PSQH Innovation Awards Winner: Holy Redeemer Hospital Improves Patient Outcomes with Antimicrobial Stewardship
By Jay Kumar
Editor’s note: The sixth annual PSQH Innovation Awards recognize healthcare organizations who overcame patient safety or quality improvement challenges. In this article, we highlight the winning submission from Holy Redeemer Hospital in Meadowbrook, Pennsylvania.
The challenge
In Redeemer Health’s submission, Dr. Hardik H. Patel, PharmD, BCPS, senior pharmacy clinical coordinator, wrote that Holy Redeemer Hospital faced significant challenges in the area of quality improvement and infection prevention, particularly in the context of antimicrobial stewardship programs (ASP). ASPs are crucial initiatives designed to prevent unnecessary antibiotic use and reduce antibiotic resistance.
In the United States, approximately 30% of antibiotics prescribed in acute care hospitals are deemed unnecessary or suboptimal, highlighting the importance of effective ASP implementation, Patel wrote. In 2014, the Centers for Disease Control and Prevention (CDC) introduced the Antibiotic Stewardship Program (Core Elements) to be implemented in hospitals across the nation. The core elements include components such as hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education. Over the years, there has been a positive trend, with the percentage of hospitals implementing ASP increasing from 48% in 2015 to an impressive 91% in 2020.
However, the challenges faced by Holy Redeemer Hospital were exacerbated by the COVID-19 pandemic, he wrote.
“The correlation between the pandemic and the rise in antimicrobial resistance became evident, necessitating a closer look at local trends in community hospitals. The pandemic led to an increase in antimicrobial use, difficulties in following infection prevention measures, and an overall surge in healthcare-associated, antimicrobial-resistant infections,” wrote Patel. “One specific consequence highlighted was the rise in extended-spectrum beta-lactamase (ESBL) producing enterobacterales in the hospital setting, increasing by 32% from 2019-2020 alone.”
Gram-negative bloodstream infections, particularly those caused by Escherichia coli, became a major concern for morbidity and mortality. The Infectious Disease Society of America (IDSA) addressed the treatment of resistant gram-negative infections, emphasizing the need for focused management.
“In the case of Holy Redeemer Hospital, being a small community hospital posed additional challenges,” Patel wrote. “The increase in gram-negative infections and antibiotic resistance prompted the need to assess the burden of gram-negative bacteremia and its impact on antimicrobial stewardship efforts during the COVID-19 pandemic. Several challenges faced by the ASP at Holy Redeemer Hospital included a lack of resources and associated costs. These challenges provided an opportunity to evaluate the hospital’s current policies and tools for managing gram-negative bacteremia. The retrospective review aimed to assess the effectiveness of current antimicrobial stewardship practices, including interventions led by Infectious Diseases Pharmacists, policy-driven measures, and various tools utilized at the local hospital level. In conclusion, Holy Redeemer Hospital encountered multifaceted challenges in implementing effective ASPs, exacerbated by the complexities introduced by the COVID-19 pandemic. The need for comprehensive evaluation and adaptation of antimicrobial stewardship practices was crucial to address the specific issues faced by the hospital, particularly in managing gram-negative bacteremia and antibiotic resistance during the challenging period of the pandemic.”
The solution
To address these challenges, Holy Redeemer Hospital conducted a retrospective cohort analysis study. This study focused on evaluating the impact of antimicrobial stewardship practices in treating Escherichia coli bacteremia in both non-ICU and ICU settings. The study took place at a non-academic small single-center community hospital with 239 beds in Pennsylvania from July 2021 to July 2022, involving patients aged 18 and above admitted to the hospital with positive blood cultures for Escherichia coli.
“Patients were excluded if their blood cultures were not positive for Escherichia coli or if antibiotics were not initiated during their hospital stay,” wrote Patel. “The primary endpoint of the study was to determine the length of hospital stay, with critical secondary endpoints including antibiotic de-escalations, duration of antibiotics, time to definitive antibiotic therapy, serum procalcitonin levels, and blood culture availabilities. To implement effective antimicrobial stewardship practices, the hospital relied on a pharmacist-led ASP that utilized various interventions, policies, and tools specifically targeting gram-negative infections/therapeutics. This approach aimed to ensure appropriateness in antibiotic use and foster de-escalation when possible. The ASP interventions were crucial in achieving the study’s objectives, as reflected in the analysis of critical secondary endpoints.”
Moreover, the hospital collaborated with a multidisciplinary team to develop yearly source-specific cumulative antibiograms for 2021 and 2022, assessing prevalence and resistance patterns during this period, Patel wrote. A segregated data analysis for ESBL organisms was also conducted, focusing on resistance patterns for urine and non-urine antibiograms. Data collection for the study involved reviewing the electronic medical record (EMR) and recording information such as demographic details, admission and discharge dates, blood culture collection dates, antibiotic treatments initiated, procalcitonin levels, and IV to PO conversions. The statistical analysis included descriptive statistics and key outcome measures related to demographics, length of hospital stays, therapy de-escalation, agents utilized for ESBL-producing E. coli bacteremia, procalcitonin levels, and positive blood cultures. The study also utilized supporting tools like antibiogram comparisons for the years 2021 and 2022.
“By implementing a comprehensive retrospective cohort analysis, Holy Redeemer Hospital successfully addressed the challenges in quality improvement and infection prevention,” wrote Patel. “The Pharmacist-led ASP, along with collaborative efforts and data-driven interventions, played a pivotal role in optimizing antibiotic use, improving patient outcomes, and contributing to the overall goal of combating antibiotic resistance in the hospital setting.”
