NHSN Antibiotic Stewardship Core Elements & Long-term Care Antibiotic Use Surveillance

Hi, everyone, and welcome to this presentation for those who were on some of the morning presentations. Hello again, as you probably heard, my name is Teresa or Terry row. I am the long term care unit lead. For the post acute care team and the surveillance branch, and I'm really excited to introduce some members from our office of the antibiotic stewardship. Dr. Sarah, and Katrina Gowan, who are going to be presenting on antibiotic stewardship and long term care facilities. I'll hand it over to Dr. Gabbani. Thank you, Terry, and thank you everyone. I'm thrilled to be that you're all are with us today and we're able to present again and talk to you about antibiotic stewardship and grateful for our NHSN colleagues for inviting us to join you today. So, I'm my name is Sarah Gabbani, my background, I'm an infectious disease physician. I've been with CDC for over 7 years now working on antibiotic stewardship overall, but specifically in long term care. And I'm glad to join to be joined by on this on this presentation by both Terry and Katrina. We've been working together on this topic for years and we're thrilled to join and talk to you about some of the work that we do. So, I'll get started. Let me know if you can see. So, as with all other speakers, I'm sure today we have no disclosures or financial relationships. So, what we'll be talking to you in the next 20 to 25 minutes is talking a little bit on a high level about stewardship priorities and long term care settings. But we're going to do that specifically within both the framework of the core elements of antibiotic stewardship, but also within the annual survey. As many of you here on this call are very familiar with the annual facility survey that you that you fill every year. We're going to try to present the core elements through the questions of the annual survey that you that you provide back to NHSN and to CDC yearly. And we're also going to report back to you some of these data that you share with us on what that looks like, both in your state and nationally. So, I will start with the why. Why are we talking about antibiotic use and antibiotic stewardship? Antibiotics are some of the most commonly used medications of long term care. And we know that the resident population you serve is, you know, you do provide a lot of care, including in treatment of infection and antibiotic use. 50 to 70% will be prescribed a course of antibiotic in a year, but we know there's opportunities for improvement. We know that there's an estimate between 40 to 75% may be inappropriate. And what we mean there, it's not that they shouldn't be getting the antibiotic, but there's opportunities for improvement. You could, you know, whether it's in the selection of the drug, whether it's in the duration, there's plenty of opportunities where we can provide better care when it comes to treatment of infections and antibiotic prescribing. And why are we also talking about this? So, antibiotic use, both necessary and unnecessary, can cause harm. Some of them are mild adverse events like nausea and abdominal pain and diarrhea. Some are more severe reactions. And in this vulnerable patient population, polypharmacy is also a really important consideration. So, we need to make sure that residents are getting the treatment that they need. One study showed that 13% of adverse events were related to secondary antibiotic use in nursing homes. And another consideration also under the umbrella of adverse events is the potential for C. difficile infection. Most of the morbidity and mortality with this infection happens in older adults, specifically in long-term care residents. There was an interesting study that was done by our public health colleagues in Ontario, Canada, where they took an interesting approach where they looked at adverse events by facility. And they looked at low antibiotic use facility and high antibiotic use facilities. And they found that diarrhea, gastroenteritis, and C. difficile were more common among those facilities that had higher overall rates of antibiotic use. And with that, we talk about what's the solution and what are we doing to improve that? And the answer is antibiotic stewardship. And I know the majority of the audience are very familiar with this term, but I like keeping that definition because frequently we are accused that we're the antibiotic police and we want to take antibiotics away. But that's not what stewardship is. Stewardship is about improving the use and reducing adverse events. It's the emphasis about resident safety and high quality health care. And CMS recognizing that included antibiotic stewardship in their final ruling requiring that all facilities have a stewardship program integrated within the infection prevention and control programs. And they highlighted two specific components, developing and implementing protocols to optimize the treatment of infections. And developing, promoting, and implementing a facility-wide system to monitor antibiotic use. And we're going to be talking a little bit more about that today. So, within that, more about the how of why we do stewardship are the core elements of antibiotic stewardship. And the core elements are a set of structural and