Operations

This year has been a busy one for healthcare – the potential reversal of the Affordable Care Act, ongoing concerns about the Zika virus, and a worsening opioid epidemic have dominated media headlines.  Even amid the resulting demands on their attention, there’s an equally important issue which healthcare executives would be wise to focus on: antimicrobial resistance.

While nearly half of the country’s healthcare systems have now implemented an antimicrobial stewardship program (ASP) to combat this growing threat, opportunities still abound to do more to get out ahead of the problem and ensure continuing efforts to minimize it. It is also worth mentioning the fact that as of January 2017 the Joint Commission (TJC) now requires hospitals to have an active ASP for accreditation and the Centers for Medicare and Medicaid Services (CMS) is expected to follow suit in the near future. With this in mind, healthcare executives who are interested in continuous improvement of their hospitals should consider these tactics:

1. Keep working together: When an ASP is initially formed, collaboration is often prioritized – doctors, nurses, pharmacists, and numerous other specialties come together to discuss problems and brainstorm sustainable solutions. It is important to remember that once the program is up and running this interprofessional approach remains critical. Everyone in the healthcare system, both inpatient and outpatient, plays a role in the program’s success. In addition to explaining roles and responsibilities to staff at the outset, healthcare leaders should make a point to check in with these groups regularly to remind them of their value and ensure that educational updates on best practices are made available. The ASP team should determine which communications channels will be most effective for each department, and use them regularly. For example, for nursing, that might mean sending a representative to periodically join the daily shift change meetings providing the ASP an opportunity to receive updates on new “wins” and challenges in addition to ensuring their agenda remains top of mind for these highly important stakeholders.
2. Emphasize reporting: Comprehensive reporting systems are an essential tool to help ASP leaders measure success and avoid potential pitfalls. While the team surely identified appropriate metrics at the outset, these measures must be reviewed regularly to ensure that they remain as relevant as possible and continue to ladder up to organizational goals. For example, reduced days of therapy, lower utilization of broad-spectrum antimicrobials, and quicker transition from intravenous to oral antimicrobials are all great measures which directly impact drug spend and may also affect hospital length of stay – two essential metrics for hospital leadership. In fact, TJC necessitates regular reporting of such metrics as one of its eight ASP-related elements for accreditation. To ensure they are in a favorable position for current and future regulatory changes and to make the best use of their internal data, ASP teams should include representation from their hospital’s information technology department to assist with automating and streamlining the reporting processes as much as possible.
3. Decrease utilization: Perhaps the most important thing ASP teams can do to increase their success is to ensure that providers remain engaged and committed to decreasing antimicrobial utilization wherever and whenever possible. This may be as simple as offering literature in the provider’s breakroom to keep ASP on their minds or taking a larger step to regularly scheduled educational sessions highlighting key topics such as: using the shortest efficacious length of therapy, narrowing antimicrobial spectrum when possible and educating patients and their caregivers on appropriate antimicrobial use before discharge to promote compliance and avoid readmissions. Given that pharmacists are perfectly positioned to provide the most up to date information on the pros and cons of different medications in different scenarios, they should work closely with providers as essential members of the ASP team, spending as much time on the patient floor as possible. Pharmacists can also prove helpful by intervening when potentially inappropriate antimicrobials are initially ordered and helping to reserve certain broad-spectrum antimicrobials for patients who meet specific criteria. Ideally, the hospital’s Electronic Medical Record (EMR) and Computerized Provider Order Entry (CPOE) systems can also be utilized to their highest potential through the use of order sets to guide providers to choose the antimicrobials best suited to the specific infection that they are treating and taking into account patient- and location-specific factors such as renal function and resistance patterns. The EMR may also be able to alert providers and members of the ASP team when new patient information such as culture results become available or when an antimicrobial may be due for reevaluation after a set number of days.
4. Look outside of the hospital: While a good inpatient ASP can have a major impact on antimicrobial resistance at a local – and ultimately, a national – level, it can be exponentially more impactful when data is shared effectively between stakeholders and a community response is formed. For example, hospitals, labs and doctors’ offices from multiple healthcare systems in the same geographic area might consider sharing data to develop a community-wide or regional antibiogram, allowing those in both inpatient and outpatient settings to assess local susceptibility rates, identify the most efficacious treatments for specific infections and monitor resistance trends. From there, the inpatient and outpatient communities, including non-provider based patient-facing groups such as community pharmacies, can work together to develop a tailored response plan to minimize antimicrobial resistance in the long term, and improve medication compliance and reduce antimicrobial adverse effects and hospital readmissions in the short term.

While getting a strong ASP off the ground in the first place can be a trying task, healthcare systems have a long road ahead even after achieving that important milestone. Fortunately, with a little proactive planning and adoption of best practices like those outlined above, they may not only find the process to be more easily achieved, but also that these measures layer well into their overall mission to provide the highest quality healthcare to their patients. 

Paul T. Green, Pharm.D., MHA, BCPS is a Clinical Pharmacy Manager for CompleteRx, one of the nation’s leading pharmacy management companies, who currently heads the clinical programs for the Upper Allegheny Health System (UAHS) with hospitals along the New York / Pennsylvania border. He has over 10 years of clinical pharmacy experience advising hospital and healthcare executives across the country on various critical issues and has successfully implemented Antimicrobial Stewardship Programs for several healthcare systems. He has presented numerous lectures and posters at the local, state, and national level and will be giving a TED Talk on antimicrobial stewardship in November 2017. He is also the president-elect of the Northwest Chapter of the Pennsylvania Society of Health-System Pharmacists and is in the process of starting a new clinical pharmacy residency program for UAHS.