Hospital's antimicrobial stewardship program serves as best practice model
Collaboration with multidisciplines is crucial
The Ohio State University Medical Center of Columbus, OH, has revamped its antimicrobial stewardship program into a state-of-the-art, collaborative, well-staffed initiative that has both saved money and increased quality of care of patients with infections.
The program has grown from having one part-time infectious diseases (ID) pharmacist and one infectious diseases physician to approval for four full-time pharmacists. Also, the ID physician's role has expanded.
Here's how the program works:
• Form a collaboration with multiple disciplines: "You need to collaborate and share the knowledge of each expert in your hospital," says Debra A. Goff, PharmD, FCCP, a clinical associate professor at the Ohio State University College of Pharmacy and an infectious diseases specialist at the Ohio State University Medical Center.
For instance, an antimicrobial stewardship program should have a clinical microbiologist on board.
"A clinical microbiologist provides antibiotics-specific susceptibility data for our hospital," Goff says. "Each antibiotic has its own percentage of susceptibility at our hospital."
With the microbiologist's data, Goff can see which antibiotic is most potent for a particular organism seen at the OSU medical center.
"You need your own hospital-specific data, so you need to collaborate with microbiology, which holds that piece of data," Goff adds.
Infection control practitioners also need to be part of the collaboration.
"We can prescribe the best antibiotics, but if no one is enforcing hand-washing then it won't make a difference," Goff says. "You need to advocate for good infection control practices in your hospital."
Larger urban hospitals could have an infectious diseases physician on staff as part of the stewardship program. Hospitals that can't afford or find a full-time ID physician could at least share an ID doctor with other hospitals in the region, Goff says.
"Usually the infectious diseases physician will be the director or co-director of the stewardship program, along with the ID pharmacist," she says. "But the reality in smaller hospitals is there usually is no infectious diseases pharmacist, and you have an ID physician who rotates between all hospitals in town."
At OSU Medical Center there are 25 infectious diseases physicians, including physicians who conduct research, she notes.
Another member of the collaborative team is a data manager, who identifies the necessary information in the hospital's data warehouse, Goff says.
• Work closely with infection control staff: Particularly with increasing rates of multidrug-resistant infections, hospital pharmacists need to work with infection control staff to make sure they are aware of the problem and have an action plan in the event of an outbreak, Goff suggests.
"This includes good hygiene control, cleaning hospital rooms properly and not cutting corners, because if they don't wipe down the handrail of a patient with a multidrug-resistant infection, then the next person in bed will touch that handrail and become infected," she says. "Your emphasis on tiny details is critical to the success of the problem."
An antimicrobial stewardship program could help with staff education about infection control practices and help convince health system management to invest resources and make changes that will help reduce the likelihood of spreading infections from one patient to another.
For instance, some hospitals have cut costs by outsourcing cleaning jobs. This might work fine, but it could create major infection control problems if the outsourced cleaning crew has high turnover rates, cuts corners, and has a lack of adequate training and education about infection control practices.
"It could increase the probability of sloppy work, of less than optimal cleaning," Goff says.
"So in the big picture, when you're trying to have cost containment in hospitals, and you outsource housecleaning, you will need to regroup when you have an outbreak," Goff adds. "You'll need to ask why the outbreak occurred, and if outsourced housecleaning is the problem, then it causes an increase in costs and decreases quality."
• Collect timely data: At OSU Medical Center, a PhD-level microbiologist oversees having every culture taken from patients tested for antibiotic susceptibility in the lab, Goff says.
"As a pharmacist, what I'm trying to do is recommend an empiric antibiotic," she says. "Patients come to our hospital, and we send their cultures to the microbiology lab, but we don't get results for two days."
This means pharmacists have to wait to make a recommendation for a hospital-specific drug based on susceptibility data, Goff says.
For some organisms, the process is getting faster.