procedural components of how do you structure a stewardship program at your facility. Initially, the core elements were developed back in 2014 for hospitals, but since they have been expanded for long-term care settings where they were adapted to the specific challenges and opportunities for prescribing in these settings. And we will talk about all seven core elements, leadership, commitment, accountability, expertise, action, tracking, reporting, and education, as I said, within the framework of the facility survey. And with that, I'm going to hand it over to my colleague, Katrina Gowen. We've been working together on stewardship and long-term care for many years, and she will share some more with you. Thank you very much, Sarah. Hi, everyone. My name is Katrina Gowen, and it is an honor to be here with you all. Hopefully, today I can share some helpful information on the antibiotic stewardship core elements that you will be able to bring back to your facilities. So, for the next few slides, I'll be leading us through the core elements of antibiotic stewardship built for nursing homes, sharing examples of how they can be implemented and how they're captured on the NHSN long-term care annual survey. So, our team at CDC uses NHSN's long-term care facility annual survey to assess changes in the uptake of the core elements in nursing homes. So, let's get to the first core element, which is leadership commitment. So, it's very important that the leadership embraces a culture of improving nursing homes' antibiotic use, and this can be achieved through commitment posters or commitment letters that are signed by leadership, whether this is the ownership level, facility administrators, or at the national level, to really show their support of efforts to improve antimicrobial use. Furthermore, leadership can also embrace this culture of improving antibiotic use by reviewing antibiotic data and resistance data in regular quality improvement meetings. So, these actions are reflected in two questions on the annual survey. Next slide, please. Having supportive leadership is not quite enough, though. We also need people who are going to lead the implementation of antibiotic stewardship programs. This is where the accountability core element comes into play. On the survey, we ask if there's an individual responsible for the impact of activities to improve use of antimicrobials in the facility and what their specific role is. Most commonly, when we've analyzed these data, we find that the individual leading stewardship programs is the director of nursing, infection preventionist, medical director, and consultant pharmacist. For an antimicrobial stewardship program, it's imperative to have access to an individual with antibiotic drug expertise to help improve prescribing practices. On the survey, the examples of drug expertise are consultant pharmacists that are trained in antimicrobial stewardship, a stewardship team at the referral hospital, or an infectious disease consultant. We encourage nursing homes to leverage the consultant pharmacist at their long-term care pharmacy to help to support stewardship implementation. And these consultant pharmacists are a great resource to help to review antibiotic courses, optimize treatment duration, interpret antibiotic use data, and ensure appropriate documentation that can comply with requirements. And our team has developed posters made for consultant pharmacists that are available on the CDC website and describe different infection and treatment scenarios in nursing homes. The next core element is action, and we'll break this down on the next couple of slides. So, action refers to having facility-specific policies and practices to improve antibiotic use, and there are four specific questions that can fulfill the action core elements that are asked on the annual survey. The first question highlights the importance of documentation of indication for antimicrobials in the medical record. So, you really want to emphasize document, document, document. This can even be done with courses that are started in the hospital and continued into the facility, because we know that the facility is also responsible for those courses that may be started in the hospital. Ultimately, this post-prescription review is important to ensure that the resident is receiving the optimal therapy. All right, moving on to tracking, which is one of my favorite core elements. So, tracking, I'll start with a quote, measurement is the first step that leads to control and eventually to improvement. If you can't measure something, you can't understand it. If you can't understand it, you can't control it. And if you can't control it, you can't improve it. So, there are four survey questions that can be used to fulfill the tracking core element. In addition to tracking specific antibiotic orders or prescriptions or administration, you can track adherence to clinical documentation in your facility. How well are the policies being followed? Is there adherence to our treatment recommendations? So, tracking is broader than just tracking antibiotic use. And in yellow, we've highlighted the tracking-specific parts of the questions, because some questions are twofold, where maybe you're fulfilling the action core element and the tracking core element. So, you