CAPT Arjun Srinivasan MD Division of Healthcare Quality Promotion Centers for Disease Control and Prevention beu8cdcgov Disclosures No financial disclosures NHSN Annual Facility Survey Must be completed by each facility that reports data to NHSN ID: 1042231
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1. An Update on Stewardship Measurement in Hospitals: Programs and Antibiotic UseCAPT Arjun Srinivasan, MDDivision of Healthcare Quality PromotionCenters for Disease Control and Preventionbeu8@cdc.gov
2. DisclosuresNo financial disclosures.
3. NHSN Annual Facility SurveyMust be completed by each facility that reports data to NHSN.Almost all acute care hospitals are currently reporting data.The survey is completed in the 1st quarter of each year to reflect the previous year.The 2017 survey is currently being completed.CDC added questions about implementation of the CDC Core Elements for Hospital Antibiotic Stewardship Programs in 2014.
4. Uptake of Core Elements, 2016Of the 4,781 acute care hospitals responding to the 2016 NHSN Annual Hospital Survey, 3,063 (64.1%) reported uptake of all 7 core elements
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8. Respondent Demographics:Characteristic201420152016 All Hospitals4,1844,5694,781 Facility Type Children's hospitals767988 General acute care hospitals3,3853,5373,610 Surgical hospitals146152155 Critical access hospitals577801928 Bed Size >200 beds1,3201,3611,359 51 - 200 beds1,5711,6341,664 ≤50 beds1,2931,5741,758 Teaching Status Major teaching 1,1211,2481,486 Non-teaching/undergrad3,0633,3213,295
9. How Accurate Is The NHSN Stewardship Survey?The NHSN survey goes to the facility administrator for NHSN- almost always in infection preventionist in hospitals.The survey instructions indicate that members of the stewardship team should be asked for input on the stewardship questions.We don’t know how often that happens or how the results might differ if we sent the survey directly to the stewardship team.
10. How Accurate Is The NHSN Stewardship Survey?CDC partnered with Vizient to try and assess the validity of the stewardship questions on the NHSN survey.In 2016, Vizient added the NHSN stewardship survey questions to their annual stewardship survey, which went to hospitals participating in the Vizient stewardship list-serv.The Vizient survey goes directly to a member of the stewardship team at the hospital.
11. Vizient and NHSN Survey Comparison189 of the 211 hospitals completing the Vizient survey were successfully matched to NHSN hospitals.83% of Vizient respondents were pharmacists, but who completed the survey varied by bed size:Hospitals with <250 beds: 88% directors of pharmacy completingHospitals with >250 beds: 77% clinical pharmacists completingOverall, about 50% of Vizient respondents indicated they had helped complete the NHSN survey.Reported implementation of all 7 elements in this subset of 189 hospitals was 58.2% in the Vizient survey compared to 54.5% in NHSN.
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14. NHSN and Vizient Survey ComparisonOverall, there was pretty good agreement, both on individual core elements and on implementation of all 7 elements.Reported implementation was higher when pharmacists completed the survey- likely reflects more awareness of specific stewardship activities.Only half of Vizient respondents had helped with the NHSN survey.It’s possible that other stewardship staff at these hospitals did have input into the NHSN survey, but this seems like an area for improvement.
15. NHSN and Vizient Survey ComparisonDifferences in reported implementation between pharmacy directors and clinical pharmacists could reflect either more familiarity with stewardship efforts by clinical pharmacists or simply reflect less stewardship implementation at smaller hospitals.Surveys in smaller hospitals were much more likely to be completed by pharmacy directors and smaller hospitals have less stewardship implementation.
16. What’s Next for the Stewardship Survey?As compliance with the core elements increases, we need to revise the survey to get a better understanding of what exactly stewardship programs are doing.How can we use the survey data, combined with antibiotic use, resistance and C. difficile data to understand what factors might be associated with more effective stewardship programs?We have asked many experts for their thoughts on this.
17. What Have People Told Us to Learn More About?The level of physician and pharmacist effort committed to stewardship.How many hours per week do people spend on stewardship?How much of their time is supported for stewardship?What types of antibiotics are people focusing their interventions on?Where does the stewardship program fit in the hospital reporting structure?Did someone from the stewardship team participate in filling out the stewardship questions?
18. Revisions to the Stewardship QuestionsWe are currently revising the survey based on the input we’ve received along with information from many hospitals that have done some pilot testing.The revised survey will have to be approved by the Office of Management and Budget and will be implemented in 2019 to cover practices in calendar year 2018.
