Speaker 1  0:25  
It's great to look over the list of attendees and see all kinds of new names and all kinds of old friends you

Unknown Speaker  0:53  
Mr. Smith, would you like to go ahead and get us started? I

Christopher Smith, NPA  1:04  
Chris Chad, I can do that. How's everybody doing today? Hello and welcome to the National institutional Hello and welcome to the National Institute of Corrections, clinical pearls webinar series. My name is Chris Smith, and I'm a national program advisor with Nic. We are thrilled to have you join us for this informative nine part series exploring the integration of clinical pharmacists into the primary care and highlighting proven approaches for correctional team medicine. Before we begin today's session, I would like to cover a few important housekeeping tips, housekeeping items. Each webinar in this series is scheduled to last approximately one hour. The sessions will be recorded and once captioned and made, 508 compliant will be available on the NIC website. This is a Listen Only event, meaning participant microphones are muted. However, we strongly encourage engagement through the web X chat function. Please use the chat to share your thoughts, ask questions or request a technical support. We will address as many questions as possible during the Q A portion at the end of the webinar to practice the chat function, everybody, please type into the chat who they are rooting for and either of the NCAA basketball tournaments and whether it's the men's or women's team. If you're not a basketball fan, then please type in your favorite sport or hobby go and just take a moment real Quick, and let's practice our chat. You

Cassandra. I see that you're not a sports person, that you like to sing. I love to sing, but I won't sing for you guys because I sound like a dying cat. But that doesn't mean that I don't enjoy singing. I'm glad to see we have lots of basketball fans in here, so I'm sure you guys are enjoying the tournament so far. Alright, I'm glad to see everybody has been able to work their chat function. Great. So if you experience any audio difficulties, we recommend connecting to the webinar audio via the phone number that the by the telephone using the number provided on your registration confirmation email throughout the series, we want to hear from you, and you can always email the Health Programs Manager, Chad Garrett at CA, garrett@bop.gov with any comments, concerns or ideas for future events, I and my team for the NIC, including some great staff from the NIC library, will be posting information in the chat during the presentation. Again, if you have any questions, please type them into the chat and we'll answer as many as we can at the end of the webinar. Thank you again for joining our webinar. Now I give you to Captain Chad Garrett, thank you. Thank

Speaker 1  4:05  
you. Thank you, Mr. Smith and ladies and gentlemen, esteemed colleagues and anyone who's accidentally just wandered in welcome today. We are diving into a topic that is crucial for public health, anti microbial stewardship in correctional settings. Say that five times really fast. Now I know what you're thinking anti microbial stewardship in a prison. Isn't that a little like trying to teach a cat to swim? Wait, hear me out, just like the inmates who can turn a bowl of toilet paper into a makeshift tattoo gun, we too can get creative when it comes to managing antibiotics where they're really needed most. Remember that Correctional Health is public health. Over the next hour, we're going to explore how effective anti microbial stewardship not only keeps our correctional facilities healthier, but also protects the communities outside these walls. We'll discuss strategies that help prevent the rise of antibiotic. Resistance, because, let's face it, nobody wants to deal with a superbug from the supermax. So buckle up, grab your copy, and let's embark on this enlightening journey together. By the end of this hour, you'll not only be equipped with valuable insight on antimicrobial stewardship, but you might also find yourself with newfound appreciation for the phrase no one is above the law, and that includes you bacteria. So let's meet our experts. Uh. Commander Landon Sams graduated with his Pharm D from Southwestern Oklahoma State University in 2011 he then completed a PGY one residency in Arizona with the Indian Health Services during his career as a public health service officer, he has been on various work groups, a few of which include an anti microbial stewardship, infection control, pharmacy and therapeutics committee. He led an opioid stewardship team, continuing education work group and an informatics work group commander. Sams has worked in inpatient, outpatient and er pharmacy, as well as managed patients in an anti coagulation, immunization, tobacco, sensation and comprehensive care clinics. Commander Sams currently works at the United States Medical Center for federal prisoners in Springfield, Missouri, where he serves as the deputy chief pharmacist. Commander Tyler Campbell has over 10 years of experience as a pharmacist with the Federal Bureau of Prisons. He is currently the chief pharmacist at the Federal Correctional Institute Elkton in Ohio. His collateral duties include serving as a regional HIV clinical pharmacist consultant and the coordinator of the BOP anti micro Bureau stewardship clinical pharmacist Consultant Program. Prior to working in the BOP, he spent five years with the Indian Health Services, including completion of a PGY one residency. So from optimizing treatment strategies from chronic and infectious diseases to meeting transformative pharmacy programs, these two will leave you in awe with their knowledge, no pressure, my friends, the floor is now yours.

