Stewardship Within Health Systems: Expanding Programs to Regional and Community Sites

Briefly describe your daily role as an antimicrobial stewardship pharmacist.

Sara: Kenmore Mercy Hospital is a community hospital that is a part of the non-profit comprehensive healthcare system Catholic Health, which serves Western New York. On a daily basis I evaluate, via prospective audit and feedback, all patients currently receiving antimicrobial therapy in the hospital. I meet with our infectious diseases physician daily for antimicrobial stewardship and ID consult rounds. In addition, we receive a report of results from the microbiology laboratory which are reviewed daily.

Nick: My role is a hybrid of clinical and operational functions, spanning a health-system which includes academic, community, critical access, and ambulatory care areas, among others.  Our primary focus is prospective audit with feedback and triaging antimicrobial-related questions throughout the day.  We intermittently round with the inpatient ID service at the academic hospital.  Daily activities also include research, system leadership opportunities, and developing clinical initiatives aimed to improve antimicrobial and diagnostic use.

What are some ways your healthy systems have expanded antimicrobial stewardship programs to regional and community sites?

Sara: Our health-system recently established a pharmacy subcommittee within our Antimicrobial Stewardship Committee to focus on pharmacy-related stewardship initiatives. This committee has allowed us to appoint a stewardship lead from each hospital site to spearhead these initiatives at the regional/community level.

We are also working to expand these initiatives to our outpatient clinics. By working closely with our ambulatory care pharmacist colleagues, dissemination of educational materials and presentations are currently underway to the clinic providers. Antimicrobial prescribing patters will be assessed post-intervention to work towards implementing antimicrobial stewardship programs at three of our outpatient clinics.

Nick: Our centralized stewardship program allows for seamless integration of ASP services ; we work at a system level to support local efforts regardless of our physical presence.  All system inpatients populate in our prospective audit EMR workflow based on pre-specified criteria, allowing those patients to be actively reviewed irrespective of hospital type.  All ASP initiatives are implemented system-wide, therefore, initiatives such as MRSA nasal swab collaborative agreements where pharmacists can independently order swabs, are available for use at all hospitals.  Additionally, we have enrolled one of our community hospitals in a national, multi-center stewardship study evaluating a fluoroquinolone restriction strategy and its effect on hospital-acquired C. difficile infections in ICU patients.  This has led to a heightened engagement of local clinicians at this hospital, which helps in our goal of promoting a culture of stewardship excellence.

What system-level or local initiative(s) are you most proud of?

Sara: Over the past year, our goal was to decrease unnecessary fluoroquinolone use. An antimicrobial stewardship policy was created which allowed advanced practice stewardship pharmacists to change patients on fluoroquinolones to the preferred therapy per the Catholic Health System Guide to Antimicrobials (in the absence of a severe beta-lactam allergy and for certain indications). In addition to advanced practice stewardship pharmacists, all pharmacists were educated and encouraged to contact the provider on order-entry and recommend alternative therapy whenever possible. Our fluoroquinolone use has significantly decreased system-wide as a result of the hard work of all the pharmacists throughout the system.

A local initiative we have implemented over the past year is the emergency department (ED) culture review service. We review the cultures of patients that were discharged from the ED and make recommendations as necessary to the emergency department providers and follow-up with the patient, a service that was previously performed by nursing. We have expanded this program’s coverage to 7 days a week which allows all of our pharmacists to be involved in this stewardship initiative.

Nick: When launching our system program, one of the first initiatives was taking over blood culture communication at all system hospitals 24 hours a day, 7 days a week.  This allowed us to expedite more optimal therapy choices and improve the interpretation and clinical response to rapid diagnostic blood culture testing output.  We submitted this project to our health system’s Innovation Center and secured funding to create our Critical Care Pharmacy Residency Program.  The Critical Care PGY-2 resident (and other residents/pharmacists) assist the ASP with triaging these calls system wide.  The communication change resulted in shorter time to optimal antimicrobial therapy for all patients and immediately displayed the potential value of collaboration with our ASP. 

With the emergence of COVID-19, our centralized system program structure allowed us to immediately shift to helping lead system COVID-19 therapeutic and diagnostic decisions and provide on-demand clinical guidance to all system providers, further solidifying our program as a viable clinical resource to all hospitals, including regional/community sites. 

What are the biggest challenges of antimicrobial stewardship at these sites?

It is critical that we continue to empower non-ID clinicians to embrace their role as a steward.  There is no stewardship program that can fully realize its potential without their engagement.  For example, both our systems have witnessed significant reductions in fluoroquinolone use and implemented MRSA PCR nasal swab collaborative practices, which are often driven and made successful by non-ID pharmacists.  It is critical that stewardship programs make all clinicians feel like part of the team, even without a stewardship title.  Alternatively, it can be challenging implementing change without strong local provider buy-in.  It’s imperative to start small and identify one or two motivated stewardship champions who are willing to help set stewardship principles in motion.

What does the future hold for stewardship at regional and community sites?

With the current landscape of minimized fiscal returns, a future with fewer ID-trained physicians, and pressing antimicrobial resistance, there is a unique gap that can be filled by ID pharmacists (on site or via telehealth) as a support system for smaller sites without direct access to ID physicians. This in no way suggests a displacement of ID physician services, rather, a middle ground to bridge the gap between “curbside” and legitimate consults.  In addition, rapid diagnostic tests are becoming more widespread even in regional or community settings. ID and non-ID pharmacists are uniquely positioned to assist providers with ordering, timely reaction to, and optimal treatment selection based on results.  Finally, opportunities remain in underserved areas to expand stewardship such as ER culture review or inpatient discharge antimicrobial reviews.

What does "Being Antibiotics Aware" mean to you?

Being Antibiotic Aware means that we should promote a culture of learning where clinicians feel compelled to seek clarity first, then assess legitimate need to prescribe antibiotics.  This involves using available resources such as electronic decision support tools or stewardship program resources to discuss optimal therapy, which often may simply be supportive care.  It also means that we should challenge historical practice dogmas and ensure we offer safe and effective use of antibiotics.  From the patient perspective, Being Antibiotic Aware means understanding that antibiotics are not useful for viral infections and your physician should discuss if/when they are appropriate for your care.

What is one pear you have for all pharmacists to help them be antibiotic stewards?

No single person or program can fundamentally shift the culture in favor of more judicious antibiotic use.  Therefore, whether we have a title or position that reflects stewardship, we all carry an honorary membership in stewardship through our daily, proactive engagement with the health care team on behalf of the patients we are fortunate to serve.