Antimicrobial resistance is increasing to dangerously high levels, threatening our ability to prevent and treat a range of infections caused by bacteria, parasites, viruses, and fungi. Without effective antimicrobials, medical procedures including organ transplantation, chemotherapy, diabetes management, and major surgery become high risk, and health care workers are left without the ability to treat common infectious diseases, which can lead to prolonged illness, disability, and death.1
Scientific literature emphasizes the need to avert inappropriate antimicrobial use in health care settings in order to reduce antimicrobial resistance, which increases the cost of health care with longer hospital stays and more intensive care required. Inpatient antibiotic stewardship programs (ASPs) have consistently demonstrated annual savings to hospitals and other health care facilities of $200,000 to $400,000.2 In addition, ASPs can increase positive patient outcomes, decrease antibiotic resistance, reduce C. difficile infections, and lower costs.2
Accredited by The Joint Commission, Children’s Mercy Hospital (CMH) comprises two main hospitals, three urgent care centers, and two freestanding outpatient clinics in the Kansas City, Missouri area. CMH has operated an ASP for almost 10 years, beginning with one FTE pharmacist who split time between the ASP program and the infectious disease (ID) consult service; in 2014, a dedicated FTE pharmacist was introduced to the ASP program. The ASP provides prospective monitoring of antimicrobial prescriptions, with real-time feedback and advice to clinicians regarding appropriate selection of optimal antimicrobial drug regimens, dose, duration of therapy, and route of administration. The goals of the program are to facilitate appropriate antibiotic utilization based on available guidelines and reinforce best practices to prevent the emergence of antimicrobial resistance, improve patient outcomes, and enhance prescriber education. Recently, CMH took additional steps to ensure compliance with the new Joint Commission Antimicrobial Stewardship Standard, MM.09.01.01.3
The Joint Commission’s New Antimicrobial Stewardship Standard
MM.09.01.01, which has been in effect since January 1, 2017, requires that hospitals implement an ASP comprising the following3,4:
Read MM.09.01.01 in its entirety at: www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf.
Implementing the New Standard
CMH operates under a decentralized pharmacy practice model with clinical pharmacy services represented on 18 medical teams. These services include multidisciplinary rounding, therapeutic drug monitoring, patient and family education, adverse drug event monitoring, and provision of pharmacotherapy recommendations. The ID clinical pharmacy specialists run a daily report of specified broad-spectrum antibiotics (see TABLE 1) and then meet with the medical teams and pharmacists to discuss either narrowing therapy or reducing duration. ID physicians and fellows also participate in this service on a weekend rotation.
Although CMH had operated an ASP for nearly 10 years, several elements of The Joint Commission standard had not been implemented. Expecting a Joint Commission site visit in the spring of 2017, we began efforts to maximize use of our EHR and data analytics software, increase data tracking capabilities, develop an ASP P&P, ensure staff receives proper antimicrobial stewardship training, and maintain ongoing compliance with ASP goals.
Maximizing Automation and Technology
MM.09.01.01 requires that leaders establish antimicrobial stewardship as an organizational priority and cites a leadership commitment to using the EHR to collect antimicrobial stewardship data as an example. CMH utilizes our EHR’s reporting capabilities, as well as newly implemented data analytics software, to track data to ensure appropriate antimicrobial usage. When a provider places an order for an antibiotic (regardless of route), a forced function in the EHR requires they select an indication and a duration.
At 48 hours from the start time of the antibiotics, pharmacy receives a task in its EHR inbox alerting them that they must revisit the antibiotic order (ie, an Antimicrobial Time-Out; see SCREEN SHOT). This time-out prompts a reassessment of the continuing need for and choice of antibiotic with additional clinical and diagnostic data typically available.4
We created a daily pharmacy email alert of antibiotics scheduled to be discontinued within 48 hours. The goal of this alert is to ensure that antibiotics with a 48-hour duration are captured in the patient’s record and to prevent the patient from missing an intended dose. ID clinical pharmacy specialists also review the 48-hour discontinue list as a backup to ensure that therapy is not stopped prematurely.
The ASP team tracks utilization of targeted antimicrobials, antimicrobial agents for specific diagnoses, the number and types of interventions made by the ASP, and compliance with ASP interventions. Outcome measures are used to determine if process changes have reduced or prevented the unintended consequences of antimicrobial use, including:
The CMH Board of Directors receives a monthly update on the various hospital-acquired conditions for which the ASP’s services are considered. Monthly multidisciplinary meetings with leaders from the various hospital-acquired condition initiatives are held to provide periodic updates.
Policies and Procedures
CMH’s Pharmacy & Therapeutics Committee approved an antimicrobial stewardship P&P, which outlines our plan to ensure compliance with MM.09.01.01 (see SIDEBAR). The goal of the P&P is to facilitate appropriate antibiotic utilization based on available guidelines and best practices to prevent the emergence of antimicrobial resistance, improve patient outcomes, and enhance prescriber education.
Providers receive in-person antimicrobial education detailing indications and durations of therapy, as well as electronic education of these considerations at the initial ordering of all anti-infective agents. Pharmacy provides both electronic and in-person education to providers regarding requirements for the 48-hour antimicrobial time-out.
Ensuring Ongoing Compliance
Pharmacy and ID meet on a semi-regular basis to review the ASP’s progress and success, identify any barriers to achieving its goals, and consider additional opportunities to increase services and efficiency. Pharmacy and infection control collaborate on additional initiatives, such as preventing surgical site infections, to ensure that ASP goals are met while other initiatives are supported.
