Q & A with Elizabeth Hermsen, PharmD, MBA, BCPS-ID
Antimicrobial Stewardship Program Coordinator
The Nebraska Medical Center
Pharmacy Purchasing & Products: What are some core antimicrobial stewardship program (ASP) strategies?
Elizabeth Hermsen: The primary goal of an ASP is to enable more appropriate antimicrobial prescribing—optimizing outcomes for the patient, minimizing adverse effects, and helping to prevent the emergence of resistance. One core strategy to help achieve this goal is to perform prospective audits with intervention and feedback. This usually involves selecting certain triggers that would prompt review by ASP personnel; for example, a patient receiving two or more agents with anti-anaerobic activity and a negative Clostridium difficile assay would prompt an ASP review to determine the appropriateness, or lack thereof, of the redundant anti-anaerobic activity. It should be noted that this strategy usually requires a fair amount of information technology infrastructure. Another core strategy is employing formulary restriction with pre-authorization required for restricted drugs; this strategy typically requires less information technology support. In addition, there are myriad supplemental strategies, including education, development of clinical pathways, antimicrobial order forms, and dose optimization.
PP&P: What are some of the critical components of a successful ASP?
EH: Multidisciplinary involvement is vital to the success of any ASP. Generally, the core members of the program are a physician and a pharmacist, and ideally both would be trained in infectious diseases. However, you need other disciplines involved as well, such as the infection control department and the microbiology department. It also is important to build strong relationships with the physician groups—such as critical care and internal medicine—that are frequent users of antimicrobials.
Establishing information/educational resources is important. As part of our program, we created a publicly accessible Web site where we post antimicrobial management reference material and any recent news from our ASP (www.nebraskamed.com/asp). In addition to this, we developed a pocketbook that details topics related to infection control, clinical microbiology, and antimicrobial stewardship. It also is helpful to establish standard operating procedures and policies, as this will standardize practices and ensure consistency.
Another critical component of a successful ASP is to budget for growth, as this will help ensure long-term success. So, when you are trying to secure funding for the program, budget for program growth three to five years down the line. Whether this means accounting for additional personnel or information technology resources, it is important to think about this upfront as it may be more challenging to acquire additional funding down the road. Partnering with the finance department can often be helpful as they are familiar with the “language” that administration likes to hear and can help you present your argument in a way that makes sense to the administration.
Access to appropriate data in a timely manner is another crucial component of a successful ASP. In order to develop appropriate interventions, you need access to information on patients receiving antimicrobials—and, ideally, you need access to this data in real-time. This access is often one of the biggest hurdles to effective antimicrobial management for institutions, as many do not have the technology necessary to access this data efficiently.
PP&P: What type of technology is necessary to access this data?
EH: There are three different levels of information technology support for antimicrobial stewardship programs. The most sophisticated level is available through computerized physician order entry (CPOE). With this technology, you can incorporate policies, alerts, clinical pathways, restrictions, and automatic stop dates into the system. Instead of alerts going to ASP personnel, they go directly to the physician at the point of care. Often, the decision support provided by the system directs the physician to the appropriate choice initially and may prevent the need for later ASP intervention.
The next level down would be an electronic clinical decision support (CDS) system, which is what we currently use. Our system takes data feeds from all our current information systems and filters the data in a meaningful manner for us—creating alerts for certain defined situations on a real-time basis. For example, we receive alerts for all patients receiving antimicrobials that are not active against the isolated organism according to susceptibility results, allowing us to make recommendations for a more appropriate antimicrobial for definitive therapy.
The third and least sophisticated level of support, which would be an option for institutions that do not have access to either CPOE or CDS software, requires identifying certain groups of patients or certain criteria that patients would have to meet, and then working with the internal information technology department to develop specific daily reports. For example, if there are restricted antimicrobials, you might want a daily report of all the patients who had orders for these drugs. One of the disadvantages of this solution is most of the time these reports are only produced once a day, so the data is not in real time.
PP&P: What should you be aware of when evaluating CDS systems?
EH: One question you need to ask during the evaluation process is, “How many users does the license include?” While comparing CDS systems, we discovered that the software that appeared to be the least expensive had low upfront costs because the license only included 10 users. To allow our nearly 80 staff pharmacists access to the system would have made this option the most expensive. A system that allows an unlimited amount of users may be more cost-effective in the long run.
PP&P: How can you make a case for the clinical and economic value of an ASP?
EH: The bottom line is that antimicrobial resistance is growing and leading to an increase in morbidity, mortality, and costs for hospitals. Just as resistance is increasing, antimicrobial development is decreasing, so we are seeing fewer new drugs coming to market. Therefore, it is critical to focus on using existing antimicrobials more appropriately, and the cornerstone of this approach is an effective ASP.
When making a case for implementing this type of program, first identify and align yourself with those individuals within your institution that also would like to see this program move forward. In addition, identify the key stakeholders— those individuals whose support you will need to move forward with the program.
Next, compile data that demonstrate a need for antimicrobial stewardship. Performing a pilot program can help supply the necessary data to make a compelling argument to administration for an ASP. Presenting relevant regulatory and legislative information—such as Centers for Medicare & Medicaid Services (CMS) reimbursement changes and TJC standards and goals associated with infection control and antimicrobial stewardship—often appeals to administrators. Providing published data/research on the topic from professional organizations and other qualified agencies also can help make your case. For example, the Infectious Diseases Society of America (IDSA) has published ASP implementation guidelines and the Centers for Disease Control and Prevention (CDC) has a 12-step program to prevent antimicrobial resistance.
