NOTES Antimicrobial stewardship program
Incorporating pharmacy student activities into an antimicrobial stewardship program in a long-term acute care hospital John M. Benson
C
onsiderable effort has been expended in recent years to implement antimicrobial stewardship programs (ASPs) at health care facilities in the United States. The primary goals of most ASPs are to optimize patient outcomes from antimicrobial use, reduce the emergence of resistant organisms, and decrease the cost of antimicrobial therapy.1 The importance of ASPs is heightened by the scarcity of new antimicrobials either approved or in development.2 Since the publication in 2007 of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines for antimicrobial stewardship,3 the implementation rate of these programs has accelerated.4,5 Annual reductions in antimicrobial costs of $200,000–$900,000 in facilities that have implemented effective ASPs have been reported.3,6 Before 2010, some elements of antimicrobial stewardship had been implemented at Promise Hospital of Salt Lake, a 41-bed long-term acute care hospital. For example, a boardcertified infectious diseases (ID)
Purpose. The impact on antimicrobial costs of an antimicrobial stewardship program (ASP) that integrated pharmacy students as integral members was evaluated. Methods. Demographic and discharge disposition data and antimicrobial acquisition cost data were retrospectively collected for all patients admitted to Promise Hospital of Salt Lake between June 1, 2009, and May 31, 2012. During this study, the primary role of pharmacy students in the ASP was to monitor all infectionrelated patient problems in the facility and meet daily with the infectious diseases pharmacist and clinical pharmacist to develop recommendations for optimizing antimicrobial use. The primary outcome measure was the mean antimicrobial acquisition cost per patient per day, calculated before ASP implementation (baseline period) and two years after ASP implementation (intervention period). The acquisition costs of antimicrobial agents
physician was recruited to chair the infection prevention and pharmacy and therapeutics committees, in addition to serving as an ID consultant for patient cases. We also recruited a pharmacy director with formal
John M. Benson, Pharm.D., is Director of Pharmacy, Promise Hospital of Salt Lake, Salt Lake City, UT, and Adjunct Associate Professor, College of Pharmacy, University of Utah, Salt Lake City ([email protected]). Promise Hospital of Salt Lake administration and its clinical pharmacists, Adiseshu Gundlapalli, M.D., Ph.D., and the University of Utah College of Pharmacy and its pharmacy students are acknowledged for supporting the antimicrobial stewardship program described herein.
per patient day were compared before and two years after implementation of the ASP involving pharmacy students. Statistical significance was determined using Student’s t test for continuous data and the chi-square test for nominal data. Results. The rate of patient discharge to skilled nursing facilities was significantly higher during the intervention period versus the baseline period (p = 0.016); no other significant comparisons were found. The mean ± S.D. antimicrobial costs per patient day were $75.37 ± $11.85 in the baseline period and $64.13 ± $13.78 in the intervention period (p = 0.022). This difference represents a cost savings of $261,630 during the two-year intervention period. Conclusion. Decreased antimicrobial costs were observed over a two-year period after implementation of an ASP that incorporated pharmacy students as integral members of the program. Am J Health-Syst Pharm. 2014; 71:227-30
training and experience in ID. However, due to insufficient resources, we were unable to implement other core strategies recommended in the IDSA/SHEA guidelines, such as a prospective audit of antimicrobial
Presented in part as a poster at the ASHP Midyear Clinical Meeting, Las Vegas, NV, December 3, 2012. The author has no declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0201-0227$06.00. DOI 10.2146/ajhp130321
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
227
NOTES Antimicrobial stewardship program
use with timely feedback to prescribers.3 Personnel costs are a common barrier to full ASP implementation,7 and this was also true at our hospital. Consequently, we sought other innovative approaches to more fully implement the ASP. In May 2010, we developed a six-week elective ID advanced pharmacy practice experience (APPE) and began accepting pharmacy students from a local college of pharmacy and incorporating them into our program. Description of the ASP As a long-term acute care hospital, nearly all of the patients admitted were referred from other health care facilities, primarily traditional acute care hospitals. Many of these patients have chronic or recurrent infections, which frequently involve multidrugresistant organisms. Consequently, the frequency of use of medications such as vancomycin, linezolid, daptomycin, and members of the carbapenem and echinocandin classes— often reserved or restricted at other hospitals—is necessarily high. Close scrutiny of antimicrobial selection
