Smaller hospitals come to grips with a requirement that is essential, unfunded, and compulsory.
In 2014, California became the first state to require antimicrobial stewardship programs (ASPs) at all general acute-care hospitals in the state. Most major institutions, particularly those affiliated with university teaching programs, already had ASP in place. But for many smaller hospitals, 2015 was a year of learning and transition.
“In a smaller hospital, you probably have limited staff, limited resources; you probably don’t have an infectious-disease-trained physician or pharmacist on site, and you probably don’t have the financial resources to hire them,” said Christine Antczak, PharmD, FCSHP, clinical pharmacy supervisor at Sutter Tracy Community Hospital, a 88-bed acute-care hospital in Tracy, a small town on the outskirts of the San Francisco Bay area. “That means you have to get creative.”
Antczak described some of the strategies that smaller hospitals and the state Department of Public Health have used to create ASPs across the state during a talk at the 2015 American Society of Health-System Pharmacists Midyear Clinical Meeting & Expo.
Leaping into ASP is not a one-time event, she said. Not only will the state require similar antibiotic stewardship efforts at all skilled-nursing facilities by 2017; the Centers for Disease Control and Prevention has recommended that all acute-care hospitals implement ASP.
“ASP is about education, getting everyone to understand the purpose behind antibiotic stewardship,” Antczak said. “Everyone has to be on board with the program, understand their roles, and be comfortable with their roles, so that we can be successful in improving antibiotic stewardship.”
The state-mandated ASP requires a physician-supervised multidisciplinary antimicrobial stewardship committee with at least one physician or pharmacist with training in the area. ASP activities must be reported to hospital quality improvement committees and are regulated by the California Department of Public Health (CDPH).
The legislature voted to require ASP, Antczak noted, but did not fund the mandate. The CDPH is adding ASP to its standard hospital survey. That means hospitals and pharmacy directors must educate hospital staff at all levels about ASP and the need to include ASP as they work with CDPH reviewers.
The lack of state funding also leaves hospitals on their own when it comes to creating stewardship programs. Fortunately, the CDC provides several core elements for hospital ASPs that can guide the way.
These elements include leadership’s dedication of staff, financial, and IT resources; accountability through appointment of a single leader responsible for ASP outcomes; drug expertise to improve antimicrobial use provided by a single pharmacy leader; implementation of at least one recommended action; monitoring of antimicrobial prescribing and resistance patterns; regular reports to prescribers, nurses, pharmacists, and other relevant staff; and ongoing education of clinicians in local patterns of resistance and optimal prescribing.
Creation of an ASP does not have to break the budget, she continued. Hospitals without an infectious disease (ID) specialist may be able to arrange remote access to an ID physician, pharmacist, or both using familiar telemedicine links. Hospitalists can lead the ASP, and non-physician extenders can play key roles.
Pharmacy can step in with automatic IV-to-oral conversion programs, renal dose adjustments, pharmacokinetic dosing, and other familiar interventions. It can also help to start by tracking a single antimicrobial agent or class.
The results can be surprising, Antczak said. Her institution found that carbapenem was being used inappropriately as first-line therapy and was not being deescalated after the first 48 hours of therapy. Pharmacy now deescalates therapy under protocol and automatically discusses alternative therapies with prescribers.
The CDPH is also pushing ASP initiatives under a five-year grant from the CDC. The California ASP Initiative offers assessment tools for existing ASP programs, monthly webinars and conference calls, a toolkit to customize ASP, discussion forums, and access to healthcare-associated infections staff.
An online spotlight provides links to four dozen existing hospital ASPs that have offered to share experience, advice, and resources. A newly expanded online toolkit offers sample protocols that can serve as templates for new and revised stewardship programs.
“Antimicrobial stewardship is an area that is blossoming for our profession,” Antczak said. “Hospitals and skilled nursing facilities are struggling with a lack of resources, and we have the expertise that can make a difference.”