>> Thank you all so much for having me here today.
So I've been working on infection prevention
in long-term care in nursing homes for several years now.
So I'm gonna be talking to you about
the overuse of antibiotics in the elderly,
something I'm very passionate about
and an initiative that we have created
in order to try and limit this.
So, when I was being trained in medical school
they often told us to, in general,
push antibiotics early and often
if there was any concern for infection
and I think that we are now realizing
some of the negative consequences of this.
In the past several years we've seen a dramatic rise
in these multidrug resistant organisms or superbugs.
These bacteria that we sometimes don't have
any antibiotic options for.
We've also seen a large rise in
the Clostridium difficile infection.
So this is a diarrheal illness that develops
in response to antibiotic exposure
and it carries significantly high
mortality and morbidity rates,
particularly in older adults.
So in response to these changes
the government formed The National Strategy
for Combating Antibiotic-Resistant Bacteria
in September of 2014.
And the strategy basically outlines plans to bolster our
antibiotic stewardship programs
as well as improve our infection prevention.
And what we learned from some of this
is that, antibiotics are vast,
and what I learned, honestly,
from being in these nursing homes,
is that antibiotics are vastly overprescribed
to older adults.
These are their pills falling down.
(laughs)
Research shows that up to 75% of antibiotics prescriptions
that are given in the nursing home are considered
unnecessary or are not concordant with guidelines.
Up to 50% of nursing home residents are receiving
at least one course of antibiotics
in a three month period living in a nursing home.
The problem here is that these older adults
are particularly at risk for experiencing
the side effects that we see with antibiotics.
So, things like normal GI upset, nausea,
vomiting, kidney injury is very severe in older adults,
Clostridium difficile infection, which I mentioned earlier,
a major problem in nursing homes, liver injury or rash.
And there's more.
Beyond these immediate side effects, we're also seeing
prolonged side effects that can last
for weeks to months to even years.
We've shown that antibiotics exposure
can lead to resistance and actually
alter your microbiome for a prolonged period of time.
So consider here a new nursing home resident
that hasn't had a lot of health care exposure.
They have a relatively healthy microbiome, hopefully,
with little resistance in the bacteria
that make up their normal GI flora.
They get a round of antibiotics
and while that round of antibiotics
does kill the bacteria that may be causing the illness,
it's also gonna kill a lot of their good, healthy bacteria
that's protecting their body from infection.
And with that you leave space for the resistant bacteria,
the ones that are able to evade that antibiotic,
to grow, take over and then transmit their resistance.
And we've seen that these effects
can actually be long-lasting.
We don't even know how there's,
different data on how long residents
stay colonized with these resistant gram-negative rods
but it is for a very long time.
The issue is here is this is a major public health issue.
We are rapidly losing antibiotic options.
We cannot develop antibiotics at the rate
that we are developing resistance to them.
You all may have been in a situation
where you have, or a loved one has been prescribed,
Ciprofloxacin, which is a fluoroquinolone up here
for a suspected urinary tract infection
and our fluoroquinolone rates of resistance
in some parts of Maryland are over 30%.
This is a antibiotic that we use all the time
and we're losing it as an option.
So in response to this, we've had a major push
to bolster our antibiotic stewardship.
(laughs)
So, what do we mean by antibiotic stewardship?
This is typically run by an ID-trained physician
or an infectious disease-trained pharmacist
and the goal is to facilitate the appropriate use
of antibiotics.
So, thinking about using the right drug,
meaning the most narrow spectrum drug
for the likely infection, at the right dose
for the right reasons, for the correct duration.
And not, obviously, treating your colds and flu
with antibiotic if you don't need to.
And this is how I think that the antibiotic stewards
were seen in the past.
Sort of as these villains coming in,
slashing physicians right's to give antibiotics
to their patients that desperately needed them.
And this is how I think we saw ourselves,
as heroes coming in, protecting global health
and antibiotics for the future.
But I think we need to start reframing this.
I think we need to start working collaboratively
to protect our patients and use antibiotics
in the way, in a judicious fashion.
So I'm gonna go into this a little bit.
The way that I think antibiotic stewardship
has been looked at in the past
is as more of a technical problem.
And what I mean by that, say your computer shuts down.
You call the tech support, ask them to come fix it.
You have water leaking in your house,
you call a plumber, ask them to come fix it.
Which is kind of how we've done this, right?
Like the steward comes in and says,
"You can't use that".
They don't really delve into why
or what's going on behind all that.
So unfortunately, inappropriate antibiotic prescribing
is really just not an easy fix like that.
Think about all the different underlying social motivations
and issues that go into a physician making the decision
to prescribe an antibiotic, especially in the long-term care
or nursing home setting.
So you have older adults with vague clinical symptoms.
You can't tell if it's truly an infection
or if they're just dehydrated.
