In today's session, we'll be talking about expanding stewardship programs into the small community hospital setting. The first question we should ask ourselves is, how does antibiotic use compare in small hospitals, compared to large hospitals? These data come from Intermountain Healthcare. What we are looking here are at 19 of Intermountain's hospitals. On the right-hand side, in the light gray, are large community hospitals that have greater than 200 beds. On the left side, in the dark gray, we see our 15 small community hospitals. The height of the bar represents the antibiotic use rates, in days of therapy per 1,000 patient days. We're looking at 3-year median antibiotic use rates, and what you can see is that a number of the small community hospitals on the left have very similar rates to the large community hospitals on the right. We also see considerable variability in our small community hospitals. The red star on the right represents Intermountain Medical Center, our largest academic medical center in the system. How many small hospitals now have stewardship programs? The CDC provides us these data from the NHSN annual survey. They asked hospitals how many of the CDC core elements of stewardship were active in their hospitals. And what we can see from these graphs is that the smaller the hospital, the more likely you are to not have a stewardship program that has all seven core elements. In fact, of the hospitals that had 0 to 50 beds, only 31% of those facilities had antibiotic stewardship programs that met all of the core elements of the CDC. However, in hospitals that had greater than 200 beds, 66% of those hospitals met all core elements. So we know that there are a large number of US hospitals that are small, with less than 200 beds. Many of them have similar antibiotic use rates compared to large hospitals. Most of these are without stewardship programs, and there's very few studies of stewardship in these settings. However, all of these hospitals will be required to have stewardship programs under joint commission regulation and forthcoming CMS conditions of participation. There are multiple similarities and differences as it pertains to development and sustainability of a stewardship program in small and large hospitals. We'll talk about bed size and location, constructing a stewardship team, patients and infections, drug resistance and microbiology lab, data collection, and cost. By definition, small community hospitals have less than 200 beds, and small hospitals are, many times, located in very rural settings. However, some may be quite urban. So what does this mean for stewardship program development? The rural hospitals oftentimes, due to their remote status, have no access to specialty care. This includes infectious disease providers, but will also include subspecialty surgical and medical specialties. Due to the small number of beds, significantly less time is needed for day to day antibiotic stewardship review. A 50 bed hospital, for example, may have only 25 patients on antibiotics. And most of these patients are likely on antibiotics for common conditions, such as pneumonia, urinary tract infection, and skin infection. Given that most of these patients have common conditions, the time required for stewardship interventions is likely to be much less than large hospitals. Constructing a team. There are similarities between small and large hospitals when it comes to constructing a team. A local leader is very important. Multidisciplinary teams are incredibly important to engage clinicians. The engagement of both the antibiotic stewardship staff and the clinicians is critical. Staff capacity is limited in both the small and large hospitals. However, in small hospitals, ID physicians and pharmacists are rare, where in large hospitals, ID physicians are common. So what does this mean for small hospitals? That we must be cognizant of small community hospitals' clinicians and their other duties that they perform for their hospitals. Many times, these clinicians will be on multiple committees and have multiple clinical commitments. It is therefore recommended to combine antibiotic stewardship meetings and committees into other standing committees, such as the pharmacy and therapeutics, or medical executive councils. ID clinicians are often rare in these instances. However, they should be actively involved, if possible. To involve ID clinicians, one must be creative. We are seeing more small hospitals utilize tele-infectious disease and stewardship programs to engage ID clinicians, and using external ID consultants under contracts. If an ID physician is unable to be used in developing the team, appropriate training must be obtained by the local physicians and pharmacists who run the team. Patients and infections. In small community hospitals, the patients are typically less complex, and they typically have more standard infections, such as pneumonia, urine infections, and skin infections. The more complex, complicated patients, many times, are transferred to large community hospitals. In terms of stewardship, this means that focusing on core syndromes in small hospitals, such as pneumonia, urine infections, and skin infections, will capture the vast majority of patients on antibiotics. It also will take generally less time to review patients, due to the less complex nature. However, there are still plenty of very sick patients that need attention quickly in small community hospitals. Drug resistance and laboratory limitations. There are significant differences between small and large hospitals when it comes to drug resistance and