is essential to optimize therapeutic outcomes and minimize drug costs. The ASP operated under the auspices of the infection prevention committee, which consisted of the ID physician, infection preventionist, infection-control nurse, director of rehabilitation, director of respiratory therapy, quality manager, chief nursing officer, and ID pharmacist. Due to the nature of the patient population served, substantial effort was expended by this committee toward infection prevention and control through careful microbial surveillance and data analysis. During this study, the primary role of pharmacy students in our ASP was to monitor all infection-related patient problems in the facility and meet daily with the ID pharmacist and clinical pharmacist to develop recommendations for optimizing antimicrobial use. During the first few days of each rotation, students received an extensive orientation regarding the facility’s medical information systems and frequent feedback on proper patient monitoring to prepare them for their role. A standardized form was used to
guide the students’ data collection. A formal evaluation of student performance also was performed at the midpoint and end of each rotation. Areas of student focus included optimizing antimicrobial dosage based on renal and hepatic functioning and serum drug concentration monitoring, determining the appropriate duration of antimicrobial therapy, checking for drug allergies, daily monitoring for efficacy and toxicity with patient-specific recommendations for change when indicated, and adjusting empirical antimicrobial therapy when additional clinical and microbiological information became known. The last task may be the most important determinant of antimicrobial optimization.8 Appropriate feedback was then provided— usually by the student—to the prescriber. Additional recommendations were made in a weekly multidisciplinary care planning meeting, and there was frequent communication with the ID physician. These activities constituted the core functions of our ASP. As has been shown previously, continuously improving and optimizing the delivery of health care results
Table 1.
Demographic and Discharge Disposition Data Before and After Implementation of an Antimicrobial Stewardship Program Variable
Baseline (June 2009–May 2010)
Intervention Period (June 2010–May 2012)
311 65.5 162 (52.1) 31.4 1.45
767 63.6 423 (55.1) 28.6 1.35
104 (33.4) 59 (19.0) 39 (12.5) 33 (10.6) 15 (4.8) 7 (2.3) 0 0 54 (17.4)
336 (43.8) 123 (16.0) 75 (9.8) 85 (11.1) 27 (3.5) 17 (2.2) 1 (0.1) 1 (0.1) 102 (13.3)
Total no. discharges Mean age, yr Males, no. (%) Mean length of stay, days Case-mix indexc Discharge disposition, no. (%) pts Skilled nursing facility Home or home health Hospital Rehabilitation facility Home care or self care Hospice Residential care Another long-term acute care hospital Died Chi-square test used for all comparisons unless otherwise noted. b Student’s t-test. c Derived from each patient’s diagnosis codes. a
228
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
pa 0.052b 0.815 0.164b 0.086b 0.016 0.288 0.206 0.832 0.326 0.972
0.112
NOTES Antimicrobial stewardship program
in reduced health care costs.9 Therefore, we elected to measure the impact of our ASP by examining our antimicrobial acquisition costs two years after implementing pharmacy student rotations as part of our program (i.e., in June 2012). Methods We retrospectively collected demographic and discharge disposition data and antimicrobial acquisition cost data for all patients admitted to Promise Hospital of Salt Lake between June 1, 2009, and May 31, 2012. Our primary outcome measure was antimicrobial acquisition costs, normalized for daily patient
census (mean acquisition costs per patient day). We calculated the mean antimicrobial costs per patient day the year before ASP implementation (baseline period, from June 2009 to May 2010). We then calculated the same data for the two years after the ASP was implemented (intervention period, from June 2010 to May 2012). The mean antimicrobial costs per patient day for the baseline and intervention periods were compared. Demographic and discharge disposition data were also compared to assess the degree of homogeneity between groups. No patient-identifiable data were collected. Statistical significance was determined using Student’s t
test for continuous data and the chisquare test for nominal data. The a priori level of significance was 0.05. Results Demographic and discharge disposition data for the baseline and intervention groups are shown in Table 1. The rate of patient discharge to skilled nursing facilities was significantly higher during the intervention period versus the baseline period (p = 0.016). No other significant comparisons were found. The mean ± S.D. antimicrobial costs per patient day were $75.37 ± $11.85 in the baseline period and $64.13 ± $13.78 in the intervention
Figure 1. Monthly means of antimicrobial costs per patient day and mean daily census before and after implementation of an antimicrobial stewardship program. Arrow indicates implementation of the program.
