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
Recent studies indicate that more than four in five US hospitals have ASPs in place. Good thing too, since in September 2019, the Centers for Medicaid and Medicare Services (CMS) finalized regulations that require hospitals to have such programs to continue receiving CMS payments.
The bad news is that 15 percent of hospitals have not yet begun their ASP implementations and the efficacy and implementation of best practices vary greatly among existing programs. Only a handful of hospitals understand the impact their programs are having on antimicrobial utilization. The result is that according to the Centers for Disease Control and Prevention (CDC), hospitals still 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 rooted in nationally aggregated baseline reference data. The 550 participating hospitals (as of 2017) 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 one indicates a hospital is using about the amount of antibiotics the NHSN would predict. Less than one indicates the hospital is using less than its peers, and more than one, of course, means it is using more than its peers.
That’s a powerful starting point, but while the number is 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 going on in specific units and what areas are ripe for improvement.
Thus once they have their SAAR number, hospitals need to be able to integrate and visualize all of the data that contribute to the ratio, rapidly dig beneath to identify potential outliers from the topline ratio, and institute process improvements to make necessary changes to prescribing patterns.
Deploy powerful analytical tools
A February 2018 article in 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. (1)
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.” (2)
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.