Community Hospitals Make Strides in Antimicrobial Stewardship

Community hospitals, regardless of size, are developing effective antimicrobial stewardship programs and reaping benefits beyond improving antimicrobial use.

Pomona Valley Hospital Medical Center in California, for example, uses antimicrobial stewardship practices to improve prescribing and prevent the development and spread of drug-resistant microbes.

But the 437-bed community teaching hospital is also leveraging its stewardship program to teach pharmacy students about antimicrobials and to demonstrate the pharmacist's role on the stewardship team.

Soon after they start their experiential rotations, pharmacy students accompany infectious diseases (ID) pharmacist David Ha or an ID physician, or both, on stewardship rounds and make antimicrobial recommendations for specific patients, Ha said.

"I tell students up front that I expect them to be presenting patients independently within a couple days and . . . that, in a very general sense, we expect them to know everything there is to know about the patient," Ha said.

"That leads to a bit of freak-out," Ha said. "But . . . the students are able to recover pretty quickly, and they're able to perform at a very, very high level."

The decision to assign assessment responsibilities to pharmacy students arose because Ha, since mid-2014, has split his time between the hospital and the Keck Graduate Institute School of Pharmacy in nearby Claremont.

"Our ID physician was actually available Monday through Friday. But initially, at least, we couldn't round for stewardship on days I wasn't there," Ha said. By having students participate in rounds in Ha's absence, the hospital gains students' expertise and the students gain valuable experience.

An observational study comparing recommendations made to the patients' primary care providers by pharmacy students, the ID pharmacist or physician, and medical residents found that acceptance rates were 78% when the pharmacy student was the primary assessor, compared with 79% overall. Students were responsible for 61% of the assessments. The study results were presented during a poster session at ASHP's 2016 Midyear Clinical Meeting.

Ha noted that pharmacy students now also participate in nursing rounds for antimicrobial stewardship.

Before facing real patients, Ha said, the students learn best practices and make mock patient presentations. Each student is provided with the hospital's antibiogram and antimicrobial treatment protocols.

Over the 6-week rotation, he said, students may assess and present as many as 100 cases.

"Pharmacy students can make a significant impact," Ha said. "And they can do a lot more than, I think, most people think they can do. They just need the right guidance, the right infrastructure, and the right setting of expectations."

Smaller community hospitals are also reporting benefits from their antimicrobial stewardship programs.

At 186-bed Olean General Hospital in New York, the antimicrobial stewardship program is associated with sharp declines in the use of meropenem and cefepime. A drop in the use of ciprofloxacin also has occurred but has been partly offset by a small increase in the use of levofloxacin.

Olean, part of Upper Allegheny Health System, contracts with CompleteRx to operate clinical pharmacy services, which are managed by clinical pharmacist Paul Green. Green, who presented data on the stewardship program at ASHP's 2016 Midyear meeting, is also the clinical pharmacy manager for 107-bed Bradford Regional Medical Center in Pennsylvania, another Upper Allegheny Health System hospital.

Green said the health system's leadership supported the creation of a stewardship program even before the Joint Commission began requiring hospitals to establish the programs.

He said the stewardship program is an interprofessional team effort at the hospitals.

"Since we don't really have a huge ID presence, we kind of lean on each other," he said. The stewardship work involves nurses as well as infection-prevention, quality-improvement, laboratory, information technology, and clinical education staff.

He said a big focus of stewardship efforts is to improve drug susceptibility trends at the hospitals.

"We're showing year-over-year improvements in some of our broad-spectrum stuff like Zosyn," Green said. "We were able to get that back [to] greater than 90% sensitivity for the first time in years, just this past year," he said of the piperacillin–tazobactam product.

The stewardship program has also helped limit Clostridium difficile infections.

"We've been able to have some success in having less recurrence of C. difficile and fewer cases of C. diff, especially on the hospital-onset end . . . in the last few years," he said. "And we attribute that to . . . getting our stewardship underway and getting people off antibiotics who don't need them."

The C. difficile infection rate has also fallen at 100-bed Rice Memorial Hospital in Willmar, Minnesota, since the hospital established its stewardship program, said clinical pharmacist Nathan Goracke.

The hospital's stewardship program has also produced savings in drug costs. According to data Goracke presented at ASHP's 2016 Midyear meeting, changes to the pneumonia care protocol resulted in a projected savings of $172,000 in drug costs over a 2-year period, including $21,000 in savings on antimicrobial drugs.

Future stewardship projects at Rice Memorial include an assessment of appropriate antimicrobials for the treatment of community-acquired pneumonia and analyses of the overall effects of stewardship activities on antimicrobial spending and use.

Goracke said his hospital's small size promotes daily interactions among healthcare providers.

"We have direct contact with the providers, and they are very accessible to us," Goracke said. "And that has really helped with our stewardship."

Also important for stewardship, he said, is having a good working relationship with local hospitalists.

"It seems like when we get hospitalists onboard with their prescribing habits, other providers who maybe aren't here as often seem to follow suit. So that has really helped us," Goracke said.

Green, at Upper Allegheny, said gaining the support of the hospitalists has likewise helped to advance stewardship efforts.

"Being able to show them the real-life data in their own patients has been important," Green said. He said hospitalists are interested in how antimicrobial use affects the hospitals' antibiogram and how antimicrobial use relates to infection rates.

Goracke, at Rice Memorial, said staffing constraints at the 8-pharmacist hospital pose a challenge to stewardship efforts. But he said the ability to demonstrate financial benefits from stewardship helps to sustain the program. He hopes to eventually be able to demonstrate additional benefits, such as shorter hospital stays.

Green acknowledged similar staffing issues at his hospitals.

"Most of the pharmacists here that are decentralized are doing the stewardship. And they're just doing that on top of all their other work, . . . the kinetics and the anticoagulation and just verifying orders," Green said. "So we had to get over that barrier and show them how important it is and all the areas that could be impacted just by . . . looking at the antibiotics."

He encouraged pharmacists at other community hospitals to make time for tasks like monitoring culture test results and recommending narrower-spectrum medications and i.v.-to-oral therapy conversion, when appropriate, for patients receiving antimicrobials.

"That's really impactful, and anybody can do that," Green said.

[This news story appears in the June 1, 2017, issue of AJHP.]