NSHA

ANTIMICROBIAL STEWARDSHIP PROGRAM

Quarterly Report

Q2 2017

January 2, 2018

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Table of Contents

Summary ............................................................................................................................ 2

NSHA ASP Structure ........................................................................................................ 3

Interventions .................................................................................................................... 3

Results & Metrics ............................................................................................................ 4

Next Steps ....................................................................................................................... 11

Education......................................................................................................................... 11

Research .......................................................................................................................... 12

Guidelines ....................................................................................................................... 12

Microbiology................................................................................................................... 12

Other Activities ............................................................................................................. 12

Strategic Planning ......................................................................................................... 12

Acknowledgements ...................................................................................................... 13

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Summary

The vision of the NSHA Antimicrobial Stewardship Program (ASP) is to ensure the safe and

effective use of antimicrobial agents in patients cared for in Nova Scotia Health Authority.

NSHA’s ASP will aim to improve patient care by modelling and promoting best antimicrobial use

practices. Over time, effective ASPs influence the culture of antimicrobial use by changing

behaviors of physicians, pharmacists, nurses, students, patients and their families. The NSHA

ASP will aim to:

Promote a culture of optimal antibiotic use in NSHA

Respect and promote regional strengths

Act in collaborative and engaging manner

Make evidence-based recommendations

Maintain an open/transparent program

Start small, build on success

The NSHA ASP team was fully formed in the July 2017. Our early activities have focused on

forming the structure of the program and surveying the current Antimicrobial Stewardship

(AMS) activities throughout NSHA. A significant focus has been placed on our communication

strategy and presentations to introduce the NSHA ASP to all healthcare workers. In addition, our

ASP pharmacists have been receiving Infectious Diseases and AMS training through online

courses and observerships within NSHA and abroad.

We have established zonal subcommittees with oversight by the NSHA ASP Steering Committee

(see organizational chart below). These committees are multidisciplinary including pharmacists,

physicians (representing a variety of services), microbiology, nursing, infection prevention and

control (IPAC), and quality improvement. A strategic plan has been developed and approved by

our sponsors. This plan outlines the vision, structure, and planned initiatives of this program.

There is cross representation on the NSHA Antimicrobial Subcommittee.

In addition, we have spent significant time obtaining quality, validated antimicrobial use,

process, and outcomes measures. This task has been complicated by different electronic

medical record (EMR) systems across NSHA. We have obtained purchasing data which provides

crude antimicrobial use (AMU) data at the level of institutions/zone (see summarized Q1

report). This data can show trends over time and determine relative use of antibiotics at each

site. We have also been working with Meditech to obtain reliable dispensing data (Defined Daily

Dose (DDD) and/or Days of Therapy (DOT)) outside of Central Zone. Within Central Zone, DDD

and cost data is available. Once we have obtained dispensing AMU data, data will be validated

over the next 6 to 12 months using secondary data sources and manual chart review.

We have initiated NSHA-wide initiatives based on baseline stewardship activities, level of ASP

pharmacist training, and a point prevalence survey conducted in 2015 (Black et al 2017).

Black E, Neville H, Losier M, Harrison M, Abbass K, Slayter K, Johnston K, Sketris I. CPJ. 2017;

150(4):S35. (Abstract)

Recently, we have successfully met the five tests for compliance for the Accreditation Canada

Antimicrobial Stewardship required organizational practice (ROP).

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NSHA ASP Structure

Interventions

The two main focuses of the NSHA ASP in the short term have been 1) IV to PO (oral) policy and

2) Prospective audit and feedback with academic detailing.

The need for an IV to PO policy was identified by a point prevalence survey showing high IV use

rates for bioavailable drugs in Nova Scotia. Such an initiative is recommended by Choosing

Wisely Canada and the Infectious Disease Society of America to reduce costs, complications

from parenteral drugs, and hospital stays. The NSHA Pharmacist Initiated IV to PO Conversion of

Antimicrobials Policy and Procedure was implemented in July/August 2017 with the plan to

measure clinical pharmacist utilization and changes in IV rates over time.

Prospective audit and feedback (PAF) is a core clinical strategy of ASPs. PAF occurs in two

intensive care units in the Eastern Zone (Cape Breton Regional ICU and CCU). In Northern Zone

(Colchester East Hants Health Centre) specific antimicrobials are targeted throughout the

hospital. In Central Zone, PAF was initiated in the two medical surgical ICUs (Victoria General

(VG) and Halifax Infirmary (HI) sites). For Western Zone, PAF includes the Valley Regional

Hospital (VRH) ICU and urinary infections/asymptomatic bacteriuria among inpatients based on

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a previous survey identifying suboptimal use of antimicrobials for such infections. Once PAF is

established in these hubs, the ASP will help establish PAF in spoke hospitals within each zone.