Mean antimicrobial costs per patient day
100
40
Mean census 90
35
30 70
20
50
40
Census
25
60
15
30 10
20 5
10
0
Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12
Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11
0
Jun-09
Mean Antimicrobial Costs per Patient Day ($)
80
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
229
NOTES Antimicrobial stewardship program
period, revealing a 14.9% decrease after ASP implementation (p = 0.022). This represents a cost savings of $261,630 during the two-year intervention period. When considering each of the intervention years separately, the mean antimicrobial costs per patient day were $66.82 in the first intervention year and $61.44 in the second intervention year. The monthly means of antimicrobial costs per patient day and monthly census data for the entire study period are shown in Figure 1. Discussion We developed and implemented a six-week ID APPE that provided pharmacy students with an excellent environment to learn about the management of antimicrobial therapy in a patient population with chronic and recurrent infections. Compared with a traditional short-term acute care hospital, the need for a successful ASP is perhaps greater in a long-term acute care hospital due to the large percentage of patients admitted with infections, many of which involve multidrug-resistant organisms. Some elements of antimicrobial stewardship, such as dosage adjustments for altered drug clearance, toxicity monitoring, and pharmacokinetic monitoring, had been implemented before. By incorporating pharmacy students into our processes, we were able to expand the scope of our ASP to include real-time feedback to prescribers and thereby effect more improvements to antimicrobial therapy. All demographic and discharge disposition variables but one (including the case-mix index, a measure of patient acuity) did not significantly differ between the baseline and intervention periods, supporting the inference that no other variable except the implementation of the ASP affected the cost of antimicrobial therapy. However, additional research, preferably prospective, is needed to verify a causal relationship. 230
A previously published study describing an ASP in a long-term acute care hospital found a 28% reduction in antimicrobial costs per patient day after 15 months of program implementation (p = 0.004).10 That program consisted primarily of weekly chart reviews with recommendations posted on patient charts. The authors reported an estimated medication cost savings of $159,580 over the 15 months, a value similar to our savings ($261,630 over 24 months). Although it appears that antimicrobial cost savings can be readily achieved with an ASP, reduced costs alone must not be the primary goal. Cost reductions are usually seen only in the first few years after program implementation, and stakeholders in an ASP would be wise to give early attention to other measures of success, especially reductions in the incidence of nosocomial infections caused by organisms such as Clostridium difficile, methicillin-resistant Staphylococcus aureus, vancomycinresistant Enterococcus, carbapenemresistant and extended-spectrum b-lactamase-producing Enterobacteriaceae, and other multidrugresistant gram-negative bacilli. 11 Future assessments of our ASP will focus on such measurements. Our ASP and the role pharmacy students played in our program were consistent with and supportive of the American Society of Health-System Pharmacists’ recently adopted Pharmacy Practice Model Initiative, which was developed to promote optimal patient care. 12 Teaching pharmacy students, participating in antimicrobial stewardship, and fostering pharmacist activities, roles, and practices that optimize medication outcomes are some of the principles on which this initiative is based.12,13 An additional measure of success of our ASP has been the consistently favorable feedback received from pharmacy students on completion of their six-week experience. Students related that they became
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