Speaker 2  7:15  
Alright. Thank you for that, Captain Garrett, and thank you all for joining us and welcome so I'm Landon Sams a clinical pharmacist specializing in antimicrobial stewardship. One of the things I get to do for the Federal Bureau of Prisons that I really do enjoy most about is providing antimicrobial consultation and review. So this group is led by Commander Tyler Campbell, who's joining me today and discuss this antimicrobial stewardship within the Correctional Health Care as our discussion moves along, I'd like to encourage everyone to add questions comments into the chat and Commander Campbell, thanks for joining us today, and would you please tell us a little bit more about

Speaker 3  7:55  
yourself. Thanks for having me today. Landon, I'm excited to be here. It's a great opportunity to share some experiences and hopefully provide a spark for audience members to incorporate antimicrobial stewardship into their health services departments, as was previously stated by Captain Garrett, I'm currently the chief pharmacist at a low security bop facility in Ohio, and I serve as the coordinator for the BOP antimicrobial stewardship clinical pharmacist Consultant Program. The program currently consists of 13 pharmacists who perform a wide variety of tasks that make up the BOP stewardship program. We're located institutions throughout the US so but for simplicity sake, you can think that we basically provide our services remotely, personally, I've been involved in bop stewardship efforts since the program started in 2014 so a little over 10 years. And prior to that, I was involved in stewardship efforts as a pharmacist with the Indian Health Services. I

Speaker 3  9:04  
so objectively today, we hope to allow listeners to formulate strategies that encourage a collaborative approach to antimicrobial stewardship, identify antimicrobial stewardship targets and identify and interventions that can help improve their usage, and finally, kind of discuss some challenges and solutions to implementing stewardship in the correctional environment. So a lot of the focus will be on pharmacist roles in stewardship. But audience members need to keep in mind that pharmacists are just one piece of the puzzle.

Speaker 2  9:39  
All right. Audience, if you would drop us a quick message in the in the chat box there and let us know if you you know you have an in microbial Stewardship Program, or where you're at with that. Is it robust? You What kind of team? Just give us a little bit information of of our audience, if you would please you. Best Program.

Speaker 2  10:12  
No formal program only. MD, yeah, yep. So Tyler, while we're waiting on a few responses, I want to emphasize something important here. I think that, you know, we all share a common goal here, healthy patients and improved outcomes, reduced resistance, cost savings. But there's always a but, right? So, so what's the but here,

Speaker 3  10:37  
how that's right? There's always the but. And there's a lot of competing priorities within any healthcare setting, and Corrections is definitely no different. And in fact, I think it's probably safe to say that the correctional environment probably has more competing priorities than most healthcare settings, because you also have to consider a lot of the non healthcare priorities, so thinking like correctional programming ensuring the safety of staff and the surrounding community. So when you add it all up, it's often difficult to muster the energy, as well as the support for something like antimicrobial stewardship, where it usually takes time to see the results from all of our efforts.

Speaker 2  11:15  
Yeah, exactly. And I was Novan administrator once who put it kind of bluntly, you know, they said, basically, if you're looking at our top issues from the administration, you know, we're focused on deaths and suicides, homicides, COVID, trauma, the drugs. So antimicrobial resistance can seem to be kind of abstract compared to these immediate challenges. So again, audience, drop some of your challenges in in that chat for us, see if we can address some of them as we go along here. And you know those competing priorities that come to mind which are provided, you know, the challenges to implementing stewardship. So Tyler, it's understandable that stewardship can get pushed to the back burner when we have, you know, limited resources and only so much bandwidth. I think the quote here on the screen sums it up pretty nicely. And can you help our audience understand why antimicrobial stewardship needs to remain a priority?

Speaker 3  12:17  
Yeah, so I mean to appreciate why it's important. I think we need to look at antimicrobial resistant infection rates, and before we get to the numbers, I just want to ensure that everyone is on the same page when we're talking about antimicrobial resistance or Amr. So AMR is when microorganisms such as bacteria, virus, fungi, change in ways that make the medication, medications that we use to treat them ineffective.

Speaker 2  12:45  
So what you're saying is our typical treatments, such as antibiotics, they don't work at all or work as intended, and basically the infections are very difficult now to treat. Yeah,

Speaker 3  12:56  
exactly. So why does antimicrobial stewardship deserve to be prioritized. Landon, there's really forceful numbers that are associated with AMR infections. So the data we see on our screen here references the costs associated with six of the most important AMR infections, VRE, crasp, MRSA, CRE, ESBL organisms and MDR Pseudomonas and these infections are a significant burden on the healthcare system. So when the CDC released their 2019 antibiotic resistance threats report, we had actually seen some progress on decreasing the infection and death rates from these organisms. But honestly, despite these reductions, the numbers are still compel compelling. So AMR caused approximately 1.2 to 7 million deaths globally each year, and in the US alone, we saw 2.8 million antibiotic resistant infections annually that resulted in over 35,000 deaths. And to put this in perspective, Landon, that's more deaths than caused by HIV or malaria. Additionally, on the screen here, we see that there were over 20 200k 22 220,000 cases and 12,800 deaths from C difficile infection, which, as we know, is one of the many concerns related to inappropriate use of antibiotics.

Speaker 2  14:27  
So you you mentioned that those stats are from 2019 but I saw some interesting data from the CDC regarding AMR infection rates during the COVID era. And so here's the title on the screen. Now it shows how those rates of some of our most concerning infections rose significantly through that pandemic and but it seems they did kind of finally plateau towards 2023

Speaker 3  14:53  
Yeah, that's right. I mean this the CDC released a new report in July of 2024 that was titled The CDC AR three. In the United States, 2021 to 2022 and it included the data that you mentioned here. So during the COVID pandemic, we did see some concerning trends. So if you take a look at the first column with the colored arrows, it'll be on the left side of the chart there. There's a lot of red, and that's not a good thing. The column compares the change in the rates of number of infections in 2020 versus 2019 corresponding to the beginning of the pandemic, and you see an increase across the board in almost all six of the infections that were mentioned earlier, and that continued in the next column of 2021, versus 2020 and so there are multiple reasons why these rates increased, but that's a whole other topic in itself. But what I find most disheartening in this data is that the pandemic really undid years of hard work on decreasing AMR infection rates. But there is a silver lining, which you alluded to, and that's the third column in the chart. And several rates have held steady, and one actually went down over the last year the data that they looked at. But if we just kind of pay attention to that final column that's highlighted in the chart, we're still higher than preprint pre pandemic levels, but yearly data says we are at least kind of starting to trend back in the right direction,