A NSHA Antimicrobial Handbook is being developed and designed (see Guidelines below).

The beta-lactam allergy algorithm for preoperative patients is a project initiated in Central Zone.

This was identified as a need by Anesthesia. The New Brunswick AMS group has developed an

excellent algorithm and are sharing this resource with our program. Allergy and Immunology is

also collaborating on this project. After implementations of the algorithm we will pilot it in

Central Zone and measure use of non-beta-lactams for surgical prophylaxis and the choice of

antibiotic in true allergic patients. We will then modify as necessary and expand it across the

province.

With the amalgamation of health authorities, there has been the need to review the formularies

across the province. We have done a review of these formularies to streamline the unified NSHA

formulary.

Pre-printed Order (PPO) management is handled through representation on NSHA Antimicrobial

Subcommittee (ASC) of the Drugs and Therapeutics Committee.

PAF: prospective audit and feedback

Results & Metrics

Point Prevalence Audit post IV to PO Policy Implementation

In September 2017, a one-day chart audit was conducted on medical units to measure

antimicrobial choice, route, and if indication, duration, or reassessment date were specified in

the orders. Results are shown below and compared with data from medical patients in the 2015

study by Black et al.

SUMMARY OF INTERVENTIONS

Zone

IV

to

PO

PAF Handbook

Guidelines

Beta-

lactam

pilot

Antibiogram Formulary

Review

Cascading

sensitivities

Eastern ✔ ✔

CBRH ✔ ✔ ✔ ✔

Western ✔ ✔

VRH ✔ ✔ ✔ ✔

Northern ✔ ✔

Colchester ✔ ✔ ✔ ✔

Central ✔ ✔

HI/VG ✔ ✔ ✔ ✔ ✔

5

Approximately one third of patients were on antibiotics. Most antibiotic orders did not include a

duration or reassessment date. There was a slight decrease in IV antibiotic use compared to the

2015 survey, but there was variation across NSHA.

Patients on

antimicrobials

Antimicrobials

in the IV PO

Conversion

Policy given IV

Orders with

an indication

Orders with

duration or

reassessment

date

TOTAL 34% 41% 77% 44%

Central 34% 30% 83% 34%

Western 29% 30% 87% 53%

Northern 37% 44% 79% 47%

Eastern 42% 55% 58% 39%

50%44%

41%

61%

43%

30%

0%

10%

20%

30%

40%

50%

60%

70%

NSHA 2015 NSHA 2017 CZ EZ NZ WZ

Percentage Antimicrobials Given IV

6

NORTHERN

PAF audit results (Mid Jul – Sep 30) # Recommendations = 25

WESTERN

At VRH, PAF focuses on patients with bacteriuria. Many patients (28%) have asymptomatic

bacteriuria, and most ASP interventions involve successfully discontinuing antibiotics for these

patients.

12%

56%

32%

0%

10%

20%

30%

40%

50%

60%

AMS Team agreed with therapy (norecommendations made)

AMS Recommendation Accepted AMS Recommendation NotAccepted

28%

56%

16%

Bacteriuria

Asymptomaticbacteriuria

UTI

CA-UTI

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EASTERN

In Eastern Zone, the antimicrobial interventions performed by clinical pharmacists is recorded in

Meditech.

0

2

4

6

8

Discontinue Antibiotic Dose Adjustment De-escalation

Recommendations

Recommended Accepted

Overall 90% acceptance

rate

0 1 2 3 4 5 6 7 8 9 10

E. Coli

Klebsiella

Enterococcus sp

Pseudomonas

Proteus

Enterobacter

S. aureus

Morganella

VGS

No Growth

Isolated Bacteria

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Total documented antimicrobial-related interventions: 169

Total accepted interventions: 131* (see next bullet)

⁃ Not included in table: 20 allergy interventions / confirmations documented resulted in

either monitoring or change of therapy; not recorded as ‘accepted’ because n/a

Antimicrobial indications documented on the patient Meditech profile: Total for Zone: 852

Total documented antimicrobial-related interventions: 269

Total accepted interventions: 255* (see next bullet)

⁃ Not included in table: 9 allergy interventions / confirmations documented resulted in

either monitoring or change of therapy; not recorded as ‘accepted’ because n/a

Antimicrobial indications documented on the patient Meditech profile: Total for Zone: 772

