Collaboration Is Key for ASP Implementation in Resource-Constrained Hospitals

by the bioMerieux Connection Editors

In a 2016 survey of leading hospitals, 82% reported having an Antimicrobial Stewardship Program (ASP). However, this number will grow much larger after the new Centers for Medicare and Medicaid Services (CMS) rule goes into effect in Spring 2020. The new rule requires all hospitals seeking reimbursement from Medicare or Medicaid to have an ASP that adheres to the guidelines of nationally recognized sources, such as the Infectious Disease Society of America (IDSA) or the Society for Hospital Epidemiology of America (SHEA).

The purpose of the 2016 study was to examine the ASP structure among high performing hospitals and determine which components of the 2016 IDSA/SHEA ASP guidelines were implemented at each location. It was performed with the goal of understanding the structure of ASPs in leading hospitals to better assist ASP implementation in other institutions. Researchers theorized that top-ranked hospitals would be more advanced in their ASP practice and could help outline future directions for the field.

The survey showed that most hospitals had implemented the majority of commitments, interventions, and optimization strategies suggested by IDSA/SHEA. The majority of hospitals who responded had an ASP established for more than five years (59%), physician and pharmacist co-leads (59%) and a program that fell within the pharmacy department (58%).

The ASPs also had many common elements such as:

  • Stewardship training and education (80%)
  • Prospective audit and feedback (88%)
  • Facility-specific recommendations for infectious syndromes (88%)
  • Antimicrobial pre-authorization (82%)
  • Promotion of intravenous (IV) to oral antimicrobial transition where appropriate (93%)

The CMS has amended an existing section of their Conditions of Participation (CoP) that applies to hospitals accepting Medicare and/or Medicaid reimbursements and now requires that, “a hospital’s infection prevention and control and antibiotic stewardship programs be active and hospital-wide for the surveillance, prevention, and control of [hospital acquired infections] and other infectious diseases, and for the optimization of antibiotic use through stewardship,” and that a program, “demonstrate adherence to nationally recognized infection prevention and control guidelines for reducing the transmission of infections, as well as best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms.”

Ideally, this new CMS rule will strengthen stewardship programs across the United States, because virtually all hospitals bill to Medicare and Medicaid. However, these conditions will have a broad impact and greatly affect hospitals with inadequate or minimal programs. The largest challenge will be for hospitals without stewardship programs. Community Access Hospitals and resource constrained hospitals who don’t have programs may need assistance implementing them.

Program adoption rates vary by hospital size. According to the Centers for Disease Control and Prevention (CDC), only 46% of hospitals with fewer than 50 beds had implemented ASPs as of 2016. “These findings underscore the challenges that lie ahead in expanding antibiotic stewardship efforts in small community and critical access hospitals, which treat underserved patient populations in rural areas and generally have very few beds, limited resources, and staff with multiple functions. Limitations in financial resources, access to experts in infectious disease and antibiotic stewardship, and technological infrastructure to facilitate data collection and analysis can pose significant obstacles to ASP implementation in these settings,” states a 2019 Academic Medicine article.

Despite resource challenges, work is being done to help smaller hospitals implement ASPs. ASP guidelines were created in 2017 by a convened facility staff of nationally accredited organizations who led successful stewardship programs in small and Community Access Hospitals. The lesson learned was that gaps in resources could be filled by outside organizations to collaboratively produce a successful program. Academic medical centers, health care systems, state and local health departments, hospital associations, and rural health associations can leverage their existing resources and networks to lead collaborative activities where stewardship tools and expertise can be pooled and shared with smaller hospitals.

Expanding collaborative efforts across regions through the leadership of state and local health organizations will be critical for the implementation of stewardship programs in resource-constrained hospitals. As the new CMS rule falls into effect, smaller hospitals will likely have to rely on those who have leading ASPs to meet guidelines and protect patients from the growing threat of antimicrobial resistance.

To learn more about the elements of hospital Antimicrobial Stewardship Programs, download bioMérieux’s 2019 edition of the Antimicrobial Stewardship Guide:

Download the Antimicrobial Stewardship Guide For Hospitals


Opinions expressed in this article are not necessarily those of bioMérieux, Inc.

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