highly confident in their ability to treat infections and expressed professional satisfaction with the integral role they played in our ASP. Conclusion Decreased antimicrobial costs were observed over a two-year period after implementation of an ASP that incorporated pharmacy students as integral members of the program. References 1. Fishman N. Antimicrobial stewardship. Am J Med. 2006; 119(suppl 1):S53-61. 2. O’Brien DJ, Gould IM. Maximizing the impact of antimicrobial stewardship: the role of diagnostics, national and international efforts. Curr Opin Infect Dis. 2013; 26:352-8. 3. Dellit TH, Owens RC, McGowan JE et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007; 44:159-77. 4. Chambers RM, Davis SL. Expanding the reach of antimicrobial stewardship. Pharmacotherapy. 2013; 33:118-21. 5. Trivedi KK, Rosenberg J. The state of antimicrobial stewardship programs in California. Infect Control Hosp Epidemiol. 2013; 34:379-84. 6. Patel D, Lawson W, Guglielmo BJ. Antimicrobial stewardship programs: interventions and associated outcomes. Expert Rev Anti Infect Ther. 2008; 6:209-22. 7. Nowak MA, Nelson RE, Beidenbach JL et al. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health-Syst Pharm. 2012; 68:1500-8. 8. Pollack LA, Gould CV, Srinivasan A. If not now, when? Seizing the moment for antibiotic stewardship. Infect Control Hosp Epidemiol. 2013; 34:117-8. 9. Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Best care at lower cost: the path to continuously learning health care in America. Washington, DC: National Academies Press; 2013:133-45. 10. Pate PG, Storey DF, Baum DL. Implementation of an antimicrobial stewardship program at a 60-bed long-term acute care hospital. Infect Control Hosp Epidemiol. 2012; 33:405-8. 11. Hurst JM, Bosso JA. Antimicrobial stewardship in the management of communityacquired pneumonia. Curr Opin Infect Dis. 2013; 26:184-8. 12. The consensus of the Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2011; 68:1148-52. 13. Pharmacy Practice Model Summit: executive summary. Am J Health-Syst Pharm. 2011; 68:1079-85.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Incorporating pharmacy student activities into an antimicrobial stewardship program in a long-term acute care hospital John M. Benson
C
onsiderable effort has been expended in recent years to implement antimicrobial stewardship programs (ASPs) at health care facilities in the United States. The primary goals of most ASPs are to optimize patient outcomes from antimicrobial use, reduce the emergence of resistant organisms, and decrease the cost of antimicrobial therapy.1 The importance of ASPs is heightened by the scarcity of new antimicrobials either approved or in development.2 Since the publication in 2007 of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines for antimicrobial stewardship,3 the implementation rate of these programs has accelerated.4,5 Annual reductions in antimicrobial costs of $200,000–$900,000 in facilities that have implemented effective ASPs have been reported.3,6 Before 2010, some elements of antimicrobial stewardship had been implemented at Promise Hospital of Salt Lake, a 41-bed long-term acute care hospital. For example, a boardcertified infectious diseases (ID)
Purpose. The impact on antimicrobial costs of an antimicrobial stewardship program (ASP) that integrated pharmacy students as integral members was evaluated. Methods. Demographic and discharge disposition data and antimicrobial acquisition cost data were retrospectively collected for all patients admitted to Promise Hospital of Salt Lake between June 1, 2009, and May 31, 2012. During this study, the primary role of pharmacy students in the ASP was to monitor all infectionrelated patient problems in the facility and meet daily with the infectious diseases pharmacist and clinical pharmacist to develop recommendations for optimizing antimicrobial use. The primary outcome measure was the mean antimicrobial acquisition cost per patient per day, calculated before ASP implementation (baseline period) and two years after ASP implementation (intervention period). The acquisition costs of antimicrobial agents
physician was recruited to chair the infection prevention and pharmacy and therapeutics committees, in addition to serving as an ID consultant for patient cases. We also recruited a pharmacy director with formal
John M. Benson, Pharm.D., is Director of Pharmacy, Promise Hospital of Salt Lake, Salt Lake City, UT, and Adjunct Associate Professor, College of Pharmacy, University of Utah, Salt Lake City ([email protected]). Promise Hospital of Salt Lake administration and its clinical pharmacists, Adiseshu Gundlapalli, M.D., Ph.D., and the University of Utah College of Pharmacy and its pharmacy students are acknowledged for supporting the antimicrobial stewardship program described herein.
