Sandra Fyfe

Implementing rapid diagnostic technologies (RDTs) into a health system can improve outcomes for patients and may be helpful in reducing unnecessary antibiotic use, according to data presented at the 2019 Annual American Society of Health-System Pharmacists Midyear Clinical Meeting & Exposition.

Katie Lusardi, PharmD and Clinical Pharmacist of Infectious Disease and Antimicrobial Stewardship at the University of Arkansas for Medical Sciences and Brandon Hill, PharmD and Clinical Pharmacist of Infectious Diseases at University of Virginia Health reviewed the multitude of RDT platforms available to practitioners and noted the role these technologies can play in collaborating with antimicrobial stewardship programs (ASPs). 

Dr Lusardi noted that all platforms for RDT offer organism identification, while some also give markers for antibiotic resistance and susceptibility results. There are a wide variety of blood and respiratory RDT platforms available, she said, but RDT are only impactful when the data are available quickly, in conjunction with active interventions to help guide antibiotic decisions. 

There are a number of benefits to RDTs, according to Dr Hill. He noted that high rates of hospital-acquired infections can lead to a lack of reimbursement from the Centers for Medicare and Medicaid Services (CMS), but showing how RDTs can impact patient care and the use of antimicrobials may convince the hospital “C suite” staff to invest in more of these technologies. 

publicly reported data available to patients on Medicare.gov

 to demonstrate to hospital administrators that RDTs can improve facility standings. Effective and timely care can improve sepsis recognition and management, he said. 

As of March, hospitals are being asked by CMS to establish ASPs, and RDTs can help facilities gain traction in reducing unnecessary antibiotic use. 

Dr Hill connected how using RDT can play a role in helping to fulfil the some of the CDC’s Core Elements of an ASP:

RDT helps clinical pharmacists streamline the process for identifying appropriate treatment options and ensuring those medications are administered in a timely manner.

RDT helps with prospective audit and feedback and offers measurable outcomes.

RDT results can be used to monitor compliance with ASP recommendations and can provide a tangible outcome to be tracked following implementation.

ASPs can use RDT to facilitate communication with key stakeholders on outcomes, and results can show pharmacy activities and their impact.

Educating administrators and clinicians on RDT can improve acceptance when beginning a new initiative; providing RDT data to raise confidence in ASP and new technology.

Dr Hill noted that the Society of Infectious Disease Pharmacists (SIDP) have stated that “RDTs are 1 strategy for ASPs to achieve goals set forth by Joint Commission’s antimicrobial stewardship requirement in the acute care setting,” and the Infectious Disease Society of America (IDSA) has backed using RDTs as part of an ASP.

The most important outcomes of RDT are reducing inappropriate antimicrobial use and patient-specific outcomes such as mortality. Although the initial cost of setting up an RDT can be high, the cost pays off in effective implementation, Dr Hill added.

To persuade hospital leadership to embrace purchasing more RDT technologies, Dr Hill suggested enlisting an interdisciplinary group, incorporating goals and a vision for the health system, and highlighting previously published studies that show patient and institution specific benefits of RDT.

Although the literature are limited in showing that respiratory-focused RDTs decrease unnecessary antibiotic prescriptions for respiratory diseases, in some studies, RDT usage has been connected with a shortened time for patients to receive antivirals. More promising results are seen with RDTs for positive blood cultures. Several studies have shown reduced antimicrobial consumption, and time to effective therapy with RDT results are combined with active ASP interventions, when compared to RDTs alone or traditional laboratory methods.

Dr Hill urged attendees to prepare a detailed RDT proposal that predicts changes in outcomes of interest such as potential clinical and financial benefits. Implementation also should have regular updates on the impact of RDT in collaboration with an ASP based on pre-determined tracking and reporting methods. Finally, Dr Hill said that development of a structured algorithm for implementing RDT and ASP interventions are key in successfully implementing these strategies.

Lusardi K, Hill B. Rapid diagnostic technologies and antibiotic stewardship: better together [210-L01]. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8, 2019. Las Vegas, Nevada.

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RDTs can improve outcomes and reduce unnecessary antibiotic use. 

Rapid Diagnostic Technologies Can Play a Role in Antimicrobial Stewardship Programs

A pharmacist-led, hospital-based infusion center based in Teaneck, NJ has been successful in both controlling costs and implementing a comprehensive, integrated care team, according to a presentation at the annual American Society of Health-System Pharmacists Midyear Clinical Meeting & Exposition being held in Las Vegas this week.  

