Antimicrobial resistance impacts almost every department of a hospital, therefore an effective Antimicrobial Stewardship Program requires buy-in and engagement from many stakeholders
Historically, many AMS programs started at a grass-root-level from the pharmacy but we have learned over the years, truly effective programs will need to also involve professionals outside of the pharmacy department, including:
- Medical staff: gain commitment to improving antimicrobial prescribing
- Nursing: contribute to timely collection of specimens and drug levels, administration of antimicrobials, reporting of adverse reactions, management of invasion lines and devices
- Infection prevention: provide a global view of infection trends and educate the providers
- Microbiology: perform diagnostic testing and introduce technology to identify pathogens quickly and accurately
- Information technology: deliver important tools to help clinicians identify patients who need antimicrobials adjusted and gather macro-level data to measure the effectiveness of the AMS program
- Environmental services: deliver a safe and secure patient care environment to prevent transmission of pathogens
- Supply chain: provide key supplies such as PPEs and cleaning agents to bedside clinicians
As engagement from multiple departments is required, it is important to gain executive leadership commitment so that it becomes an organizational priority and trickles down to individual department goals. This is not just a recommendation but rather a standard from the Joint Commission:
Standard MM.09.01.01: The hospital establishes antibiotic stewardship as an organizational priority through support of its antibiotic stewardship program.
Securing hospital leadership commitment for your Antimicrobial Stewardship Program
It is well-recognized that antimicrobial resistance is a major threat to patient safety and healthcare organizations. However, in an age of diminishing operating margins and often significant financial challenges, it can be difficult to compete for financial and human resources from the C-suite to fund a robust antimicrobial stewardship program. Pharmacists should take advantage of the regulatory and accreditation headwinds this year to champion for resources needed to start or expand their antimicrobial stewardship programs.
Understanding your audience’s needs and priorities is important to advocate for your program. Securing hospital leadership commitment often necessitates pharmacists in building a business case to support their initiative.
The financial case for investing in your AMS program
Antimicrobial resistance carries significant costs to every healthcare organization. For example, studies have shown that a C. diff infection increases hospital costs by an average of $17,260 while carbapenem resistance in Pseudomonas aeruginosa increases the cost of care by 42%.
You may project the estimated financial burden of antimicrobial resistance by analyzing the number of cases in the previous year and multiplying that number into evidence-based data as noted above. For example, if your organization had 25 hospital-onset of C. diff infections in the previous year, the economic burden can be approximated by multiplying 25 by $17,260 to arrive at $431,500. Next, consider the impact of antimicrobial stewardship interventions may have in reducing that incidence based on scientific evidence and the likelihood of success at your local level. For example, your organization may experience a higher-than-normal use of quinolones and the use of proton pump inhibitors without a clear indication. With a supportive medical staff also interested in reducing the incidence of hospital-onset C. diff infection, you estimated that your antimicrobial stewardship initiative to reduce quinolones and proton pump inhibitors use may realistically reduce such cases by 20%. The potential cost avoidance can be estimated:
25 cases/year x 20% x $17,260/case = $86,300/year
You may repeat this exercise for the top 3 to 5 antimicrobial resistance issues at your organization and provide a reasonable return on investment number to your C-suite to secure financial commitment to support your program. In addition to making financial sense, emphasize to your organization’s leaders that the Joint Commission clearly states that hospitals must allocate financial resources for staffing and information technology to support your AMS program in its Elements of Performance 10.
This year, pharmacists have further leverage to argue for additional financial resources to support their AMS programs. Many hospitals provide care to Medicare beneficiaries and the Medicare Promoting Interoperability Program is introducing a new requirement to submit Antimicrobial Use and Resistance (AUR) data to National Healthcare Safety Network (NHSN) as part of its Public Health and Clinical Data Exchange objective in 2024. Noncompliance may result in a 75% reduction in the scheduled annual reimbursement increase for acute care hospitals and a reduction of reimbursement of 101% of reasonable cost of care to 100% for critical access hospitals.
Pharmacists should meet with the hospital’s quality and finance departments to discuss the potential monetary impact of non-compliance. Often, downward payment adjustments for Medicare patients are much greater than the cost of allocating the human and technology resources to fund an AMS program.
Identifying your champions across departments
In addition to obtaining leadership and financial commitment to build out your AMS program, pharmacists shall identify and recruit champions from other departments. Informal socialization of your desire to improve antimicrobial use by having conversations with key stakeholders can help you identify potential champions. You may also use data to help you identify patient care areas with persistent resistance problems and orient your conversations to their pain points.
For example, review your aggregate microbiology data to determine units with a high incidence of carbapenem resistance or C. diff. The nurse managers and nurses in such units may experience pain points in needing to gown up before entering a patient room and slowing down their processes. They may be recruited to be a champion if you can paint a future state where their pain points may be alleviated.
In another example, you may secure the support of the director of microbiology if he or she desires to introduce new technologies or instruments to improve turnaround time. Or perhaps the microbiology lab is interested in reducing add-on follow-up resistance testing for new antimicrobials. The most effective AMS leaders will take the time to discern the priorities of each stakeholder and tailor and customize their approaches to increase everyone's engagement to the AMS program.
Key steps to starting; developing strategies to move toward your AMS goals
Once you have identified your key stakeholders to participate in your AMS program, schedule regular meetings to determine your program’s goals. Then determine what strategies and tactics will be necessary to move toward those goals. In newly established AMS programs, we encourage pharmacists to set realistic, achievable goals and incorporate some interventions that are easy, low-hanging fruit, so that you may celebrate small successes early to keep the momentum going.
Of course, data collection is important to document any change from the baseline. In subsequent articles of this series, we will discuss how you would design key metrics and how to collect them quickly to determine if your interventions are moving the needle and if a course pivot is needed.