As for the economic value of an ASP, these programs can include measures that decrease antimicrobial costs, such as more aggressive price negotiations for certain drugs, decreasing the use of a particular product, or IV to oral conversion initiatives. When you consider that antimicrobials make up a fairly substantial portion of a hospital pharmacy’s drug budget—usually 15% to 20%—more efficient use of these products can translate into a significant cost savings for hospitals. You also can demonstrate the economic value of an ASP by tracking cost savings as a result of decreased infection rates from interventions.
When building your case, look for less obvious issues in your institution that could be resolved by employing an ASP. For example, we recognized a problem with contaminated blood cultures in our emergency department, and subsequently instituted multidisciplinary interventions that led to a decrease in contamination in these cultures. This resulted in cost savings from the reduction of unnecessary treatment and follow-up tests on these contaminated cultures.
Also, look for opportunities to demonstrate cost avoidance, as it is important to establish the value of this with your administrators. For example, our microbiology lab was considering implementing technology that would more rapidly identify organisms from blood cultures, and we worked with them to perform a cost effectiveness analysis. Our analysis uncovered that one of the older techniques would actually be the most cost effective because of labor issues within the lab, thus money was saved by not purchasing the newer technology.
Keep in mind that while it is generally necessary to demonstrate economic
value, improved patient safety should be stressed as the primary goal when making a case for implementing an ASP.
PP&P: When evaluating pharmacists to lead an antimicrobial stewardship program, what key skills should you look for?
EH: Given the multidisciplinary nature of an ASP, it is important to hire someone who works well with others. Oftentimes, antimicrobial stewardship pharmacists are making unsolicited patient care interventions, so good interpersonal and conflict resolution skills are a must. It also is important that someone in this position possess excellent written and verbal communication capabilities. The crux of any ASP is education—whether that involves making a presentation to a large group or a one-on-one phone intervention with a physician—so well-honed communication skills are essential.
In addition, look for someone with strong clinical and research experience in infectious diseases. While the requirement for clinical skills is common sense, the need for strong research skills is subtler. An ideal antimicrobial stewardship pharmacist needs to study what they do and demonstrate how ASPs impact patient care. Ultimately, whomever you hire should have the desire and training to contribute to the continued improvement of this discipline through shared knowledge via publication in peer-reviewed journals.
PP&P: What training resources are available for pharmacists interested in antimicrobial stewardship?
EH: There are antimicrobial stewardship educational resources and training programs offered through various organizations, and we are only going to see these opportunities increase as interest in antimicrobial stewardship gains momentum. MAD-ID, a non-profit foundation that provides continuing professional education in the area of infectious diseases pharmacotherapy, has an annual meeting every May and this year the organization introduced an antimicrobial stewardship training program. There are three components to the program: an internet learning module, live programming that requires attendance at the MAD-ID meeting, and a practical component/exercise. The Society of Infectious Diseases Pharmacists (SIDP) is putting together a certificate program as well, which should be available by late summer. The SIDP program will include 15 hours of online learning and five hours of live interaction. At ICAAC (the Interscience Conference on Antimicrobial Agents and Chemotherapy), there is generally a pre-meeting workshop that focuses on antimicrobial stewardship. In addition, ASHP just published a white paper on antimicrobial stewardship and they are launching a series of webinars on this topic (www.ashpadvantage.com/stewardship).
We started offering a visiting scholar preceptorship through our ASP in 2009. The goal of this program is to provide physicians and pharmacists with the information needed to gain support for and implement a formal antimicrobial stewardship program. The day and a half on-site visit consists of lectures and hands-on experience as well as a brainstorming session on antimicrobial stewardship approaches that can be taken at the participant’s specific institution, and our administrators meet with participants to help them draft a business plan. In addition, participants earn continuing education credits for attending the program.
Elizabeth D. Hermsen, PharmD, MBA, BCPS-ID, is the Antimicrobial Stewardship Program coordinator at The Nebraska Medical Center. She also is an adjunct assistant professor at the University of Nebraska Medical Center, Colleges of Medicine and Pharmacy, and is an active clinician, educator, and researcher. Dr. Hermsen received her doctor of pharmacy degree from the University of Nebraska Medical Center. She pursued post-doctoral training, including a pharmacy practice residency at The Nebraska Medical Center, a fellowship in infectious diseases research at the University of Minnesota College of Pharmacy, and a master in business administration with emphasis on marketing and health care industry from the University of Minnesota Carlson School of Management.
Dr. Hermsen has contributed to the profession with publications in peer-reviewed journals, book contributions, and by serving as a reviewer for several professional journals. She also has given a number of presentations at state, regional, national, and international meetings. Dr. Hermsen currently holds memberships in the American College of Clinical Pharmacy, the Society for Infectious Disease Pharmacists, the Infectious Disease Society of America, the Society for Healthcare Epidemiology of America, and the American Society of Microbiology. Dr. Hermsen is on the board of directors for the University of Nebraska Medical Center College of Pharmacy Alumni Association, the Annual Meeting Programming Committee for the IDSA, the Guidelines Committee for SHEA, and the Inter-Organizational Planning Committee for SIDP.