Reversing the trend of resistant infections
Cutting costs with automated screening
"It was pretty primitive, what we were doing," says Sarah Bland, RPh, senior clinical pharmacist, Center for Drug Policy at the University of Wisconsin Hospital and Clinics, referring to the method of screening drug orders before she began to use Premier Inc.'s web-based tools.
"I would print from the pharmacy billing system a list of patients who were on a dozen different antibiotics we were targeting for reasons of high cost and high risk in terms of resistance. It wouldn't tell me how long they had been on them. It was time-consuming, and I couldn't really look in depth."
Saving time with automated surveillance
That was before Premier Inc. pitched an automated system to flag positive culture results and screen pharmacy data to the hospital's infection control department. With the new system, Bland says, instead of being able to look at only a dozen or so drugs, she could screen all antibiotic orders if she thought it necessary or at least screen orders that raise concern — for instance, patients who have been on vancomycin for three days.
In trying to identify candidates at risk for infections, clinicians can spend two to five hours a day sifting through paperwork, says Premier's Scott Pope, PharmD, national director for SafetySurveillor, a web-based tracking tool.
With the product in hand, Bland and an infectious disease physician set up the parameters they wanted to track. For instance, they wanted to be alerted each time a broad-spectrum drug was ordered for a gram-negative organism, because as she explains, there "aren't really any new drugs in the pipeline for gram-negative organisms so we want to hold on and conserve those drugs very tightly."
Once she is flagged about the order, she can review the patient's medical record to determine if the prescription is appropriate. If she thinks it is, she can then review the culture after three days. "Now I want to look when the cultures are back, is it appropriate? Does the patient have an organism based on the culture results that justifies the continued use of the drug?" She continues to receive alerts in these cases to determine if the treatment period has been sufficient or if it's necessary to run the patient on a full course.
While "it may not be a significant change for the individual patient," she says, "since that patient is going to get better whether they hit eight days, 10 days, or 12 days, but if I can get eight days maybe some future patient is going to be better off."
And that's where tight screening pays off, she says. She acknowledges that if a patient develops a hospital-acquired infection (HAI) the hospital will not receive reimbursement but points out that since the hospital is paying it's better to not pay for the care of a resistant and more time- and resource-consuming infection.
Every day Bland runs a report and goes through the 60-90 alerts she might get. Going through those, she whittles the cases down to about 15 that need follow up. In concert with the infectious disease physician, she narrows that list further to identify ones that require intervention.
Relaying this to the unit pharmacist, physicians get recommendations on drug coverage such as warnings about redundant coverage or switching from IV to oral therapy — "simple cost-saving measures," Bland says.
Measures that add up.
Reducing cost per admission
Bland is analyzing "whether we've been able to stem the tide of resistant organism development" and has found that the cost of antibiotics had been increasing at about 10-15% before the implementation of the tracking tool. "We were able to stop that cold," she says. "In fact, we've been able to actually reduce the cost per admission in terms of antibiotics by about 10%" by reducing the "cost of antibiotics in terms of percentage of the overall drug budget."
Beyond the financial success, though, she adds that the real benefit to curbing resistance is that "when you're reducing antibiotic use, you're reducing the pressure on the microbe environment in the hospital and thereby you're going to be able to reduce resistance in the hospital."
What does she credit for the success they've had and their "pretty stable" antibiogram? "It's a combination of good infection control practices, good Antibiotic management, keeping patients well isolated, and keeping antibiotic use to a minimum," she says.
Narrowing coverage, Bland says, is integral to reducing resistance. Other suggestions she offers:
- keep antibiotic use limited to what's appropriate and the appropriate length of time;
- dose appropriately;
- don't forget cases in which you're running antibiotics, which happens Bland says because side effects from that are not necessarily noticeable.
As far as wiping those infections out of hospitals, Bland says: "You're not going to eradicate a hospital-acquired infection. You're not going to eliminate the possibility that all of your patients will not pick up an infection. But I think you can lessen the risk that you're going to have some highly resistant organisms with good infection control and good antibiotic management."
For smaller, standalone hospitals that can't afford technology like Premier's, she suggests starting any automated system and allowing that system to sort through the drug orders. "Don't waste your personnel going through and sorting the orders, the sort of thing a microprocessor can do," she adds.
"Have an education component every so often to not abuse antibiotics. Inappropriate antibiotic use is just a lack of familiarity or a fear of not covering appropriately. If people have the right information, they will do the right thing."