The National Healthcare Safety Network’s (NHSN’s) Standardized Antimicrobial Administration Ratio (SAAR) offers hospitals an important opportunity to improve patient safety and quality of care while achieving cost savings through an enhanced antimicrobial stewardship program (ASP). SAAR not only helps hospitals benchmark their results against their peers but more importantly, it can help hospitals optimize their ASPs by pairing SAAR data with the following:
- Analytical tools that pinpoint areas for potential improvement.
- Pharmacy-centered process improvements.
The state of antimicrobial stewardship in the US
As of 2021, 95% of U.S. hospitals have ASPs in place, largely due to the Centers for Medicaid and Medicare Services (CMS) requiring hospitals to have such programs to continue receiving CMS payments.
As of 2023, over 2,400 acute care hospitals in the U.S. have voluntarily reported to the NHSN Antimicrobial Use and Resistance (AUR) module. This represents significant progress compared to earlier years. The Centers for Medicare & Medicaid Services (CMS) announced that, starting in 2024, AUR reporting will be required under the Public Health and Clinical Data Exchange Objective.
Despite this progress, there are still implementation gaps, and the efficacy and implementation of best practices vary greatly among existing programs. Hospitals continue to prescribe unnecessary or suboptimal antibiotics about 30 percent of the time.
That percentage remains unacceptable given the costs to human health and hospital bottom lines. Understanding best practices and tailoring them to each hospital’s unique concerns is an imperative that hospitals can no longer ignore.
What is SAAR?
Hospitals that participate in the NHSN Antimicrobial Use Option receive a number, called SAAR, that is based on nationally aggregated baseline reference data. More than 2,400 participating hospitals (as of 2023) compose the reference denominator, and the NHSN adjusts each hospital’s number, a soft ratio, based on hospital size, hospital location, and the level of services provided.
A SAAR of exactly 1 indicates a hospital is using about the amount of antibiotics the NHSN would predict. A value less than 1 indicates the hospital is using less than its peers, and a value greater than 1, of course, means it is using more than its peers.
That’s a powerful starting point, but while the number provides a clear picture of utilization and patterns over time and across an entire hospital, it does not indicate the appropriateness of what each hospital is prescribing, much less what is happening in specific units or which areas are ripe for improvement.
Once they have their SAAR number, hospitals need to be able to integrate and visualize all data that contributes to the ratio, rapidly dig deeper to identify potential outliers in the topline ratio, and implement process improvements to make necessary changes to prescribing patterns.
In September 2022, the AUR module was further refined by incorporating the Targeted Assessment for Stewardship (TAS) to provide the AU-cumulative attributable difference (AU-CAD) value, which translates the SAAR target into a tangible number of antimicrobial days to reduce or add to achieve a desired SAAR. This data can support analysis of ASP-targeted interventions, like identifying the volume of work required, which can help determine staffing levels.
The benefits of tracking SAAR data
Tracking your Standardized Antimicrobial Administration Ratio offers distinct advantages for hospitals looking to elevate their antimicrobial stewardship programs. When facilities leverage this data effectively, they unlock significant improvements across financial, operational, and clinical domains.
- Cost savings: Tracking antibiotic use and pairing it with targeted stewardship interventions helps hospitals reduce excess antimicrobial consumption. According to 2022 internal data from Montefiore Health System, the organization realized $500,000 in cost savings. They achieved this by reducing antibiotic use through a series of stewardship interventions, which included providing detailed antimicrobial use feedback reports to prescribing providers.
- HAI insights: By leveraging SAAR, antimicrobial stewardship programs and infection control and prevention teams can gain insights into the impact of HAIs caused by drug-resistant pathogens on antimicrobial use.
- Prescribing pattern improvements: When shared with providers, SAAR results can improve local antibiotic use and lead to improved patient outcomes.
Deploy powerful analytical tools
The Joint Commission Journal on Quality and Patient Safety found that the one important best practice is the integration of properly selected information technology (IT) because it enables real-time interventions to optimize antimicrobial therapy and patient management.
Some hospitals assume that their electronic health records (EHRs) can provide enough insight to inform their ASP properly. The problem is that alerts bundled with EHRs generate too many false positives, and those alerts rarely supply detailed enough guidance to reduce practice variation around antimicrobial prescribing. Furthermore, EHR reports often lack the crucial data to provide actionable insights on the performance of antimicrobial stewardship.
Such a tool can provide actionable, risk-stratified information and critical insight into resistance trends, drawing attention to urgent issues and the greatest opportunities for improvement. Real-time notification of orders for restricted antimicrobials, drug-bug mismatches, de-escalation opportunities, renal dosing adjustments, patient allergy or drug-drug interaction risks and prevention of hospital-associated infections ensure rapid, effective response. The tool can also reduce the time associated with regulatory reporting and preparation of reports that point to performance improvement opportunities. And the resulting data-driven workflows provide the needed foundation for a proactive response.
Process improvements put pharmacy at the center
Using a powerful clinical surveillance tool also puts pharmacy at the center of an effective ASP. In fact, according to the CDC, “Highly effective hospital antibiotic stewardship programs have strong pharmacist engagement, either as a leader or co-leader of the program. It is important to identify a pharmacist who is empowered to lead implementation efforts to improve antibiotic use. Infectious diseases trained pharmacists are highly effective in improving antibiotic use and often help lead programs in larger hospitals and healthcare systems.”
Pharmacists monitoring a well-designed dashboard connect and engage nurses and physicians to respond to critical questions, such as:
- Were the antimicrobials truly needed?
- Were they prescribed appropriately?
- Were they discontinued or de-escalated when no longer necessary?
Raising awareness in this way is, of course, the key to changing habits throughout the hospital. We have seen hospitals achieve up to a 25 percent reduction in antimicrobial expenditures and a 35 percent decrease in antibiotic costs per patient day emerging from dose adjustments, de-escalation, shorter duration, and by avoiding unnecessary medication use.
Such numbers demonstrate that SAAR can be much more than a benchmarking tool. Through a combination of technology and intelligent process design, hospitals can use SAAR as a leaping off point to either inform early-stage ASP or to take existing ASP programs to a whole new level, with concurrent enhancements to regulatory compliance, financial returns, and patient safety and outcomes.