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RHODE ISLAND M EDICAL J OURNAL SPECIAL SECTION ANTIMICROBIAL STEWARDSHIP GUEST EDITOR: CHESTON B. CUNHA, MD, FACP JUNE 2018 VOLUME 101 • NUMBER 5 ISSN 2327-2228 STAY FOCUSED AMONG THE DISTRACTIONS. Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. MEDICAL PROFESSIONAL LIABILITY INSURANCE ANALYTICS RISK MANAGEMENT EDUCATION Insurance products issued by: ProSelect Insurance Company® coverys.com RHODE ISLAND M EDICAL J OURNAL 16 Antimicrobial Stewardship CHESTON B. CUNHA, MD, FACP GUEST EDITOR C. Cunha, MD 18 Antimicrobial Stewardship Programs (ASP): On the cover: This Petri dish Perspective on Problems and Potential culture plate had contained cy- CHESTON B. CUNHA, MD, FACP closerine, cefoxitin, and fructose agar (CCFA), which had been 22 Overview of Antimicrobial Stewardship inoculated with a Clostridium D. Quilliam, MPH U. Bandy, MD N. Alexander-Scott, MD Activities in Rhode Island difficile bacterial culture, and had DANIELA N. QUILLIAM, MPH; subsequently given rise to numer- KERRY L. LAPLANTE, PharmD, FCCP, FIDSA; ous bacterial colonies. In this par- REBECCA REECE, MD; UTPALA BANDY, MD, MPH; ticular view, the plate had been NICOLE ALEXANDER-SCOTT, MD, MPH illuminated using long-wave UV irradiation, hence, the bacterial colonies emitted a yellow-green, 26 Role of the Pharmacist in or chartreuse fluorescent glow. Antimicrobial Stewardship PHOTO COURTESY OF CDC/ R. Fortin, PharmD M. Dorobisz, PharmD D. Parente, PharmD RACHEL FORTIN, PharmD, BCPS JAMES GATHANY 28 Antimicrobial Stewardship Metrics: Prospective Audit with Intervention and Feedback MONICA J. DOROBISZ, PharmD; DIANE M. PARENTE, PharmD 31 Antimicrobial Stewardship Program Perspective: IV-to-PO Switch Therapy J. Lonks, MD F. Romo, MD CHESTON B. CUNHA, MD, FACP 35 Infection Control and Antimicrobial Stewardship JOHN R. LONKS, MD 38 Antimicrobial Stewardship in Community Hospitals FRANCINE TOUZARD ROMO, MD R. Reece, MD P. Chace, MD S. Ranucci, RPH 42 Antimicrobial Stewardship in Long-Term Care Facilities REBECCA REECE, MD; PATRICIA CHACE, MD, CMD; STACEY RANUCCI, RPH, BCGP, CDE 45 Communicating with Facility Leadership; Metrics for Successful Antimicrobial Stewardship Programs (ASP) in Acute Care and Long-Term Care Facilities M. Beganovic, PharmD K. Laplante, PharmD MAYA BEGANOVIC, PharmD, MPH; KERRY L. LAPLANTE, PharmD, FCCP, FIDSA 3 RHODE ISLAND M EDICAL J OURNAL 8 COMMENTARY Evidence-based Medicine JOSEPH H. FRIEDMAN, MD Civil commitment laws for substance abuse treatment: An acceptable option? HERBERT RAKATANSKY, MD 14 RIMJ AROUND THE WORLD Vienna, Austria 56 RIMS NEWS Are you reading RIMS Notes? Convivi um Working for You 5th Annual Convivium Save the Date RANT M G M NOR 4 RHODE ISLAND M EDICAL J OURNAL IN THE NEWS PARTNERS HEALTHCARE, CARE NEW ENGLAND 62 65 US VETERANS AffaIRS sign definitive agreement expands telehealth, allowing providers to treat patients across state lines RHODE ISLAND FREE CLINIC 63 adding dental care for uninsured adults 66 VA CENTER CARE NEW ENGLAND 64 funding for Neurorestoration and achieves $4.4 M gain in Q2 Neurotechnology renewed RHODE ISLAND HOSPITAL 64 66 ROGER WILLIAMS UNIVERSITY researchers publish findings on stem cells, osteoarthritis public health program partners with RIDOH PEOPLE/PLACES PENELOPE DENNEHY, MD 68 72 PREETHA BASAVIAH, MD receives Hamolsky named Brown trustee Outstanding Physician Award 72 RWMC BARBARA WOLFE 68 Geriatric Oncology team presents URI nursing dean, at Rhode Island Cancer Summit honored by Yale 74 RICK MAJZUN BETTY VOHR, MD 68 named president, COO at W&I receives distinguished alumna award 75 DAVID SAVITZ , PhD new Associate Dean for Research ANGELA C. ANDERSON, MD 69 at School of Public Health named Woman Physician of the Year 75 DENNIS F. LYNCH elected Chairman of South R. JAMES KONESS, MD 69, County Health Board of Trustees honored by BU at Roger 75 DANI HACKNER, MD, Williams’ Cancer Center named southcoast Physician- ANA TUYA FULTON, MD 69 in-Chief for Medicine named Fellow of American Geriatrics Society 75 ELIZABETH ROCHE SMITH, MD AMS GRADUATES 70 named president of Southcoast receive Rakatansky, Physicians Group Throop awards 76 ST. JOSEPH NURSING SCHOOL graduates 116th class RENA WING, PhD 72 receives Distinguished 77 SOUTHCOAST HEALTH Research Achievement Award opens Wound Care Center at St. Luke’s Hospital 5 JUNE 2018 VOLUME 101 • NUMBER 5 RHODE ISLAND Rhode Island Medical Society R I Med J (2013) M EDICAL J OURNAL PUBLISHER 2327-2228 RHODE ISLAND MEDICAL SOCIETY 101 PRESIDENT BRADLEY J. COLLINS, MD 5 PRESIDENT-ELECT 2018 PETER A. HOLLMANN, MD VICE PRESIDENT June NORMAN M. GORDON, MD PUBLIC HEALTH Secretary 50 Rhode Island Lung Cancer Incidence and 1 CHRISTINE BROUSSEAU, MD Stage at Diagnosis, by Histologic Subtype, TREASURER CATHERINE A. CUMMINGS, MD 2004–2015 JUNHIE OH, BDS, MPH IMMEDiate past PRESIDENT SARAH J. FESSLER, MD C. KELLY SMITH, MSW EXECUTIVE DIRECTOR NEWELL E. WARDE, PhD 54 Vital Statistics ROSEANN GIORGIANNI EDITOR-IN-CHIEF DEPUTY STATE REGISTRAR JOSEPH H. FRIEDMAN, MD Associate EDITOR KENNETH S. KORR, MD PUBLication StaFF MANAGING EDITOR MARY KORR [email protected] GRAPHIC DESIGNER MARIANNE MIGLIORI ADvertisinG ADministrator SARAH BROOKE STEVENS [email protected] RHODE ISLAND MEDICAL JOURNAL (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 405 Promenade Street, Suite A, Providence RI 02908, 401-331-3207. All rights reserved. ISSN 2327-2228. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode Island Medical Society, unless clearly specified. Advertisements do not im- ply sponsorship or endorsement by the Rhode Island Medical Society. © COPYRIGht 2013–2018, RHODE ISLAND MEDICAL SOCIETY, ALL RIGHTS RESERVED. 6 Your records are secure. Until they’re not. Data theft can happen to anyone, anytime. A misplaced mobile device can compromise your personal or patient records. RIMS IBC can get you the cyber liability insurance you need to protect yourself and your patients. Call us. 401-272-1050 IN COOPERATION WITH RIMS IBC RIMS INSURANCE BROKERAGE CORPORATION 405 PROMENADE STREET, SUITE B, PROVIDENCE RI 02908-4811 MEDICAL PROFESSIONAL/ CYBER LIABILITY PROPERTY/ CASUALTY LIFE/HEALTH/ DISABILITY Commentary Evidence-based Medicine JOSEPH H. FRIEDMAN, MD [email protected] 8 9 EN WHAT TO DO? to write my own advice, While I believe this was the correct I am writing an opinion I checked some of the approach, I cannot keep from thinking piece on the management published recommenda- that for two thousand or more years, of psychosis in Parkin- tions by others. A recent bloodletting was a “clearly” efficacious son’s disease. My respon- review from a prominent treatment for a number of disorders sibility is, of course, to and estimable European until falling out of favor, presumably not review the literature, and expert group reviewed related to a placebo or active treatment- propose an algorithm. At the data and did not rec- controlled research study. “Bloodletting risk of being immodest, ommend using the drug. vs. penicillin for the treatment of strep I like to think I am an An earlier publication throat” would have been unlikely to expert in this disorder, by an expert group in gain IRB approval. and have the experience the U.S. noted the lack Evidence-based medicine is always to merit the status of providing an expert of “proven” benefit but stated that its limited by the subject population, either opinion. My problem was how to recom- members thought the drug helpful, not, by design or by happenstance. If you mend a particular drug that I find very however, recommending its use, some- study people with PD and bipolar dis- helpful in the face of three, well-per- thing along the lines of, “despite evi- order, you don’t know if the treatment formed, adequately powered clinical dence to the contrary, several members may also work for people with PD and trials demonstrating a lack of statisti- of our committee have found it helpful.” anxiety. A recent study had inclusion cally significant benefit. Evidence-based (Not a real quote). Another European criteria that allowed demented people medicine is based on evidence, and the expert cited the risk, rather than the into the study, but the mean score for evidence indicates that the drug is not benefits, in advising against its use the subjects indicated that few, if any, effective. In trials of this medication at In a quandary I decided I’d do my first were demented. Since the study drug much higher doses in a very different Survey Monkey and sent out a single will be used primarily in PD patients population, the drug had some adverse question, to be replied anonymously, with dementia, what can be deduced? effects, and in meta-analyses, involving asking if the recipient found this drug to Perhaps more problematic is the heavy very large numbers of patients, the drug be helpful and used it sometimes to treat reliance on “intention to treat” trials, has a small but significant increased risk PD psychosis. I chose 40 people, mostly in which subjects are included in the of mortality, large enough to require neurologists, but a few psychiatrists outcome assessment once they sign an a “black box warning.” So, we have as well, whom I regarded as experts in informed consent document and are a drug with “proven” lack of efficacy this area. The result was 19 responses, assigned to a treatment arm, whether and a black box warning of increased all in favor of the drug’s use. Now, they get the treatment or not. A person mortality. While it sounds like an easy armed with a survey, I can write that becomes a “subject” once the informed decision to state the data and not advise I recommend this drug’s use, despite consent is signed. The subject becomes its use, the problem is that I’ve used the evidence to the contrary, and that 19 a data-contributor once randomized to drug a lot, probably a lot more for this experts, all of whom are familiar with a treatment arm.