Speaker 2  16:27  
alright, so no doubt, limiting AMR infections is very important, and given all the inherent challenges in correctional medicine, you know, with the limited resources, high turnover, diverse health needs. Where, where do we even start with implementing

Unknown Speaker  16:47  
stewardship again,

Speaker 3  16:49  
before we get rolling with how, just to make sure we're all on the same page, I'm just gonna go over a few more definitions. On a slide, you see the definition of antimicrobial stewardship from both the CDC and the Association for professionals and infection control and epidemiology, and generally speaking, it's a coordinated program which aims to measure and improve the use of antimicrobials in an effort to improve outcomes for our patients and limit the spread of AMR infections. So just kind of take notice that there's nothing in these definitions which specifies what makes up a quote, unquote program. And there are excellent tools that are available that can help guide you in developing your stewardship efforts. The CDC has their core elements program. The Infectious Disease Society of America has stewardship guidelines, but we're going to use the CDC core elements for outpatient stewardship as an example as we go through our presentation here, and I feel these fit the best for the correctional healthcare setting. So the CDC recommends that you have four core elements, commitment, action, tracking and education, it's only four elements. They're not only specific, and honestly, the last three are often tied to like single intervention. So for example, if we consider the action element, when you look at it, it specifically says at least one policy or practice, so just one, so you don't need to feel pressure to have some huge, robust program right out of the gate. So where do we even start? I think the most important key here is to start small. Because they say, don't try to boil the ocean.

Speaker 2  18:35  
I like that. Don't, don't boil the ocean. Start small. So so keep the competing priorities in mind, but focus on what's feasible with your available resources and the capability of your health services department. Maybe you know, what disciplines do you have that are available within those disciplines? Who has availability to complete the requirements of an antimicrobial team with minimal disruption to patient care. Is there an obvious problem that needs to be addressed? All right, so let's say I'm thinking about pharmacist involvement in antimicrobial stewardship. I might want to think about what does pharmacy look like in your system? Do you have pharmacists on site? Do you have direct communication with pharmacy services if they're not on site, and what kind of medical record access is available to pharmacists? But I guess no matter what your answers to these questions are, you keep in mind just start simple and keep it small. Yeah, you got it.

Speaker 3  19:35  
I mean, I'll use the BOP as an example. So there was an executive order signed in 2014 titled combating antibiotic resistant bacteria, and it kind of set the framework, but the federal government would work to detect, prevent and control illness and death related to AMR infections. And this EO got the ball rolling for our program. It provided big picture commitment to. Start a sewer stewardship program. But we did start very small. There were six pharmacists who were selected to what the BOP terms advisory group, and the major role was just to manage an internal clinical guidance document on treating infections that were frequently encountered within the Bop It was honestly just a lot of behind the scenes work. And although updating and maintaining that guidance document took time and was by no means a small task, we were under very minimal time constraints, and our efforts weren't delaying any direct patient care

Speaker 2  20:36  
interesting. So even though it wasn't a small task, it wasn't time sensitive, and it allowed you to work on it as time was available. And you get to, you know, utilize the resources available, keeping it relatively simple and at least in terms of involvement. So if we go back to the CDC core elements and use them as their outline for thinking about stewardship, the first element is commitment. Could you expand a little bit on what is meant by commitment?

Speaker 3  21:06  
Sure. So most importantly, we need to remember that effective stewardship really is a team effort, and that effectiveness is increased when there's commitment from both administrative and clinical personnel. Administratively, that might look like providing antibiotic stewardship training, the addition of a position for stewardship activities, authorization for forming a stewardship team, or even just as simple as granting authority to certain individuals to complete stewardship interventions and effectively communicating this authority to those involved in your team, thinking about it clinically, the commitment really can come from any discipline. Most resources will recommend at a minimum either medical provider or pharmacist involvement. But commitment truly does involve any discipline. So if you look at our program, the BOP provided further administrative commitment about six years ago, they changed us from an advisory group to clinical consultants, and regardless of verbiage, what it ultimately did was it gave our group more authority to complete interventions. So you can think of it kind of as like a more hands on approach and visible versus behind the scenes. So you and our pharmacist in the correctional setting. So an example of how pharmacists can be committed to stewardship activities in our environment, making something like transitions of care, so the movement of someone from the outside hospital back to the facility of incarceration, it's a wonderful opportunity for pharmacist intervention. And three areas really immediately come to my mind. The first one would be just kind of a total duration of treatment, so pharmacists can ensure that discharge orders are not duplicating days of therapy. And what I mean by this is like if an infection typically requires 14 days of therapy and the patient's already been admitted and received five days of therapy while in the hospital, the discharge prescription should ideally only be written for those remaining nine days. However, we know this is often not the case. Oftentimes, discharge orders are just transcribed directly from the inpatient order and reflect that original duration of treatment. So careful review of these discharge prescriptions can help to limit antibiotic exposure by ensuring proper durations. The second thing I would think about is like formulary equivalencies doing medication reconciliation. Encephalo sporon Antibiotics are what I most often think about with this intervention, basically substituting an equivalent antibiotic that is locally preferred can be important in limiting exposure and limiting the use of more antibiotics at your institutional level. And finally, the third thing that I think of with transitions of care is ensuring proper IV to PO conversion. This would require access to outside hospital treatment records to some extent, and when possible, review of these conversions can ensure that the use of oral agents will provide adequate coverage while maintaining the narrow spectrum of activity possible. And there are other ways pharmacists can be utilized even if they're not on site. So we just touched on like durations on hospital discharge prescriptions, but you could apply that same intervention even if you don't have if you just needed to put it on like antibiotic prescriptions that are written at your facility, let's say so it would take coordination with the facility that processes and fills your prescriptions and. But for example, we continue to see evidence in literature for common outpatient infections that shorter courses of antibiotic therapy are non inferior to longer courses in terms of their efficacy, and these shorter courses lead to fewer adverse drug events, decrease the risk of resistance development. We'll take community acquired pneumonia. For example, five to seven days of therapy has consistently been shown as effective as therapy duration is longer than seven days. So as an intervention, you could request that when pharmacists at your facility that fills your prescriptions receive an antibiotic prescription for the treatment of cap with a duration greater than seven days, they automatically could, like obtain clinical justification from the prescriber for why the longer duration is necessary prior to doing the actual dispensing. But just I mean, as we said earlier, keep in mind that stewardship activities aren't limited to pharmacists.

