Antimicrobial Stewardship in a Community Hospital: Investigation to Compliance and Outcomes

From the 2018 HVPAA National Conference

Heather Lusby (Magnolia Regional Health Center), Raul Ramirez (Magnolia Regional Health Center), Branden Moore (Magnolia Regional Health Center), Brentley Frossard (Magnolia Regional Health Center), Sahar Jahan (Magnolia Regional Health Center), Abram Arnold (Magnolia Regional Health Center), Kristopher Schock (Nova Southeastern University College of Osteopathic Medicine), Elizabeth McCaskey (Nova Southeastern University College of Osteopathic Medicine), Waqaar Arshad (DeBusk College of Osteopathic Medicine), Cortney Booth (DeBusk College of Osteopathic Medicine), Hayes Baker (Magnolia Regional Health Center)

Background

Current scientific literature emphasizes the need to reduce the use of inappropriate antimicrobials in health care settings due to developing antimicrobial resistance. Studies analyzing outcomes of antimicrobial stewardship programs (ASP) exist; however data is limited in the community hospital setting.

Objectives

The primary outcome was to determine whether physicians are compliant with antibiotic recommendations made by an Infectious Disease (ID) physician as part of an ASP. Secondary outcomes were to further look at: 30-day hospital readmissions, cost of stay, length of stay (LOS), days of antimicrobial therapy, and 30 day Clostridium difficile infection (CDI).

Methods

We performed a retrospective observational cohort study through chart review of the Electronic Medical Record (EMR). The inclusion criterion was any adult admitted to our facility between the time period of August 1, 2016 to July 31, 2017 that had an infectious disease intervention. This included both ASP intervention notes and Infectious Disease Consult (IDC) notes. The results were further categorized based on full, partial, or non-compliance of the primary physician with ID recommendations. The following patients were excluded: multiple interventions making differences in antibiotic coverage difficult to determine, transfer to another facility, transition to comfort care only, or pregnancy.

Results

Overall there were 484 IDC notes and 184 ASP notes, with combined full compliance at 81.1%. IDC had full compliance of 89.2% and ASP had full compliance of 59.7%. Upon review of secondary outcomes, all cause 30-day readmission rates were 17% in the full compliance group, 19% in the partially compliant group, and 23%(P=0.003) in the non-compliant groups. Further multivariate regression model also showed that physicians were 3.22 [95% CI: 2.22,3.33] times more likely to have full compliance than partial compliance when patients had an increased illness severity index.

Conclusion

This study shows that there was a compliance of 81% with antibiotic recommendations made by an ID specialist with the use of the EMR in a community hospital setting in rural Mississippi. The illness severity index was calculated using comorbid conditions to case match patients in each group. Our data showed that the compliant group had the highest severity index of 2.9 and the non-compliant group had the lowest severity index at 2.6 with (P<0.05.) This was further observed in our multivariate regression model with the physician compliance noted to be 3.22 times higher in the full compliance group, which was statically significant.

Upon review of our secondary outcomes, a decrease in hospital readmission rates was noted in patients in which there was partial or full compliance versus non-compliance (P=0.003). Upon literature review, another study showed decreased hospitalizations in the community hospital setting with ASP intervention, but exclusively looked at skin and soft tissue infections. Our study further showed that intervention in the form of antibiotic recommendations by ID specialist led to a decrease in 30-day hospitalizations, therefore demonstrating the cost effectiveness of such ASP programs.

Currently there is no standard or universally accepted way to implement ASP; this study further shows programs can be successfully implemented in community hospital settings.

Implications for the Patient

Readmissions are routinely used as a quality measure in modern day healthcare settings. This study shows decreased all cause 30 day readmissions with ASP intervention in a rural community hospital. This further leads to increased cost effectiveness, decreased utilization, and increased quality of patient care.