"Our microbiology lab is doing a rapid Staphylococcus blood test," Goff says. "In two hours I know if an organism is Staphylococcus aureus, and it used to take two days to get the results."
The hospital's data manager assists the antimicrobial stewardship team with researching information that provides clues about new infectious disease trends and that help with quality improvement projects.
"We can look up patients' length of stay (LOS), our antimicrobial costs per patient day, and other markers," Goff says. "We can see if the program is making an impact in the hospital, and we can see the resistance rate of antimicrobials."
The hospital's microbiologist produces a quarterly or an annual hospital antibiogram that shows which drug-resistant organisms are most common in the hospital, she says.
"We have intensive care unit-specific antibiograms that show us the sickest patients with the highest rates of drug-resistant organisms," Goff says. "We run those at least once a year, but we will also run those quarterly to look at them."
ID physicians oversee epidemiological data that identify all of the hospitals' infections and their underlying causes, Goff says.
"They're responsible for identifying the cause of an outbreak, checking our compliance with hand hygiene, and identifying the rates of nosocomial-acquired infections," she adds.
These data also can be used to track the hospital's compliance with regulations. For instance, the Centers for Medicare and Medicaid (CMS) will no longer reimburse hospitals for several nosocomial-acquired infections, a change that took place in October, 2008, Goff says.
"Now that we're not being reimbursed, there's a whole different interest level in antimicrobial stewardship," Goff says.
• ID pharmacist serves central role: Antimicrobial stewardship programs rely heavily on pharmacist support. At OSU Medical Center, the ID pharmacist plays a key role in making certain all information about infectious diseases are reviewed and analyzed centrally.
For instance, sometimes infection control departments do not communicate with antimicrobial stewardship programs, and this can provide an obstacle to the ID pharmacist spending his or her time as effectively as possible.
"The way the infection control practitioner helps me is by telling me which patients are in isolation with multidrug resistance," Goff says.
"I have a list of everyone on antibiotics, and they have a list of everyone with multidrug-resistant infections," Goff says. "The infection control practitioners get a list from microbiology every morning about who has multidrug-resistant organisms so they can put those patients in isolation."
Goff needs that same list, and now she receives it.
"That's more effective communication when we can work as a team," Goff says.
"We each have knowledge in different areas, and if you pool your knowledge, then you have a much more effective program," she adds. "I have all the antibiotics, and they have information, and the microbiologist has susceptibility data, and it does us no good if they each keep that information in their own departments."
So now the antimicrobial stewardship pharmacists receive the same multidrug resistance report that the infection control department receives.
"I can look at the same patients to see what kind of antibiotic therapy they're on," she says.
The ID pharmacist also documents when patients arrive in the hospital with a drug-resistant infection, such as a catheter-related urinary tract infection or a catheter-associated bloodstream infection, Goff says.
Another change was to have the lab call the antimicrobial stewardship pharmacist directly with drug-resistance results.
With the old method, the lab would call the nurse or physician with the results; now the phone calls comes to the antimicrobial stewardship pharmacist, Goff says.
"Then we'll recommend the most effective antimicrobial therapy," Goff says. "Our role is to coordinate the efforts between all the departments and take the data from the microbiology lab, infection control practitioners, and come up with the best antibiotic regimen for patients."
[Editor's note: This is the second part of a series of articles about the major changes underway in hospital pharmacy practice in the 21st century. In this issue are stories about a hospital that serves as a model for transitioning to clinical pharmacy care and about how pharmacists increasingly are becoming involved with medication therapy management (MTM). In the August issue of Drug Formulary Review, there were stories on hospital pharmacists participating in patient care teams, a look at how one hospital prepared for a transition to a decentralized pharmacy, and suggestions on how to prepare staff for the change.]
The Ohio State University Medical Center of Columbus, OH, has revamped its antimicrobial stewardship program into a state-of-the-art, collaborative, well-staffed initiative that has both saved money and increased quality of care of patients with infections.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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