Recent movements on the national stage are the raising the bar on how hospitals and health systems approach antimicrobial stewardship. The Joint Commission mandates and a proposed rule by the Centers for Medicare and Medicaid Services are underscoring the need for high-performing programs.
The implications are clear. Multidrug resistant organisms infect 2 million people annually in the U.S., resulting in roughly 8 million hospital days and causing 23,000 deaths, according to the Centers for Disease Control and Prevention (CDC). On the global stage, the World Health Organization currently ranks inappropriate use of antibiotics as one of the three greatest threats to human health.
Healthcare organizations increasingly recognize the high stakes, yet proactive response to antimicrobial resistance is not easy. Today the industry faces two notable challenges:
- Loss of effective antibiotics coupled with the introduction of fewer new options limits the ability of healthcare organizations to combat infectious disease and manage complications.
- The choice for costlier drug options—some more toxic to patients—is often necessary when first- and second-line antibiotics are not effective.
While there is no quick fix, the U.S. National Strategy for Combating Antibiotic-Resistant Bacteria is addressing the issue by promoting implementation of formal antimicrobial stewardship programs (ASPs) in healthcare organizations across the country. These programs address inappropriate use of antibiotics, which encompasses as much as 50% of those prescribed. Along with slowing the rise of resistant microorganisms, these programs also improve the cost of care by ensuring medication therapies are patient-appropriate.
Most healthcare organizations have some antimicrobial processes in place. But the question is: are they enough? Aligning with current industry movements will require comprehensive programs based on industry-respected models such as that laid out by the CDC.
Antimicrobial Stewardship: What’s Missing
The CDC outlines seven core elements of an effective ASP:
- Leadership Commitment: Dedicating necessary human, financial and IT resources.
- Accountability: Appointing a single leader (physician ideally) responsible for program outcomes.
- Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use.
- Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment.
- Tracking: Monitoring antibiotic prescribing and resistance patterns.
- Reporting: Regular reporting information on antibiotic use and resistance to relevant staff.
- Education: Educating clinicians about resistance and optimal prescribing.
While most hospitals have some antimicrobial processes in place, many do not fully engage all of these elements. In truth, the industry at large is varied in its approach to antimicrobial stewardship, and the results are mixed. For this reason, it’s critical that the industry standardize ASPs around best practices to optimize the impact.
Many hospitals have basic processes in place such as conversion of IV medications to oral options (IV to PO) and antibiotic de-escalation. IV-to-PO oversight promotes fewer hospital days and faster recoveries, and de-escalation strategies minimize use of broad spectrum antibiotics by promoting choices for drugs that are tailored to a patient’s specific care.
While these actions represent important first steps, ASPs must evolve to encompass greater oversight and more formal application. For instance, many programs lack an ASP committee that is comprised of a broad array of disciplines. In addition, efforts to address antimicrobial resistance often rely on time-consuming manual processes as opposed to automation. These efforts are often characterized by staff running EHR reports and sifting through patient information to identify issues with antibiotic use or specific microbiology cultures. Because the status of most patients is fluid, information is often outdated by the time an issue is recognized.
Intermediate stage programs may have established leadership around antimicrobial stewardship but lack best-practice protocols for addressing such areas as de-escalation, duplicative antibiotic review, IV-to-PO conversion and 48-hour antibiotic stops without cultures that support a bacterial infection. In this case, programs need to evolve to support documentation of all interventions and acceptance rates by providers or use of an electronic surveillance system to facilitate intervention reporting.
Clinical and financial leaders often struggle with identifying the right ASP initiatives and focus areas that will produce the greatest return on investment (ROI). Because resources are spread thin amid the push and pull of many converging regulatory initiatives, antimicrobial processes typically fall to the pharmacy department, although programs are most impactful when responsibility is shared across staff.
Moving ASPs Toward High Performance
In reality, high-performing ASPs align well with the industry’s shift to value-based care and can deliver significant ROI. Patients who receive a broad-spectrum antibiotic are three times as likely to become infected with more resistant organisms, significantly increasing potential for healthcare-associated infections (HAIs) and other adverse events. Also, inappropriate use of antimicrobial agents significantly increases costs, reaching as high as $34 billion annually in the U.S., according to the CDC.
As clinical and financial leaders mature antimicrobial stewardship efforts, the first step is identifying a starting point. Gap analysis tools exist in the industry to help healthcare organizations evaluate their current processes and benchmark against industry best practices.
In tandem with CDC core elements, health systems that have high-performing ASPs increasingly find that a two-pronged strategy leveraging advanced surveillance technology and workflow governance delivers the desired outcomes. Early identification of potential issues is critical to effective response, and all ASPs can substantially benefit from electronic surveillance systems that continuously aggregate real-time data concerning at-risk patients and orders for inappropriate antibiotics.
Surveillance technology is well-positioned to keep antimicrobial processes proactive through rules-based infrastructures that provide intelligently filtered alerts. Also, real-time notification of orders for restricted antimicrobials, drug-bug mismatch, comparisons of antimicrobial regimens, renal function surveillance, patient allergy or drug-drug interaction risks and possible hospital-acquired infections ensure resources are allocated effectively to have the greatest impact.
In truth, use of some advanced solutions on the market has resulted in notable workflow gains hospital settings—increasing clinical interventions related to antimicrobial use by as much as 750 percent in some cases. Some hospitals are also improving the outlook on HAIs and other infections by more than 50 percent and reducing antibiotic costs by as much 35 percent per patient day.
Antimicrobial stewardship is a shared responsibility across the industry that must be addressed at a high level. It is also an opportunity that can better position healthcare organizations to address risk-based care delivery. Those organizations that take steps now to design impactful programs and invest in the right infrastructures will reap the benefits.
Justin Clark, PharmD, is the clinical program manager-pharmacy and fellowship director for Pharmacy OneSource, Wolters Kluwer Health.