Structuring your antimicrobial stewardship program for success

Antimicrobial resistance affects almost every department of a hospital, therefore an effective Antimicrobial Stewardship program requires the support and involvement of many stakeholders

Historically, many AMS programs have started at the grassroots level from the pharmacy, but we’ve learned over the years that truly effective programs also need to involve professionals outside the pharmacy department, including:

• Medical staff: commitment to improving antimicrobial prescribing
• Nursing: Contribute to timely collection of samples and drug levels, administration of antimicrobials, adverse event reporting, management of invasion lines and devices
• Infection Prevention: Provide a global view of infection trends and inform providers
• Microbiology: perform diagnostic tests and introduce technology to quickly and accurately identify pathogens
• Information Technology: Provide key tools to help clinicians identify patients in need of antimicrobials and collect macro-level data to measure the effectiveness of the AMS program
• Environmental Services: Provide a safe environment for patient care to prevent transmission of pathogens
• Supply Chain: Delivery of key supplies such as PPE and cleaning supplies to doctors at the bedside

Since the involvement of multiple departments is required, it is important to gain commitment from executive leadership so that this becomes an organizational priority and trickles down to individual department goals. This is not just a recommendation, but rather a standard of the Joint Committee:

Norm MM.09.01.01: The hospital establishes antibiotic stewardship as a organizational priority by supporting its antibiotic stewardship program.

Ensure hospital leadership commitment to your Antimicrobial Stewardship Program

That is well recognised antimicrobial resistance poses a major threat to patient safety and healthcare organizations. However, at a time of shrinking operating margins and often significant financial challenges, it can be difficult to compete for C-suite financial and human resources to fund a robust antimicrobial stewardship program. Pharmacists should take advantage of regulatory and accreditation headwinds this year to champion the resources needed to launch or expand their antimicrobial stewardship programs.

Understanding your audience’s needs and priorities is important to advocating for your program. To secure the commitment of hospital leaders, pharmacists often need to create a business case to support their initiative.

The financial case for investing in your AMS program

Antimicrobial resistance imposes significant costs on any healthcare organization. For example, studies have shown that a C. div infection increases hospital costs by an average of $17,260, while carbapenem resistance in Pseudomonas aeruginosa increases healthcare costs by 42%.

You can project the estimated financial burden of antimicrobial resistance by analyzing the number of cases in the previous year and multiplying that number by evidence-based data, as noted above. For example, if your organization had 25 hospitalizations C. div infections in the previous year, the economic burden can be approximated by multiplying 25 by $17,260 to arrive at $431,500. Then consider the impact of antimicrobial stewardship interventions on reducing that incidence based on scientific evidence and the likelihood of success at your local level. For example, your organization may be confronted with 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 hospitalization C. div infection, you estimated that your antimicrobial stewardship initiative to reduce the use of quinolones and proton pump inhibitors could 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 can repeat this exercise for the top 3 to 5 antimicrobial resistance problems in your organization and give your C-suite a reasonable return on investment to get financial commitments to support your program. In addition to emphasizing that it makes financial sense, emphasize that to your organization’s leaders the Joint Commission states clearly that hospitals should allocate financial resources for staffing and information technology to support your AMS program in its Elements of Performance 10.

This year, pharmacists have more leverage to advocate for additional funding to support their AMS programs. Many hospitals provide care for Medicare beneficiaries and the Medicare to Promote Interoperability Program introduces a new requirement to submit antimicrobial use and resistance (AUR) data to National Health Care Safety Network (NHSN) as part of the 2024 public health and clinical data exchange target. Non-compliance could result in a 75% reduction in planned annual reimbursement increases for acute care hospitals and a 101% reduction in reimbursement of reasonable healthcare costs up to 100% for critical access to hospitals.

Pharmacists should meet with the hospital’s quality and finance departments to discuss the potential financial consequences of non-compliance. Often, downward payment adjustments for Medicare patients far exceed the cost of allocating the human and technological resources to fund an AMS program.

Identification of your champions across departments

In addition to gaining leadership and financial commitment to build your AMS program, pharmacists will identify and recruit champions from other departments. Informal socialization of your desire to improve antimicrobial use through conversations with key stakeholders can help you identify potential champions. You can also use data to help you iidentify patient care areas with persistent resistance issues and orient your conversations towards their pain points.

For example, review your aggregated microbiological data to determine units with a high incidence of carbapenem resistance or C. div. The nursing managers and nurses on such wards may experience pain points from having to get dressed before entering a patient room, which slows down their processes. They can be recruited to become champions if you can paint a future state where their pain points can be alleviated.

In another example, you can get the support of the director of microbiology if he or she wants to introduce new technologies or tools to improve turnaround time. Or perhaps the microbiology lab is interested in reducing additional follow-up resistance testing for new antimicrobials. The most effective AMS leaders will take the time to discern each stakeholder’s priorities and tailor and adapt their approach to increase everyone’s involvement in the AMS program.

Key steps to get started; developing strategies to achieve your AMS goals

Once you have identified your key stakeholders to participate in your AMS program, schedule regular meetings to determine your program goals. Then determine what strategies and tactics are needed to achieve those goals. In newly established AMS programs, we encourage pharmacists to set realistic, achievable goals and include some interventions that are easy, low-hanging fruit so you can celebrate small successes early to keep the momentum going.

Of course, data collection is important to document any change from baseline. In subsequent articles in this series, we’ll discuss how you would design key metrics and quickly collect them to determine whether your interventions are moving the needle and whether a course pivot is needed.