Speaker 2  26:03  
Yeah, definitely, each role is very crucial and brings that unique value to the program. So like, you know, I'm thinking prescribers, you know, effective communication is absolutely key. They gotta be comfortable having those difficult conversations with patients, including being able to say no when antibiotics aren't indicated. And it's it's important that they maintain those open lines of communication with the other healthcare team members and clearly communicate those expectations to the patients. You know what improvement should look like, what warning signs to watch for, you know why an antibiotic might not be needed. They also need to stay current with both the those external and internal guidance documents. And, you know, nurses, man, those are really our frontline champions in our stewardship. They often have the most frequent patient contact and develop trusting relationships that kind of makes them, you know, just that natural Patient Advocate. Their role is particularly valuable because it, you know, they're they're usually present at the point of care and multiple patient interactions throughout the day. So this puts them in that excellent position for tasks like monitoring symptoms and performing the wound care, following up on that wait and see kind of approach they can also provide, you know, the crucial education to both patients and the providers. For instance, they can help reinforce symptom management strategies for upper respiratory infections, or when, you know, when antibiotics aren't really needed. And then, you know, the lab team, oh, man, do they play a critical role in, you know, helping us with that diagnostic stewardship. They're responsible for that, communicating important results quickly, especially when dealing with high resistant organisms or positive cultures for concerning pathogens such as C Diff or MRSA, help they help guide appropriate testing through practices like limiting certain sensitivity results, managing those reflex urine cultures and their input helps ensure we're Making the treatment decisions based on accurate and timely diagnostic information. So you know, successful stewardship really requires buy in and participation across multiple disciplines, and each team member brings a valuable expertise. Pharmacist with their medication knowledge is physicians with their clinical expert experiences and nurses with their patient care insights, lab their diagnostic expertise.

Speaker 3  28:24  
Yeah, exactly right. So how about we talk through kind of another example, and I'll give you an opportunity to kind of respond as we go, putting me on the spot. All right, let's do it. Okay. So let's say you work at a facility that has experienced five cases of C difficile infections in patients returning from the hospital in the past three months, you would like to closely monitor outside hospital discharge antibiotic prescriptions with the hopes of decreasing your cases, but you're the solo primary care provider at your Short staff jail, so you don't have in house pharmacists or any other prescribers due to vacancies, but what you do have is plenty of Rn help. So what interventions might be options that you can implement locally to help lower the number of C Diff cases at your facility?

Speaker 2  29:21  
Alright? So plenty of RNs, but very little other staff. So we'll go back to what you were talking about earlier with that. You know, start small and use what I've got use my resources. So thinking about an intervention that could be done relatively quick, but is tailored to the RN skill set, work experience and their their knowledge

Speaker 3  29:43  
base. I, I totally agree. So you mentioned previously that nurses are sort of our quote, unquote, frontline stewards. They have a lot of patient interaction, and they're most often the first health care provider that interact with our patients. So an intervention that takes. Advantage of these attributes, it would be ideal. Yes,

Speaker 2  30:03  
I'm I'm thinking something maybe an area of like the transitions of care, right when the patient is evaluated upon intake back from the facility, from an outside hospital. That makes sense to me. Yeah,

Speaker 3  30:14  
you have nursing help, deploy them in the capacity is an excellent utilization of the resources available to you.

Speaker 2  30:23  
So one part of the antibiotic use that carries an increased risk of C diff, infections, prolonged exposure to antibiotics. You know, confirmation of antibiotic durations of therapy upon discharge would be an option that seems to fit our criteria. I

Speaker 3  30:39  
agree you could really kind of narrow it down by creating some criteria that would trigger the need to contact the discharging hospital for confirmation. So, for example, do any high risk antibiotics? So I'm thinking like the C Diff risk associated with clindamycin, or, as we previously discussed if a discharge antibiotics written for a duration of therapy beyond a specific length. But these are just a few examples of what could kind of trigger this intervention.

