Guest Column | January 30, 2017

Antimicrobial Stewardship Programs: Overcoming 5 Barriers To High Performance

antimicrobial resistance

By Steve Riddle, PharmD, BCPS, FASHP, director of clinical development with Wolters Kluwer, Pharmacy OneSource Solutions

Hospitals and health systems increasingly recognize the importance of antimicrobial stewardship. Concerns over the growth of antibiotic-resistant organisms are prompting unprecedented action on the national and international stage.

For instance, 2107 will usher in new requirements from the Joint Commission governing the implementation of formal antimicrobial stewardship programs (ASPs). The Centers for Medicare and Medicaid Services also introduced a proposed rule in 2016 to add ASP structure and processes to their Conditions of Participation. This rule is expected to be finalized in 2017 and will also heighten requirements for ASPs.

In truth, the evolution of regulatory oversight is expected to continue following recommendations laid out in the National Strategy for Combating Antibiotic-Resistant Bacteria. While hospital and health system executives increasingly recognize the need for high-performing ASPs, the reality is many programs remain understaffed and underfunded, lacking the infrastructures and workflows needed to deliver the desired return on investment (ROI).

The good news is high performance is achievable when the right combination of advanced clinical surveillance, clinical decision support (CDS), and governance exist. And the value proposition is substantia, delivering ROI in the millions for many health systems. Healthcare organizations face five key barriers to effective ASP implementation: clinical knowledge, finances, physician buy-in, the right data, and the infrastructures needed to streamline processes and support regulatory compliance. Outlined below are best-practice considerations for overcoming these obstacles to mature ASP initiatives.

Barrier 1: Clinical Knowledge

Treating infections is complex business, and many clinicians simply lack knowledge when it comes to choosing the best antibiotics. Differing opinions around best practices exacerbates the situation, leading to treatment inconsistencies and excessive prescribing practices. In fact, the Centers for Disease Control and Prevention estimates between 20 and 50 percent of antibiotics prescribed in the U.S. are either unnecessary or inappropriate.

The foundation of a high-performing ASP begins with knowledge and expertise. As such, hospitals and health systems must assess and correct deficits. Leveraging a pharmacist or physician trained in infectious disease — ideally both — to lead a multi-disciplinary ASP team is an important first step. The next step is defining guidelines and standards to eliminate variation and then operationalizing them across prescribing physicians.

Technology can play an all-important role in making this happen. The reality is infectious disease resources are limited in today’s healthcare climate and expected to become scarcer as demand increases. Thus, most healthcare organizations cannot provide 24/7, in-house consultation when issues arise. When advanced surveillance technology and CDS is leveraged to guide treatment, healthcare organizations are much better positioned to address variation and improve the outlook.

Barrier 2: Finances
It’s no secret hospital revenue margins are decreasing and many high-level initiatives are competing for increasingly scarce dollars. Thus, clinical leaders must clearly communicate the antimicrobial stewardship opportunity. While extensive literature exists documenting the negative impact of inappropriate antibiotic use on outcomes and costs, the most compelling presentation often begins with an internal assessment of challenges and opportunities.

In addition, current regulatory drivers make the business case for ASPs a much easier one to make. The reality is today’s C-suite must often delineate between clinical initiatives that are nice and those that are necessary based on their limited resources. Regulatory requirements give antimicrobial stewardship the teeth and momentum that it may have lacked in the past.

Any process improvement initiative considered in today’s lean healthcare climate must run as efficiently and effectively as possible. It is in this area that clinical surveillance technology can notably improve the outlook on ASP investments. Real-time surveillance infrastructures aggregate needed patient data, providing the most up-to-date information to move processes from reactive to proactive. It is not uncommon for clinical teams to realize a double to five-fold increase in interventions related to antimicrobial prescribing practices.

Barrier 3: Physician Buy In

One of the hardest issues to address with antimicrobial stewardship — especially when gray areas exist with best practices — are long-standing physician prescribing practices. Any time a hospital or health system requests physicians change how they approach treatment, there must be solid evidence and established trust to back up the request. Otherwise resistance or push-back can marginalize the effectiveness of an ASP.

Clinical leaders in charge of operationalizing an ASP are wise to lay the groundwork for getting physicians on board with data — covering both internal physician prescribing trends and industry evidence. Historical data aggregated within a clinical surveillance system can detail how physician prescribing practices compare on the peer level and against industry best practices. Then, clinicians knowledgeable in infectious disease and stewardship can educate staff regarding needed changes.

Barrier 4: The Right Data

Having the right data at the right time is critical to proactive, impactful ASPs. In addition, consistent application of clinical rules and best practice guidance helps minimize variation and poor prescribing practices.

Technology is critical to successfully positioning a high-performing ASP as manual processes for identifying patient issues and tracking antimicrobial use often make proactive response impossible. Specifically, clinical surveillance technology eliminates the need to manually aggregate data and ensures clinicians always have a real-time snapshot of antimicrobial issues. Also, CDS systems help ensure that clinical rules and recommendations by clinical leadership are applied consistently resulting in less variation in care.

Barrier 5: Infrastructure And Tools
Clinical teams leading ASP initiatives need tools at their disposal that enable real-time identification and tracking of antimicrobial issues, prescribing patterns and antibiotic use. Specifically, clinical teams are best positioned when solutions support development of dashboards, clinical rules and reports that automatically fit into clinician workflows. The outlook is even better when these tools require minimal internal IT support. In addition, robust functionality for tracking antimicrobial use trends for regulatory reporting and internal process improvement initiatives is an important consideration for future positioning. The most advanced clinical surveillance solutions provide actionable, evidence-based information at the point of care that enables clinicians to immediately address issues, optimize quality and deliver consistent care.

Moving Towards High Performance

As regulatory expectations heighten, hospitals and health systems must do more than simply check off boxes that antimicrobial stewardship processes exist. A high-performing ASP not only tracks key information but also uses it to empower the continuous quality improvement process by creating the feedback loop between identification of a gap in care, implementation of a solution and measuring the response. Forward-thinking healthcare organizations are leveraging an advantageous combination of advanced clinical surveillance, CDS and governance to move ASPs from infancy to maturity.

About The Author

Steve Riddle, PharmD, BCPS, FASHP, is the director of clinical development with Wolters Kluwer, Pharmacy OneSource Solutions.