In 2014, California became the first state to require acute care hospitals to implement antimicrobial stewardship programs in their facilities. Nearly three years later, it remains the only state in the nation with such a law—but that is set to change. In June 2016, the Centers for Medicare & Medicaid Services (CMS) announced proposed changes to its Conditions of Participation (CoP), the requirements hospitals must meet to participate in government-run health insurance programs, which include the addition of a hospital-wide antimicrobial stewardship program.
The following month, the Joint Commission released a new antimicrobial stewardship standard for acute care hospitals and long-term care facilities (https://tinyurl.com/h497yv2) that took effect Jan. 1. It outlines eight elements of performance, largely mirroring the national guidelines created by the Centers for Disease Control and Prevention (CDC) (https://tinyurl.com/lzktjxh).
CMS hasn’t revealed an expected timeline for hospitals to comply with its CoP, but the comment period has passed and a proposed rule is in development.
“After the proposed rule is published, we have up to three years to publish a final rule; however, we expect to publish a final rule as expeditiously as possible,” says Lindsey O’Keefe, a public affairs specialist for CMS.
That means healthcare organizations need to start prioritizing antimicrobial stewardship now. The CDC estimates 20–50 percent of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate. This misuse can lead to antibiotic resistance, which the agency says is responsible for 23,000 deaths annually.
“The growing epidemic of human antibiotic resistance is not a problem that’s coming in the future; it’s a problem that’s already here,” says Marcus Dortch, PharmD, senior director of clinical pharmacy services for HealthTrust. “Healthcare organizations need to pay attention to the message being sent by the Joint Commission, CMS and CDC.”
Mishawaka, Indiana-based Franciscan Health has already prioritized antibiotic stewardship with the development of a pharmacy-specific team and a systemwide, multidisciplinary antimicrobial stewardship team under the leadership of Maria Adamopoulos, PharmD, corporate clinical pharmacy manager.
The pharmacy team is made up of clinical pharmacists with an interest in infectious diseases at each of the system’s 14 hospitals in Indiana and Illinois. The pharmacists act as liaisons to promote antimicrobial stewardship at the local level. The multidisciplinary team, formed last November and co-led by a clinical pharmacist and a physician, also brings the unique perspectives and skillsets of analytics, microbiology, infection prevention, IT, nursing, quality and safety to the program.
“To combat resistance, control costs and improve outcomes, antibiotic stewardship has to be a multidisciplinary effort,” Adamopoulos says.
She speaks from experience. In the past, when her pharmacy team rolled out antibiotic stewardship initiatives, they didn’t always get the buy-in of other departments. Now that stakeholders from multiple departments will be involved from the beginning, Adamopoulos expects they’ll see more wins.
The Joint Commission’s standard also prescribes a multidisciplinary approach, and identifies four key members of the team: infectious disease physician, infection preventionist, pharmacist and nurse practitioner. The qualifier is when these personnel are “available in the setting,” to provide flexibility to smaller facilities. The commission also allows members of the antibiotic stewardship team to be part-time, consulting or telehealth staff.
“The physician on your team doesn’t have to be trained in infectious diseases,” Adamopoulos says. “You might instead find a hospitalist who has a passion for optimizing the use of antibiotics. If you don’t have enthusiastic participants, you won’t be successful.”
When Franciscan Health launched its antimicrobial stewardship efforts five years ago, its hospitals operated in silos. That meant 14 different formularies and a lot of variation, including in the case of antibiograms, the periodic summaries of antimicrobial susceptibilities designed to help facilities understand local threats and track resistance trends.
Today, the health system has a single formulary, a standardized template for antibiograms, and predetermined order sets optimized for antimicrobial stewardship. Then those order sets are built into the system for electronic health records.
“It can take a while to get all the moving parts in place,” Adamopoulos says. “But it’s necessary if you want to actually implement and practice good stewardship.”
The timeline for a federal mandate for antimicrobial stewardship may be unknown, but action is imminent—and it’s likely that it will cover outpatient facilities in the future. The Joint Commission is already moving its standards development work in that direction.
“Don’t wait to prioritize antimicrobial stewardship in your facilities,” Dortch says. “Assess your level of readiness and formulate a plan of attack based on your patient population, case mix and baseline of pathogen resistance.”
From a practical standpoint, Dortch recommends supply chain leaders consider automated surveillance systems with real-time alerts, and tracking tools to identify areas for improvement and measure the impact of infection prevention initiatives.
“Take a look at those tools so that you can put in budget requests as soon as possible,” Dortch says. “It can take time to get data collection processes in place that will identify areas where you have the most significant gaps.”
Antibiotic stewardship programs are more about improving care than saving money. But they can potentially cut costs. CMS estimates its proposed changes, including both antibiotic stewardship and infection prevention programs, could save hospitals up to $284 million annually. Those savings come from more judicious antibiotic use, as well as the avoidance of treating adverse drug reactions and Clostridium difficile (C-diff) infection. C-diff alone adds 40 percent, or an average of $7,286, in additional costs per patient, according to a study published in the Nov. 2015 American Journal of Infection Control.
Joint Commission Antimicrobial Stewardship Standard at a Glance
- Make antimicrobial stewardship an organizational priority. In other words, buy-in from the executive suite is crucial.
- Upon hire and periodically thereafter, educate frontline clinicians about antibiotic resistance and antimicrobial stewardship practices.
- Educate patients and their families regarding the appropriate use of antimicrobial medications.
- Create a multidisciplinary team to oversee antimicrobial stewardship efforts.
- Include the CDC’s seven core elements of an effective antimicrobial stewardship program: leadership commitment, accountability, drug expertise, action, tracking, reporting and education.
- Use organization-approved multidisciplinary protocols, such as antibiotic formulary restrictions, preauthorization requirements for specific antimicrobials, and use of
- Collect, analyze and report data on your antimicrobial stewardship program.
- Take action on improvement opportunities identified in the antimicrobial stewardship program.