Early advocates of antimicrobial stewardship tended to focus on prescribing in outpatient settings. In recent years, attention has shifted toward the ED — and there are many good reasons for this shift, according to Michael Pulia, MD, MS, director of emergency medicine antimicrobial stewardship at the University of Wisconsin School of Medicine and Public Health.
Pulia says although much antibiotic prescribing takes place in outpatient settings, most of these prescriptions are for oral pills, which are more narrow-spectrum. “You are using your more expensive, intravenous, broad-spectrum antibiotics in the hospital, which is a bigger concern for resistance,” he says.
However, Pulia also says the ED is unique because it straddles both the ambulatory setting and the inpatient setting. “The ED is increasingly, in the U.S. at least, the gateway to the hospital,” he says.
This makes the ED’s role in antibiotic prescribing critical. The antibiotic the emergency provider selects will affect clinical outcomes in terms of whether the drug is a good match for the illness. For patients who will be admitted, there could be an effect Pulia refers to as therapeutic momentum. “Those antibiotics [prescribed in the ED], whether they are appropriate or inappropriate, have a tendency to be continued after the patient is admitted,” he says.
The American College of Emergency Physicians issued a policy statement stressing the importance of antimicrobial stewardship to quality care in the ED.1 However, most experts acknowledge there is still ample room for improvement.
Pulia observes that maintaining paperwork proving the existence of an antimicrobial stewardship program is different than performing the job well. But he also notes there are few ED-based pharmacists to drive such an effort. Still, that should not deter smaller, lower-resourced departments from trying to improve. With the right steps, experts find EDs can raise the level of care they are providing to patients, enhance safety, and preserve the disease-fighting power of antibiotics.
For ED leaders who see antimicrobial stewardship as a key target for improvement, Pulia recommends they find a physician champion to lead the effort. “This could be the quality director for your group, someone who has an interest in this area, or perhaps someone that you assign,” Pulia offers. “It is a pretty intensive [role] if you think about all the conditions that should or shouldn’t be treated with antibiotics.”
It is OK if the person in charge of the effort has other responsibilities, but it helps if those duties overlap with antimicrobial stewardship.
After appointing a champion, this person will need access to data. That may require some help from a data analyst who can generate reports on specific diagnosis codes of interest from an antimicrobial stewardship perspective. “Most groups [generate similar reports] for ... other quality metrics. It would really just be tuning their existing data-reporting infrastructure so that they start getting reports on stewardship,” Pulia says.
Start by targeting conditions for which it is non-controversial to refrain from prescribing antibiotics (e.g., bronchitis, asthma attacks, and viral illnesses). With a data analyst’s assistance, see which providers tend to prescribe antibiotics in cases where antibiotics are inappropriate or unnecessary, then determine how to feed that data to the providers.
Some champions may want to provide the benchmarking data to all emergency providers. Others may choose to interact with providers who are clear outliers regarding antibiotic prescribing for the targeted conditions.
Auditing prescribing patterns and intervening with outlier providers who too often prescribe antibiotics inappropriately can be effective, but Pulia favors systems interventions that aim to make it as easy as possible for prescribers to do the right thing.
Pulia and colleagues developed an antibiotic order set, designed with human factors engineers to consider how clinicians think about diagnostics. The order set is divided into the main infection categories. Clinicians use the set as a guide to find to the preferred antibiotic. For example, if a patient has sepsis, the clinician will be asked to provide more details about the nature of the condition, whether the patient has any allergies, and whether the patient reported kidney function issues.
Pulia says the tool went through several iterations to reach the point where clinicians actually use it. Today, leaders do not have to provide so much one-to-one feedback or counseling to individual providers because most antibiotic orders go through the tool. Notably, the order set does not address issues of clinical judgment that might require a behavioral-educational intervention. Still, the tool helps clinicians pick the right antibiotic at the proper dose for the correct number of days. “Every stewardship problem has a unique solution. That could be a behavioral intervention, a systems intervention, or a balance of the two, with the percentage of the split tailored to the specific problem,” Pulia says.
Administrators at smaller departments find it challenging to commit more resources to stewardship. Some systems have created centralized stewardship programs to help deliver core resources to multiple facilities concurrently. In 2018, the University of Pittsburgh Medical Center (UPMC) instituted the Centralized Health System Antimicrobial Stewardship Efforts (CHASE) program to respond to new requirements around stewardship put forth by TJC and CMS. Leaders also sought to standardize best practices throughout the UPMC system, explains Tina Khadem, PharmD, UPMC’s antimicrobial stewardship pharmacy director.
