Jumpstarting an Antimicrobial Stewardship Program

The threat of increased incidence of antibiotic-resistant strains is well understood in the healthcare industry, creating urgency to combat antimicrobial resistance on the local, regional and national levels. For many, the effort begins with the introduction of an antimicrobial stewardship program, an investment of resources that many healthcare experts believe can deliver benefits that far outweigh the cost.

ASPs have a proven track record for lowering antimicrobial resistance, effectively leading to solid return on investment by reducing drug-related adverse events, improving clinical outcomes and shrinking healthcare costs. But while the concept is gaining favor, it remains out of reach for many hospitals. The reality is that many facilities simply do not have the resources required to initiate the effort — especially with so many other mandates competing for a place within cash-strapped budgets.

Justin ClarkThis is where advanced surveillance technology can play a crucial role. Hospitals can leverage the efficiencies created by these systems to free up resources and effectively jumpstart an ASP. Consider the outcomes achieved in one year at Texas Health Arlington Memorial Hospital, a 300-bed community hospital located in north central Texas. Pharmacists were able to increase antibiotic-related interventions by more than 54 percent, from 1,022 in 2009 to 1,577 in 2010, resulting in a notable decrease in their antibiotic costs per patient day.

Not only was a solid return on the initial investment easily achieved, but automation created efficiencies that freed up infection prevention personnel to focus on higher-priority efforts as well. And that is exactly where their resources need to be going forward, especially as regulatory and accrediting bodies are placing a heavier emphasis on reducing healthcare-associated infections and hospital-acquired conditions.

Setting the stage

Prior to launching its ASP, Arlington Memorial took several steps to position itself for long-term success with antimicrobial stewardship strategies. First, the hospital deployed Sentri7 clinical surveillance software from Pharmacy OneSource to free up staff resources previously consumed by such tasks as sifting through charts and building daily paper reports.

The overriding goal of deploying the software was to help the pharmacy team — a mix of centralized staff pharmacists and decentralized clinical pharmacists — operate more efficiently and optimize patient care. It also allowed pharmacists to get their feet wet before the ASP's official launch by allowing them to undertake stewardship activities that were already built into the software. This ultimately made the transition to the full program much easier.

With automation in place, the pharmacy team focused on launching the formal ASP, the primary objective of which was to optimize antimicrobial utilization and minimize the adverse events associated with indiscriminate use. The secondary objective was to reduce costs without adversely impacting quality of care.

The deployment of the software was crucial to achieving these overall goals, as success ultimately depended on the pharmacists' ability to gather and analyze data related to antimicrobial resistance trends and manage the ASP process for effective decision making. Manual procedures would make this task overwhelming at best and limit the data's ability to be used in a meaningful way.

When aggregating required data is automated and the information is made available in real time, healthcare professionals can easily access intelligently filtered information to identify problematic areas and can make necessary adjustments. Surveillance technology also leads to a more proactive approach to infection prevention by prompting professionals when the potential for antimicrobial resistance exists.

Through its surveillance technology, Arlington Memorial is now able to customize clinical rules on targeted antibiotics for patients with positive cultures. For example, Arlington is able to identify opportunities to de-escalate antibiotics along and monitor for resistant organisms, such as:

  • E. coli-positive patients on levofloxacin therapy
  • Pseudomonas aeruginosa–positive patients on piperacillin-tazobactam therapy susceptible to other therapies
  • Methicillin-sensitive Staph aureus–positive patients on either vancomycin or linezolid
  • Enterococcus faecalis–positive patients on vancomycin with corresponding penicillin sensitive results

Without intelligent, real-time monitoring of these targeted areas, infection prevention efforts would be limited by cumbersome manual processes, limiting hospitals to a reactive approach to infection prevention rather than the desired proactive approach.

A complementary strategy

Establishing an electronic foundation to support the ASP was an important first step. Equally important was a solid human workflow strategy that included an identified team of professionals alongside policies and procedures to ensure workflow practices supported the goals of the ASP.

The formalized program was championed by an infectious disease physician, and pharmacists were assigned to make interventions for antibiotics. Alongside these leadership initiatives, staff members were assigned to monitor the data gathered by the surveillance technology to identify areas where interventions and adjustments were necessary.

Instead of pharmacists pulling data from charts and analyzing after the fact, the system proactively alerts them to potential problems. It may determine that a patient's culture results suggest resistance to the current antimicrobial therapy and will alert the pharmacists to that fact when data shows that the physician has not reviewed the results within the previous 24 hours. Because the pharmacists are able to see the results in real time, they can in turn alert the physician and get the therapy streamlined more rapidly to appropriate options — essentially getting patients "the right drug for the right bug."

The ability to create within the surveillance technology clinical rules that address specific targeted or problematic areas has been crucial to the overall success of the ASP initiative. For example, pharmacists are able to leverage the technology to identify opportunities to change therapy from intravenous to oral antibiotics. The rule was built taking into account several patient-specific factors, including length of current intravenous antibiotic treatment, current nil per os (NPO)/per os (PO) status, patient diagnosis and trending for white blood cell and temperature values.

The pharmacists can also track how well they are doing with monitoring the data and intervening, keeping the ASP accountable to goals and metrics. The functionality of the surveillance technology includes a performance reporting tool that tracks the number of times a rule matches the patient parameters as well as the corresponding number of times an intervention has been initiated for the specific rule.

In addition to ASP activities, Arlington Memorial pharmacists utilize a dashboard related to patient safety issues. A rule is in place for core measures, which analyzes data to identify patients who are not on appropriate medications for a stroke diagnosis.

They also have a National Patient Safety Goal dashboard for anticoagulation monitoring, and additional rules have been built for renal dose monitoring and IV-to-PO conversions for non-antimicrobial agents. For example, one rule on this patient safety dashboard looks for patients receiving erythropoietin who have hemoglobin levels greater than 12. Giving erythropoietin to a patient who has a hemoglobin level of more than 13 g/dl can increase the risk of cardiovascular events.

Far-reaching potential

The pharmacy department at Texas Health Arlington Memorial Hospital has only just begun to tap into the opportunities available for effectively leveraging surveillance technology in conjunction with a solid ASP workflow strategy. The efficiencies created have enabled more high-level initiatives that are positively impacting quality metrics and patient safety.

Clinical rules can ultimately be expanded to impact compliance with Joint Commission's National Patient Safety Goals as well as the CMS' core measures performance expectations. Surveillance technology has far-reaching potential to positively impact workflow and patient safety across many hospital departments.

Justin Clark, PharmD, is the former clinical pharmacy coordinator for Texas Health Arlington Memorial

More Articles on Antimicrobial Stewardship:

8 Antimicrobial Stewardship Findings

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