microbiology limitations. In small hospitals, there's often decreased antimicrobial resistance, in terms of MRSA, vancomycin-resistant Enterococcus, and drug-resistant gram-negatives. Small hospitals often utilize and rely more on offsite microbiology labs, as compared to large facilities. In addition, small hospitals have a decreased number of bacterial isolates for the development of antibiograms. And small hospitals, given their reliance on offsite microbiology labs, utilize rapid tests often much less than the larger facilities? So what does this mean for stewardship? Given the decreased antibiotic resistance in small hospitals, the stewardship program should match the antibiotic restriction policies to the microbiology of the facility that they see. If the facility does not see large numbers of drug-resistant bacteria, antibiotics targeting these agents should be restricted. Given the few numbers of bacterial isolates that will populate an antibiogram, it is critical that antibiotic stewardship programs promote the obtaining of appropriate clinical cultures. Many small community hospitals have partnered with other regional facilities to develop community-based antibiograms to add depth to their antibiogram and provide the appropriate power. It should also be noted that, given the offsite nature of the microbiology labs and the few rapid diagnostic tests that are available, antibiotic de-escalation is often delayed, due to long turnaround times obtained at small community hospitals. This means that empiric therapy needs to be appropriate, and setting clear care process models to define appropriate initial therapy is critical. Data collection and analysis. In small hospitals, just like in large hospitals, many stewardship programs are uncertain of what to measure, in terms of antibiotic stewardship programs. However, in small hospitals, there's often a lack of access to data, due to the lack of sophisticated IT departments in order to pull electronic data. In addition, small hospitals often lack an infectious disease provider to interpret the data and put it into the national context. Our recommendation is that small hospitals obtain antibiotic consumption data in a consistent manner. Most often, small hospitals rely on defined daily doses, as this is a metric that is easier to obtain than days of therapy, which requires individual patient-level data. If possible, small hospitals should utilize their healthcare system or network to obtain antibiotic usage data. That being said, chart reviews to assess antibiotic appropriateness is often easier at small community hospitals, due to the few number of patients. And appropriateness measures can be obtained on an ongoing basis to assess antibiotic prescribing in small hospitals. In the end, however, it is essential that all stewardship programs measure something, and do it in a consistent and sustainable manner. And finally, cost. As in large hospitals, it is equally as important in small hospitals to have administrative support of the stewardship program. The difference, however, is that in small hospitals, it often does not require hiring a full-time position to develop a stewardship program. Whereas in large hospitals, it is often required to hire one to three additional trained ID personnel to develop their stewardship program. A business case must be developed, and well thought through for small hospitals to ensure that time is protected for the staff to do stewardship activities. Dedicated time is required to establish the antibiotic stewardship program in both small and large facilities. In small hospitals, antibiotic stewardship program must be made a priority, and dedicated time must be given to the appropriate staff. What we've done is we developed the Infectious Disease TeleHealth Program. This telehealth program provides infectious disease services for our 16 community and rural hospitals in Utah and Southern Idaho. We provide inpatient, face-to-face ID consultation via in-room camera, and perform full infectious disease consultation telehealth visits. We also offer telephone consultation and advice for inpatient, outpatient, emergency department, acute care clinics, and provide this service 24 hours a day, 7 days a week via an infectious disease hotline. And finally, our Infectious Disease TeleHealth Program staff supports the antibiotic stewardship efforts at all of these 16 community hospitals. We have an infectious disease pharmacist that monitors real-time alerts, and alerts local clinicians and pharmacists with interventions. In addition, our Infectious Disease TeleHealth Program staff monitors and mentors local health stewardship programs, and provides them central guidance for projects, and data, and education. Here is an example of our central data that we provide to all of our 16 small community hospital stewardship programs. What you see here is an antibiotic usage dashboard that we provide on a monthly basis that shows antibiotic usage rates for all antibiotics, and then also CDC-defined categories on a monthly basis. These dashboards are fully transparent, and one hospital can see the antibiotic usage rates of other hospitals. In conclusion, small community hospitals are different than large hospitals in many ways, and implementing an antibiotic stewardship program will also be different. One size does not fit all. Utilizing a collaborative approach and tailoring stewardship activities to the needs of small hospitals and the resources available can lead to successful programs. However, new models of stewardship will need to be evaluated to meet the needs of small hospitals, thank you.