get counted for both of those. And on the next slide, we'll dive a little deeper into tracking. So, monitoring and reviewing antibiotic use data is the critical first step for facilities to identify opportunities for improvement. And you can use your own data to determine where to start and get a sense of which practices need to be focused on. And it may differ by facility. Tracking antibiotic use can also help to monitor practice changes. And the benefit is that you can demonstrate improvements in your prescribing to leadership by showing maybe you've decreased duration of courses or decreased days of therapy over time. So, I definitely recognize that there are challenges for tracking and reporting antibiotic use in the nursing home. So, we wanted to just present the different data sources that can be considered. So, on the survey, we highlight that facilities can leverage their pharmacy services, EHR, or an infection control log, or other systems to track their antibiotic use. And we're specifically interested in capturing this information on the survey to best understand how facilities are tracking their antibiotic use to inform how we can advance that process to track and report antibiotic use in the future. So, the data that we collect on antibiotic use can be leveraged in many ways to optimize antibiotic prescribing in your facility. You can describe baseline prescribing rates and track changes over time to inform your stewardship intervention. You can look at the rate of overall antibiotics or specific antimicrobial of interest to assess the impact of an intervention that you've already started. For example, if you have an intervention to assess antibiotic initiation, you could look into how successful you are at avoiding testing and treatment of asymptomatic bacteria. Facilities can also assess how long the residents are on an antibiotic by looking at antibiotic course duration and determining how many of my courses are prolonged, how many are for prophylaxis, and is there anything we can do to optimize this? Antibiotic use measures can also be used to track progress in prescribing of certain classes that might be a target for improvement, such as for quinolones, or agents to treat infections such as fetus, or yeast infections. Using azithromycin for respiratory infections, it's truly unique to your facility and what action you want to take to improve prescribing. And finally, another important thing to consider is the site of that antibiotic initiation to allow your facility to tailor stewardship interventions by either engaging prescribers in your facility or perhaps the referring hospital. So, now I have some interesting data to show you about our analysis of NHSN annual survey. However, less than a third of facilities reported using the EHR for tracking of antibiotic use, and we found that half of these facilities were actually tracking antibiotic use manually. In addition, a quarter of facilities used their pharmacy services to monitor antibiotic use. Thus, enhanced EHR implementation can improve quality of care and help to automate antibiotic use tracking, because we don't want you to have to do this always manually. We want you to leverage the resources that you have in your EHR to help make this process easier and more efficient to greatly enhance the efficiency of monitoring antibiotic use. And so, on that note, I will turn it over to Dr. Terry Rowe to describe NHSN's upcoming long-term care antibiotic use module. Thanks, Katrina, and just to, some of you may have heard some of this earlier as I presented several of these slides at the morning presentation, but just based on, you know, what we just heard about how facilities monitor and track antibiotic use, you know, we, you know, put our heads together and, you know, thought it would be useful for facilities to have the option of reporting long-term care antibiotic use into NHSN. And so, we have developed and are in the process of building out a long-term care antibiotic use module for NHSN, again, for nursing homes to report data on their antibiotic usage. So, this antibiotic use module will be electronic data reporting, which will help reduce time on data entry, as we know many, all the other modules right now are manual entry, but this module, or proposed module, will have no manual reporting. It will be at the person level and will hopefully be able to take both orders and administrations. Oops, sorry. As we just heard, you'd evaluate antibiotic stewardship programs, so have the data right there to be able to look at your programs and see if they're working or how you can make improvements. Or just, you know, days of therapy, which is a very common sort of metric for antibiotic use. But we're really excited to get this started and to potentially have the option for nursing homes to report into NHSN in this way. We also anticipate having, you know, a pilot phase and then, again, just sort of thinking about how to make this most useful to nursing homes. You know, would we develop, you know, dashboards or things to sort of feed back to nursing homes to use for their programs? So, up and coming. You'll hear more in the next, you know, several months to a year. I think I'm going to hand it back over now. Yes, thanks, Sherry. This Annual Approval Use Module is definitely