Erin K McCreary,
Pharm D and Sheryl L Henderson, MD, PhD
American Family
Children’s Hospital and University of Wisconsin School of Medicine
Since
2002, our hospital has successfully operated a robust, multidisciplinary
antimicrobial stewardship program (ASP) for a 500+ bed adult population. We
have recently embarked on the journey of ASP development within the associated 88-bed
children’s hospital, with the support of senior leadership. A pediatric
infectious disease specialist has long been a member of the Antimicrobial Use
Subcommittee, but traditionally the focus of P&T has been on adult
medicine. While all realize the importance of pediatric medicine, very few are
trained in this art. Those with pediatric specialty training are inherently
creative in the practice of medicine since far less evidence exists to guide
therapeutic decisions. Implementing a pediatric ASP requires a union of
imagination and standardization.
Growing pains lead
to significant gains
We
currently find ourselves facing exciting opportunities and challenges that come
with the establishment of a formal ASP in the children’s hospital. A common challenge within academic medical
centers is the regular interface with providers whose experience is primarily adult
medicine. For example, pharmacy, surgical, and emergency care residents are
often at the forefront of patient care decisions when working at the children’s
hospital, even though they may have only one rotation dedicated to pediatrics. There is a desire from these trainees
to learn the intricacies of pediatric care, turning challenge into opportunity
and providing a niche for education; a foundational tenant of stewardship.
As
a pharmacy resident, I quickly discovered that what works in the adult world does
not always correlate to success in the pediatric realm. For example, IV to PO interchange may simply not be possible
because a child does not like the flavoring of the medication. It is refreshing
to focus on the humanistic aspects along with the scientific nature of
antimicrobial stewardship.
Teamwork makes the
dream work
To
build a successful ASP, it is crucial to harness the energy of those most
passionate about change and to also gain input from those that may not know
about or believe in the value of stewardship.
To choose our program’s priorities, we are listening to questions raised
by pediatric providers and pharmacy staff. We are also meeting with several stakeholders
(MDs, PharmDs, RNs, etc.) and have distributed an implementation survey to
discern what is known about benefits of an ASP and assess what respondents would
like to gain from our ASP.
The
goal of an ASP is to fine-tune antimicrobial prescribing in order to provide
the safest, most effective and judicious antimicrobial-related patient care. We
recognize that all providers can be stewards. We also collaborate with
microbiology laboratory directors to promote rapid diagnostic testing and
information technology pharmacists to facilitate order set development and
electronic health record alerts. Some aspects of the program, such as daily
prospective audit and feedback of all patients on antimicrobials by a
pharmacist and physician pair, mirror our adult program. Other priorities are not
unique to the pediatric population, but require a different approach to
stewardship than in adults. These include: optimization of the use of
vancomycin and vancomycin alternatives, standardization of antimicrobial use
for managing neutropenic fever in pediatric oncology patients, and promotion of
IV-to-PO conversion through an interactive clinical decision support tool.
Remarkable care
that we can share
A
conference speaker once stated that no one wakes up wanting to use
antimicrobials inappropriately. This simple statement resonates with us. No one
wants to do things wrong, but we need guidance on how to do things the best way. The desire to implement
positive change does not imply an underlying failure or brokenness of the
current system. It simply indicates that opportunities exist to go from good to
great.
It
is easy amidst all the rules and paperwork we face from U.S. News and World
Report, The Centers of Disease Control, The Joint Commission, and Centers for
Medicare & Medicaid Services to lose sight of the most important piece of
the stewardship puzzle: the patient. Regulations exist to ensure safe and
optimal care is provided to every single patient. Keeping the patient at the
core of all conversations and using objective data to drive key decisions leads
to meaningful stewardship interventions that are more readily accepted. Our
journey has just begun, and unparalleled patient care is our destination. We look forward to the opportunity to build a
stewardship network across our health system.
Asked by Anonymous
