In this article the adoption of Firstline as a city-wide platform to support antimicrobial stewardship in collaboration with New York City Department of Health and Mental Hygiene is discussed.
Interview with: William Greendyke, M.D.
Interview by: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP
Article Posted 3 June 2023
We have come a long way since the term “Antimicrobial Stewardship” first appeared in the medical literature in 1996, brought to us by John McGowan and Dale Gerding. As of the end of May 2023, the term brings just over 8,500 hits in pubmed.
There have been multiple guidelines on antimicrobial stewardship published by the Infectious Disease Society of America. There are now regulatory requirements on antimicrobial stewardship from The Joint Commission and Center for Medicare and Medicaid Services. There are Core Elements on antimicrobial stewardship that the Centers for Disease Control and Prevention (CDC) has published for hospitals, outpatient, nursing homes, and limited-resource settings.
Internationally antimicrobial stewardship has the attention of many agencies and governments, which are putting out guidelines, policies, and other strategies to combat the threat of antimicrobial resistance. Antimicrobial stewardship truly is a big deal today.
As antimicrobial resistance remains a major challenge in the United States (as outlined in this CDC Special Report), focused efforts to address it are essential. This includes making data accessible and communicating best practices. One key strategy towards accomplishing this is through leveraging new technologies while cultivating collaborations. For example, leveraging user-friendly guidelines to standardize practices which may improve decision making and contribute to better outcomes, more efficient workflows, and reduced healthcare costs.
At the New York City Department of Health and Mental Hygiene (NYC DOHMH) there are things brewing which are on point with what is needed in the large-scale effort to battle antibiotic resistance and it involves collaboration with the innovative technology company Firstline. Funded by a CDC grant and working in collaboration with a team of talented individuals, Dr. William Greendyke is one of the key NYC DOHMH leaders on the project.
Recently I was able to have the opportunity to connect with Dr. Greendyke and learn about the collaboration. The following is the result of our correspondence. Here are insights on Firstline as a city-wide platform to support antimicrobial stewardship in New York City. It is a really an exciting collaboration that I am grateful to help share the word about!
1. Dr. Greendyke, how did you get into the field of infectious diseases and what is your role today with the New York City Department of Health and Mental Hygiene?
A mentor suggested that I pursue a specialty which I enjoyed reading about at night, and I realized I loved reading about all things infectious-diseases (ID) related! After fellowship, I started out doing a handful of all things in the realm of clinical ID: teaching, transplant ID, and OPAT. Later I became more involved with stewardship and hospital epidemiology at my hospital, and I found it incredibly rewarding to make an impact at an institutional level.
I am fortunate to now be a team lead within the Antimicrobial Resistance Unit at the NYC DOHMH, and now I get to think about how to make a difference in antimicrobial resistance across all of New York City. Our unit currently conducts surveillance for a variety of multi-drug resistant organisms (MDROs) across the city, and we are quite busy with a variety of prevention and response activities.
2. Can you explain why it is so exciting to have Firstline helping to support production of a city-wide antibiogram?
We are thrilled to work on a regional antibiogram that encompasses all five boroughs of NYC.
The general idea is that we are going to be combining hospital systems’ own antibiograms to create one that represents what is happening across the entire city. From a public health perspective, this will help us take a snapshot about what is happening with antimicrobial resistance (AR) rates, and the hope is that yearly updates will provide us information on AR trends across the city. But we are also aiming to stratify antibiogram data to make it relevant and useful for frontline clinicians as well.
We have been talking with stewardship programs across the city, and there is a lot of interest in using the antibiogram so we can drill down on specific patient populations, such as emergency department patients, pediatric patients, or patients residing in one particular borough. We have had a lot of excitement among hospital systems to participate in this initiative, and currently have 29 hospitals representing over 53% of hospital beds represented, with others waiting to come on board.
3. How might the New York City DOHMH use Firstline to reach providers who may not have the support of large health-systems?
In addition to creating the regional antibiogram, we are also partnering with Firstline to distribute outpatient prescribing guidelines that are intended for frontline providers.
These guidelines will be available for any clinician to access, free of charge, from the Firstline app that they can download to their smartphone. The Firstline team has really designed a nice app that is very simple to use, and unlike a pocket card, will always be up to date. What we are most excited about doing is using the antibiogram data to inform these guidelines.
For instance, an urgent care provider can look at the prescribing guidance for urinary tract infection and not only see that nitrofurantion or TMP/SMX are recommended therapies, but they would also be able to see what local resistance rates from the city-wide antibiogram actually are so they can understand *why* those are the recommended therapies. The idea then is that settings that are not as well-resourced as some of the larger healthcare systems in the city can still benefit from the data everyone is sharing.
4. What are some of the priority areas to work on for outpatient stewardship, from a city-wide department of health perspective?
Right now our priority areas will be to compile resistance data and develop prescribing guidance that clinicians will find useful. Once that is in place, I think the next step will be to disseminate and get the word out.
Down the line, we are looking for ways to identify which prescribers in NYC would benefit the most from targeted outreach – that way they will know we have resources developed to help them care more effectively for their patients.
5. New York City is an area rich in expertise, how can Firstline help bring minds together in the fight against antimicrobial resistance?
We are very fortunate in NYC to have such an abundance of ID physicians and pharmacists dedicated to good stewardship practices. DOHMH previously has put together a few pilot projects that have attempted to take advantage of this critical mass: an outpatient UTI antibiogram and a city-wide Strep pneumo antibiogram.
What is changing because of our partnership with Firstline is really the scale of this project. Through grant funding, we have been able to underwrite the hospitals’ own use of Firstline’s decision support platform for their own internal prescribing guidelines and incentivize participation in the city-wide initiatives, like the antibiogram. What we’re hoping to see through this partnership is a much larger scale than anything we have been able to do in years past. The more hospitals that participate, the better our data is, and the better we can ascertain what’s happening city-wide and develop prescribing guidelines in response to that data.
6. If you could fast-forward 5 years into the future, what are some things you hope this new partnership between New York City DOHMH and Firstline might yield?
We are really envisioning the Firstline app as being a one-stop shop for frontline prescribers in the city. In addition to the antibiogram data and the prescribing guidance, we are exploring ways to potentially deliver prescribing feedback to providers.
With the coming mandate to report AU/AR data into NHSN, we are also thinking about ways to synthesize that data for hospitals and report it back out to prescribers. As someone who has been in the position of many of our frontline clinicians, I find it very important to get actionable epidemiological data in the hands of clinicians. One of the unique roles we play at the NYC DOHMH is that we have access to a lot of mandatory reporting data, and I really view one of our key priorities is getting this data back to key stakeholders in a way that is really meaningful.
ABOUT THE INTERVIEWEE
Dr. William Greendyke is a medical epidemiologist at the New York City Department of Health and Mental Hygiene. After graduating from medical school in Texas, Dr. Greendyke completed his residency in Internal Medicine and fellowship in Infectious Diseases at New York Presbyterian Hospital/Columbia.
Following completion of his training, Dr. Greendyke remained on the faculty at Columbia’s Division of Infectious Disease for 6 years where he served as a hospital epidemiologist and stewardship lead.
In 2022, he joined the NYC DOHMH’s Bureau of Communicable Disease and currently serves as a Team Lead within the Antimicrobial Resistance Unit.
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