per patient day were compared before and two years after implementation of the ASP involving pharmacy students. Statistical significance was determined using Student’s t test for continuous data and the chi-square test for nominal data. Results. The rate of patient discharge to skilled nursing facilities was significantly higher during the intervention period versus the baseline period (p = 0.016); no other significant comparisons were found. The mean ± S.D. antimicrobial costs per patient day were $75.37 ± $11.85 in the baseline period and $64.13 ± $13.78 in the intervention period (p = 0.022). This difference represents a cost savings of $261,630 during the two-year intervention period. Conclusion. Decreased antimicrobial costs were observed over a two-year period after implementation of an ASP that incorporated pharmacy students as integral members of the program. Am J Health-Syst Pharm. 2014; 71:227-30
training and experience in ID. However, due to insufficient resources, we were unable to implement other core strategies recommended in the IDSA/SHEA guidelines, such as a prospective audit of antimicrobial
Presented in part as a poster at the ASHP Midyear Clinical Meeting, Las Vegas, NV, December 3, 2012. The author has no declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0201-0227$06.00. DOI 10.2146/ajhp130321
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
227
NOTES Antimicrobial stewardship program
use with timely feedback to prescribers.3 Personnel costs are a common barrier to full ASP implementation,7 and this was also true at our hospital. Consequently, we sought other innovative approaches to more fully implement the ASP. In May 2010, we developed a six-week elective ID advanced pharmacy practice experience (APPE) and began accepting pharmacy students from a local college of pharmacy and incorporating them into our program. Description of the ASP As a long-term acute care hospital, nearly all of the patients admitted were referred from other health care facilities, primarily traditional acute care hospitals. Many of these patients have chronic or recurrent infections, which frequently involve multidrugresistant organisms. Consequently, the frequency of use of medications such as vancomycin, linezolid, daptomycin, and members of the carbapenem and echinocandin classes— often reserved or restricted at other hospitals—is necessarily high. Close scrutiny of antimicrobial selection
is essential to optimize therapeutic outcomes and minimize drug costs. The ASP operated under the auspices of the infection prevention committee, which consisted of the ID physician, infection preventionist, infection-control nurse, director of rehabilitation, director of respiratory therapy, quality manager, chief nursing officer, and ID pharmacist. Due to the nature of the patient population served, substantial effort was expended by this committee toward infection prevention and control through careful microbial surveillance and data analysis. During this study, the primary role of pharmacy students in our ASP was to monitor all infection-related patient problems in the facility and meet daily with the ID pharmacist and clinical pharmacist to develop recommendations for optimizing antimicrobial use. During the first few days of each rotation, students received an extensive orientation regarding the facility’s medical information systems and frequent feedback on proper patient monitoring to prepare them for their role. A standardized form was used to
guide the students’ data collection. A formal evaluation of student performance also was performed at the midpoint and end of each rotation. Areas of student focus included optimizing antimicrobial dosage based on renal and hepatic functioning and serum drug concentration monitoring, determining the appropriate duration of antimicrobial therapy, checking for drug allergies, daily monitoring for efficacy and toxicity with patient-specific recommendations for change when indicated, and adjusting empirical antimicrobial therapy when additional clinical and microbiological information became known. The last task may be the most important determinant of antimicrobial optimization.8 Appropriate feedback was then provided— usually by the student—to the prescriber. Additional recommendations were made in a weekly multidisciplinary care planning meeting, and there was frequent communication with the ID physician. These activities constituted the core functions of our ASP. As has been shown previously, continuously improving and optimizing the delivery of health care results
Table 1.