very exciting. So, we know that tracking is very important, but the other part piece that goes hand-in-hand with tracking is reporting. We don't want to just track our antibiotic use data for the sake of tracking it. We want to be able to use these data for action and share it back to the people who can help to make a difference. So, reporting can help to motivate staff and sustain practice changes. This can include providing feedback to prescribers on their prescribing practices or compliance with facility antibiotic use protocols. Provider-specific feedback and peer comparison has been shown to be an effective way to change prescribing behavior, which has mostly been demonstrated in the outpatient setting. But on this slide, we have an example of a peer comparison audit and feedback intervention conducted by Public Health Ontario Research Group, in which 1,200 providers in long-term care facilities were randomized to receive audit and feedback through a prescribing report. So, each provider received a prescribing report based on their prescribing practices. And the result was that it generated reductions in antibiotics that were used for prolonged durations, decreasing total antibiotic days of therapy across the population. And this report out example of provider feedback demonstrates how antibiotic use data can be used as data for action to improve antibiotic prescribing. So, tracking with a purpose for improvement. The last core element is education, and it is important to educate healthcare professionals, including frontline staff, infection preventionists, clinicians, and all other staff in the facility on improving antimicrobial use. CDC offers antibiotic stewardship and IPC training courses, and has also developed a toolkit for effective communication with residents and families about antibiotic use, understanding how challenging these interactions and expectations can be. Furthermore, there are several implementation tools available to long-term care professionals that we will share with you in the coming slides. And in addition, educating your residents and their families will help to set expectations and address concerns about antibiotic prescribing. All healthcare professionals, including those in the long-term care setting, can be antibiotic aware. Sarah, I'll hand it back to you to show some of the recent data on the core elements of long-term care facilities. Thank you. Thank you, Katrina and Terry. So, I'll round it up for us for the presentation, and we're eager to hear your questions after. I'm going to share. So, Katrina presented some of the practices that you're reporting back to NHSN and CDC within the facility survey. So, next few slides, I'm just going to show you an aggregate of these data and how we use these data to help us identify what resources we need to improve and how we can help. A lot of these aggregated data, both at the national and state level, are shared on the U.S. Antimicrobial Resistance and Patient Safety Portal. The link to the portal is in the slides. This is just a social media graphic for that portal, but this portal allows you to see a lot of different data from different healthcare settings, both on antimicrobial resistance, but also on antibiotic use. Right now, we don't have long-term care. There's outpatient and hospital, and there's the uptake of the stewardship core elements, both from hospitals and long-term care. So, you're going to see something, and I'll show you a few screenshots from the portal, but we've been basically using the NHSN facility survey to hear back from you on the uptake of the core elements of antibiotic stewardship and long-term care facilities back from 2016. Back in 2016, 43% of facilities told us they were meeting all seven core elements in their practices, and that number, as you can see in the shaded dark blue, in terms of proportion, increased over time, where in 2022, 83% of facilities told us they were meeting all seven core elements. As you can see by the height of the bar chart, the number of facilities that are submitting the facility survey and reporting to NHSN has changed over time, and there's a lot of variables that went into play, whether with the QIN-QIO support for C. diff reporting, we saw an increase, and when that went away, that decreased. But with increased reporting to NHSN overall during the COVID pandemic, many facilities also, although it wasn't necessarily mandatory, also reported their facility survey, and we were able to learn a lot from your experiences. And we realized that this is self-reported, so we're just looking at a box that tells us, yes, we have it, or no, we don't, and we don't necessarily have a lot of nuance of how that differs. What's yes to you could be very different than yes to a facility that's down the road. But that said, we learn a lot when you tell us no on what you don't have, and we try to work with our colleagues here at CDC and with partners in this space, whether it's developing resources or learn more how we can provide that support. And part of what Terry and Katrina presented on long-term care AU reporting comes from that. So these are some screenshots from the patient safety portal. If you have a chance to play with it, hopefully after the presentation, we'd love to hear back from you more how we can