St. Luke’s Magic Valley (SLMV) Medical Center in Twin Falls, Idaho, provides a model case for how a small hospital can dramatically reduce overuse of antimicrobial drugs when the microbiology lab and pharmacy work collectively and continuously with the clinical staff on stewardship. St. Luke’s “Bug Squad” program saved the hospital $830,000 in fiscal year 2013 and was awarded the Idaho Awards of Excellence in Healthcare Quality from Qualis Health in 2014.
According to the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) 2007 guidance for implementing effective hospital-based antibiotic stewardship program (ASP), a crucial component of success is having a multidisciplinary ASP team in place that includes the close integration of the clinical, pharmacy and microbiology team members. Both large and small hospitals can significantly reduce overuse of antimicrobial drugs with this approach.
According to IDSA/SHEA guidelines, small hospitals that have implemented the guidelines have reduced antimicrobial drug use by 22% and saved $200,000. Large academic medical centers have reduced unnecessary drug use by up to 36% and saved as much as $900,000.
In the first year of the “Bug Squad” program at SLMV, the cost of daptomycin (Cubicin, Merck), fell to $30,000 from $256,000. Additionally, in 2014, the average length of stay for patients hospitalized with uncomplicated pneumonia decreased by 40%—from 4.5 to 2.7 days—by implementing appropriate treatment more rapidly. SLMV has come much closer to the benchmark for large academic medical centers.
So, how did this 224-bed hospital in southern Idaho achieve such stunning success?
The ASP program is spearheaded by Kenny Alexander, PharmD, BS, a hospitalist pharmacist who works exclusively on helping to achieve optimal antimicrobial drug use. He does rounds with the physicians, reviews charts, and receives real-time lab results so that immediate drug changes can be made.
For ASP team members Janie Palmer, MT (ASCP), SM and Alexander, reducing antibiotic overuse clearly means making sure patients receive optimal antimicrobial therapy with as little exposure as possible to drugs that won’t help battle an infection.
“St. Luke’s was ahead of the curve when it came to antimicrobial stewardship,” said Palmer, supervisor of the microbiology lab with 38 years’ experience.
“We had the support of hospital management from day one. They realized that resistance is a serious problem and that we could do something to spare our patients from needless infections, as well as save resources from misused and overused antibiotics and antimicrobial drugs. Kenny is proof of St. Luke’s genuine commitment to stewardship.”
“I was hired 3 years ago as a committed pharmacy member of the Bug Squad,” said Alexander. He does not work in the pharmacy, but is dedicated to the ASP, working daily with Palmer and physicians and nurses caring for patients with infections.
“With each patient, our goal is to identify as quickly as possible which drug will work best,” Alexander said. “Likewise, when we learn something new and need to make adjustments, we strive to do this immediately. Letting time pass while a patient is receiving the wrong therapy is not an option for us. We want to act as quickly as possible. Other hospitals that have made this their goal have demonstrated significant reductions in resistance. That’s our goal.”
“We act on the results of our automated culturing system and antimicrobial susceptibility platform immediately,” said Palmer.
“Why have state-of-the art automated and rapid systems like these if you don’t use the data immediately? In many hospitals, the lab and the pharmacy operate in silos with very little communication between them. That’s not how we work here. I talk to Kenny every day and as soon as we have results, he gets a phone call.”
“I review every chart and collaborate with our doctors,” said Alexander. “We work collectively to make sure we’ve made optimal drug selections and to watch for out for drug interactions and duplications of therapies. Eighty percent of what I do covers infectious disease and antibiotic use. Pharmacy is a great profession, but this job is very unusual and very satisfying. I love it.”
In addition to constant communication, St. Luke’s Bug Squad meets twice a week to discuss infectious disease patients. The team also includes physicians, infection prevention nurses, and the hospital’s sepsis coordinator. The purpose of the meetings is multifactorial, but the overall goal is “to improve and to intervene,” said Palmer.
The micro lab brings the latest results on infections that have been red-flagged.
“In one case, a patient with a Staph infection was about to be discharged with a course Keflex (cephalexin),” Alexander said. “But the lab team member at the Bug Squad meeting had recent results showing that an anaerobe was growing as well, which Keflex won’t touch. As a result, the therapy was changed before the patient was discharged. This isn’t an unusual situation. Typically, that patient would go home, take the full course of the wrong antibiotic, only to be readmitted. Our goal is to get patients healthy as fast as possible. In the process, we’re able to save a tremendous about of money that can be used more wisely somewhere else in our care continuum.”
At each Bug Squad meeting, the team tracks consults, therapy selections, and the dollars saved from avoiding or mitigating sub-optimal treatments. They send letters to doctors who are overusing antibiotics, and they review central line infections, urinary tract infections, and cases of ventilator-associated pneumonia, as well as anything that could lead to a process improvement.
“There are two major pieces to this puzzle,” said Palmer. “The lab must have the best equipment, and the hospital must be committed to good stewardship. You need both to succeed. Many hospital stewardship teams meet once a month with little or no interaction otherwise. That doesn’t work. Everyone has to be engaged in order to battle antimicrobial resistance.”
- Dellit, T.H. 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; CID 2007:44 (15 January).
Opinions expressed in this article are not necessarily those of bioMérieux, Inc.