Demographic and Discharge Disposition Data Before and After Implementation of an Antimicrobial Stewardship Program Variable
Baseline (June 2009–May 2010)
Intervention Period (June 2010–May 2012)
311 65.5 162 (52.1) 31.4 1.45
767 63.6 423 (55.1) 28.6 1.35
104 (33.4) 59 (19.0) 39 (12.5) 33 (10.6) 15 (4.8) 7 (2.3) 0 0 54 (17.4)
336 (43.8) 123 (16.0) 75 (9.8) 85 (11.1) 27 (3.5) 17 (2.2) 1 (0.1) 1 (0.1) 102 (13.3)
Total no. discharges Mean age, yr Males, no. (%) Mean length of stay, days Case-mix indexc Discharge disposition, no. (%) pts Skilled nursing facility Home or home health Hospital Rehabilitation facility Home care or self care Hospice Residential care Another long-term acute care hospital Died Chi-square test used for all comparisons unless otherwise noted. b Student’s t-test. c Derived from each patient’s diagnosis codes. a
228
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
pa 0.052b 0.815 0.164b 0.086b 0.016 0.288 0.206 0.832 0.326 0.972
0.112
NOTES Antimicrobial stewardship program
in reduced health care costs.9 Therefore, we elected to measure the impact of our ASP by examining our antimicrobial acquisition costs two years after implementing pharmacy student rotations as part of our program (i.e., in June 2012). Methods We retrospectively collected demographic and discharge disposition data and antimicrobial acquisition cost data for all patients admitted to Promise Hospital of Salt Lake between June 1, 2009, and May 31, 2012. Our primary outcome measure was antimicrobial acquisition costs, normalized for daily patient
census (mean acquisition costs per patient day). We calculated the mean antimicrobial costs per patient day the year before ASP implementation (baseline period, from June 2009 to May 2010). We then calculated the same data for the two years after the ASP was implemented (intervention period, from June 2010 to May 2012). The mean antimicrobial costs per patient day for the baseline and intervention periods were compared. Demographic and discharge disposition data were also compared to assess the degree of homogeneity between groups. No patient-identifiable data were collected. Statistical significance was determined using Student’s t
test for continuous data and the chisquare test for nominal data. The a priori level of significance was 0.05. Results Demographic and discharge disposition data for the baseline and intervention groups are shown in Table 1. The rate of patient discharge to skilled nursing facilities was significantly higher during the intervention period versus the baseline period (p = 0.016). No other significant comparisons were found. The mean ± S.D. antimicrobial costs per patient day were $75.37 ± $11.85 in the baseline period and $64.13 ± $13.78 in the intervention
Figure 1. Monthly means of antimicrobial costs per patient day and mean daily census before and after implementation of an antimicrobial stewardship program. Arrow indicates implementation of the program.
Mean antimicrobial costs per patient day
100
40
Mean census 90
35
30 70
20
50
40
Census
25
60
15
30 10
20 5
10
0
Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12
Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11
0
Jun-09
Mean Antimicrobial Costs per Patient Day ($)
80
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
229
NOTES Antimicrobial stewardship program
period, revealing a 14.9% decrease after ASP implementation (p = 0.022). This represents a cost savings of $261,630 during the two-year intervention period. When considering each of the intervention years separately, the mean antimicrobial costs per patient day were $66.82 in the first intervention year and $61.44 in the second intervention year. The monthly means of antimicrobial costs per patient day and monthly census data for the entire study period are shown in Figure 1. Discussion We developed and implemented a six-week ID APPE that provided pharmacy students with an excellent environment to learn about the management of antimicrobial therapy in a patient population with chronic and recurrent infections. Compared with a traditional short-term acute care hospital, the need for a successful ASP is perhaps greater in a long-term acute care hospital due to the large percentage of patients admitted with infections, many of which involve multidrug-resistant organisms. Some elements of antimicrobial stewardship, such as dosage adjustments for altered drug clearance, toxicity monitoring, and pharmacokinetic monitoring, had been implemented before. By incorporating pharmacy students into our processes, we were able to expand the scope of our ASP to include real-time feedback to prescribers and thereby effect more improvements to antimicrobial therapy. All demographic and discharge disposition variables but one (including the case-mix index, a measure of patient acuity) did not significantly differ between the baseline and intervention periods, supporting the inference that no other variable except the implementation of the ASP affected the cost of antimicrobial therapy. However, additional research, preferably prospective, is needed to verify a causal relationship. 230