To begin her presentation, Nancy Palamara, PharmD, the Director of Pharmacy Services at the Infusion Therapy and MS Center at Holy Name Medical Center in Teaneck, NJ opened her presentation with what she dubbed “mysterious case of the ‘high cost pharmacy.’” She noted that the hospital where she worked had the lowest cost in every area except drug spending when compared to all hospitals in the state. In fact, she explained, their hospital had the highest drug spending.  

Palamara attributed this to the hospital “doing such a good job of controlling inpatient costs” that it skewed the results. She attributed the highest spend to having a lack of control in outpatient spending, where there was “far less control and no contract negotiating.” As a solution, a team was created to help manage costs that could be controlled outside, such as maximizing reimbursement. The team also reached out to hospital management and implemented a program where the infusion team reported into a few pharmacy managers, rather than falling into the model that had been in place, which was the oncology department. 

Palamara explained that pharmacy managers can play a strategic role in hospital settings because they can provide two essential skill sets in their role. The first skill set centers on clinical training, where pharmacists offer skills such as direct patient care and help with continuity of care and medication assistance. Secondly, pharmacists have operations skills such as an understanding of supply chain, improving processes, and streamlining workflow. This knowledge ensures the best patient care and best practices for cost saving and smooth operation.  

Despite these skills sets, Palamara noted that those involved in the infusion department were initially skeptical. She acknowledged that some of the nurses in the center were resistant to be managed by non-nurse staff, which she attributed to a misconception that pharmacists are largely science and operations oriented rather than staying centered on compassionate patient care. In addition, pharmacy managers do not have the same level of support staff as nurses. This means they need to be sure they spend enough time with pharmacy staff and finding time to make the rounds, Palamara noted in her presentation. 

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After two years of implementing the pharmacy manager model in the infusion unit, however, Palamara said the outcomes have been a patter on better communication with fully engaged nurses who now embrace the model and are now working as a “truly interdisciplinary care team.” The culture of the clinical setting had also greatly improved, she said.

She attributed the success to the open-mindedness of her C-suite staff, who embraced the concept the pharmacy staff support, the work of the director/manager, the clinical pharmacy specialists, the nurses. and the administrative assistants working as a collaborative care team. 

Palamara N, Schiller D, Tichy EM. Advancing pharmacy practice with strategic clinical leadership [208-L04]. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8, 2019. Las Vegas, Nevada.

Pharmacists provide clinical training and operational skillsets.

Pharmacy Managers as Strategic Leaders: What Is the Effect?

Despite some reductions in the overall antibiotic resistance problem, much more work needs to be done, according to a presenter at the 2019 Annual American Society of Health-System Pharmacists Midyear Clinical Meeting & Exposition.

Captain Arjun Srinivasan, MD, who is associate director for Healthcare-Associated Infection Prevention Programs with the Centers for Disease Control (CDC) began his talk by explaining that every year in the United States, 2.8 million people have an infection that resists first-line antibiotic treatment. 

Dr. Srinivasan noted that although there has been progress in health care settings, over the past 5 years there have been important reductions in some areas, other organisms, like drug-resistant gonorrhea, present ongoing challenges.

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He noted that the Centers for Medicare and Medicaid Services (CMS) has urged health systems, by March of 2020, to implement Infection Control and 

programs for all acute care and critical access hospitals in the United States. 

He noted that the CMS recommendations align with the 7 Core Elements of Antibiotic Stewardship outlined in 2014 by the CDC. Srinivasan said that the number of hospitals that self-report they have implemented all 7 elements of these stewardship recommendations has increased from 41% to 85%, and, he noted, every type of hospital from larger to smaller health systems have reported progress.

Dr. Srinivasan detailed a number of important enhancements under each Core Element heading, specifically:

 – Hospital leaders must ensure their facilities invest enough time, money, lab equipment and IT technology. Top executives are urged to meet with the stewardship team to understand what resources are necessary to meet antibiotic stewardship goals. Top leaders should be kept informed of progress.

 – There is a need for program management and outcomes that should be co-led by a physician and a pharmacist. Leadership requires collaboration and good communication skills. Dr. Srinivasan reported that 59% of current programs are currently co-led by a physician and a pharmacist, and he said, these programs are the model to follow.