Speaker 2  31:12  
So when all these disciplines work together effectively, we create a strong foundation for stewardship. If we go back to the CDC core elements, this interdisciplinary collaboration directly supports several key components, from demonstrating commitment to reach team members, dedication to supporting education and expertise through shared knowledge, but perhaps most importantly, it ties into that crucial second element, that action for policy and practice. So you mentioned these core elements emphasize implementing at least one policy or practice to improve antibiotic prescribing. So with our diverse team in place, we're better positioned to identify where these interventions are most needed and how to implement them effectively. And this brings us to an important question, though, like, what once you have this team commitment and collaboration in place. How do you decide where to focus your efforts? What makes a good target for Antimicrobial Stewardship intervention? Tyler, can you share some of your insights and identifying these opportunities for us?

Speaker 3  32:15  
Oh, yeah, of course. So we've already mentioned all the competing priorities, and so it makes sense to start small, especially with limited resources. So it's extremely important that we attempt to make our interventions as impactful as possible. So there's common stewardship program targets that often focus on characteristics of antibiotics, such as those that are broad spectrum or high cost, as well as diagnostic targets. So these are often associated with inappropriate use of antibiotics. An example would be like acute bronchitis or most upper respiratory tract infections. Our example, we just gave, talked about limiting risk factors for C Diff infection. Those are examples of common targets and but really, ideally, you would be able to develop a specific or personalized target to your facility. It could be the same as a common target, but it should represent a problem that is within your healthcare environment. So the problem with this specific approach is that it does require resources to identify this target. It requires data time so you can kind of see where your problem areas are. But it is important because, for example, you wouldn't want to focus an intervention on the treatment of MRSA if you only receive a handful of MRSA isolates annually. But again, in order to determine if MRSA is a problem, you would need accurate culture data and someone available to review the data. So it's resource intensive.

Speaker 2  33:49  
Custom targets certainly require some resources, and a few other common targets that come to my mind are infections caused by those multi drug resistant bacteria treatment durations that extend beyond two weeks, or reviewing IV to PO

Speaker 3  34:04  
conversions? Yeah, definitely. And honestly, when starting out, there's nothing wrong with just choosing one of those common targets, alright,

Speaker 2  34:12  
so let's assume we have a target determined. Are there certain interventions we need to consider certain interventions more effective than others

Speaker 3  34:24  
in terms of interventions to consider, I hope everyone up to this point has determined that the best intervention, especially initial phases, is one that's feasible and takes advantage of resources that are available to you. But with that being said, there are interventions that are more effective than others, and another set of CDC core elements. There are hospital core elements. The CDC states that the two most effective interventions are perspective, audit and feedback and pre authorization. Those hospital core elements also specify that the use of facili. Specific treatment guidance establishes clear recommendations for Opto antibiotic use, and these recommendations seem to be consistent across multiple sources, but there are a lot of other stewardship intervention options can use, order sets, provider report cards, mandatory culture reviews, another one that can be very useful, but it's labor intensive, is allergy reconciliation, because it often involves allergy challenges, desensitization.

Speaker 2  35:28  
Interesting. So I know you had mentioned when the BOP program started, your only real task was to develop a clinical guidance document, and you were creating facility specific guidance to optimize your antibiotic use, an integral piece of stewardship, according to the CDC, and an intervention that was slower pace and allowed for time commitment to be spread out and you you only had pharmacists working on this document. Yeah,

Speaker 3  35:56  
that is correct. So antibiotic stewardship resources are very clear on the important role that pharmacists play in effective programs. All of our guidance and recommendations in this clinical guidance document were approved by our chief medical officer prior to publication to the field, but yeah, we were the main drivers behind the guidance.

Speaker 2  36:17  
You know, as a pharmacist, I think that's pretty cool. Do you have any examples that you can use of target identification or interventions that you and the BOP team have implemented? Yeah,

Speaker 3  36:30  
definitely. So when that transformation mentioned earlier to the clinical consultant pharmacists took place, the first thing that we did was review bop prescription data for broad spectrum antibiotics, and what we found was that there was a disproportionate number of prescriptions for fluoroquinolones compared to the acuity and type of infections typically being treated in the BOP

Speaker 2  36:58  
So you took that common Target, broad spectrum antibiotics, and tailored it to the agency based on your data. Yes, exactly.

Speaker 3  37:07  
Our next step was to determine kind of what intervention we could implement to achieve our goal of ultimately decreasing the number of fluoroquinolone prescriptions. And we settled on conducting a modified perspective audit and feedback process where prescribers are engaged after they've written an antibiotic order, we realized there was no way we could conduct a fully prospective review of fluoroquinolone prescriptions without negatively impacting patient care. So we did set some parameters. Prescriptions were reviewed and feedback was provided within 48 hours of the prescription being written, orders from weekends or holidays were reviewed the next business day, if it was determined that fluoroquinolone therapy was inappropriate, we provided feedback via email correspondence directly to the prescriber, and included on That email were all of the other clinical consultant pharmacists, the pharmacist at the local institution as well as the local institutions clinical director. But something to kind of keep in mind with this intervention is that it is a persuasive intervention, so it still allows provider autonomy. So in other words, we were providing a recommendation to change therapy in some manner, but the prescriber has no requirement to follow the recommendation that

Speaker 2  38:27  
we give. How did, how did you decide which prescriptions would qualify for review? Well,

Speaker 3  38:33  
we would run a daily report of all the prescribed fluoroquinos in the bop. Our goal is to review all these prescriptions, but we did quickly realize that was not feasible. So to be honest, we just kind of made the decision that we would have to live with reviewing, however many reviews we could

Speaker 2  38:50  
complete. There were several prescriptions that weren't even subject to the review. Do you think that negatively impacted your intervention?