Maybe you have poor communication between
the nurse and the prescriber.
Often the prescriber is offsite
so you can't really get a good picture of the story.
Family pressure, very, very common in long-term care.
Fear of litigation, belief they may be preventing sepsis,
limited diagnostic resources,
the list really goes on and on.
So you understand here that there's so many other things
going into this, it's not something
we can approach technically.
So the thought is, to start looking at this
as more of an adaptive problem.
Meaning this will require learning on both the side
of the antibiotic steward as well as the prescriber
in order to create a culture change
the way we think about antibiotic prescribing.
We need to reframe the landscape of antibiotic stewardship.
Make this a patient safety issue.
Put this at the forefront and approach this
from an adaptive standpoint.
The idea of patient safety in health care
actually really only came about relatively recently
and it was sparked by this book by Linda Kohn,
"To Err Is Human" and the book showed
that 98,000 deaths were caused annually
by medical error alone.
Which really sparked the patient safety initiatives
from the government standpoint so the Department of Defense
came out with a patient safety initiative,
followed by the Joint Commission,
followed by the TeamSTEPPS program
which was a collaboration patient safety
between Department of Defense and AHRQ
and most recently, in 2011, the CUSP program,
The Comprehensive Unit-Based Safety Program
was created as a collaboration between
AHRQ and Johns Hopkins Armstrong Institute
which looked at engaging all levels
of the healthcare staff, improving their teamwork
and communication in order to help identify
medical errors and improve patient safety.
The goal was to reduce health care associated infections.
So we used a lot of these ideas from the CUSP program
in order to develop our antibiotic stewardship initiative,
which basically uses some of these ideas.
So we're merging patient safety methodology
with these adaptive and technical aspects
of the approach to antibiotic stewardship
in order to change the way prescribers
throughout the health care field look at antibiotics.
The National AHRQ Safety Program
for Improving Antibiotic Use spans the health care system.
So it actually rolled out to 500 acute care sites
starting in December of 2017.
We just finished up a pilot in six sites,
six long-term care sites in December,
or just finished it up in March
and we'll be rolling out to national sites
all over the country in December
and this will be followed by ambulatory care.
So the intervention is multimodal and multidisciplinary
and each of the interventions are created
for that specific site.
So all of our, we have specific cases for long-term care.
We basically walk the long-term care facilities
into choosing who to use for their stewardship program,
showing them how to track their antibiotic usage,
teaching them how to talk to families and residents
about antibiotics, showing them how to track their usage.
All things that have not been done in long-term care,
really to date.
So the Centers for Medicare and Medicaid
have recently posted these mandates
that all long-term care facilities will require
antibiotic stewardship programs by November of 2018.
So many of these facilities are really scrambling
for an answer to this.
I won't go into everything that we do with the program
but this is an example of some of the tools we've created.
So this is a, I don't know if this works.
This is a commitment poster we created
to help educate residents and family members
about the risks of antibiotics.
This is a four moments graphic
basically to walk the prescriber through
how they're thinking about
the antibiotic prescribing process,
making sure that they're considering narrowing
at all levels.
And I know we don't have a lot of time
so I won't go into all the outcomes
and everything we're going to do
but the goal is to basically improve
the safety culture throughout the facility,
reduce these side effects we've seen from
so much antibiotic overuse,
including Clostridium difficile infection
as well as the multidrug resistant organism rates,
improve antibiotic decision-making
and the safety culture in these facilities
and finally to help them improve compliance
with these new government mandates.
I'd be happy to talk to anyone further
about this afterwards, so,
thank you very much for having me.
(clapping)
>> Nice work.
>> Woman: I have a quick question.
I do a lot of data analytics for third-party payers
and something that we're always challenged with
is hospital system algorithms.
>> Yes.
>> Around okay you're in the hospital in the last
three months, two months, one and a half,
whatever it is for that particular system,
so you go on a fluoroquinolone.
So there's a lot of algorithmic care
deciding patient-level outcomes.
I would like to know your thoughts on that.
>> Yeah, so I mean, this is a challenge
that we have been navigating, pretty much nonstop.
I guess in terms of, are you asking like in terms of
what antibiotics they've been exposed to
or the outcomes from fluoroquinolone use?
>> Woman: No, I'm just meaning that
we all talk about we need to do something
to help individual patients but we abdicate
everything so high up and create algorithms
that are driving the problem.
That's a two-headed snake.
Where do you intervene?
>> Yeah, so I agree with that.
I mean and that's why I'm very excited about this program
'cause I think the goal is not to just be looking at
the numbers and telling them,
you can only use fluoroquinolones 50% of the time.
You need to have these rates for your readmission.
And more to just get them thinking
about why we're making these decisions
and helping them to understand the downstream complications
of those decisions.
>> Thanks very much, Morgan.
>> Thank you.