How are rural hospitals handling the CMS antimicrobial stewardship mandate?
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[Editor’s note: Click here to read our recent feature on ID care in rural America.]
In 2019, CMS announced a rule that all acute-care hospitals participating in Medicare or Medicaid would be required to have an antibiotic stewardship program beginning in 2020.
The rule applies even to rural hospitals, many of which do not have an infectious disease specialist on staff.
We asked Rutul Dalal, MBBS, MD, FACP, FIDSA, medical director of infectious diseases at Penn State Health, Eastern Pennsylvania Region, how rural hospitals are handling the mandate.
Expanding antimicrobial stewardship to community hospitals is vital and now required by regulatory agencies.
Rural hospitals are an integral part of the health care system. They provide services across the continuum of care from primary care to long-term care. In recent years, however, they have faced challenges. Factors such as low reimbursement rates, increased regulation, reduced patient volumes and uncompensated care have caused many rural hospitals to struggle financially. On top of it, there is already a dire shortage of infectious disease physicians — especially of those who are willing to work in a rural setting.
I worked as an ID physician in the North Central Pennsylvania region. In general, rural areas have poorer health, and antibiotic overuse has led to antibiotic resistance and adverse effects.
Recently, there has been a spate of mergers and acquisitions of smaller health systems by larger ones. This probably has helped slightly in the efforts toward better stewardship. In my region, some hospitals did not have a single staff member trained in antibiotic stewardship, and that is where bigger hospital systems and telehealth were able to help. ID doctors and ID-trained pharmacists from larger hospitals reviewed electronic medical records every single day. When someone from a rural hospital needed to order an antibiotic, they would first need to state a reason for the antibiotic, and pick a dose, duration and route of administration. This information would, in turn, be reviewed at the larger health care center. If an intervention was necessary, the local pharmacist working at the rural hospital would be contacted — via email, regular virtual meetings or phone — and would then intervene with the patient’s provider and advise them of the possible changes.
If the providers had any question or concerns about the recommendation, they would also have a chance to connect with the central antibiotic stewardship team located at the larger health system.
We also initiated certain tools in our EMR that would automatically stop the antibiotic after a certain period. If it needed to be renewed, the provider had to add a justification in the EMR. Also, the central team used telehealth to monitor the EMR daily to watch for potential drug interactions or drug-bug mismatches and would provide recommendations about narrowing the spectrum of the antibiotic after appropriate culture and sensitivities were available. Of course, we also installed new lab gadgets that could tell us if there was indeed a microorganism isolated in the medium and identify it quickly so antimicrobials could be amended, if needed.
Public education campaigns using print and electronic media were also being arranged by some hospitals hoping to educate the community about the ill effects of excessive exposure to antimicrobials. This was also imparted to health care personnel.
Because of these initiatives, significant advances were made toward the stewardship objective, but there were still some limitations, chief among which were the following:
- It was difficult to monitor outpatient provider offices and their prescription habits in real time.
- Providers had a choice of whether to adhere to the advice, particularly if there were no antibiotic stewards on the ground.
- EMRs cannot decide the clinical nature of the disease, and sometimes provider discontent grows because not all ID ailments are a simple drug/bug decision.
- Some patient and family members insist on antibiotics and do not understand the global ramification of indiscriminate use of antimicrobials.
Antibiotic stewardship remains an issue in rural America, but with the use of technology, indiscriminate and uncontrolled use of antibiotics has gone down. Still, there is a lot of work to do.
References:
- Medicare and Medicaid programs; regulatory provisions to promote program efficiency, transparency, and burden reduction; Fire safety requirements for certain dialysis facilities; hospital and critical access hospital (CAH) changes to promote innovation, flexibility, and improvement in patient care. https://www.federalregister.gov/documents/2019/09/30/2019-20736/medicare-and-medicaid-programs-regulatory-provisions-to-promote-program-efficiency-transparency-and. Published Sept. 30, 2019. Accessed Jan. 30, 2024.
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