make it useful. It is a resource mostly for our public health and state health department partners because it allows them to look at what's happening within their state, but we also hear from researchers and others who think that this data is useful to them because you can look at, you know, in your state, you can compare what you are doing at your facility to what others in the state and nationally are doing. And as you can see, we report the numbers of facility reporting, you know, how many are implementing the seven core elements and how that changed over time. And there are links to methodology on how this is analyzed and defined if you're interested. And it's an interactive webpage where you have an interactive map where you hover over different states and you can see those actual numbers. And we report these changes over time and by core elements. And you can, you know, you can easily select what you're interested in and look how that changed over time. And it's a unique functionality in that portal is what's called the state profile, where we have an example here for Georgia, where all the data, the resistance data, the AU and stewardship data is all in one page where that state can see itself what it's doing, but also compare against the national average of what others are doing. So we're open to your feedback and any way you can think we can improve the functionality of that platform, we'd love to hear from you. And Katrina mentioned some of the trainings. Unfortunately, I know we only have 25 minutes, so we're not going to be able to go in detail over stewardship practices and implementation. And I think any one of the core elements we can spend an hour discussing. That said, there is a CDC training on antibiotic stewardship that is available on the link that's publicly available and associated with continuing education credits for MDs and pharmacists and nurses and different professional categories. Although some aspects of this course is dedicated to the outpatient settings, but many of the modules apply across the board. The first three modules is a basic introduction of antimicrobial resistance, antibiotic stewardship. The first three slides we talked about sort of an expanded version of that. There is a module specific for nursing homes that provides an overview, in-depth overview of the core elements. But I would also think there's also a module specific to urinary tract infections that may be very useful as it has a focus on older adults and it goes over the general concepts of what's asymptomatic bacteria and what's a urinary tract infection. And some of these, you know, review of those basic concepts could be useful. So when you're conducting education in your setting, you know, if someone does these basic concepts, you can go more into detail of what you can do at your own facility. And also Katrina mentioned the nursing home infection prevention training course also includes some stewardship content. And it's also really, it's a great, another great resource. We've been talking a lot about antibiotic use tracking and reporting. And on this slide that you have access to, you'll be getting, there are some of the resources developed by academic or public health colleagues that include tracking sheets, tools for implementation and other resources that you can potentially leverage for antibiotic use tracking at your facilities. Until we have the NHSN modules, I think these are great, but hopefully once we do, you know, we hope that's going to be a great resource for you. So we've reviewed over the last, I want to say 25 minutes, that antibiotic stewardship is a set of those commitments and actions that improve antibiotic use and reduce adverse events. And we provided an overview of those practices within your facility survey. So next time you fill the survey for next year, we hope, you know, you remember some of what we've discussed today. And if you have any questions, if you think the wording of those questions can be improved to assess your practices better, again, we'd love to hear from you as we think of updating and optimizing this over the years. And with that, you mark your calendars, US Antibiotic Awareness Week is in November. I would, it's an annual observance that we have on improving antibiotic use. In your local health departments and, you know, CDC with partners, we have a lot of engagement and educational content and social media engagement around improving antibiotic use. So we'd love if you participate with us in any way and tell us what you're doing and how you're working on improving antibiotic use with your facility. And with that, I'm going to invite Katrina and Terry back to come on back on camera. I love all these emojis. I know these remote presentations can be challenging. And I, this is heartwarming. Thank you so much. And we're very grateful. I know how busy every single one of you is. And for you to take time of your busy day to be here with us is, we're immensely grateful. Thank you. You do all the hard work. I feel like this is the most heart emojis I've seen. This is awesome. Okay. I'm happy. We are happy in stewardship to take credit for that. But it's all, we're grateful for our NHSN colleagues. And as I said, you all do the hard work and we're grateful to be able to support you. Thank you.