Improve the efficiency of your antimicrobial stewardship program
Improve the efficiency of your antimicrobial stewardship program
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Hospital and pharmacy leaders will be focusing more attention on antimicrobial stewardship in 2010 as this area is expected to receive increased regulatory scrutiny.
Many hospitals have antimicrobial stewardship programs in place. But one question hospital pharmacists should be asking themselves is "How efficient and effective is my program?"
For instance, one approach to antimicrobial stewardship is for a hospital pharmacist to conduct a prospective audit, reviewing patients' antimicrobial medications to see what they are being prescribed, what the doses are, their body weight, and other demographics and restrict the medications choices, says Robert C. Owens, Jr., PharmD, co-director of the antimicrobial stewardship program at Maine Medical Center in Portland, ME.
The other approach is a back-end model in which a pharmacist reviews what has already been prescribed and makes recommendations for changes when appropriate.
At Maine Medical Center, an infectious diseases pharmacist, an ID pharmacy resident, and an ID physician review patients receiving antimicrobials for suggestions to improve use, Owens says.
"Do we get to all the patients today?" he says. "No, we try to make it efficient."
One way they improve efficiency is through reviewing reports for the low-hanging fruit, he says.
"We make dosing adjustments based on patients' body weight," Owens explains.
For instance, a typical example is the 40-year-old, 160-kilogram man who has uncontrolled diabetes and a diabetic foot infection and who surely needs more vancomycin than the 1 g every 12 hours prescribed to him. Or, the 50-kilogram woman who is 91 years old requires less than 1 g of vancomycin every 12 hours. Still, physicians often will prescribe the same dosages, regardless of the patient's body weight, and pharmacists can catch these errors and correct them, Owens says.
"One gram of vancomycin is what everyone prescribes, regardless of age and body weight," he adds. "A 23-year-old will clear vancomycin like the wind and may require 1.5 g every eight hours, instead of the traditional dosage."
So the low-hanging fruit are cases in which the dosage does not correspond with the patient's weight and age.
"We're working on sending out alerts where if someone has a trough value out of range, then we'll get those reports back to make sure nobody falls through the cracks," Owens says.
It often is up to pharmacists to make antimicrobial stewardship a priority because as hospitals' patient populations increasingly are sicker, older, and more complicated medically, physicians move antibiotic-related issues down the priority list, he notes.
"Physicians logically address the top concerns of the day and move on," Owens says. "My job is to make certain that antibiotics are in the top 3, and if not, then I can help them with antimicrobial stewardship."
Owens works with an infectious diseases physician and an infectious diseases pharmacy resident, who recently have become part of the stewardship program.
"So now we have a team of three, and we'll be able to become more efficient," Owens says. "We divide and conquer: We each take a handful of reports, go through those reports, and identify perhaps 20 patients who need to be seen and others we can easily help."
When the antimicrobial stewardship team gives feedback to physicians, they use a nonconfrontational style, often leaving notes that identify the patients who need an intervention, he says.
More than two-thirds of the recommendations are made in notes, and nearly a third is made through phone calls or face-to-face interactions, Owens says.
"We have a two-part carbonless form we leave in the chart as a recommendation, and we explain in the recommendation why we suggest this and give them an educational vignette," Owens says. "This doesn't step on toes as much as a restrictive program, where you have to go through an individual to get the antibiotic you want."
Also, the notes, written on 1.5-inch long sheets of yellow paper are not kept as a permanent part of the medical record, he adds.
So this gives Owens the freedom to get physicians' attention with wording that might say, "This regimen will increase the likelihood of mortality by 50%."
Pharmacists follow-up on those notes with an immediate phone call, and the form is left as a reminder to those who follow, including other medical/surgical teams that might be following the patient, Owens says.
He'll include references to studies on the topic.
"They are often appreciative of that," Owens says. "It's so significant that you leave a note behind for educational purposes and that the note gets pulled at discharge, so it's not kept in the medical record or in the progress notes."
This retrospective method works well in a hospital that mainly has community physicians, he adds.
The restrictive method will create interpersonal problems and ultimately lead to long-term problems, he says.
"It creates adversarial relationships in many cases," Owens says. "Restrictive methods work because physicians will use the nonrestrictive drugs more often because they don't have to go through a gatekeeper, but sometimes the nonrestrictive drug might be the inappropriate one."
The model employed at Maine Medical Center is one that has potential to lead to better outcomes over the long-run, he adds.
When there is a medication problem that requires immediate attention, the pharmacist will contact the prescriber immediately and explain why the prescription needs to be changed, Owens says.
The passive notes method also works to educate physicians about excess durations of therapy, and those interventions often get a call too.
For example, if a patient has ventilator-associated pneumonia and has been receiving antibiotics for too long, the note might say, "Day 11 of 8 for ventilator-associated pneumonia," Owens says. "The doctor might come by and say, 'I should have stopped on day 8.'"
So that's a subtle way to get the message out to not only the prescriber, but to others on the medical team, he adds.
"If you don't leave the note the therapy might be changed, but the education is lost between you, me, the prescriber, and the 12 other people following the patient," Owens says.
Because of this intervention, the hospital has one of the lowest antibiotic utilization rates for a hospital of its size, Owens notes.
One more key to an effective and efficient antimicrobial stewardship program is continuing education even when it seems that everyone gets it.
"What I've learned is you can do this hard and heavy for seven months and then interventions go down for several months," Owens says. "But at the end of those three months, it magically goes back up, and you're doing 20, 30 interventions a day again."
Pharmacists can educate about antimicrobial stewardship, but they can't stop the education.
"If prescribers don't continue to hear something, they'll go back to what they were taught," Owens says.
Hospital and pharmacy leaders will be focusing more attention on antimicrobial stewardship in 2010 as this area is expected to receive increased regulatory scrutiny.Subscribe Now for Access
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