CENTRAL

Antimicrobial Use Q1

Total Antimicrobial Use Systemic Antibacterial Use Systemic Antifungal Use

Cost Costs/ 100

bed-days

DDD/ 100

bed-days Cost

Costs/

100 bed-

days

DDD/ 100

bed-days Cost

Costs/ 100

bed-days

DDD/ 100

bed-days

HI ICU

(5.2) $10,513 $1,268 153.56 $8,059 $972 138.82 $753 $91 6.39

VG ICU

(3A) $26,709 $4,474 240.60 $7,515 $1,259 157.47 $17,827 $2,986 66.83

DGH ICU $4,903 $859 92.40 $4,159 $728 79.54 $363 $64 2.54

Medicine

HI (8.2) $15,492 $740 164.61 $12,529 $598 126.56 $22 $1 3.44

Gen Surg

VG (9A) $15,504 $662 70.88 $11,313 $483 53.53 $3,900 $167 14.76

Surgery

DGH

(3East)

$7,706 $254 64.80 $7,301 $241 55.01 $6 $0 0.63

There is a delay by 1 quarter for central zone as the Central Zone ASP started PAF in mid-July

2017.

The graphs below show antimicrobial use (DDD/100 bed-days) and antimicrobial cost

(Dollars/100 bed-days) for central zone intensive care units.

0 10 20 30 40

Discontinue abxIV to PO

Change empiric therapyDuration optimization

De-escalation

Dose optimizationEscalate therapy

Labs/imaging recommendedRenal/hepatic dose adjustment

2nd Quarter 2017-2018

No. accepted

9

0

50

100

150

200

250

300

0

2

4

6

8

10

12

14

16

18

Cost/100bed-days

DDD/100bed-days

HIICU(5.2)

DDD/100beddays Cost/100beddays

0

200

400

600

800

1000

1200

1400

1600

1800

0

5

10

15

20

25

30

35

Cost/100bed-days

DDD/100bed-days

VGICU(3A)

DDD/100beddays Cost/100beddays

0

50

100

150

200

250

300

350

400

450

0

5

10

15

20

25

Cost/100bed-days

DDD/100bed-days

DGHICU

DDD/100beddays Cost/100beddays

10

0

10

20

30

40

50

60

70

80

90

100

0

2

4

6

8

10

12

14

16

18

Cost/100bed-days

DDD/100bed-days

HIMedicine(8.2)DDD/100beddays Cost/100beddays

0

50

100

150

200

250

0

2

4

6

8

10

12

Cost/100bed-days

DDD/100bed-days

SurgeryVG(9A)

DDD/100beddays Cost/100beddays

0

10

20

30

40

50

60

0

2

4

6

8

10

12Cost/100bed-days

DDD/100bed-days

SurgeryDGH(3east)DDD/100beddays Cost/100beddays

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Next Steps

Obtain antibiotic dispensing data for each hospital at the unit level for zones outside

central. This work is close to being ready and is in testing stages now.

Summarize the data by quarter to identify trends in antibiotic use and areas of high

antibiotic use.

Validate over the next 6-12 months with other data sources

Outcomes Data

*Aberdeen includes beds in a stepdown unit

**St. Martha's Regional Hospital coded Q1 data has not been submitted to CIHI

Readmission rate: The rate of readmission to any unit within 30days

Education

1. NSHA ASP Educational Day on July 13, 2017. Presentations included principles of behavior

change, introduction to microbiology, mechanism of beta-lactamases, fungal infections, and

intraabdominal infections. In addition, we role-played audit and feedback scenarios based

on a decision framework shared by Sinai Health System-University Health Network

Antimicrobial Stewardship Program (SHS-UHN ASP).

