Remote Antimicrobial Stewardship: A Solution for Meeting The Joint Commission Stewardship Standard?

Abstract

The purpose of this study was to determine the time required for antimicrobial stewardship (AS) activities at a small community hospital (SCH) as well as barriers to remote AS to satisfy The Joint Commission (TJC)'s AS standard. Methods: This was a prospective chart review and time study conducted in patients identified by a clinical decision support application as potential opportunities for antimicrobial therapy modification at a SCH between December 12, 2016, and March 31, 2017. Potential interventions were communicated electronically to the clinical pharmacy specialist, who would then communicate the recommendations to the patient's provider. The primary endpoint was a time study for stewardship activities. Secondary endpoints included describing barriers encountered to remote AS as well as a cost-benefit analysis of remote AS. Results: The time study revealed an average of 11 alerts per day, 9 chart reviews per day, 8 interventions per day, and 5 minutes per chart. Seven hundred twenty-four alerts were evaluated with the most common alerts constituting opportunities for deescalation (29%), targeted drugs (22%), positive blood cultures (18%), Intravenous (IV) to oral (PO) (17%), and antimicrobial renal monitoring (8%).Interventions were accepted (11%), accepted modified (6%), rejected (35%), or undetermined (48%). Barriers to implementation included workflow and indirect communication. For patients with accepted interventions, there was an average savings of $279.82 per patient in pharmacy charges. Conclusion: Through remote AS, a SCH can have an antimicrobial stewardship program that is in compliance with the basic elements of the TJC standard MM.09.01.01, performs daily chart review by an infectious diseases trained pharmacist to increase the quality of patient care, and achieves a mean savings of $279.82 in pharmacy charges and $1,126.26 in hospital charges per patient with accepted interventions.

Tele‐antimicrobial stewardship programs: A review of the literature and the role of the pharmacist

“…Fully remote TASPs include an offsite ID specialist conducting PAIF on individual patient cases and directly contacting prescribers through various telehealth delivery systems. Examples include on‐demand review of antibiotic prescriptions facilitated by requests through a secure web application 19,20 or telephone hotline, 21 or TASP‐driven PAIF with a shared EHR and/or clinical decision support software (CDSS) 22,29 . These models may or may not include engagement of on‐site pharmacists, and only some were able to demonstrate measurable decreases in antimicrobial consumption, prevalence of multidrug‐resistant organisms (MDRO), or declining CDI rates as a proof of concept for TASP 20,22,23 .…”

“…Howell et al described an integrated TASP to support an on‐site non‐ID‐trained clinical pharmacist with ASP responsibilities to ensure The Joint Commission (TJC) compliance at an affiliated 110‐bed suburban hospital 29 . The TASP consisted of ID pharmacists and ID physicians who developed infrastructure needed for TJC compliance, such as staff education on antimicrobial stewardship, medication use evaluations, a formal ASP policy and committee, pharmacist‐driven protocols, and disease state‐specific EHR order sets.…”

Opportunities and challenges in improving antimicrobial use during the era of telehealth expansion: A narrative review

“…The IDt specialist must have EMR access for remote review, but if EMR access is lacking, the IDt specialist can collaboratively review the EMR with frontline caregivers. Communication of feedback and recommendations to frontline caregivers may be asynchronous (ie, EMR notes or e-mails) [19][20][21][22][23][24][25] or synchronous (phone calls or teleconferences) with direct communication to local caregivers. [26][27][28][29][30] All but 1 study involved a remote ID physician as a member of the IDt ASP.…”

“…[26][27][28][29][30] All but 1 study involved a remote ID physician as a member of the IDt ASP. 19 The level of engagement of local caregivers in the IDt ASP can also vary; some programs identifying local ASP champions such as pharmacists, 19,21,22,[27][28][29][30][31][32] physicians, 30 or infection preventionists, 21,31 and others operate remotely and independently. In addition to PAF, some IDt ASPs provide didactic and case-based sessions led by IDt specialists during synchronous teleconferences.…”

“…Participants also felt that teleconferences enabled discussions between frontline clinicians and the stewardship team, which was preferable to asynchronous forms of communication. 21 Studies on IDt ASPs have reported improved outcomes such as decreased inpatient antimicrobial use, 20,[23][24][25][26][28][29][30][31] decreased cost related to inpatient antimicrobials, 19,22,32 decreased Clostridioides difficile infections, 22,23 and improved antimicrobial susceptibility patterns of common organisms. 20,24,25,32 One study also reported a 40% increase in ID consultations after the implementation of IDt ASP.…”