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20. Critical Access Hospitals Are Not Spared the Problems of Resistance and C. difficileMost critical access hospitals have had to treat infections with Methicillin Resistant S. aureus (MRSA) and Clostridium difficile.A growing number are now encountering infections caused by highly resistant gram-negative pathogens as well.2015: 1.7% of CAHs reported a healthcare associated infection with a highly resistant gram negative pathogen.2016: 2.9% of CAHs reported a healthcare associated infection with a highly resistant gram negative pathogen.
21. Critical Access Hospitals Use Antibiotics About As Much As Larger Hospitals
22. Barriers to Implementing Stewardship Programs in Critical Access HospitalsHas not been a priority, perhaps due to (mis)perception that antibiotic overuse and complications of antibiotic use are limited to larger hospitals.Limited access to infectious disease clinicians who have historically been champions for and led antibiotic stewardship efforts.Previous recommendations for stewardship have ignored the realities of critical access hospitals (e.g. assemble a team led by an ID clinician and ID pharmacist).
23. Supporting Implementation Antibiotic Stewardship in Critical Access HospitalsDiscussions with staff in critical access hospitals indicated that specific guidance on how to implement the core elements in CAHs would be helpful.CDC embarked on an effort to do just that.Efforts informed at all stages by discussions with and guidance from staff working in critical access hospitals.“Suggestions from CAHs for CAHs”
24. Implementing Core Elements in CAHsInput from CAHs in several states (in green below)Developed in collaboration with: Federal Office of Rural Health Policy, The American Hospital Association, The Pew Charitable Trustshttps://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.html
25. Some Key Lessons Learned and Tips from CAHsBedside nurses can play a key role in antibiotic stewardship in CAHs.CDC and American Nurses Association recently released a white paper on the role of nurses in hospital stewardship programs: http://www.nursingworld.org/ANA-CDC-AntibioticStewardship-WhitePaperStrong relationships between staff members often makes performance improvement efforts easier to implement and more successful in CAHs- once CAHs decide to do it, they will succeed.Small prescribing staff makes individual feedback and one on one education a realistic, and very effective, option.Design multi-faceted improvement efforts: C. difficile+stewardship+sepsis
26. Incentivizing Stewardship Implementation in Critical Access HospitalsMedicare Beneficiary Quality Improvement Program (MBQIP) is seeking to expand stewardship programs in CAHs.99% of CAHs participate in MBQIPHospitals are supported by state Flex granteesImplementation of the CDC Core Elements is now a Core/Required Element of MBQIP (2018-2021).
27. National Healthcare Safety Network Antibiotic Use OptionCaptures electronic data on antibiotics administered, along with admission/discharge/transfer data.Calculates rates of administration for use:By facilities to monitor interventions on single units or facility wideTo collect aggregate information on antibiotic use at a regional and national levelEventually, to create antibiotic use benchmarks.
28. Facility-level AU reporting548 facilities have reported at least one month of data500 facilities have reported at least one month of data in 20172017 data as of December 1st
29. Demographics of AU reportersAs of December 1st 2017, AU data has been submitted from:81 different location types46 states, the District of Columbia (DC), and the Armed Forces Europe (AE) CharacteristicNumber of facilities Facility type General acute care373 Veteran's Affairs83 Critical access46 Military22 Children's7 Other*13 Bed-size Category Small: <50 beds97 Medium: 50-200 beds205 Large: >200 beds242 Teaching status No medical school affiliation187 Undergraduate teaching hospital69 Graduate teaching hospital120 Major teaching hospital166*Surgical (3), oncology (2), orthopedic (2), rehab (2), women’s (2), women and children’s (1), long-term acute care (1)
30. Percentage of NHSN facilities submitting to AU Option, by stateData as of November 2017
31. Standardized Antibiotic Administration Ratio (SAAR)CDC’s 1st attempt at developing a risk-adjusted benchmarking measure for hospital antibiotic use.SAAR expresses observed antibiotic use compared to predicted use.Predicted use is calculated with risk adjusted modelsCDC working with many partners to develop the SAAR measure to try and make it most useful for stewardship.