2. Nursing presentation: August 16, 2017

3. Internal Medicine Grand Rounds: Sept 19, 2017

4. Medicine and pharmacy training

Location Patient Days LOS Avg Mortality Rate Readmission rate

CBRH ICU FY16-17 4247 9.14 18.6% 15.0

Q1 1081 7.75 22.2% 18.5

CBRH CCU FY16-17 1540 3.36 5.7% 33.0

Q1 394 3.56 7.4% 35.2

St. Martha's ICU FY16-17 1726 2.96 2.6% 15.8

Q1 431 Data not submitted**

Aberdeen ICU* FY16-17 2914 3.82 4.7% 14.2

Q1 789 3.44 4.3% 21.4

Colchester ICU FY16-17 2774 3.63 4.9% 16.4

Q1 683 4.39 6.7% 18.0

Cumberland ICU FY16-17 1290 4.63 9.4% 20.8

Q1 342 4.83 16.7% 19.7

DGH ICU FY16-17 2245 4.77 8.8% 15.3

Q1 585 4.3 6.8% 20.5

VG ICU FY16-17 2325 4.31 16.4% 38.9

Q1 607 4.07 10.7% 34.7

HI CVICU FY16-17 3883 3.20 3.1% 11.9

Q1 999 3.7 6.2% 10.3

HI ICU FY16-17 3503 4.69 16.4% 10.9

Q1 849 4.5 19.7% 9.6

SSRH ICU FY16-17 1537 3.63 6.3% 13.2

Q1 358 5.2 3.2% 23.2

VRH ICU FY16-17 2377 3.30 8.7% 10.9

Q1 586 4.0 9.5% 11.7

YRH ICU FY16-17 1931 4.11 9.4% 14.7

Q1 451 4.7 3% 14.9

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a. ASP introduction and teaching incorporated into the Infectious Diseases rotation for

medical clerks and residents

b. Incorporate pharmacy resident rotations into NSHA ASP

5. Infectious Diseases and Medical Microbiology curriculums

a. Development of AMS objectives and itinerary for fellows

6. Beta-lactam allergy presentation by Dr. Lori Connors from Allergy and Immunology. Posted

to NSHA ASP website.

Research

Collaborating with Emily Black of Dalhousie Pharmacy Department for future NSHA funding

application.

Working to support a variety of residency (MD and pharmacy) research projects

Guidelines

NSHA Antimicrobial Handbook

The formation of a NSHA Antimicrobial Handbook was initiated prior to the formation of the

NSHA ASP by the Central Antimicrobial Agents Subcommittee. This handbook will provide

guidance on antimicrobial use for a broad range of syndromes. It will also include information

on best practices, therapeutic drug monitoring, and surgical prophylaxis. Updates will be done

by priority of topic to facilitate workflow and approval.

The first 3 topics (Staphylococcus aureus bacteremia, Candida bloodstream infections,

meningitis) have been disseminated for stakeholder review.

Microbiology

Antibiogram for Central Zone has been updated. We are exploring options to stratify the

antibiogram by patient location/type

We have improved on our time to identification of blood culture isolates using rapid

diagnostic technologies. This currently is being done with direct identification of positive

blood culture bottles using our matrix-assisted laser desorption/ionization - time-of-flight -

mass spectrometer (MALDI-TOF-MS) in Central Zone.

Developing a pilot project in conjunction with the Hospitalist Medicine Unit (8.4 at the

Halifax Infirmary) to improve the processing of specimens in the microbiology lab to

minimize reporting and treated for asymptomatic bacteriuria.

Site visits to peripheral labs by Dr. Davis.

Representation on the Susceptibility testing subcommittee of the Microbiology Service

Advisory Committee

Other Activities

Dashboard development

a. Working with Clinical Applications to develop a dashboard that identifies antimicrobial

use in real-time, linked with laboratory data

NSHA ASP website live on May 6, 2017

a. Frequent updates as material becomes available

Strategic Planning

Collaborate with SHS-UHN ASP and Saskatchewan stewardship programs

Collaborate with Department of Health and Wellness (DHW) Nova Scotia

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Andrea Kent, NSHA AMS Clinical Pharmacy Coordinator; Co-lead AMS Program has

performed site visits to all zones to introduce pharmacy groups to the NSHA ASP

The NSHA ASP is represented nationally by Kim Abbass, Eastern Zone AMS Pharmacist who

has been working on Association of Medical Microbiology and Infectious Disease Canada

(AMMI) Canada Antimicrobial Stewardship and Resistance Committee (ASRC)

Exploring use of DIS to summarize outpatient antibiotic use

Acknowledgements

Executive sponsors: Dr. Lynne Harrigan (VP Medicine & Integrated Health Services) and Colin

Stevenson (VP Quality, System Performance and Transformation)

Gail Blackmore (Senior Director Quality Improvement, Safety, Patient Relations), Dr. Steven

Soroka (Senior Medical Director Pharmacy Services), and Glenn Cox (Senior Director

Pharmacy Services)

Dr. Todd Hatchette: Chief of the Division of Microbiology in the Department of Pathology

and Laboratory Medicine

Dr. Shelly McNeil, Division Head Infectious Diseases

Tammy MacDonald, Central Zone Director, Quality Improvement, Safety & Patient Relations

and NSHA Infection Prevention and Control Lead

Heather Neville & Stephen MacKay, analyzing antibiotic use metrics

Emily Black: collaborating and sharing study results

SHS-UHN ASP: sharing resources, education of team members, and collaborations

David Evans: Application Specialist Meditech Pharmacy Program