CMS currently requires that all hospitals have an Antimicrobial
Stewardship program in place to assure proper antimicrobial usage. This
mandate is part of an effort to stem the ever increasing problem of
antimicrobial resistance. These programs are usually comprised on a
"physician champion", usually an Infectious Disease (ID) physician as
well as an ID trained pharmacist. These programs usually entail some
form of prospective audit and feedback to prescribing physicians to
ensure appropriate antibiotic choice and duration. Most of these
stewardship programs are under-funded in terms of percent time and
salaries support such that only a small percentage of patients on
antibiotics are reviewed i.e. we barely scratch the surface.
A similar shortcoming to stewardship programs is also encountered on most hospital's Infectious Disease Consult services. In hospitals the attending physicians call for consults on cases that they deem to be difficult and require assistance. Unfortunately, with this setup an Infectious Disease consultation is not called on patients that could most benefit from the expertise of an ID physician. A typical hospital ID consult service will see about 15 patients were day. In an average sized community hospital of 250 beds this would equate to ~6% of inpatients being seen. Data from numerous studies indicate that at least 50% of inpatients are on systemic antibiotics equating to ~125 patients in a 250 bed hospital.
So, what we currently have at most hospitals are "half ass" stewardship programs that meet the CMS criteria and "half ass" ID consult services with a number of patients falling through the cracks. I say we scrap the arcane ID consult service entirely and revamp and re-fund the stewardship programs. Hospitals should hire and 100% fund an ID physician or physicians for a large hospital to run with pharmacy and entirely new type of stewardship program. In this setting ALL patients in the hospital with positive cultures or on systemic antibiotics would be reviewed in real-time. The stewardship program would conduct walk rounds floor by floor speaking with Attending Physicians and making countless interventions. Physical exam findings, micro results, lab studies and radiographic studies could be still be interpreted and acted upon by ID physicians but gone would be the requirements of the incessant documentation required to fulfill billing requirements.
Data actually is available that this approach works. Sarah Parker and her colleagues at the Children's Hospital Colorado developed an approach where all inpatient antimicrobial prescriptions were reviewed by physician and pharmacist "stewards" (Pediatric Infectious Disease Journal 2016; 35:1104-1110). The stewards then relayed all recommendations in person to the treating physicians on the hospital wards. They also fielded questions from physicians even if there were no specific recommendations. They termed this program "Handshake Stewardship". Implementation of the program was associated with a 10% decrease in antimicrobial use. The Clostridium difficile incidence rate decreased significantly during the implementation phase from 8.3 down to 4.9/10, 000 patient days ;p<0.01.
These troubling times of increasing antimicrobial resistance and deadly C. difficile infections call for radical solutions. Get rid of the formal Infectious Disease consultation service I say and instead implement "Handshake Stewardship". In athletics a goal is often to get the ball in the hands of talented athletes as often possible to make meaningful plays that affect the game's outcome. This is referred to as getting the star "touches". Handshake Stewardship ensures that Infectious Disease physicians get the maximum amount of touches to improve outcomes.
A similar shortcoming to stewardship programs is also encountered on most hospital's Infectious Disease Consult services. In hospitals the attending physicians call for consults on cases that they deem to be difficult and require assistance. Unfortunately, with this setup an Infectious Disease consultation is not called on patients that could most benefit from the expertise of an ID physician. A typical hospital ID consult service will see about 15 patients were day. In an average sized community hospital of 250 beds this would equate to ~6% of inpatients being seen. Data from numerous studies indicate that at least 50% of inpatients are on systemic antibiotics equating to ~125 patients in a 250 bed hospital.
So, what we currently have at most hospitals are "half ass" stewardship programs that meet the CMS criteria and "half ass" ID consult services with a number of patients falling through the cracks. I say we scrap the arcane ID consult service entirely and revamp and re-fund the stewardship programs. Hospitals should hire and 100% fund an ID physician or physicians for a large hospital to run with pharmacy and entirely new type of stewardship program. In this setting ALL patients in the hospital with positive cultures or on systemic antibiotics would be reviewed in real-time. The stewardship program would conduct walk rounds floor by floor speaking with Attending Physicians and making countless interventions. Physical exam findings, micro results, lab studies and radiographic studies could be still be interpreted and acted upon by ID physicians but gone would be the requirements of the incessant documentation required to fulfill billing requirements.
Data actually is available that this approach works. Sarah Parker and her colleagues at the Children's Hospital Colorado developed an approach where all inpatient antimicrobial prescriptions were reviewed by physician and pharmacist "stewards" (Pediatric Infectious Disease Journal 2016; 35:1104-1110). The stewards then relayed all recommendations in person to the treating physicians on the hospital wards. They also fielded questions from physicians even if there were no specific recommendations. They termed this program "Handshake Stewardship". Implementation of the program was associated with a 10% decrease in antimicrobial use. The Clostridium difficile incidence rate decreased significantly during the implementation phase from 8.3 down to 4.9/10, 000 patient days ;p<0.01.
These troubling times of increasing antimicrobial resistance and deadly C. difficile infections call for radical solutions. Get rid of the formal Infectious Disease consultation service I say and instead implement "Handshake Stewardship". In athletics a goal is often to get the ball in the hands of talented athletes as often possible to make meaningful plays that affect the game's outcome. This is referred to as getting the star "touches". Handshake Stewardship ensures that Infectious Disease physicians get the maximum amount of touches to improve outcomes.
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