MARTINSBURG, WV—Three VAMCs that formed a collaborative group to optimize use of a shared clinicalsurveillance system saved more than $2.3 million in two years.

Those results were presented recently at the IDWeek 2018 conference.1

Most medical centers in the VA develop and monitor their own antimicrobial stewardship programs, based on guidance from the VA and the CDC. The VAMCs in Martinsburg, WV; Washington, DC; and Baltimore, MD, followed that course at first. All three had launched antimicrobial stewardship (AS) programs by 2014, in keeping with VA Directive 1031, issued in January of that year.

The directive arose from the work of the VA’s Antimicrobial Stewardship Task Force, created in 2011 and co-led by the National Infectious Diseases Service and the VA’s Pharmacy Benefits Management program.

The VA’s focus on antimicrobial stewardship has put it on the leading edge of the field, which has gained urgency in the last decade. “A dwindling antibiotic pipeline, the emergence of drug-resistant bacteria, and other harms of antibiotic use have driven the development of antimicrobial stewardship programs, systematic processes to reduce inappropriate use of antibiotics,” said Kelly Echevarria, PharmD, a member of the National Antimicrobial Stewardship Task Force as well as national clinical pharmacy program manager, Infectious Diseases and Pharmacy Benefits Management Designee co-lead.

The 2014 directive required “each VA facility to develop and implement an antimicrobial stewardship program with a written policy, annual evaluation, and adequate dedicated staffing and resources, especially for the physician and pharmacist who co-lead the program,” Echevarria said.

The three VAMCs in the VA Capitol Health Care Network (VISN 5) decided that integrating their programs could produce better results than any of them could get acting alone. They began working together in 2015 to align their existing antimicrobial stewardship programs and procure a shared contract for Document Storage Systems, Inc.’s (DSS) TheraDoc clinical surveillance system, which all the facilities installed between November 2015 and March 2016.

Within the clinical surveillance system, “each AS program designed alerts and interventions specific to its own medical center and collaborated to develop a group of 27 interventions that were shared by all sites,” said lead author Ann Marie Laake, MD, of the Martinsburg VAMC and her colleagues. “There was no attempt to alter individually determined AS practices of each VAMC.”

Over time, though, the programs’ surveillance goals evolved. Initially, all three programs focused on “restricted drugs and drug: bug mismatch,” said Matt Zuzik, PharmD, of DSS and a co-author of the study. By the end of year 1, “the programs had expanded into fluoroquinolone duration surveillance, c. diff. focused surveillance and other targeted de-escalations.”

As the teams became more comfortable with the system, they added additional goals and alerts. Recent additions focus on nitrofurantoin contraindication with low glomerular filtration rates, thrombocytopenia and antibiotic usage, and elevated creatinine phosphokinase on daptomycin, Zuzik told U.S. Medicine.

Daily Alerts

The pharmacists and other members of the antimicrobial stewardship teams review daily alerts for the clinical surveillance system each morning and also use the system to view medication lists and pending items notices. The Flag Report provides a central hub for the team to track its work and communicate.

The clinical surveillance system is fully integrated with VistA/CPRS, according to Zuzik. “As events occur in VistA, data is transferred to TheraDoc in real-time,” which allows aggregation from “VistA’s disparate systems, and presents the data in usable format to aid clinicians in patient care decisions,” he explained.

A SharePoint site also facilitates exchange of best practices and resolution of issues.

Automation of record review for each patient and standardized alerts that suggest treatment changes enabled lean antimicrobial stewardship teams to attend to all high priority issues without having to individually review patient records. Each of the teams operates with one pharmacist and half to three-quarters of an infectious disease specialist’s time.

Together, the VAMCs include 853 acute care beds and 523 long-term care or rehabilitation beds. Each year the network processes approximately 130,000 pharmacy encounters.

The increased ability to conduct reviews led to a more than three-fold rise in the number of pharmacy interventions driven by antimicrobial concerns. Interventions increased from 2,946 in 2016 to 10,016 in 2017.

That rise in interventions also significantly increased savings. Across the three VAMCs, “the shared ASP interventions led to $532,520 of estimated cost savings in 2016 and an estimated $1,790,906 of cost savings in 2017,” the authors said.

Cost-saving interventions included discontinuing medications that are poorly matched or unnecessary for the pathogen identified in cultures or by clinical presentation, preventing adverse drug events, conversion of intravenous medications to less expensive oral formulas, eliminating redundant antimicrobials, switching patients to narrower and less expensive antimicrobials, shortening duration of drug therapy to guideline recommended length of time, and restricting use of certain medications without approval of an infectious disease specialist.

Reflecting the differences between the facilities and the priorities of their antimicrobial teams, the top five interventions varied significantly between the VAMCs. For all three the most common intervention was an ASP consult, but in Maryland the next four were infectious disease review, dose adjustment of antibiotic, minor adverse event prevention and avoided use of continued IV vancomycin. In Martinsburg, by contrast, the next four most common interventions were intravenous to oral conversion, antibiotic discontinuation, adverse event prevention and review of positive cultures.

1. Laake AM, Bork J, Dave R, Adenew A, Seitzinger H, Zuzik M, Chang J, Liappis AP. A Regional Collaboration to Share Antimicrobial Stewardship Resources in Three Geographically Related Veterans Affairs Medical Centers. IDWeek 2018. #1867. Poster Abstract Session: Antimicrobial Stewardship: Potpourri. October 6, 2018.