Strategies for improving antibiotic use are evolving. As more organizations take steps to optimize antibiotic use, these interventions should be evaluated to determine which deliver the most significant benefit in combating antimicrobial resistance.4
Future goals for CMH’s ASP include introducing new employee education and annual staff education, developing a family/teen advisory board, and increasing nursing engagement.
Additional ASP Tools
The CDC offers helpful toolkits and checklists that can be used to augment existing ASPs and help create new programs. These tools are available at: www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
Richard K. Ogden, Jr, PharmD, MBA, BCPS, is an assistant director of pharmacy at Children’s Mercy Hospital. A graduate of the UMKC School of Pharmacy, Richard’s responsibilities include pharmacy clinical services, formulary management, and the PGY1 Residency Program.
II. The goals of the program are to facilitate appropriate antibiotic utilization based on available guidelines and best practices to prevent the emergence of antimicrobial resistance, improve patient outcomes, and enhance prescriber education.
III. The ASP functions are integrated within the ID division, but are independent of the ID consultation service.
IV. Antimicrobial Stewardship Program Core Members
A. ASP Leadership:
1. ASP Medical Director
2. ID Pharmacist(s)
B. ASP Core Members:
1. Pediatric ID Physician/APRN
2. Director of Microbiology
3. Hospital Epidemiologist
4. Pediatric ID Fellows
5. Infection Preventionist
6. Data Analyst
7. General Pediatric Clinician
I. Programmatic Description (tracking, audit and feedback, reporting, use of guidelines, antibiotic education)
A. Prospective audit and feedback for each patient receiving broad-spectrum antimicrobial therapy will be performed by an ID physician/APRN on a daily basis; patients receiving broad-spectrum antibiotics for 2 calendar days will be reviewed.
1. If the antimicrobial therapy is considered to be appropriate, no further interventions are needed.
2. If the antimicrobial therapy may be optimized based on clinical syndrome, pathogen, susceptibility data, history of patient allergy, and antibiotic side effect profile:
a. Direct communication with the prescriber will be ongoing to ensure appropriate therapy.
b. If the recommendations are accepted or a mutually acceptable plan is agreed upon, a brief note outlining the recommendations and rationale may be placed in the medical record.
3. To track the efforts of the ASP, an electronic form will be completed within the EHR.
B. The ASP pharmacist reviews patients who have received a broad-spectrum antimicrobial for 7 calendar days in order to identify potential IV to PO transitions, and reviews inpatients’ positive cultures with the antimicrobial utilization information to determine whether the prescribed antimicrobials are appropriate.
1. The appropriateness of the prescribed antimicrobial therapy is based on the review of clinical presentation and illness course (as written in the medical record) as well as clinical laboratory and microbiology data.
2. Assessment of the appropriateness of therapy per indication, optimal dosage, and appropriate duration of therapy will be performed, based on the best available evidence from the medical literature.
II. Clinician and Patient Education/Development of Guidelines
A. Continuous effort to educate practitioners on the appropriate use of antimicrobial agents will include, but are not limited to:
1. Use of CPOE/EHR to provide and update guidelines and reminders about acceptable and recommended diagnostics and antimicrobial use
2. Provide real-time antimicrobial education to clinicians through patient-based cases
3. Provide education to parents and families regarding appropriate antibiotic use
4. Formal educational opportunities about the program and various antimicrobial therapy-associated topics to medical house staff, members of the medical staff, and nursing staff
5. Develop and perform annual updates of empirical antibiotic guidelines and apply the hospital antibiogram to guide empiric antibiotic selection
6. Integrate evidence-based practice and clinical practice guideline development to guide antibiotic best practices
III. Outcome Measures
A. Performance measures:
1. Process measures will be used to determine the activity of ASP and whether interventions have had impact on the utilization of antimicrobials, which include:
a. Track utilization of targeted antimicrobials
b. Track utilization of antimicrobial agents for specific diagnoses
c. Track number and types of interventions made by the ASP
d. Track compliance with ASP interventions
2. Outcome measures are used to determine if process changes have reduced or prevented the unintended consequences of antimicrobial use, including:
a. Susceptibility data will be utilized to identify antimicrobial agents requiring preauthorization for use; for example, Enterococcus, Staphylococcus aureus, Klebsiella spp., Acinetobacter spp., Pseudomonas aeruginosa
b. Incidences of health care-associated infections due to antibiotic-resistant target organisms are tracked hospital-wide and for high-risk units
c. Incidences of health care-associated C. difficile infections are tracked hospital-wide and by unit
d. Adverse drug events related to antimicrobial agents are tracked
Monitored antibiotics*: The ASP actively monitors broad-spectrum antibiotics including: third-generation cephalosporins (ceftriaxone, cefotaxime, ceftazidime), fourth-generation cephalosporins (cefepime), beta-lactam-/beta-lactamase-inhibitor combinations (amoxicillin/clavulanate, ampicillin/sulbactam, piperacillin/tazobactam), carbapenems (meropenem), fluoroquinolones (ciprofloxaxin, levofloxacin), aminoglycosides (amikacin, tobramycin), aztreonam, colistimethate, linezolid, daptomycin, vancomycin; additionally, antimicrobials that may not be on the Children’s Mercy Hospital formulary are also reviewed. The monitored drugs could change at any time based on changes in utilization and prescribing and the addition of new anti-infective agents as they become available. *Note: This policy includes the minimum antibiotic-monitoring requirements. CMH may provide surveillance of other anti-infectives not included here.
Restricted antimicrobials: levofloxacin, linezolid, daptomycin. These antimicrobials are selected for restriction (ie, require approval before use) due to their spectrum of activity relating to commonly observed drug-resistant organisms and cost (when effective, less costly alternatives are available). The restricted drugs will change based on prescribing practices and the availability of new drugs.
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