This wording has been updated from the earlier recommended “Drug Expertise” to better reflect the role of pharmacists and showcase their vital importance this area, he said. Dr. Srinivasan added that most US hospitals don’t have access to infectious disease-trained pharmacists, so general clinical pharmacists need to be supported with education and resources.

This involves implementing the antibiotic interventions. The top two priorities Dr. Srinivasan noted were prospective audit and feedback, and reviewing therapy, where an expert gives providers feedback on antibiotic interventions. Providers are encouraged to seek preauthorization–currently only 41% do. They should also seek permission for certain restricted antibiotics. The third priority is to have facility-specific treatment guidelines. Srinivasan said focus was needed on 3 conditions that are most often prescribed antibiotics: lower respiratory infections, urinary tract infections, and skin and soft tissue infections. Providers are urged to follow treatment guidelines, optimize therapy length, have better urine culture practices, and narrow spectrum therapy for skin and soft tissue infections for antibiotic stewardship.

Facilities should report on use and resistance to prescribers, pharmacists, nurses, and hospital leadership regularly, and share information among different types of hospitals. Providers should compare reports with peers, and summaries should be regularly shared with leadership and hospital board, Dr. Srinivasan explained.

Teaching adverse reactions, resistance and optimal prescribing to prescribers, pharmacists, and nurses is a necessary aspect of stewardship. Srinivasan said case-based teaching is especially effective. Information should also be tailored to a specific provider group. In addition, providers need to better educate patients about judicious antibiotic use. 

Prescription monitoring, intervention impact, and disease resistance patterns need to be tracked, Dr. Srinivasan said. Outcome measures, process measures of adherence to treatment guidelines and recommendations should be tracked and reported; hospitals report data to CDC’s National Healthcare Safety Network Antibiotic Use option to benchmark use.

Multiple measures are needed to ensure implementation, Dr. Srinivasan said. The use of the Standardized Antimicrobial Administration Ratio (SAAR), a ratio of actual use to predicted antibiotic use can facilitate tracking of antibiotic use.

“Predicted use is modeled based on all data submitted and is risk adjusted based on a variety of hospital characteristics, but not on any patient level factors,” Dr. Srinivasan said. SAARS was endorsed by the Quality Forum 2016 and can be used for different groups of antibiotics, adult and pediatric locations, ICU and non-ICU locations, and calculated at individual unit level or hospital wide.

Many facilities have rates of use greater than 1 (

using more antibiotics than other hospitals

). Dr. Srinivasan stressed that SAARS just records rates of use and not appropriateness. He pointed out that higher rates of use are a reason to investigate that particular location, and added that 25% of locations are using 20% more antibiotics worldwide. “This is a new metric and we are still trying to understand what the values mean,” he said.

Changing prescriber behavior and “helping find the bright spots,” meaning, following behaviors that are effectively reducing unnecessary use of antibiotics are both key in reducing antibiotic resistance. 

In outpatient settings, Dr. Srinivasan emphasized that providers can tell patients that avoiding unnecessary antibiotics can protect them. Educating patients can also help them avoid adverse drug reactions and avoid disruption of the microbiome, which can increase the risk of sepsis.

Dr. Srinivasan urged a collaborative process in creating stewardship programs because it provides partnership and solidarity between different providers. While the CMS is now urging antibiotic stewardship in all hospitals, it needs to be enforced to work, he said. 

Dr. Srinivasan noted how bedside nurses play a critical role–because they administer antibiotics. They can prompt the provider and care team, and educate the patient and family, he said. He also emphasized the pharmacist’s role in helping with antibiotic stewardship: pharmacists can verify penicillin allergy, avoid duplicate anaerobic coverage, deescalate anti-MRSA coverage by confirming infection, avoid treatment of ASB, and limit antibiotic duration when symptoms improve. 

According to Dr. Srinivasan, the CDC is urging judicious antibiotic use accreditation for urgent care centers. They are also working with the Health Services Resource Administration to reach out to federally qualified rural health care programs to improve antibiotic stewardship. CDC officials are also working with National Center for Quality Assurance to expand health Effectiveness Data information Set measures for outpatient prescribing.

Srinivasan A. CDC update 2019: Antibiotic stewardship in America’s hospitals [337-L04]. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8, 2019. Las Vegas, Nevada.

Health systems urged to adopt antibiotic stewardship programs by March 2020. 