Speaker 3  39:00  
It's hard to know for sure what we missed by not being able to review all the prescriptions, but we definitely were able to make an impact with the reviews that we were able to complete. There were over 5900 fluoroquinolone orders written during the time we conducted our audit and feedback, and we managed to review just over 3700 of those orders. So about 62 62% of those 5900 prescriptions we did end up making recommendations on about 16 and a half percent of those orders that were reviewed. And so of those recommendations, 271 or 44% 44% of our recommendations were accepted. And finally, just kind of looking at at our results, you see that over the two years that we conducted the audit and feedback, which is represented by the light green area on. Graph, we did see a decrease in the total number of fluoroquinolone orders written. So if we actually compare the 12 months prior to our intervention to the finer final 12 months of our intervention, so the 12 months before to year two the intervention, there was a 53% decrease in the number of fluoroquinolone prescriptions during that time. That's

Speaker 2  40:22  
pretty impressive. And in real life, positive example of you know that impact identifying a meaningful target, deploying effective intervention, and how that can have an optimizing antibiotic use. So the action of the core elements, tracking and reporting, core element would seem to be really critical piece in the success of a program, and it provides that opportunity to fine tune interventions if needed, and also can let the clinicians providing care you know how that care is actually being impacted. It seems it could also provide justification for stopping an intervention if it appears to be ineffective or has, you know reached its goal. You sorry,

Speaker 3  41:05  
yeah, and so that's actually what led our program to actually stop the audit and feedback intervention. So after two years time, we were actually seeing similar total number of fluoroquinolone orders over the preceding year, and additionally, the percentage of prescriptions the result of our recommendation, had remained kind of consistent in that 15 to 20% range for several quarters. So along with kind of similar acceptance rates on the recommendations we were making, we just kind of decided that our time would probably be better spent with a different intervention and conveniently. At the same time, there had been some internal push to get our team to review non formula requests for antibiotics, due to concerns of how often non formula items were being approved. The hope was that by introducing subject matter experts, we would improve our utilization of non formulary items. So the team shifted its focus to a new intervention, and that was pre authorization, or non formulary authorization.

Speaker 2  42:12  
Pre authorization, the other intervention proven to be most effective, and this intervention is more restrictive in a lot of ways, because it requires providers to obtain that approval prior to prescribing the medications. It's often associated with antibiotics that have a specific indication or place in therapy, high cost items where those agents with an increased adverse event risk regardless review is completed prior to initiating therapy.

Speaker 3  42:40  
Yeah, yes. And in the BOP, our process is set up to allow a little bit of wiggle room to prevent significant delays in care, but for the most part, it mirrors that pre authorization. So in March of 2022 stewardship pharmacist started reviewing non formula requests, and this is the kind of longitudinal intervention that we currently have our clinical consultant pharmacist completing. So on the screen, you have a kind of a graphic of the BOP non formulary process. It involves the review of a non formula request at the local level by both the pharmacist and the local clinical director, and most final determinations of approval or disapproval are completed by a central office pharmacist, the central thought central office pharmacist can also refer their quest up another level to a central office Medical Director. Kind of think of that as like a second opinion the central office pharmacist review, which is the right side of the diagram, is delegated to clinical consultant pharmacist groups for select agents, and as I said, this is the case for antimicrobials. So in the calendar year prior to reviews being completed by our group, just a little over 86% of all antibiotic non formula requests were approved at that central office pharmacist level, while only a little over 3% were disapproved. The remainder of those requests were referred up for review by the central office physician, and the data indicated that pharmacist review determined that requested treatment for non formula agents was inappropriate only 3% of the time. And that's just it's difficult to believe. And the data since shifting central August pharmacist review to the stewardship pharmacist does support this thought so, from the time we took over till September of 2024 which is an approximately a 30 month time period, the BOP clinical consultant pharmacists have reviewed over 6000 non formula requests for antibiotics, and that approval rate has dropped to 73% and our disapproval rate went from just above three. Percent to almost 16% so basically, our approvals fell by 13% while the disapproval rate increased by about 12 and a half percent. I think it's worth mentioning, like in a perfect world, we would approve 100% of requests and have no disapprovals, because this would indicate that providers are only requesting appropriate therapy. But I do think that these numbers indicate that providers are being directed towards more appropriate therapy at a greater rate. Additionally, our involvement in the non formulary process provides a great opportunity for us as pharmacists to accomplish the last core element, and that's education and expertise, our electronic non formula Request Form have ample room for each individual involved in the process to comment on the on the request. So when the clinical consultant pharmacist team disapproves any requests, we do provide prescribers with information on recommended courses of treatment or those antibiotics which are preferred. Here you see kind of how that education looks on the pre authorization form in the

Speaker 2  46:11  
bop. So in this example, it looks like a provider has requested Cipro for epididymitis and central office pharmacist comments box. It looks like the clinical consultant. Pharmacist has provided multiple education points. Started with general information, what determines treatment, age, STI, risk, why the requested therapy is not recommended. And then they apply these to the patient specific information and give the recommended treatment based on guidance. And finally, they apply these those institutional parameters and make a recommend, recommendation for the treatment. It is good use of this process to incorporate education. As a pharmacist, what other education do you provide within the BOP Do you think disciplines outside of the pharmacy respect the knowledge you're providing?

