With 60% of hospitalized children receiving antimicrobials
and more than 40% of antimicrobial use being deemed inappropriate, there’s a
great deal of room for improvement. Yearly at Children’s Hospital Colorado (CHCO),
there are 15,000 inpatient admissions, and 45,000 antimicrobial orders. All of this adds up to why CHCO implemented
an Antimicrobial Stewardship Program (ASP) in 2011, with the aim of supporting
providers in appropriate antimicrobial prescribing.
ASP program started small, with one employee devoting 20% of a full-time job to
the program. But with the development of a successful business case, the
program has grown: Sarah
Parker, MD, Associate Professor of Pediatric Infectious Diseases and
Medical Director of the ASP, now devotes 50% of her full-time position to the
ASP. And, the program also boasts one additional FTE for a full time pharmacist,
split between Jason Child, PharmD and Amanda Hurst, PharmD.
The pillars of the
program are patient safety and quality care, provider support and education,
scholarship to forward pediatric dosing, and a national and international presence.
In 2013, a team consisting of Dr. Parker, Jason Child and Sarah
Kinder, MD, applied to the Institute for Healthcare Quality, Safety and
Efficiency (IHQSE) Certificate Training Program (CTP)
because they wanted to strengthen their approach to tackling patient safety
initiatives. Once accepted, they began working toward the goals of:
Decreasing use of broad spectrum antimicrobials
Decreasing overall use of antimicrobials
Decreasing adverse drug events
Containing antibiotic resistance and C. difficile rates
Containing anti-infective cost
Containing hospital costs
So far, the results have been positive.
Through a 2013 pilot program that was part of
their hands-on IHQSE training, 1,831 patient cases were reviewed
post-prescription. This review resulted in a 9% intervention rate, which saved
approximately $600 per intervention. If this type of intervention were extended
to all patients, it could mean a conservative estimated cost avoidance of
$98,874--all from avoiding unnecessary prescriptions.
Children’s Hospital Colorado saves more than
$50,000 annually by switching from the drug ertapenem to a less expensive drug
with no clinical differences in patients with appendicitis.
Use of vancomycin in the Pediatric Intensive
Care Unit has dropped by half.
Orally bioavailable agents are now administered
orally more often than intravenously on the medical units.
Two grants were awarded to the program,
including a CCTSI CO-Pilot Independent Faculty Award “Pilot study of
metronidazole pharmacokinetics in pediatric patients”, and a CHCO Clinical and
Operational Effectiveness and Patient Safety Small Grant, “Stewardship of
Antimicrobials Aims to Increase the Judicious, Safe and Effective Use of
Antimicrobials while Preventing Resistance, Side Effects and Excessive
Four IRB/ORRQIRP protocols approved
Development of a new clinical rotation in
Stewardship for residents and medicals students in 2013
Seven major clinical care
guidelines/protocols, with follow up evaluation underway
Dr. Parker’s appointment to three major
The team estimates that an additional $1 million in cost
avoidance could be attributed to a 10% decreased use in unnecessary
antimicrobials and associated laboratory testing, as well as a 10% reduction of
drug resistant cases with a 4% impact on C.
The ASP will again survey providers to learn about what they
want and need from the ASP. While some hospitals have implemented a request
process before using antimicrobials, Children’s Colorado has not, choosing
instead to focus on appropriate use and de-escalation of antimicrobials with
post-prescriptive provider support, and collaborative effort at the section
level to change systematic practices.
The team will continue to work toward a culture shift,
increasing universal interest among all subspecialties, increasing dialogue between
providers, and increasing collaboration between sections. The team will have forthcoming publications
on many of their successful projects from the past two years.