While the CHASE program provides antimicrobial stewardship oversight to all UPMC hospitals, it offers particular value to lower-resourced facilities with few resources. The centralized team, which originally consisted of Khadem, an infectious disease (ID) pharmacist, and an ID physician, interact regularly with the pharmacists at hospitals with fewer stewardship resources, providing individual patient reviews and help with local projects.
The approach has delivered benefits. At 13 UPMC hospitals, between 2018 and 2020, antimicrobial usage rates decreased by 16%, with the rates of decline at hospitals with robust internal stewardship programs similar to those at facilities with limited means.2
Although this study concerned antimicrobial use in the inpatient setting, Khadem says the CHASE program works with EDs, too. In both cases, the interactions generally take place through the local hospital pharmacist. “A lot of our sites also have on site an infectious disease consultant. The ED providers can also consult an ID physician to come see their patient ... and make recommendations related to the patient’s infectious disease,” she says. “Sometimes, the ID consultant will confer with the pharmacist in choosing the appropriate antibiotic.”
Khadem says there are plenty of targets on which almost any ED could focus for improvement. “We know that the top three indications for antibiotic use in the hospital are usually pneumonia, UTI [urinary tract infection], and skin and soft tissue infections,” she says. “I would start with one of those disease states.”
Departments without onsite pharmacists may want to start with a clinical pathway for a specific condition. “If the hospital has an EMR that uses order sets, you can embed your preferred antibiotics into the order set,” Khadem says. “A lot of sites try to use [this approach], especially when they don’t have a clinical pharmacist who is monitoring the usage of broad spectrum antibiotics.”
EDs at smaller hospitals may be at an advantage when it comes to identifying providers who are outliers. “We have some teaching hospitals where there are attending physicians, residents, and interns. Sometimes, the person placing the order isn’t always the person who made the decision to prescribe the antibiotic. It can be hard to tie the order to the person who made the decision,” Khadem says.
Without many layers of personnel, it can be easier to track prescribers. Either way, providing continuous peer comparisons of this nature may provide a sustainable way to change prescriber behavior.
Anecdotally, Khadem has observed an uptick in inappropriate prescribing during the COVID-19 pandemic. For instance, she notes some patients who arrived from the community who may not have been severely ill were prescribed antibiotics for a concurrent bacterial pneumonia/COVID-19 diagnosis. However, that is uncommon.
In such cases, the only way to tell whether the illness is exclusively caused by SARS-CoV-2 is by collecting good sputum cultures to see if the patients are positive for bacterial pneumonia. “However, being in the hospital or the ICU for several days alone puts a patient at risk for healthcare-associated infections,” Khadem says. "It is not unheard of that a patient would acquire pneumonia by just being on a ventilator in the hospital.”
Even in these difficult cases, the centralized expertise available through the CHASE program can help providers make the right treatment decisions.
“The model of us reaching out to the local pharmacists at all of our community hospitals, and empowering them with both the knowledge and the confidence to reach out to their prescribers with recommendations — I think that has served as a force multiplier for us,” Khadem says. “We are really efficient at reviewing patient charts and coming up with recommendations ... but we can’t reach out to every single provider on our own.”
Khadem says work remains. A key target for improvement is in the ED. “In the last several years, a big emphasis has been on the inpatient side of things, but I think our model works,” she says.
Recently, the CHASE program added a second ID pharmacist. A software program has made CHASE more efficient. “It alerts us to the [cases or] drug/drug combinations we care about the most, and it is also gives us a new means of communicating with our hospital pharmacists,” Khadem says. “We can text message each pharmacist within the software, and the message is tagged to the patient profile.”
The software also documents the work of the CHASE program. If an intervention is recommended, the hospital pharmacist can indicate whether the intervention was accepted. “The software has increased our bandwidth,” Khadem says. “We are now at the stage where we are setting expectations [on] the amount of time that each hospital needs to dedicate toward stewardship requirements.”
REFERENCES
- American College of Emergency Physicians. Policy statement. Antimicrobial stewardship. June 2020.
- Khadem TM, Nguyen MH, Mellors JW, Bariola JB. Development of a centralized antimicrobial stewardship program across a diverse health system and early antimicrobial usage trends. Open Forum Infect Dis 2022;9:ofac168.
Early advocates of antimicrobial stewardship tended to focus on prescribing in outpatient settings. In recent years, attention has shifted toward the ED — and there are many good reasons for this shift.
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