Speaker 3  46:59  
So in terms of the second question of respect. We really have kind of become the face of bop antimicrobial stewardship. And I think as time has gone on, we've earned a level of respect with plenty of our care providers. A lot of us about consistency and building that reputation, and hopefully that reputation is a positive one, but we provide a lot of education to the field. We still perpetually update our clinical guidance document. The BOP annually participates in CDC antibiotic Awareness Week, and during that time period, we provide brief informational updates on various Pro on various topics to the field. There's also an antimicrobial stewardship, stewardship section to the local P and T committee meeting template, which allows each institution to provide meaningful information at that local level. And finally, I just feel like we're constantly receiving requests for presentations on stewardship at some level.

Speaker 2  48:03  
So before we get too deep into implementation, I think we should finish by addressing the elephant in the room, the unique challenges we face in the correctional healthcare that can make these antimicrobial stewardship particularly challenging. We're dealing with quite a complex set of barriers here. Our thing about our population dynamics. We have constantly changing patient population with high turnover rates, incredibly diverse health needs, often higher rates of infection and outbreaks than you see in traditional healthcare settings. And many of our patients come to us with a lower health literacy levels, which only adds another layer of complexity to patient education and compliance. So then there's the environmental and resource challenges. We're often dealing with, hygiene and sanitation challenges, sometimes even stigma around the issues. From an operational standpoint, we're frequently managing tight budgets, working with limited staff, sometimes lacking specialized training opportunities, often struggling to gather and analyze that kind of data. We need to you know for effective stewardship programs. So Tyler, given your experience in this Correctional Health Care, how have you seen facilities successfully navigate these barriers, and what strategies have you found effective for implementing stewardship programs despite all these challenges?

Speaker 3  49:31  
This can be tricky Landon, but there are definitely ways we can promote effective antibiotic stewardship in our setting. And again, it really boils down to getting creative with your situation, to overcome different population dynamics, you'll have that education champion that can both provide professional education to your health services employees, as well as education at an appropriate literacy level to your patient population. We've mentioned, like adding therapy. Durations to prescription directions that can help to avoid excessive durations due with your high population turnover in terms of environmental challenges, ensuring appropriate contact precautions are followed. It's applicable to both the patient population as well as staff members. It's really crucial in avoiding infectious outbreaks. I

Speaker 2  50:25  
want to add something about environmental barriers, okay, avoiding that stigma that correctional settings are inherently unsanitary. I think it's very important. If our patients perceive their conditions as unsanitary, they're probably more likely to request the antibiotics unnecessarily. Yeah,

Speaker 3  50:43  
that's that's a really great point. And finally, for the limited resources, I know I sound like a broken record, but it really does require you to use the staff available to you, really, to their full extent. Get the stewardship champion. Consider centralizing your efforts, if possible, it's worked really well for us in the BOP, I've found that navigating all the barriers and variables in our work environment starts by kind of recognizing that they exist and starting with something small, even smaller vengeance can have an impact. Focus on how you can use your staff positions and their knowledge to initiate some intervention. We talked about interventions that are proven or most effective, but you know, you might need to get creative. It's really just managing your resources and time to come up with something. Finally, I think I would say that you need to ensure you keep other staff members informed of interventions that are being implemented so like even if they aren't directly involved or fully committed to stewardship efforts, open lines of communication with everyone about what's going on will help to avoid any future problems.

Speaker 2  51:55  
Well, thanks Tyler for sharing that and your experience and your expertise with us today, and before we do open it up to questions, could you just give us your key takeaway messages for the healthcare professionals looking to start or enhance their antimicrobial stewardship programs in the correctional setting

Speaker 3  52:16  
recognize there are a lot of inherent barriers and competing priorities. Resources are limited in our health services department, so utilize that team approach and maximize resources available, including pharmacists. And finally, don't allow picking a starting point to overwhelm you. Start small, simple, with an intervention that is within the bandwidth of your department.

Speaker 2  52:44  
So we do have a few minutes here. We'd love to hear from our audience. Feel free to put something in the chat when you're getting started or overcoming specific challenges, or, you know, sharing a story of how, you know, maybe success that you've had. And thank you for your Tyler and thank you audience for tuning in today. Hey,

Christopher Smith, NPA  53:06  
gentlemen. This is Chris Smith, again, I do have a couple one question and one statement so far, if you guys don't mind entertaining them while folks are typing in any additional questions. Alright, our first question was from David P Martin, and he said, I'm newer at this role, and have and have had little more than CDC module training, but what happened to the seven core elements that seem to be so important, leadership, accountability, pharmacy, tracking, action, reporting and education? Is this the four core element system only related to corrections?

Speaker 3  53:40  
So that's a good question. So the seven elements that that you mentioned are the, I guess, for the inpatient related to inpatient hospital core elements. So for the outpatient setting, those are paired down to, really those, those four core elements that we mentioned our presentation today, and we utilize those again, because, kind of from our perspective, they kind of fit best with our practice setting in terms of the resources we have available to us, how our population works, the acuity of things that we see and treat in house. So the seven elements that you mentioned definitely still exists. It's still part of the CDC core elements. It's just a different set. All

Christopher Smith, NPA  54:44  
right. Well, thank you. I appreciate that, David. I hope that answered your question, and then, as we're waiting, I haven't got any more questions, gentlemen, but I did get one statement, if you want to address it, as from Danica. She says sometimes providers are worried about legal liability, and so they are more. Inclined to prescribe something than D prescribe something not indicated.

