1000 pt. days
1st QTR 2005
DDD/1000 pt. days
Vancomycin
$86.36
1st QTR 2004
Anti-VRE
370
1st QTR 2004
DDD/1000 pt. days
$0.00
200.00
TOTAL
Ciprofloxacin - IV
$10.00
59
155
50.00
$100.00
5.78
Change antibiotic
IV to oral therapy change
Ciprofloxacin - PO
Antibiotic Use Comparison: Antibiotic Cost Per Patient
$30.00
500.00
Antibiotic Streamlining
Interventions
Discontinue antibiotic
100.00
Gatifloxacin - PO
$50.00
800.00
154
Linezolid - IV
1st QTR 2004 DDD/1000 1st QTR 2005 DDD/1000
pt. days
pt. days
8709
320- UTI
Levofloxacin - IV
0.00
Patient days
416- Sepsis
Levofloxacin - PO
150.00
$60.00
YTD
432
2.26
$40.00
Mean LOS
187.7
Linezolid - PO
$70.00
1st qtr 2005
228.8
200.00
$90.00
Antibiotic Use Comparison:
Defined Daily Dose Per 1000 Patient Days
Intervention Details
250.00
1508
629
8.0 +/- 6.7
days
4
7.23
Discharges
YTD
Inpatient LOS (patients discharged
during study period only)(mean +/- SD)
7
1st qtr 2004
7732
70.5 +/- 16.5
years
273, 43.4%
16
Inpatient Length of Stay: All Patients
Patient days
Total No. of patients who received
antibiotic therapy during study period
22
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
Quinolones
$80.00

Characteristic
36
11
1577
Patient Demographic Data
41
Excessive duration of prophylactic antibiotic
Use of multiple antibiotics with similar/ overlapping
antimicrobial spectra
Use of broad spectrum antibiotic with coverage of
nosocomial organisms in patients with no prior hospital
exposure
Discharges
Total No. of patients who received antibiotic
therapy during study period: 629
56
18
Implementation Date: January 3, 2005
Data from 1st quarter of 2005
Anti-VRE
No.
Excessive duration of antibiotic therapy for active infection
RESULTS
Age (mean +/- SD)
Antibiotic Use for Selected Antibiotic Classes
Rationale for antibiotic therapy change or
discontinuation
Use of antibiotic therapy in patients with insufficient
evidence of active infection
Adjustment of antibiotic therapy based on culture data or
other diagnostic test result
Inappropriate antibiotic selection based on evidence-based
medicine and standard of care
Use of multiple antibiotics when single agent would
provide adequate antimicrobial coverage
Other (or rationale not specified)
Mean LOS

RESULTS (CONT.)
Intervention Details (Cont.)
1. Daily phone conversation between clinical pharmacist and
ID consultant
2. Daily interaction between nurse case managers, discharge
planning and clinical pharmacist
3. Weekly meeting with clinical pharmacist, nurse case
managers, discharge planning and administration
The Facility
 Mount St Mary’s Hospital (MSM) is a 100 bed secondary care
facility
• A member of the Ascension Catholic hospital network
• 11 bed intensive care unit
• Non-teaching facility
• At the time of implementation, no significant measures to
improve cost-effectiveness of antibiotic therapy were employed
RESULTS (CONT.)
1st QTR 2005
DDD/1000 pt. days
Aminoglycosides
Estimated potential cost savings
over 3-weeks:
$8,354.00
Estimated Cost savings assuming 85%
compliance w/ recommendations:
Estimated cost savings per quarter
based on 3-week assessment
assuming 85% compliance with
recommendations:
Actual cost savings (1st qtr 2004 vs.
1st qtr 2005) normalized for increased
patient volume (=$19.80 saved per
patient X 1577 patients):
$7,100.90
$30,770.57
($123,082.27
annually)
$31,224.60
($124,898.40
annually)
DISCUSSION
 By achieving an 83% acceptance rate, this quality improvement initiative
validated the cost savings projected by the feasibility study
 Antibiotic management through collaboration amongst a clinical pharmacist,
physicians and nurse case managers resulted in improvement of antibiotic use
and earlier discharge of patients leading to substantial savings in both direct and
indirect hospital costs
 The largest reduction in utilization resulting from implementation of the
management team was seen with the quinolone and anti-VRE therapies
 To accurately capture actual utilization of antibiotics and potential impact on
cost, billing rather than purchasing data was captured for comparison
 No difference in utilization between the yearly quarters was observed using
DDD/1000 patient days for total antibiotics, likely due to:
•Increase in proportion of infectious-related DRG’ in 2005
•Use of one quarter data vs. annual
This represents the first report of collaboration with case managers and
pharmacists to demonstrate that optimization of care can result in reduction in
length of stay
 The impact on overall inpatient LOS suggests that the influence of the clinical
pharmacist on patient care extends beyond the impact of antibiotic utilization