A previously published study describing an ASP in a long-term acute care hospital found a 28% reduction in antimicrobial costs per patient day after 15 months of program implementation (p = 0.004).10 That program consisted primarily of weekly chart reviews with recommendations posted on patient charts. The authors reported an estimated medication cost savings of $159,580 over the 15 months, a value similar to our savings ($261,630 over 24 months). Although it appears that antimicrobial cost savings can be readily achieved with an ASP, reduced costs alone must not be the primary goal. Cost reductions are usually seen only in the first few years after program implementation, and stakeholders in an ASP would be wise to give early attention to other measures of success, especially reductions in the incidence of nosocomial infections caused by organisms such as Clostridium difficile, methicillin-resistant Staphylococcus aureus, vancomycinresistant Enterococcus, carbapenemresistant and extended-spectrum b-lactamase-producing Enterobacteriaceae, and other multidrugresistant gram-negative bacilli. 11 Future assessments of our ASP will focus on such measurements. Our ASP and the role pharmacy students played in our program were consistent with and supportive of the American Society of Health-System Pharmacists’ recently adopted Pharmacy Practice Model Initiative, which was developed to promote optimal patient care. 12 Teaching pharmacy students, participating in antimicrobial stewardship, and fostering pharmacist activities, roles, and practices that optimize medication outcomes are some of the principles on which this initiative is based.12,13 An additional measure of success of our ASP has been the consistently favorable feedback received from pharmacy students on completion of their six-week experience. Students related that they became
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
highly confident in their ability to treat infections and expressed professional satisfaction with the integral role they played in our ASP. Conclusion Decreased antimicrobial costs were observed over a two-year period after implementation of an ASP that incorporated pharmacy students as integral members of the program. References 1. Fishman N. Antimicrobial stewardship. Am J Med. 2006; 119(suppl 1):S53-61. 2. O’Brien DJ, Gould IM. Maximizing the impact of antimicrobial stewardship: the role of diagnostics, national and international efforts. Curr Opin Infect Dis. 2013; 26:352-8. 3. Dellit TH, Owens RC, McGowan JE et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007; 44:159-77. 4. Chambers RM, Davis SL. Expanding the reach of antimicrobial stewardship. Pharmacotherapy. 2013; 33:118-21. 5. Trivedi KK, Rosenberg J. The state of antimicrobial stewardship programs in California. Infect Control Hosp Epidemiol. 2013; 34:379-84. 6. Patel D, Lawson W, Guglielmo BJ. Antimicrobial stewardship programs: interventions and associated outcomes. Expert Rev Anti Infect Ther. 2008; 6:209-22. 7. Nowak MA, Nelson RE, Beidenbach JL et al. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health-Syst Pharm. 2012; 68:1500-8. 8. Pollack LA, Gould CV, Srinivasan A. If not now, when? Seizing the moment for antibiotic stewardship. Infect Control Hosp Epidemiol. 2013; 34:117-8. 9. Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Best care at lower cost: the path to continuously learning health care in America. Washington, DC: National Academies Press; 2013:133-45. 10. Pate PG, Storey DF, Baum DL. Implementation of an antimicrobial stewardship program at a 60-bed long-term acute care hospital. Infect Control Hosp Epidemiol. 2012; 33:405-8. 11. Hurst JM, Bosso JA. Antimicrobial stewardship in the management of communityacquired pneumonia. Curr Opin Infect Dis. 2013; 26:184-8. 12. The consensus of the Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2011; 68:1148-52. 13. Pharmacy Practice Model Summit: executive summary. Am J Health-Syst Pharm. 2011; 68:1079-85.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