Post-implementation
The implementation of antimicrobial stewardship practices led by pharmacists at Holy Redeemer Hospital has shown significant positive impacts, especially in addressing Escherichia coli bacteremia during the COVID-19 pandemic in 2021, Patel wrote. The net impact of the solution is evident in various key areas, including the length of hospital stay, antibiotic de-escalations, and the utilization of procalcitonin monitoring and blood culture assays.
Length of hospital stay: The primary endpoint of the study focused on determining the impact of pharmacist-led interventions on the length of hospital stay. The results indicated variations based on the setting: In the ICU setting, patients with Escherichia coli bacteremia had an average length of stay of 16.6 days. In the Non-ICU setting, the average length of stay was significantly lower at 7.3 days. For patients with ESBL E. coli bacteremia, the length of stay was 6.8 days. The differences in length of stay between ICU and Non-ICU settings were expected due to the disease burden and complications associated with ICU patients.
Antibiotic de-escalations: Critical secondary endpoints included antibiotic de-escalations, which were a key focus of ASP interventions. De-escalation occurred in 61% of patients through these interventions. Cephalosporins, particularly ceftriaxone and cefazolin, were the most common de-escalating agents in both Non-ICU and ICU settings. A total of 1061 ASP interventions targeted broad-spectrum antibiotics, with a notable focus on carbapenem de-escalation (13.3%). In the Non-ICU setting, out of 27 patients, 18 experienced de-escalations, occurring within an average time of 3.3 days. In the ICU setting, 7 out of 8 patients had de-escalations within an average time of 3.6 days. For patients with ESBL E. coli bacteremia, the antibiotics initiated and switched were detailed, with three patients ending up on appropriate antibiotics (carbapenems) and three on inappropriate antibiotics.
Procalcitonin monitoring: Procalcitonin (PCT) monitoring was a crucial aspect of the ASP’s efforts. Admission serum PCT levels were available for 29 patients. The average PCT level in the ICU setting was higher (23 ng/mL) compared to the Non-ICU setting (10 ng/mL). PCT levels exceeding 2 ng/mL were associated with an average length of stay of 9.6 days. The ASP utilized PCT levels to guide de-escalation, with an average time of 3 to 4 days to de-escalate antibiotics when PCT levels exceeded 2 ng/mL.
Blood culture assays: Blood culture identification panels (BCID) played a pivotal role in optimizing antibiotic use. The BCID panel had an average turnaround time of 1.2 days, allowing the ASP sufficient time to de-escalate antibiotics based on the results. The panels were effective in providing rapid pathogen-related information, guiding empiric selection of therapy.
“Despite challenges, the ASP at Holy Redeemer Hospital demonstrated a positive impact on patient outcomes, including decreased length of hospital stay, effective antibiotic de-escalations, and utilization of biomarkers like procalcitonin and rapid diagnostic tests,” Patel wrote. “The implementation of ASP led by pharmacists has shown promising results in improving patient care and reducing the selective pressure of antibiotics and resistance in a small community hospital setting. Future research with a more rigorous study design and a larger population sample could provide further insights into the generalizability of these findings to other facilities.”
Honorable mentions
The following submissions were selected as honorable mentions:
South Carolina Hospital Association, Columbia, SC
To address ongoing concerns about healthcare-associated infections (HAI) in South Carolina hospitals, the South Carolina Hospital Association (SCHA) in 2014 launched the Certified Zero Harm Program (CZHP) to recognize South Carolina hospitals that were on the forefront of preventing medical errors and provide education and resources to hospitals related to HAI reduction and prevention. The CZHP began as one clinical category with four areas of focus and has now grown to a clinical category with 8 areas of focus and two additional award categories focusing on SCHA priorities and leadership. The impact of the advancements created by the CZHP has yielded a consistent decrease of HAIs in the state and an increase in the number of awards hospitals receive for achieving zero harm in their facilities. Since its inception in 2014, the program has awarded more than 1,000 awards to South Carolina hospitals for achieving zero harm in key categories in their facilities. In 2023, 69 of 90 SC hospitals participated in the CZHP leading to more than 2,300 fewer days in the hospital for their patients and savings of more than $7.5 million in healthcare costs in seven clinical categories. This also equates to 114,661 central lines day without harm, 282,646 patient days without harm, over $2 million dollars saved in avoided surgical site infections, and 6,802 surgical procedures (SSI Abdominal Hysterectomy, SSI Colon Surgery, SSI Hip replacement and SSI Knee Replacement) without infection during 2022.
Baptist Health South Florida, Coral Gables, FL
In an effort to prevent and reduce surgical site infections (SSI) and improve patient safety/experience while making it easier for clinicians to review possible data points they could learn from, Baptist Health South Florida wanted to be able to pull discrete documentation from the electronic medical record to allow the end user to review compliance with essential elements of surgical care across the perioperative continuum without creating additional work. By reviewing all surgical patients for compliance with evidence-based practices that prevent SSI, the organization is able to ensure the best possible care delivery. This allows for early identification of any gaps in surgical site infection prevention interventions, which allow for risk mitigation activities in the care of the patient and real-time education of providers on best practices to prevent recurrences. An interdisciplinary team was assembled to create an automated report that retrieves all the relevant data elements required to evaluate the implementation of evidence-based practices to prevent SSIs in all surgery patients. Data elements in more than 90 categories are pulled from the 24 hours before surgery, the intraoperative record, and the 24 hours after surgery. The report leverages multiple sections of the EHR including the medication administration record, the pre-operative checklists, the vitals, intraoperative record and anesthesia flowsheet. As a result, Baptist Health saw significant improvement and efficiency in reviewing SSI cases, a reduction in review time of SSIs across the perioperative continuum, increased audit capabilities without increased labor efforts, and prevention of SSIs by improving compliance with antimicrobial decolonization, skin preparation, preoperative antimicrobial medication compliance for drug type, dosage, timing, and redosing, and mechanical and antimicrobial bowel preparation.