Unknown Speaker  55:11  
Landon, you want to comment on that? Or you want me to

Christopher Smith, NPA  55:16  
go ahead? Tyler,

Speaker 3  55:19  
yeah, I think that's definitely I hear. We hear that a lot. You know that they're worried about not treating when, when something could serious could be, you know, missing something, basically. And you know that there is that kind of aspect of, you know, oftentimes, if a patient gets severe enough, has to be admitted to the hospital, there's all the issues that go along with having, you know, a patient being admitted outside of our facility. But, you know, open lines of communication trying to kind of pick an area where, you know, maybe choose a certain diagnosis, or something where you know, okay, that's fine. You want to err on the side of caution when you are concerned that maybe a patient has festering, you know, pneumonia, that it just looks like bronchitis right now, but it might be kind of going to progress to pneumonia. Okay, give some leeway with that, but maybe picking something else, you know, Greenland SST eyes, using conservative treatment of ind or warm compresses first before automatically going to oral antibiotic treatment. You know, sometimes maybe you can find them halfway or meet them halfway in terms of some sort of intervention, but, yeah, it definitely is something that we hear of a lot with provider concern.

Speaker 2  56:51  
I will jump on Tyler on that one for a little bit. I think you also can go back to your your team approach. And like we mentioned that, especially when you, you know the watchful waiting or something, you rely on your team, especially those nurses, to, you know what? What should we be seeing improvements of signs and symptoms, and you know, hoping you're you've got that open communication and feedback going to so, you know, maybe they're a little hesitant to prescribe one thing or the other or nothing at all, but together as a team, working together on both sides of that spectrum, I think is definitely something to keep in mind too. But great,

Speaker 3  57:31  
that's, yeah. I mean, definitely, again, use the resources that you have basically,

Christopher Smith, NPA  57:39  
Alright, appreciate you. We may have this time for this one. Lastly, a short answer to this question. Of course, this question is also going to prove that I'm the one non medical person in the room, so when I mispronunciate this word here in a moment, please forgive me. Says it's from Dunleavy, and it says your perspective audit and feedback of floral. Yeah, that sounds about right. Ended over two years ago. Has there been any follow up to determine if the decrease you saw in the prescriptions has been maintained now that prescribers do not receive feedback. Thank you for the save. By the way,

Speaker 3  58:15  
that's a great question. So we said follow ups necessary. So I said that our numbers have kind of remain consistent, but we felt like we had kind of a good baseline of where our numbers should fall, but we decided to just kind of follow up by looking quarterly at where we were. And about a year after stopping the intervention, we decided that to kind of try to limit fluoroquinol prescribing in another way, we actually received approval from the BOP national P and T committee to increase formula restrictions for fluoroquinolones. So essentially, what's happening now is that we're catching a lot of these through the perspective audit or through the pre authorization process. So we get, we have some inclusionary diagnosis, but the rest of the stuff all gets reviewed by us anyway, so we're still catching a lot of them, numbers of state that fairly consistent. So

Christopher Smith, NPA  59:15  
alright, we got two minutes. So there's one last question that I'm going to take and this one might be able to you might be able to Raina has, what is the importance of natural environment in the healing of an inmate, as some of our Ihu unit for sick inmate facilities are all indoors and not exposed to sunlight and open air.

Unknown Speaker  59:38  
Is that a minute and a half question? Answer?

Speaker 3  59:43  
I'm not sure I would be happy to follow up with them on this. I'm not really sure. I'm quite sure what the question is asking. I apologize. I. I'm

Speaker 2  1:00:00  
not, I'm not sure either, but I I, if I'm reading this right, I would think it would be very similar to your nursing home patients, or, you know, your when you're admitted in the hospital, you're still, you're not going to have a lot of access, always to expose sunlight and open air. I mean, maybe I'm over generalizing that, but to specifically answer the question, I don't I don't have much either.

Christopher Smith, NPA  1:00:28  
Yeah, I think you guys grabbed the question. That's how I read it, as well as if would moving a patient to an outdoor arena be beneficial to their to their health while they're recuperating? So alright, Reina, if you if that doesn't answer your question, or you have more questions, you can only questions, you can always write to us the email address I gave out earlier. Feel free to send, send Mr. Garrett an email, and he may be able to respond back to you, or at least direct you to a more appropriate place if you still have question. All right, that is all the questions we have today, gentlemen, thank you, perfect. So on

Speaker 1  1:00:58  
behalf of the National Institute of Corrections. Thank you for your time insight and commitment to advancing anti microbial stewardship in the correctional setting. We recognize the demands of your roles and truly appreciate your dedication to improving patient care in this complex environment. As we conclude, let's remember, stewardship is not a task, it's responsibility every decision we make from diagnostic choices to treatment plan shapes, not only individual patient outcomes, but also the broader landscape of antimicrobial resistance, progress is not about finding a single answer, but about continually asking the right questions, refining our approaches and embracing the power of a collaboration. So again, if today's discussion sparks some new insights or challenge some existing practices, then we've really accomplished our goal here. If you leave with more questions than answers, that's even better, because a meaningful change really starts with curiosity and that commitment to lifelong learning. On that same note, join us again next week for harm reduction and reentry program, same bat channel, same bat time. We're going to explore evidence based harm reduction strategies that not only improve health outcomes, but also foster successful reintegration into the community. So this is the conversation you are not going to want to miss. So until then, continue challenging the status quo, championing best practices and striving for excellent patient care. Thank you again for your engagement. Stay curious, stay committed, and we look forward to seeing you next time. This is Captain Garrett saying Thank you. Applause.

Transcribed by https://otter.ai