Antimicrobial stewardship programs (ASPs) have been shown to improve patient care by reducing inappropriate antimicrobial use, antimicrobial resistance, and hospital-acquired infections. Clinical guidelines suggest that a multidisciplinary hospital team, including an infectious diseases (ID) physician and an ID-trained pharmacist as core members, should be assembled to properly manage such a program.
Abbott Northwestern Hospital, part of the 11-hospital Allina Health system, is the largest not-for-profit hospital in the Twin Cities, with 629 licensed beds serving the upper Midwest. The hospital is fully automated, utilizing ADCs for drug distribution; BCMA in most patient care areas, including the ED; and CPOE. In recent years, hospital leadership and the infection control (IC) department have become increasingly concerned about rising C. difficile (C. diff) rates in the hospital. This concern prompted the development and implementation of a robust ASP, led by pharmacy, to monitor, track, and reduce inappropriate antimicrobial use. The strategy behind implementing a pharmacy-led program was to provide consistency in the daily activities of the ASP and prevent the perception of physician-driven consults. The goals of the ASP were to reduce inappropriate antibiotic use and costs, ensure compliance with The Joint Commission’s (TJC’s) core measures, and reduce the incidence of hospital-acquired C. diff infection.
Develop and Implement the ASP
A Pharmacist-Led Program
Abbott Northwestern Hospital is a large community teaching hospital with four independent ID physician practices. Given this, we determined that an ID physician should not be involved in the daily operations of the ASP due to concerns that the ASP could drive physician consults to the practice that was involved. Likewise, if multiple ID physicians were involved, there could be inconsistencies in the daily activities of the ASP due to differences in practices. Thus, the ID physicians recommended an ID-trained pharmacist lead the daily operations of the ASP with ID physicians serving a consulting and supporting role.
In the planning stages, the ID trained pharmacist and ID physicians reviewed and revised hospital policies and procedures (P&Ps) and order sets to ensure they were up-to-date. In addition, they worked with the P&T committee to develop hospital-wide antimicrobial usage guidelines, designed to assist the ID pharmacist in determining appropriate use of the most commonly utilized broad-spectrum antibiotics. Beyond reviewing individual patients, it was decided that the ASP team also would review antibiotic-related measures for The Surgical Care Improvement Project (SCIP) core measure and the pneumonia core measure. Due to a limited number of studies describing the success of a pharmacist-led ASP, we decided to first pilot the program on one unit. The pilot was conducted by the ID-trained pharmacist and a PGY1 pharmacy practice resident.
Beginning the Pilot Program
A small, three-month pilot of the ASP commenced in July 2009 on one medical-surgical unit. The patients on this unit are primarily renal patients,including hemodialysis patients, post-surgical patients, and general medicine patients. The ID pharmacist and PGY1 resident were charged with leading the daily operations to ensure program consistency and to review antibiotic orders for adult patients who did not have ID consults. The ID pharmacist and PGY1 resident made recommendations based on clinical and hospital antibiotic usage guidelines; the PGY1 resident discussed all recommendations with the ID pharmacist prior to making them. ID physicians were available for patient questions if required, but were not involved in daily ASP operations.
At the outset, we tracked the number of patients reviewed per day, the percentage of patients requiring an intervention, the type of intervention made, and whether the intervention was accepted. We also assessed antibiotic use and antibiotic cost. At the end of the three-month pilot study, we presented the results to the P&T committee: Approximately 33% of patients required interventions, and the acceptance rate for interventions was 85%. Based on these positive results, the P&T committee permitted us to roll out the program hospital-wide, which we did in December 2012.
In our experience, laying a good foundation is key to successfully developing and implementing a pharmacist-led ASP. Involving all stakeholders during the planning stage, creating effective, complete P&Ps and order sets, and developing antimicrobial usage guidelines will ensure a solid foundation and support system for the pharmacist. Be sure to delineate the goals of the program early on and measure infection and medication use outcomes throughout the initiative. In addition, ensure the program has support from administration and physicians prior to rolling out the pilot. Ideally, an ID physician should be involved, but if one is not available, involve physicians you frequently work with or who have an interest in ID.
The primary outcomes we tracked were interventions (eg, if an antibiotic was discontinued or switched), overall antibiotic use, antibiotic cost, and hospital-acquired C. diff rates. We initially started tracking antibiotic use by defined daily dose (DDD) per 1000 patients based on administrations of the most frequently utilized antibiotics; later, we were able to build a report that tracked antibiotic usage using days on therapy (DOT) per 1000 patient days based on administrations from the eMAR. One DOT is defined as the administration of a single agent on a given day to a single patient regardless of the number of doses or dosage administered. The IC committee, ID physicians, and pharmacy determined that DOT was a better metric than DDD because it gives a clearer estimate of antibiotic exposure since renal function and dosage based on indication are not affected. It also allowed us to look at all antibiotics, as opposed to manually running reports for individual antibiotics.
In addition to DOT, the report also pulls the antibiotic cost based on administrations. Our eMAR already had the functionality for pharmacy to document interventions, link an intervention to specific patients or medications, and document whether the intervention was accepted. This functionality also contains a comments area where additional information can be added, for example, we can specify if the intervention was made to satisfy a core measure regarding antibiotic usage.
