As the chief patient experience officer for the Intermountain Healthcare system in Salt Lake City, Shannon Phillips, M.D., knows the value of antibiotic stewardship—efforts to improve antibiotic use to reduce drug resistance and increase patient safety. She recently spoke with Pew to share her philosophy on antibiotic use, Intermountain’s prioritization of stewardship, and the positive effects the organization is already seeing across its system, which includes 24 hospitals and more than 180 office practices as well as home care and telehealth. The conversation has been edited for length and clarity.
A: The natural consequences of not having good antibiotic stewardship are worse patient outcomes and more expensive care. A lot of people don't think of antibiotics as a dangerous category of medications, but in fact, there are real risks that patients shouldn’t be exposed to unnecessarily. One in five patients on antibiotics in the hospital has an antibiotic-associated adverse drug event—Clostridium difficile (C. diff), also known as Clostridioides difficile, being one of the most serious. Stewardship helps protect patients from these dangers and slows the development of resistance by bringing an awareness to the importance of using the most appropriate antibiotic at the right time, for the right reasons, and for the right duration. Our Office of Patient Experience is focused on safety, quality, great outcomes at the right cost, and a positive patient experience. And from that standpoint, antibiotic stewardship is a natural fit—it hits all those boxes and makes good sense to us.
A: Our medical director for antibiotic stewardship and our infectious diseases pharmacy manager work together to lead efforts to improve antibiotic use across our entire system. They are really in the trenches, collaborating with our clinicians to look at our resistance patterns across our system and what the literature says about how to create and implement best practices for antibiotic prescribing. They also develop and track metrics on antibiotic use, including for patients who go home from the hospital with IV antibiotics, for example. Ultimately, the goal of their work is to make sure that we have consistent, integrated, effective stewardship across our entire care network.
A: It all starts with focusing on the patients and their needs, and what brought them in to seek care. That helps us understand how to address whether or not an antibiotic is appropriate and how to deliver the best care possible.
Systemically, our stewardship team has done several things that have created a supportive environment for improved antibiotic use. More recently, they have focused on antibiotic stewardship in our ambulatory and telehealth settings to make sure that all channels of care that a patient accesses have consistent stewardship.
Urgent care centers are a major part of this—about half of the encounters in these facilities are related to infectious disease concerns, which is why our stewardship team’s work in urgent care has been really important. First, informed by patient and provider discussions, they have developed materials and media campaigns to educate the community about antibiotic resistance and the importance of using antibiotics appropriately. Second, there is full transparency of data to urgent care providers on their antibiotic prescribing. This means every provider can see the details of their own prescribing, as well as how that compares to prescribing trends in the system overall. Third, we’ve leveraged the electronic health record (EHR) as a tool to help providers with antibiotic prescribing decisions in real time while they’re caring for a patient. Lastly, all our urgent care providers have access to infectious diseases consultation via a telephone hotline when questions arise, giving them access to support and backup.
We also provide antibiotic stewardship support in our 24 hospitals. In terms of how this plays out on a patient-by-patient basis, let’s take a hypothetical example. Say I have a patient with a complex pneumonia and I want to get support beyond what is being offered to me in the EHR or through our care process models. I can simply call the pharmacy, and they can get input from the antibiotic stewardship folks to help me select the right medication for my patient based not only on my patient’s data but also data from the entire system. They can help me determine what drugs have been most effective against the different resistant strains we’ve been seeing.
And other times, it will be our stewardship team that reaches out to the doctor taking care of patients in the hospital. Pretty much every antibiotic prescription gets looked at behind the scenes by this team. And based on both direct observations and what the data are showing, they might simply call you and say, “Hey, did you think about this?” I've been on the receiving end of this kind of outreach from the stewardship team a few times, and I'm grateful for it. Their approach is consultative and educational. They listen to what you're thinking, share their best knowledge, and are available to talk through hard cases, which is very powerful.
Stewardship is a big deal. Not only is it completely the right thing to do for the patient, but now The Joint Commission and the Centers for Medicare & Medicaid Services require stewardship in many health care settings. If we are committed to keeping people healthy and reducing antibiotic resistance, we need good stewardship programs. I hope it matters to people simply because it's the right thing to do, but I also recognize that that's not sufficient sometimes. And that’s where the data is critical. Our stewardship efforts are already improving prescribing, and we’ve seen really encouraging progress in specific areas like reductions in rates of C. diff. Our plan is to publish this data so that others can see the value of stewardship in black and white. The bottom line is that stewardship is effective. To me, it’s a no-brainer.
I encourage health systems to consider using a system level structure like we have for antibiotic stewardship efforts rather than trying to have stewardship-specific staff at every facility, big and small. Think about ways that you can maximize the use of stewardship pharmacists and infectious disease experts who might lead these sorts of programs and can beam in and beam out via telehealth and other means. This approach is efficient, makes it easier to scale efforts up as needed, and fosters consistency in quality across the continuum of care. Several years ago, this model enabled us to successfully integrate antibiotic stewardship into our rural health care practices fairly seamlessly, and now we’re continuing these efforts in urgent care.