32. Standardized Antibiotic Administration Ratio (SAAR) CategoriesBroad spectrum agents predominantly used for hospital-onset/multi-drug resistant bacteria.Broad spectrum agents predominantly used for community-acquired infection.Anti-MRSA agents.Agents predominantly used for surgical site infection prophylaxis.All antibacterial agents.SAAR categories are calculated separately for different patient care locationsICU and WardPediatrics and Adult
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34. Adults ICUs: 2015 vs. 2016 SAAR distributionsAdult Medical, Medical/Surgical, Surgical Intensive Care Units: SAAR DISTRIBUTIONS 2015 (n=138)2016 (n=275) Q1MedianQ3Q1MedianQ3 Broad Spectrum Hospital Onset Agents0.630.841.060.620.881.21 Broad Spectrum Community Onset Agents0.600.781.110.570.761.03 Anti-MRSA Agents0.710.921.170.610.871.14 Surgical Site Infection Prophylaxis Agents0.410.731.460.370.711.26 All Antibacterial Agents0.760.911.090.710.891.06
35. Key Questions About the SAARDoes the SAAR help point to locations and/or agents where there are meaningful opportunities to improve antibiotic use? How would additional data for risk-adjustment impact the SAAR?Will the SAAR values change if antibiotic use is improved?
36. Comments on the SAAR From One HospitalThe SAAR has pointed us to agents and locations to prioritize further investigations.Knowing that our use is higher than others, rather than just thinking that it is, helps us when we talk to providers and has pushed us to do more.It would help to know the distributions of SAAR values.We’d like a SAAR for NICUs!
37. Using NHSN AU Data to Focus Stewardship EffortsCourtesy of Eddie Stenehjem
38. Using the SAAR to Evaluate StewardshipFacility-level Standardized Antimicrobial Administration Ratios (SAAR), 2013-2015Livorsi DJ, et al. Using the SAAR to monitor the influence of antimicrobial stewardship activities. Poster presented at: IDWeek 2016; October 2016; New Orleans, LA.
39. Assessing the SAAR Risk Adjustment:Facility Level vs. Patient Level DataCollaboration with Kaiser of Southern California looking at risk adjusted benchmarks using a variety of patient level data (DRG, case-mix, diagnosis codes, WBC, Charlson etc) in addition to facility level data.NHSN AU currently only gets facility level data.Comparing these benchmark values (KP ratio) to SAARs.Slides courtesy of Kalvin Yu, Jason Jones, Liz Moisan
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42. Next Steps for the SAAR MeasureMore work on exploring and refining risk adjustment.More work on assessing application of the SAAR for stewardship.Duke Antimicrobial Stewardship Outreach Network working on a project toEnroll a group of hospitals in NHSN AUImplement or expand stewardship core elementsAssess the impact on SAAR measures
43. Using NHSN AU Data: Potential Impact of SEP-1 MeasureThe Centers for Medicare and Medicaid Services (CMS) began requiring hospitals participating in the Inpatient Quality Reporting Program to implement a sepsis management bundle (SEP-1), effective October 2015.Concerns raised about potential increases in broad spectrum and anti-MRSA antibiotics.We looked at NHSN AU rates across two 12-month time periods:Pre-SEP1: October 2014 – September 2015Post-SEP1: October 2015 – September 2016Compared VA and non-VA hospitals since VA hospitals did not have to implement SEP-1.
44. CDC Preliminary Exploratory Sepsis Analysis: Results Total number of locationsNo. (%) of locations with a statistically significant increase in use of BSHO agentsᵠNo. (%) of locations with a statistically significant increase in use of Anti-MRSA agents* VA locationsNon-VA locationsVA locationsNon-VA locationsVA locationsNon-VA locations ICUs (adult med, med/surg, surg)523111 (21%)7 (23%)9 (17%)5 (16%)Wards (adult med, med/surg, surg)1015922 (22%)20 (34%)**14 (14%)12 (20%)** ᵠBSHO agents are broad spectrum agents used predominantly for hospital-onset or multi-drug resistant infections and include: Amikacin, Aztreonam, Cefepime, Ceftazidime, Ceftazidime/Avibactam, Ceftolozane/Tazobactam, Colistimethate, Doripenem, Gentamicin, Imipenem/Cilastatin, Meropenem, Piperacillin, Piperacillin/Tazobactam, Polymyxin B, Ticarcillin/Clavulanate, Tigecycline, Tobramycin*Anti-MRSA agents include: Ceftaroline, Dalbavancin, Daptomycin, Linezolid, Oritivancin, Quinupristin/Dalfopristin, Tedizolid, Telavancin, IV Vancomycin** Differences not statistically significant, p=0.10 for BSHO and p=0.30 for anti-MRSA agents
45. ConclusionsMeasurement remains a key focus for CDC hospital stewardship work.What gets measured gets doneMeasurement is important on several fronts:Program implementationAntibiotic useAppropriate antibiotic useWe value your suggestions on what we can do to advance measurement in stewardship.