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Best Practice Spotlight: Antimicrobial Stewardship

16 Sep 2018 10:57 PM | Anonymous

At the MSHP/KCHP Spring Meeting, the pharmacy staff at St. Luke’s Hospital in Kansas City, MO were recognized with the Best Practice Award for their innovative antimicrobial stewardship activities surrounding utilization of rapid diagnostic tests.  Shelby Shemanski, PharmD, BCCCP (Critical Care Pharmacist) and Nick Bennett, PharmD, BCPS (Antimicrobial Stewardship Pharmacist) have graciously shared details of their program with the MSHP membership for those who may be interested in instituting similar practices.

1.  Please describe the program you started at your institution?
Bloodstream infections (BSI) represent a significant burden to health care systems and are associated with increased morbidity and mortality. Emergence of rapid diagnostics tests (RDT) have allowed for earlier optimization of therapies for various infections. In 2015, Saint Luke’s Health System (SLHS) launched our centralized Antimicrobial Stewardship Program (ASP) which covers all system hospitals utilizing an electronic medical record (EMR). Concurrently, our microbiology department acquired a new diagnostic technology called MALDI-TOF, which is mass spectrometry microbial identification.  In 2014, the lab had implemented Filmarray PCR for blood cultures, which identifies a large percentage of organisms. In order to maximize the rapidity and understanding of test results, in 2016 microbiology staff began communicating positive blood culture results directly to an ASP pharmacist Monday through Friday, 0700 to 1530, or system pharmacists/residents at Saint Luke’s Hospital all other hours of the week. The goal of our project was to determine if integrating ASP and pharmacy personnel with RDTs would improve outcomes for patients with BSIs.

2.  How do you (pharmacists) in your program provide care to patients and ensure safe and effective medication therapy?
Upon receiving a positive blood culture result, pharmacists are expected to review patient-specific data provided in the EMR. This is followed by contacting the appropriate provider with the culture results and suggestions for therapy changes if needed. Pharmacists then place a progress note in the medical record including physician contacted, date and time of communication, and blood culture results. This data is recorded in a database and includes if recommendations were accepted or rejected. All cultures and communications are reviewed by ASP staff the following day or Monday following a weekend to ensure appropriate treatment selections were made or to address issues pharmacists noted in the communication log.

Prior to 2016, microbiology staff communicated positive blood culture results to nursing staff, who then had to relay the information to the physician. Our process change allowed pharmacists to have a more proactive role in optimizing therapy, but also minimizes nursing interruptions to allow for better patient care.  Additionally, the change supports provider decision making regarding critical patient information. 

3.  What services have you determined to be essential to support your programs?
Because our ASP program is not a 24/7 service, we utilize our pharmacy residents and pharmacists at Saint Luke’s Hospital on evening, overnight, and weekend shifts. In addition, the SLHS Innovation Center, a program launched in 2015 to promote innovative care ideas from staff, was an essential resource for this project. Funding from the center allowed us to implement a PGY2-Critical Care Pharmacy Residency.  The intent of funding the PGY-2 position was to support the research and other staffing needs to help get this new process up and running.

4.  How did you gain support of hospital administrators, physicians, and nursing to implement your program?
The project was one of two funded projects out of a pool of 53 submissions in 2015.  The Innovation Center is supported on a system level with input from a multidisciplinary group of physicians, pharmacists, administrators and nurses who have ideas to improve efficiency and quality of patient care.  All employees can submit ideas for consideration.  The Innovation center not only provided funding to support the project, but also allocated a project manager and research mentor which were essential to the success of the project.

5.  What are key barriers that needed to be overcame to start your program?
The biggest issue we faced was education on the process change, as providers were not accustomed to pharmacists directly communicating critical test results.  Over time, providers understood the value of pharmacist knowledge in microbiology and therapy selection as it relates to blood culture results.  Likewise, nursing staff became less involved with the communication, so we had to devise a method to make the information transparent.  Thus, we developed a progress note titled “critical notification” which is inputted into the progress notes section of the chart after communication with the provider.

6.  What are some key considerations to gain employee acceptance and buy-in for your program? 
Make sure you have support from multiple levels ranging from senior leadership, physicians, nursing staff, and your internal staff.  The more people that buy into the value of the service, the less external (or internal) pressure you will receive when making practice changes.  Senior leadership support tends to make process changes happen at a quicker pace and remove barriers that might otherwise slow down progress.

7.  What benefits have you been able to show with your program?
We collected and compared pre- (2014, pre-ASP and MALDI-TOF) and post-intervention data (2016) for patients with legitimate positive blood culture results. We found that time to optimal therapy was reduced by 9.2 hours in the 2016 group (p=0.004). There was a trend in reduced inpatient and antimicrobial costs in 2016, with an estimated $110,000 in savings attributed to drug optimization alone. Documented discussions between providers and pharmacists found a high rate of agreement for antimicrobial therapies based on culture results. All recommendations for no change or escalation/dose modification were accepted. Of the 39 proposed de-escalation attempts, only 31 (79.5%) were accepted. Additionally, a physician survey was completed prior to and after our process change. Survey results indicated the new process improved communication amongst clinicians and facilitated a shared-decision making process with a perceived improvement in patient care.

8.  What are lessons learned while implementing your program that you would like to share with other pharmacists?
Understand the significant value you bring to the health care team.  Always be looking for ways we can integrate ourselves into current workflows or redesign one to minimize inefficiencies and maximize results.  The health care landscape is constantly shifting.  We as a profession either have to push along with the shift or ahead of it to ensure the value we provide remains visible and desired.  In infectious diseases, RDTs are a perfect example of merging our knowledge of microbiology with therapy optimization for the betterment of patient care.  The technology will continue to advance and it’s our job to help patients get the most from this new technology and support the health care team along the way.

The MSHP Newsletter Committee would like to thank Shelby and Nick for sharing their practice with the membership!  If you have questions about this practice, or want to share a best practice of your own, please contact Sarah Cook at sarah.cook@ssmhealth.com!

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