To ensure identification of patients who would benefit from the program, various tools were developed within our eMAR to audit and track these patients, including a real-time report that identifies patients receiving anti-infectives and an antibiotic usage report that calculates DOT and antimicrobial costs based on drug administration. Be sure to allow sufficient time and staff to properly set up the necessary infrastructure to allow the program to be successful. Building our antibiotic usage report—to enable tracking by DOT—took approximately 18 months, but it was vital to develop the report correctly to track and audit data efficiently in order to prevent rework later.
Hospital Infection Control Efforts
The ASP at our hospital is one of several initiatives designed to decrease hospital-acquired C. diff rates. Other initiatives that have been put into place include efforts focused on decreasing transmission between patients via increased hand hygiene compliance rates and improved environmental cleaning practices. In 2012, we purchased a room disinfection device that combats microbiological contaminants and disinfects a hospital room in approximately 15 minutes by utilizing pulsed xenon UV light. The device is typically deployed following the discharge of a patient with a known C. diff infection and after housekeeping cleans the room. The implementation of this device has undoubtedly contributed to the reduced C. diff rates at Abbott Northwestern.
During the initial three-month pilot, approximately 50 to 60 patients were reviewed per day over a period of five to six hours, with an average rate of 6.33 minutes per patient. After the pilot, we did not track the total amount of time per day or the number of patients reviewed.
In 2012, the ASP made 907 recommendations with a provider acceptance rate of 90%; the number of recommendations was lower in 2012 than in 2010 and 2011 due to a leave of absence. In 2010 and 2011, the ASP made 1419 and 1560 recommendations with an acceptance rate of 90% and 88%, respectively. The most common recommendations were to discontinue/assess duration of antibiotic therapy and to change or modify antibiotic therapy. The ASP prevented 18 antibiotic-related TJC core measure misses as a result of inappropriate surgical prophylaxis or pneumonia antibiotic therapy. Implementation of the pharmacist-led ASP resulted in a 9.6% decrease in total antibiotic DOT per 1,000 patient days, a 46% decrease in total fluoroquinolone DOT per 1,000 patient days, and an 11.6% decrease in antibiotic cost per patient day. The reduction in total antibiotic use was considered one contributing factor to the 39% reduction in hospital-acquired C. diff rates from 2008 to 2012.
Over the first two years of the program, Abbott saved approximately $400,000 on antibiotic costs. However, it is important to use caution when evaluating cost reductions. For example, although we saved a significant amount the first year after implementing the ASP, the hospital then started to expand its advanced heart failure program and significantly increased the number of heart transplantations, as well as the number of ventricular assist devices placed. Therefore, we have a new patient population that is typically in the hospital for several days and may use a significant amount of antibiotics. Remember that as the ASP program is reducing antibiotic use and costs, new service lines may increase use and costs. This consideration must be taken into account when tracking and auditing results.
In addition to the hard benefits of the ASP, we also experienced intangible benefits, including an elevation in pharmacy’s role as a driver of reducing health care-acquired infections and a leader in antimicrobial stewardship. Moreover, pharmacy resident involvement in stewardship enhances training and educational experiences.
Continuing ASP Improvements
Last year we implemented an improvement to the ASP, a pharmacist-to-pharmacist consult service to further encourage stewardship. If a high-acuity patient requires a consult, the decentralized pharmacist taking care of the patient can send us a message via the eMAR. This allows the ASP team to prioritize patients appropriately, since resource limitations prevent us from reviewing all patients in the hospital on antibiotics.
In February 2013, the ASP at Abbott expanded to provide support to New Ulm Medical Center (NUMC), a 25-bed critical access hospital within Allina Health. The pharmacist-driven ASP at NUMC utilizes the ID pharmacist at Abbott to review patients on a daily basis. The ID pharmacist makes recommendations to a pharmacist at NUMC, who then determines whether the recommendation will be made to the provider and documents the recommendation.
In addition, Allina Health has developed and is currently implementing a clinical scoring tool within our eMAR. This tool assigns patients a number value based on several criteria, including antimicrobial stewardship-specific criteria: Patients taking an IV vs PO antibiotic, antifungal, or antiviral; patients receiving a broad-spectrum antibiotic for ≥72 hours; pharmacy to dose vancomycin or aminoglycoside consults; isolation precautions due to multi-drug-resistant organisms; etc. After each patient receives a rating, they are sorted by acuity to identify those who require the most intense attention. Once these patients have been addressed, their eMAR is time stamped, indicating a review was completed. This allows us to more accurately track and prioritize patients. We are currently completing development of this tool for antibiotic stewardship and foresee starting a pilot program of the tool in the coming months.
The pharmacist-led ASP at our institution is innovative in that it does not involve a physician in its daily operations, yet was successful in reducing inappropriate antibiotic use and costs, increasing TJC Core Measure compliance, and reducing hospital-acquired C. diff infection. In addition, TJC surveyed our hospital last year and was pleased with the results of our efforts to ensure proper antimicrobial stewardship. We look forward to continually improving the reach and success of the ASP in future years.
Jessica S. Holt, PharmD, BCPS (AQ-ID), is the pharmacy coordinator for infectious diseases and the HIV and PGY2 infectious disease residency director at Abbott Northwestern Hospital. She earned her doctor of pharmacy degree from the University of Minnesota-Twin Cities and completed her pharmacy practice and infectious diseases residencies at Thomas Jefferson University Hospital in Philadelphia. Jessica led the development and implementation of the pharmacist-driven antimicrobial stewardship program, which received one of the 2011 ASHP Best Practice Awards. Her professional interests include antimicrobial stewardship, antimicrobial resistance, and precepting residents and students.