Contract Pharmacy Improves Antibiotic Stewardship in a Rural Community

An increased focus on antibiotic stewardship (ABS) began for Trego County-Lemke Memorial Hospital, a 25-bed critical access hospital in WaKeeney, Kansas, about two years ago, shortly after the Kansas Department of Health and Environment (KDHE) released a statewide heat map showing the prevalence of E. coli resistance. This report included a ratio of antibiotic usage, and Trego County was high on the list. The health care system needed to do something to address the issue.

As an infection preventionist and risk manager, Kiley Wheeles, BSN, RN, recognized the limitations of her role as it related to ABS. She could only see trends but was not comfortable making specific antibiotic recommendations. She sought to build an effective ABS program and provided new and fresh interventions to ensure a more responsible approach to antibiotic prescribing. Trego County-Lemke Memorial is a small hospital with no in-house pharmacy but has an existing relationship with a contract pharmacy that provides monitoring and oversight of medication programs.

According to Janis Hughes, PharmD, augmenting hospital ABS programs is still a relatively new service line for Hospital Pharmacy Management (HPM), a hospital pharmacy service company based in Iola, Kansas. This service is offered in two phases: Phase 1) Development/review of an antibiogram and development of indication-specific order sets, and Phase 2) Longitudinal monitoring of usage patterns and rates.

The project aimed to leverage the expertise of Iola’s HPM pharmacists to develop specific order sets based on disease processes that included recommendations for first-line and second-line antibiotic use. The idea was to make responsible and informed antibiotic prescribing easy for prescribers. Everything they needed for common conditions, including recommended antibiotics, labs and nursing orders, would be included in a single-step, electronic order set. For example, if the prescriber admits a patient for a urinary tract infection (UTI), the order set would recommend appropriate antibiotics based on the hospital’s formulary and community resistance patterns. This approach prompts prescribers rather than asking them to remember current or updated recommendations across various clinical conditions. For Trego County-Lemke Memorial Hospital, appropriate antibiotic use for UTIs was the initial quality improvement goal. UTI rates were high, specifically for the elderly population. Any patient with an abnormal urine result appeared to be receiving an antibiotic.

PLAN: The initial KDHE heat map report got the attention of hospital leadership, which provided the essential leadership buy-in necessary to plan for change and implement new processes. As part of the planning process, this same heat map was shared with the hospital’s providers to demonstrate the need for change. Trego County-Lemke Memorial had an established ABS Committee. Membership included a pharmacy nurse*, the infection preventionist, the chief nursing officer and a physician champion. However, this did not have a real purpose and lacked pharmacist representation.

HPM’s planning process includes working closely with the organization to identify the quality improvement activities/priorities the organization is interested in working on or an area they are specifically struggling with. Trego County-Lemke Memorial Hospital struggled to ensure patients with a UTI received the correct antibiotic.

DO: Adding the HPM representative to the ABS committee changed the entire group dynamic and gave substance to the reports the committee produced. The initial interventions implemented included developing an antibiogram, developing indication-specific order sets and leveraging the 72-hour time-out setting within the Cerner electronic health record (EHR). The 72-hour time-out setting was not a part of the initial planning but was recommended by the pharmacist. This time-out setting is a feature that provider organizations can opt into. This feature provides a 72-hour notice to providers (based on the timing of the antibiotic start date/time) asking the prescriber if the patient still needs the antibiotic, suggesting that it could be discontinued, defining the duration of antibiotic therapy, changed to PO (by mouth), etc.

Initially, Trego County-Lemke Memorial focused only on its inpatient and emergency department populations. Adopting improved order sets helped clinical staff evaluate the whole person being treated, rather than providing an antibiotic to every patient with an abnormal urine result, even if they were asymptomatic.

STUDY: As treatment behaviors and patterns were observed after implementation, clinical staff began to focus on why they were treating patients. Based on the established order sets and updated ABS committee recommendations, nursing staff must critically think through the next steps based on specific clinical indicators or a combination of clinical indicators. Some of the incidental findings include:

• Reduction in testing for Clostridioides difficille (C. diff) potentially indicating previous over-testing.
• Improved instruction and effectiveness of “clean catch” urinalysis (UA) samples: The hospital could also initiate a standing order for a straight catheter UA sample if the patient cannot give a clean catch specimen within four hours of admission. This has resulted in better specimen collection and allowed clinical staff to treat the patient’s condition more accurately.
• Reduced contamination when accessing ports for culture samples: Culture results did not match the patient’s presentation, requiring clinical staff to consider what could be causing the culture results. It has been interesting to see how much E. coli resulted from contamination rather than an actual infection.

While it hasn’t been formally studied, infection prevention and clinical pharmacists believe that overall antibiotic usage, specifically IV antibiotics, has decreased, and de-escalating to oral antibiotics has also improved. It hasn’t yet been a whole year that the new processes have been in place, but this is a planned area for study.

ACT TO HOLD THE GAINS: The current plan is to continue the process. It seems that the monthly review of progress continues to result in identifying other improvement opportunities (i.e., C. diff cultures, clean catch process). Additionally, the changed process is still new enough that prescribers are at risk of slipping back into old prescribing habits. Hence, continuing education is vital until it becomes a permanent change. The timing is perfect for continued education and enhancements to the process, as provider organizations are just starting to step back from COVID response and focus on priorities other than COVID.

Some key takeaways from the program’s development and implementation include:

• Pharmacists are an essential part of the care team, and small hospitals can successfully incorporate this discipline into their care teams through contract arrangements even if they don’t have employed pharmacy staff.
• The most impactful intervention was the order sets for specific disease processes, and they have been received very well by providers. Smaller hospitals may have an easier time implementing this intervention because it’s easier to identify the types of common admissions (smaller population) and pre-define the necessary order sets.
• How order sets are presented to providers is important. You’re not telling them what to do or prescribe; you’re just giving them options based on current evidence, thereby saving time. Providers can still select from the provided recommendations.

One additional consideration that Trego County-Lemke Memorial Hospital and HPM had hoped to implement included a hard stop for laboratory orders if appropriate indication was not provided. For example, if the system could prompt response to specific clinical questions (i.e., is the patient symptomatic), the hospital could potentially avoid unnecessary reflex micro-testing; if the patient is not symptomatic, there is no reason to send the urinalysis for further testing. However, this function does not currently exist in their EHR and was not a priority for their vendor to add.

Understanding and Enhancing the Contracting Pharmacy Role: Most small hospitals without an on-site pharmacy department/employed pharmacist have a relationship with a consultant or contract pharmacists. There is no reason to reinvent a role to support medication management programs. While there are differences in the contract pharmacy role from state to state (i.e., time to review orders from 72 hours to seven days), most state boards of pharmacy require that facilities have a pharmacist in charge (PIC) designated. However, this role primarily provides a retrospective review of initiated pharmacy orders. In smaller communities, most hospitals contract with their local community pharmacist to meet this requirement. However, the retail/community pharmacy role differs from a health system or hospital pharmacy perspective. The health system approach can provide a prospective relationship whereby orders are reviewed as they come in by the pharmacy consultant, reviewing renal function and allergies and adjusting the orders before they reach the patient. Small hospitals may consider re-evaluating their contract pharmacy relationship to leverage hospital or health system pharmacy experience or approaches.

*Pharmacy Nurse – A nurse with specific experience in pharmacy and nursing manages the hospital’s formulary and liaisons between departments.

Iola Pharmacy in Iola, Kansas