Antimicrobial Stewardship

Utilizing our present EHR system and unable to find an acceptable alternative we built our own in-house Antimicrobial Stewardship Program to meet all federal, state, CDC and Joint Commission guidelines and mandates.We moved from a paper-based system taking hours with incomplete tasks to now completing mandated antibiotic rules on all patients in less than 3 hours.We did this through the creation of custom health issues to develop advanced patient lists and searches for specific criteria of antibiotic use.

Advanced patient list consists of antibiotic review of all patients after 48 hours, 7 days and 3 or more antibiotics plus a notification for IV to PO conversion.We optimized and automated these functions with a series of custom MLMs, informational columns and an easy to read clinical summary view.The end product allows pharmacists to complete antimicrobial review of all patients, increased pharmacists interventions by 48% and decrease our most common antimicrobial usage by 20%. An overall savings of greater than $900,000 per year has been realized.

Antimicrobial stewardship is mandated by CMS, Joint Commission, many state’s regulatory and other agencies. Almost if not all hospitals have such a program. However, many hospitals have not put forth full effort into implementing these programs to the levels as stated in the CDC booklet The Core Elements of Hospital Antibiotic Stewardship Programs. This is basically the cookbook for having an Antimicrobial Stewardship program.

One issue that comes up is the economic costs and benefits of such a program.

I will address these issues that I believe show conclusively that the time, money and effort spent on an antimicrobial stewardship program saves significantly more money than spent, improves quality, improves hospital morale, and has many intangible benefits which while not quantifiable end up improving a hospitals bottom line expenditures.

Based on our hospitals experiences in the design of our program as well as others, we have collected data showing the significant monetary advantages of implementing a full-fledged antimicrobial stewardship program.

This would include full-time pharmacists preferably infectious disease trained, dedicated to running the program with other dedicated pharmacists serving as backup. It would also include dedicated Infectious Disease physicians who are compensated for their extra time and effort.

It is also necessary that this is a coordinated effort with not only Pharmacy and the Infectious Disease physicians but the Information Technology Department, Infection Control department, and the medical staff. Laboratory, nursing, housekeeping services are often left out but become integral to coordination of care, getting information spread and preventing problems or solving them.

Our own experience and supported by the literature is that we saved over $600,000 per year in antibiotic costs compared to pre-ASP utilization.

Other hard costs savings but not calculated were the decreased number of intravenous bags used and prep time for making them, delivering them to the floors and the nurses delivering and documenting the medication.

Soft costs savings have included decrease length of stay, decreased readmissions, decrease incidence of C. difficile colitis infections as well as decrease incidence and MRSA and MDRO. Our hospital was able to unequivocally demonstrate improvements in anti-microbial sensitivity and decrease C. difficile colitis infections but not MRSA and MDRO. Hospital acquired infections cost on average $35,000 per case extra. These costs can range from approximately $11,000 for a C. difficile infection to $45,000 for a bloodstream infection.

By developing an efficient EHR based computer monitoring ASP system we saved over 6 hours per day in pharmacist time or the equivalent of approximately 2 pharmacist FTE's.

ASP needs for optimization of program

• EHR based, preferably integrated fully.
• Patient lists automatically populated and automatically removed if no longer meets criteria.
• Easy to remove patients from lists.
• Patient list meet all mandated measures and internal needs.
• Patients accessed directly from lists.
• Easy to use and medically inclusive clinical summary to evaluate each patient.
• Able to generate reports.
• Automated processes and clinical decision support (mandated) especially frequent issues such as isolation, positive blood culture and sepsis.
• Antibiotic indications and stop dates.
• Easily accessible list of all antibiotics patient have been treated with during present and even prior admissions, active and discontinued.
• Scheduled times to perform evaluations and meet with infectious disease specialists.
• Ability to contact ordering physicians easily.
• Infectious disease and pharmacy leader and champions.
• Policies on antibiotic use especially restricted one and preferably listed in ordering sections of CPOE.
• Order sets for common processes: sepsis/pneumonia/C. difficile colitis/etc.
• Questionable and complex cases are reviewed routinely at ASP meeting.
• Documentation of interventions by who and why.

ASP advanced patient list: value analysis.

The ASP advanced patient are lists that look for specific patients to meet core measures such as reevaluation of all patients after 48 hours or other high-value targets based on your institutions own experience. Using our own experiences, the 3 highest value patient lists are the 48 hour reevaluation, 3 or more antibiotics simultaneously and the expensive/restricted antibiotic lists. These lists have led to the most amount of interventions. Our largest impact was felt to be the 3 or more antibiotics list in which the pharmacists working with the infectious disease physicians and attending's were able to much more rapidly de-escalate antibiotics even before 48 hour review. The 7 days of treatment list has not proved to be beneficial to review since it had a very high incidence of appropriate antibiotic, involved infectious disease physician and unlikely to make any change in therapy. However, our institution feeling possible overuse use of MRSA antibiotics in patients without any documented MRSA infection, has designed that list. The IV to PO conversion, although mandated and seems to be high-value, these patients tended to be covered in the 48 hour review or other screens. The largest amount of cost savings has been through our expensive/restricted antibiotic patient list.

The best way of documenting soft dollar cost effectiveness and developing value is quantitative measures of interventions for the ASP program in general and then which specific antibiotic interventions are used the most for changes.

Also, beneficial for documenting soft dollar cost effectiveness and value is demonstrating a decrease incidence hospital-acquired infection such as C. difficile colitis, MRSA and MDRO's and improvements in antimicrobial sensitivities on the antibiogram.

• 48 hour reevaluation: mandated, high-value.
• 3 or more antibiotics: high-value
• 7 days treatment: low value
• Expensive/restricted antibiotics: high-value
• IV -> PO conversion: mandated, low – medium value
• Positive blood culture/serious infection: mandated, high-value
• Bug – drug mismatch: ?Mandated?, moderate value
• C. difficile infection: high-value
• MRSA treatment without documented MRSA: moderate – high-value.

Conclusion: Antimicrobial stewardship costs and savings

Having a well-run antimicrobial stewardship program can save significant amounts of money for a hospital in both direct savings as well as significant indirect savings. Based on our own experiences and studies, hospital’s should be able to save between $3000 and $3750 per patient bed per year. This cost is not free. It does include pharmacist time, other personnel involvement and especially Infectious Disease physician buy in and active involvement. In an inefficient system pharmacists can easily spend over 8 hours per day reviewing antibiotic needs. However, with optimized electronic system, review time can easily average about 2 hours per day for core measures and generally around 3 hours per day to include all antibiotic review. The Infectious Disease and other physicians generally should be compensated for their efforts in this program. Eventually, though they learn that these programs do not decrease their number of consultations or patient visits but actually lead to a net increase in their utilization and expertise.

Improved return on investment or soft dollars, indirect, can be best demonstrated by documenting pharmacists ASP interventions and responses.

David Ratto MD

Core Elements of Hospital Antibiotic Stewardship Programs

National Quality Partners Playbook™: Antibiotic Stewardship in Acute Care

Zimlichman E, Henderson D, Tamir O, et al. Health Care–Associated InfectionsA Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013;173(22):2039–2046.

Pa Patient Saf Advis 2010 Sep;7(3):102-7.

Demonstrating Return on Investment for Infection Prevention and Control

G. N. Forrest, T. C. Van Schooneveld, R. Kullar, L. T. Schulz, P. Duong and M. Postelnick, “Use of electronic health records and clinical decision support systems for antimicrobial stewardship,” Clin. Infectious Dis., vol. 59, pp. 122–133, 2014.