A path to success for LTC antibiotic stewardship
James M. Keegan, M.D.
There are two dates fast approaching that will have a major impact on long-term care operations and revenue:
On Nov. 28, 2017, Phase II of CMS's final rule for long-term care conditions of participation in Medicare and Medicaid goes into effect. By that date, facilities must establish an antibiotic stewardship program (ASP) as part of the overarching Infection Prevention and Control Program.
On Jan. 1, 2018, skilled nursing facilities will be subject to 30-day readmission penalties under the Protecting Access to Medicare Act.
Both deadlines reinforce the need for SNF staffers to take a fresh look at how antibiotics are prescribed in the post-acute setting. According to the latest research from the Centers for Disease Control and Prevention, up to 70% of nursing home residents receive antibiotics each year, yet up to 75% of those antibiotics are prescribed incorrectly.
Overprescribing broad-spectrum antibiotics can destroy the “good” bacteria on the skin and in the intestinal tract–protective bacteria which keep patients safe from things like Clostridium difficile infection (CDI), methicillin-resistant Staphylococcus aureus (MRSA), and other highly resistant bacteria that can lead to costly hospital readmissions. CDIs have a 20% readmission rate, and the mortality rate for elderly patients is nearly 9%.
Here are some recommendations for a smooth and successful ASP implementation in your organization:
- Get upfront help from an ASP expert – Why reinvent the wheel when you can turn to an infectious disease specialist or ASP-savvy physician to design a program? An expert can help you create a comprehensive program tailored expressly to the needs of your facility.
- Don't empirically prescribe an antibiotic as a “just in case” solution – Some LTCs have been known to prescribe antibiotics to patients experiencing cloudy urine or confusion. Dehydration is often the root cause of the former, and confusion is not a reliable sign of infection.
- Review your local antibiogram – An antibiogram (available from the nearest hospital) analyzes the sensitivity of local bacteria to different types of antibiotics. Some bacteria are likely to be sensitive to several antibiotics, while others may show signs of resistance to commonly used antibiotics. The LTC medical director and other staffers should pay close attention to the antibiogram as they weigh whether or not to prescribe a certain antibiotic.
- Create a preferred antibiotic list based on your antibiogram – Since some antibiotics clearly work better against specific infections, you should establish a short list of the ones to use. Anything not on that list would need to be approved by the LTC medical director.
- Think about the financial benefits of not prescribing antibiotics that are likely to be ineffective – Most sinus infections and coughs are viral, so prescribing an antibiotic would be both fruitless and expensive.
- Explore rapid diagnostic technology – The cost of rapid diagnostic systems has dropped significantly in recent years. It's now possible to quickly determine whether an infection is bacterial or viral – and antibiotics would be useless in the latter case.
Finally, remember to educate the entire care team about the benefits of protective bacteria. Many of your staffers may not realize that eradicating good bacteria can increase the chances for CDI and MRSA cases, leading to more hospital readmissions.
LTCs have recently seen their maximum civil monetary penalties double, and no facility wants to pay hefty hospital readmission penalties on top of that. Your organization has just a few months left to implement an ASP, and establishing a program will help reduce your exposure to readmission fines. The simple steps outlined above can help your facility raise the quality of care while lowering costs.
James M. Keegan, M.D., is an infectious disease specialist who directs the Antibiotic Stewardship service line at PYA (Pershing Yoakley & Associates), a healthcare consulting firm serving clients in all 50 states.