Metrics That Matter

LifePoint Health Receives 2018 HealthTrust Innovation Grant for Advances in Antimicrobial Stewardship

Just a year after starting a systemwide antimicrobial stewardship program, Brentwood, Tennessee-based LifePoint Health reported significant achievements in promoting the appropriate use of antimicrobials at all of its facilities (numbering 72 at the time). In June 2016, when the enterprisewide initiative began, just five hospitals had signed letters of support from hospital administrators for antimicrobial stewardship. By June 2017, that number jumped to 67. In the same time period, antibiotic spend per adjusted patient day dropped from $6.75 to $6.34, which represents a $1.6 million (9.4 percent) savings to the organization.

Physician leaders were energized by the progress and ready to accelerate efforts at the hospital level, but they challenged system administrators to provide better, more meaningful data.

The antimicrobial stewardship team is led by clinical leadership from LifePoint’s Health Support Center, including Ken Gagnon, PharmD, vice president, pharmacy services; John Theobald, PharmD, group director, pharmacy services; and Chris Frost, M.D., national medical director. This team had already supplied a number of key metrics to hospitals, such as days of therapy and antibiotic spend per adjusted patient day, but those only provided a high-level picture of antimicrobial use.

“Our data was fairly rudimentary,” Gagnon says. “It gave us an idea about antimicrobial consumption overall, but it wasn’t detailed enough to give us the ability to impact care going forward.”

At the same time, LifePoint Health was also looking for a less labor-intensive way to comply with the National Healthcare Safety Network’s (NHSN’s) antimicrobial usage and resistance (AUR) reporting program.

“Right now, reporting is voluntary,” Theobald notes. “We’re fairly certain that it’s going to be mandatory in the next year or so. We’re doing what we can to prepare for it and other eventual reporting requirements, such as those likely to come from the Centers for Medicare & Medicaid Services (CMS).”

In addition, LifePoint Health reports data for the Leapfrog Hospital Survey of which AUR reporting is included. The reporting tool could help ensure LifePoint meets upcoming requirements from the CMS—the NHSN’s AUR reporting is one of the Additional Public Health Registry options for Meaningful Use 3.

Together, these needs led the antimicrobial stewardship team to develop and implement a related reporting tool that simplifies compliance with reporting requirements and 
provides facility leaders with the detailed data they need to encourage appropriate and cost-effective use of antimicrobials.

Curbing Infections & Costs

Because of LifePoint’s efforts, HealthTrust recognized the implementation team, representing eight distinct departments within the organization, as the recipient of its 2018 HealthTrust Innovation Grant. Valued at $50,000, the grant will help offset the cost of further developing the in-house tool and provide HealthTrust expertise to advance the organization’s reporting capabilities.

“Misuse and overuse of antimicrobials is one of the world’s most pressing public health problems,” says John J. Young, M.D., chief medical officer of HealthTrust. “People infected with antimicrobial-resistant organisms are more likely to have longer, more expensive hospital stays, and may be more likely to die as a result of an infection. By tracking, reporting and taking action based on these data, LifePoint will help curb hospital-acquired infections and improve the cost, quality and outcomes associated with treating them.”

Initially, the team considered an outsourced solution. But given LifePoint’s unique needs, which included consolidating and normalizing data from nine disparate electronic health record (EHR) platforms, the cost was just too high—$700,000 plus an annual maintenance fee of $235,000—for a tool that could not deliver the full range of services that stakeholders sought.

Developing the in-house reporting capability presented a cost-savings opportunity, but success required an all-hands-on-deck approach that went beyond the team’s initial expectation.

“That first meeting about the tool included just four or five people,” Frost says. “By the next month, we had to move the weekly meetings into a bigger room. Every team member we added allowed us to further modify the tool to meet the demands of all of our stakeholders.”

LifePoint service lines that played a role in the development and implementation of the reporting tool included supply chain operations; pharmacy services; health informatics and technology services; quality operations; enterprise data and program management services; physician services; nursing services; and diagnostic imaging services.

“This project proved that antimicrobial stewardship belongs to the entire organization, not just to pharmacy,” Gagnon says. “Unlike other drugs, antibiotics have a transmissible loss of efficacy over time. Because of that, it really takes the entire organization to support this.”

Refining the Reporting

While the team indicates the reporting tool can potentially be used for many metrics, including those outside of antimicrobial stewardship, it started where the need was greatest—days of therapy.

In May 2018, not even a year after the initial team meeting, the first detailed days of therapy report was generated. Using Power BI, a Microsoft platform, the tool automatically pulls data from EHRs on a weekly basis, giving hospitals as close to real-time reporting as possible on days of therapy, antimicrobial resistance, and the benchmarking and trending of operational, clinical and financial outcomes. The dashboard is interactive, allowing viewers to sort by a variety of metrics, including medication class, medication, disease state, prescriber and patient location, such as med/surg or ICU.

The reporting tool is currently available at 32 hospitals, all of which utilize two of the nine LifePoint EHR platforms. By the end of this year, the team expects the tool to be in place at 90 percent of its hospitals. For now, it’s being used as needed, but Gagnon expects quarterly reports will be distributed once the tool has been implemented at more facilities.

Gagnon adds, “We know each hospital has different needs, so the quarterly reports provide enterprise-wide data to identify and drive change for the organization. We also plan to produce an annual report for all LifePoint facilities that provides more focused details around specific opportunities for appropriate antimicrobial use.

“For example,” he continues, “one hospital might have a quinolone problem so we want to give an individual facility the flexibility to drill down into what their pain points might be. In a 
standardized report, those might not be as visible.”

The team also has plans to roll out additional reporting modules, including order set utilization, adherence to sepsis bundles and other clinical pathways targeting various infectious diseases like C. diff. Frost says these should help the organization pinpoint variations in care, which will provide an opportunity to enhance clinical care and identify potential cost savings.

“When you look across a healthcare organization of our size, you will see a fair amount of unintended clinical variation,” he says. “There are circumstances where practicing outside traditional guidelines to meet the clinical needs of a specific patient is appropriate.

“However, a significant amount of the variation we see is not this type of intentional decision-making, “ Frost says. “Instead, the variation is driven by non-adherence to evidence-based guidelines. Appropriate use of antimicrobials and the decision to de-escalate antimicrobials are two examples where this type of variation exists. In order to identify these opportunities, we need robust, detailed reporting. This type of reporting will help us improve clinical care and improve our overall efficiency.”

Continuous improvement is a key part of any product lifecycle, and this reporting tool is no different.

“We know there’s still work to be done,” Gagnon notes. “As facilities use the tool, we have been able to make it even better. Within days of roll out, we got our first request to add month-to-month trending, since the tool previously only provided quarter-over-quarter and year-over-year trending.”

The tool, in its current state, is only the beginning. The team has plans to share the capability—and the knowledge acquired—with other service lines, including ambulatory and emergency prescribing practices.

“We don’t want this project to live in its own discrete silo,” Gagnon says. “We often talk about a domino effect in a negative way. The work that has been done on this project has the potential to have a positive domino effect. The exciting part is yet to be seen.”

As part of its innovation grant, the team plans to utilize the $25,000 of HealthTrust expertise to develop provider education, improve existing metrics and identify additional tracking possibilities.

 

(Left to Right) Ken Gagnon, Chris Frost, Allen Armstrong, John Theobald, Sandi Hyde, Alex Ladd, Greg Hostetler

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