Dr. Hamby is regional director of pharmacy at CHRISTUS Hospital Southeast Texas, Beaumont, Tex.
Experts have estimated that somewhere between one third and one half of antimicrobial use in the United States is inappropriate1? a factor that has a negative impact on the cost and quality of health care. Pharmacists, physicians, and patients all share the blame, with some thinking that the medication would help and others thinking that at least it would not hurt. Science has indicated, however, that widespread, unnecessary use of antibiotics could indeed complicate care.
With this situation have come efforts to correct inappropriate use. Guidelines from organizations including the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America provide recommendations that range from the simple, such as frequent hand washing, to the complex, such as compiling localized data on microbial resistance.
Health care institutions have taken these recommendations seriously, often implementing policies or processes that address these concerns. The appropriate use of antibiotics or antiinfectives should be not just a policy but an expectation. Every hospital in the country has a responsibility.
This responsibility can be a challenge to manage, requiring the resources to collect and analyze data from multiple sources, interpret the analysis into meaningful information, and implement an intelligent policy. These sources include not only patientrelated data, such as laboratory results and medication allergies, but also evidence- based data, such as pharmacologic profiles.
Software systems that integrate this information can help users in all disciplines to more easily manage the data relevant to responsible antibiotic management and to positively impact care. At CHRISTUS Hospital Southeast Texas, this has been most evident in the pharmaceutical department, where both clinical and staff pharmacists have used electronic data and decision making to improve care through increased interventions.
Early this year, the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (SHEA) published guidelines, created in collaboration with 6 additional associations, to assist institutions in developing programs to enhance antimicrobial stewardship. According to the document, the primary goal of any such program should be to maximize clinical outcomes while minimizing the unintended consequences of antimicrobial use, such as toxicity, the selection of pathogenic organisms, and the emergence of resistance.1
Their suggestions include the formation of a multidisciplinary antimicrobial stewardship team with recommended personnel, disciplines, powers, and support. This team may approach stewardship using 1 or 2 suggested strategies: prospective audit with intervention and feedback and/or formulary restriction and preauthorization.
Evidence exists that prospective audit with intervention and feedback by appropriate personnel can decrease the inappropriate use of antimicrobials.1 It also shows that formulary restriction and preauthorization can cause an immediate and significant reduction in antimicrobial use and cost during a nosocomial event, but long-term benefits are not as clear.1
Either or both of these methods should be supported with additional efforts that include the following:
Before the installation of STELLARA Clinical Intervention and Patient Monitoring software from bioM?rieux Inc (Durham, NC), pharmacists at CHRISTUS reviewing medication orders had to go through multiple records, pulling patient laboratory histories and results as well as medication profiles. The time-consuming process could mean untimely delivery of the appropriate therapies. Drug?drug interactions and adverse events could occur, or the drug assigned might not completely match the patient?s infections.
STELLARA alerts users to these conditions, using decision-recommendation technology powered by TheraDoc Expert System Platform. The integration of online evidence-based literature references allows clinicians to incorporate the strongest evidence into their daily practices.
The software tool offers flexibility in reporting, allowing users to customize reports and set parameters for workflow management, intervention opportunities, and priorities. CHRISTUS pharmacists have flags to indicate possible interventions, including changes in therapy, agent, or dose.
Prior to the system?s installation, CHRISTUS pharmacists would write their own professional reports to personally deliver to clinicians. Pharmacists were reluctant to have this interaction. This information interaction exchange activity, however, will be an important part of pharmacy in the future, especially in institutions.
To bring pharmacists to a level where they would be comfortable intervening regularly, I wanted to standardize and automate the process?which a computerized program would allow. If a system can pull the information from a number of different sources into 1 place, it can save time.
STELLARA was implemented in a staged rollout, first with clinical pharmacists, who handle departmental responsibilities, and then with staff pharmacists, who work with individualized patient reports. These reports, delivered daily, include recommendations regarding changes in response to new patient medications and/or physiology as well as antibiotic-susceptibility reporting.
Each staff pharmacist is responsible for a given patient population that he or she addresses throughout the day. No longer do clinical pharmacists travel through the hospital all day.
Armed with the clinically relevant data and discussion tips, the staff pharmacists have increased confidence and increased abilities. The process has worked.
The hospital has gone from no staff pharmacist interventions to 40 to 60 a month. In fact, interventions have become so prevalent that I intend to rewrite job descriptions to include intervention activity. The role of a pharmacist is changing from a technical function to expertise in information management and in the interface with other disciplines.
The hospital pharmacists were wary of the new system at first, suspecting that it would involve more work. The hospital did want more documentation but developed innovative ways to create it. Previously, the facility had zero documentations from staff pharmacists, but the new system has enabled a number of ways to document interventions. Pharmacists can perform these simple tasks themselves or send orders to the clinical pharmacy department for assistants to log them in.
Prior to the system installation, there were challenges not only with creating documentation, but also with associating value with pharmacist interventions.
Two years ago, the department used reports to the pharmacy and therapeutics committee to determine that the total value of interventions performed on a monthly basis had a modest value of about $20,000. In recent months, that value has risen to $80,000. A direct comparison of data from February and March of 2006 and 2007 illustrates the savings further: total intervention values in February and March 2006 were $17,800 and $9,401 respectively; in 2007, the numbers were $66,360 and $80,119, respectively (Figure).
The department also has greatly decreased its expenditures?consistent with average reports with similar installations. Comprehensive programs have consistently demonstrated a decrease in antimicrobial use, by 22% to 36%, with annual savings of $200,000 to $900,000 in both larger academic hospitals and smaller community hospitals.1
By annualizing numbers, the value of a staff pharmacist can be well-documented. Empowered pharmacists will have an even easier time performing interventions, allowing the antimicrobial stewardship program to improve patient care and be financially self-supporting. The advice pharmacists dispense then becomes as valuable as the medication.
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