December 09, 2019
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Q&A: Infection prevention programs as a model for ASPs

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George E. Nelson, MD
George E. Nelson

A review of existing literature on the practices of antimicrobial stewardship programs, or ASPs, showed there are few streamlined recommendations for appropriate staffing, researchers said.

Healio spoke with George E. Nelson, MD, assistant professor of medicine, director of the antimicrobial stewardship program and associate hospital epidemiologist at Vanderbilt University Medical Center, about the review. Nelson explained how ASPs can be modeled after infection prevention (IP) programs, and discussed barriers to sufficient staffing and appropriate compensation. – by Marley Ghizzone

Q: What inspired the review?

A: One of the main questions I hear from colleagues in the antimicrobial stewardship community who are trying to set up or expand their program is, What resources are available to advocate for additional personnel? Regardless of the setting, from a small rural critical access hospital to a large urban referral center, antimicrobial stewardship leaders face challenges in gathering resources to lead their ASPs. ASPs provide vital services for individual patients and population at large. Despite increasing visibility and evolving regulatory guidance, many programs have difficulty gaining traction to garner support. While looking through the published literature and surveying facilities across the spectrum, the common refrain was insufficient personnel and resources. This need was the genesis of the review to collect some of the instructive literature available to serve as a resource. As we got deeper into reviewing the staffing and resource literature, the parallels with IP and other health care teams emerged, as did the need to advance the discussion around staffing standards.

Q: What barriers stand in the way of appropriate ASP staffing?

A: There are a lot of ASP success stories, but there remain a lot of challenges, especially regarding staffing. Many of these barriers are ones that have been encountered, and continue to be encountered, by IP programs, as well as many other hospital ventures and individual providers: too much work and not enough bandwidth. Even though ASP is positioned as an ideal product by improving care and saving money, marketing ASP can be difficult. There are endless competing demands for hospital leadership, and increasing ASP support often means deprioritizing something else. Also, because of the expansive breadth of ASP functions, encapsulating a singular message that speaks to all facets of leadership is complex. A multitude of ASP approaches have been individualized at the hospital level often because of differing needs affected by numerous factors, including the care delivery model, complexity of care, availability of infectious diseases personnel and hospital setting. This flexibility is necessary and of massive benefit but makes staffing standardization difficult. Although there is ample evidence of the benefits and necessity of ASPs, it can sometimes be hard to link an upstream ASP intervention with a downstream outcome such as readmissions or length of stay, further complicating a business case to hospital leadership. ASP metrics are strong, but still evolving and not as entrenched as IP-related measures. Given the widespread challenges with ASP staffing, it becomes even more important to have a larger discussion on the topic rather than having every program wage its own case.

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Q: How can the IP model inform ASP staffing?

A: IP serves as an important model for leveraging ASP infrastructure. Both share a similar breadth of activities, ranging from individual patient safety and quality care initiatives to operational surveillance and systems process improvement. These efforts involve all team members and disciplines across the health care continuum of care. IP staffing has evolved over time and sheds light on potential challenges and solutions; ASP’s path has a lot of similarities, although the speed of regulatory changes may be more compressed. IP established a robust research foundation demonstrating the benefit of IP activities as well as IP-specific expertise. One of the early studies that informed the initial staffing benchmark evaluated the time required to perform vital IP functions. Only later in the SENIC study was it evident that the benchmark resulted in a 32% reduction in nosocomial infection rates. Subsequent studies further refined optimal staffing ratios that are now widely accepted and adopted by hospitals as standard of care. Even with these evidence-based ratios and increased visibility, incorporation on the front lines at individual hospitals lagged. Similarly, the case for ASPs and their effectiveness is abundant. Initial studies evaluating time required to execute ASP functions to develop proposed ratios have been conducted, and more recent studies link ASP staffing to outcomes. Awareness and emphasis around optimal ASP composition, metrics and processes continue to increase, but staffing recommendations are lagging and often remain vague by acknowledging that these critical programs should be staffed appropriately with sufficient time and resources without explicit benchmarks. But recent iterations of CDC’s Core Elements, like the stepwise advances of IP guidance previously, continue to progress and elevate the need for resourcing ASPs.

Q: What recommendations do you make?

A: Ideally everyone would see the benefit of ASPs and staff them appropriately. But realistically, it is difficult to change practice given the myriad critical and competing priorities. For this reason, benchmarks should be discussed and developed further and ultimately incorporated into regulatory guidance. Only in this way will ASP personnel be able to realize what they have long been advocating for but rarely attain. An initial bare minimum threshold that surfaced during the review was that there should be at the very least one total full-time equivalent (FTE) ASP position for every 250 beds, optimally with approximately one physician for every three pharmacists. But given the range of staffing levels that have been raised, many of which suggest a higher level of support (up to one FTE per 100 beds), this should not be the default, only the starting place. The above-mentioned recommendation focuses on physician and pharmacy support, but analytic and administrative support are also key needs; there just wasn’t the same degree of available literature examining those areas to include in the initial thresholds. For hospitals with fewer beds, there would likely have to be a minimum requirement such as a minimum of 0.25 FTE physician and 0.5 FTE pharmacy support for hospitals with less than 100 beds. Beyond the initial step of creating some minimal benchmarks, there needs to be more research on the topic. Research is necessary both to demonstrate the impact of ASP staffing on outcomes to support and further refine optimal staffing ratios and also to evaluate arenas with less robust data, namely long-term care facilities, outpatient clinics and locations that serve specialized populations, such as transplant and critical care patients.

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Q: How should physicians performing antimicrobial stewardship be compensated?

A: In reviewing all the literature, the one universal takeaway is that physicians, pharmacists and support staff need to be compensated for their efforts. Currently, many do this work without renumeration or with minimal support because it is the right thing to do. But given the escalating requirements and reach of stewardship, this approach is not sustainable. How the compensation is arrived at and by what method is less clear. There are differences between academic and non-academic hospitals in terms of how salaries are configured, either by time (eg, FTE), productivity or other arrangements. Many ASP functions, such as quality improvement, safety initiatives and administrative functions, don’t lend themselves to traditional work productivity units or billing. The compensation model likely would follow the examples of quality officers and many IP programs. Funding could be directed from hospital operations or quality budget and justified by annual reports demonstrating progress with mutually agreed-upon goals.

Reference:

Greene MH, et al. Infect Control Hosp Epidemiol. 2019;doi:10.1017/ice.2019.294.

Disclosure: Nelson reports no relevant financial disclosures.