By Stan Deresinski, MD, FACP, FIDSA

Clinical Professor of Medicine, Stanford University

Dr. Deresinski reports no financial relationships relevant to this field of study.

SYNOPSIS: A work group in the Veterans Administration determined that the necessary staffing of antimicrobial stewardship programs dealing with inpatients (including long-term care) is 1.0 clinical pharmacy specialist with infectious disease knowledge and 0.25 physician (preferably trained in infectious disease) per 100 occupied beds. Needs for outpatient stewardship, which is now mandated, were not included in the assessment.

SOURCE: Echevarria K, Groppi J, Kelly AA, et al. Development and application of an objective staffing calculator for antimicrobial stewardship programs in the Veterans Health Administration. Am J Health Syst Pharm 2017; doi: 10.2146/ajhp160825. [Epub ahead of print.]

Hospitals in the United States now are required to have antimicrobial stewardship programs (ASP). The CDC has listed extensive activities that such programs should implement. These activities require sufficient personnel to fulfill them in an appropriate manner. But the question remains: How many personnel are required to fulfill the activities to assure the patient safety improvements that accrue from their full implementation? A formal process within the Veterans Administration, which like the rest of the U.S. healthcare system requires stewardship programs, was developed and executed with the aim of determining the number of personnel required for this purpose.

To this end, a Tools and Resources Work Group was assigned the task of developing and validating a calculator capable of estimating, in full-time equivalents (FTE), the necessary number of clinical pharmacy specialists and physicians. The work group collaborated with the Clinical Pharmacy Practice Office to develop the calculator. They developed a list of stewardship activities for hospitalized or long-term care patients related to both patient care and management functions and assigned a time value to each activity.

For validation, 12 facilities with average daily census ranging from 72 to 418 completed the staffing calculator over one five-day work week. Six of the sites were large, complex facilities, while the other six were of moderate or low complexity. None of the facilities had more than 1.0 pharmacist at the time of evaluation.

The median need based on the calculator and the observed activities was 1.1 pharmacist FTE per 100 occupied beds (IQR, 1.0-1.47). Patient care activities accounted for 70% of the FTE requirement, while program management activities accounted for 30%. The majority of the time spent on patient care activities involved audit and feedback.

The final recommendations were that to provide a strong ASP, an FTE investment was needed of 1.0 pharmacist, ideally with ASP or infectious disease experience, per 100 occupied beds. They also recommended 0.25 physician per 100 occupied beds, ideally with a physician with infectious disease training.

COMMENTARY

Antimicrobial resistance has been acknowledged as a global public health crisis, analogous in a number of respects to the problem of climate change. In the United States, critical access and acute care hospitals are required to address this issue via the vehicle of antimicrobial stewardship programs. Unfortunately, many hospital administrators primarily look upon such programs as a financial burden and fail to provide the necessary support. Determining the number of needed personnel by benchmarking against other institutions is not of value since it only indicates the inadequacies of staffing at many or most hospitals, not the number to robustly fulfill the requirements of optimizing patient care while working to slow the emergence of antimicrobial resistance and, thus, assuring safety and sustainability.

The approach taken by this working group within the VA system has determined that proper staffing of a hospital ASP requires one FTE pharmacist with ID knowledge for every 100 occupied beds and 0.25 physician, preferably ID trained, per 100 occupied beds. It should be noted that half the hospitals included in this analysis were of only moderate to low complexity. It also should be noted that the analysis did not include stewardship in outpatient facilities, something which now is required in the rest of the U.S. healthcare system for all hospital-affiliated (as determined by tax identification number) outpatient settings. Now is the time for funding to catch up with the critical need.