What is Expected from Your Antimicrobial Stewardship Program
on 4/27/2021 10:00:00 AM
Stewardship is defined as the act of conducting, supervising, or managing something. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance.
The CDC has called on all hospitals to implement antibiotic stewardship programs (ASP), and CMS incorporated additional antibiotic stewardship requirements into their 2020 updates. There are minimum elements of a stewardship program that an organization is required to implement. These are defined by the Center for Medicare and Medicaid Services (CMS). CMS revised their conditions of participation effective 2/21/20 and placed ASP under 482.42 (acute care) and 485.640 (critical access) which are the infection prevention and control chapters. Placement of the guidelines in these chapters makes it clear that those responsible for infection control and prevention within the organization must play a critical role in stewardship and collaborate and communicate with the overall antibiotic stewardship program.
Organizational leadership must make a commitment to antimicrobial stewardship program. This includes dedicating the necessary human, financial, and information technology to support the program. Appointing a senior executive leader to serve as a point of contact for the program will help ensure that the program has the resources and support to accomplish its mission. Reporting stewardship activities and outcomes (success stories and financial improvements) to senior leadership and the hospital board also increases backing.
An organization’s governing body must appoint a qualified leader. The leader is responsible for the overall program, collaboration with medical leadership, pharmacy leadership, nursing leadership as well as the hospital’s infection control and QAPI programs, and documentation of the program’s activities. If you are a part of a hospital system, you may decide to have a unified infection control/prevention and antibiotic stewardship program implemented at the system level, however the overall program must address the uniqueness and differences of each hospital individually and show that use is managed at each facility within the system. A system hospital that performs trauma and/or cardiothoracic surgeries would certainly have antibiotic-use concerns that are different than a system owned critical-access hospital. These must be reflected and addressed in the system’s antibiotic stewardship program.
Additionally, if the system decides to have a unified system level infection control /antibiotic stewardship program, each individual hospital must also appoint a leader for the antibiotic stewardship program that has expertise in infection control and disease prevention. This leader is responsible for implementing the policies and activities dictated by the unified program, communicating with the system on activities at their hospital, and for providing education to the medical and hospital staff.
Drug expertise is an important part of the program. Usually led by a pharmacist along with an infectious disease physician, they are vital in developing policies, clinical pathways or facility treatment guidelines, and providing concurrent monitoring for antibiotic use. At the very least, every organization would be expected to have evidence-based treatment guidelines for the most common conditions: community – acquired pneumonia (CAP), urinary tract infections (UTI), and skin and soft tissue infections (SSTI). Examples of monitoring can include antibiotic time-outs, IV to oral exchanges, monitoring for overlapping antibiotic spectrums, and dose optimization or adjustments. A robust program includes daily review of culture susceptibility for appropriate antibiotics and interventions by a pharmacist or provider to change the antibiotic regimen if indicated, as well as at least an annual review of the microbiology antibiogram.
Education to hospital staff and providers is an important although often overlooked requirement of the antimicrobial program. This expectation by CMS is clearly stated – training is expected for “hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services…” Education can be in the form of articles in hospital newsletters, posters, flyers, electronic communication or formal and informal presentations at meetings, or individual feedback in person. The education provided is especially effective when paired with interventions and outcomes data and tailored to the audience (i.e., culture techniques for nurses, pneumonia guidelines for physicians, etc). As always, make sure there is documentation of the education provided.
Tracking is critical to identify opportunities for improvement as well as to assess the impact of interventions. This can be done in several ways and can be greatly assisted by information technology if available. Hospitals may choose to track days of therapy, adherence to treatment guidelines, or changes in C-difficile rates. Hospital CFOs often enjoy seeing cost savings as a result of interventions and it is a nice way of showing the initial effectiveness of the program. After a period of marked savings, costs often stabilize so other tracking mechanisms should also be implemented. Other ideas are to monitor how often treatments are changed based on pharmacy interventions made, assessing if patients are discharged on correct antibiotic therapy, or monitoring IV to oral conversion. Incorporate the data into a dashboard for use in the QAPI program.
Smaller and critical access hospitals face special challenges in implementing antibiotic stewardship programs. Limitations in infrastructure, staffing, and resources make it especially challenging. But they can still have successful programs, just in a smaller footprint. The core elements of antibiotic stewardship can fairly easily be accomplished. Let’s break it down:
- Leadership Commitment and Accountability: Develop a policy and create a reporting structure. Integrate stewardship activity into a hospital initiative (e.g., improve sepsis management). The leader is officially appointed by the governing body.
- Drug Expertise: Appoint a team including pharmacy, nursing, infection prevention, and an infectious disease provider (if available) or chief medical officer. Consider having stewardship included in the job description of a pharmacy leader. Consider remote consultation (e.g., telemedicine) if needed for support.
- Action: Consider the core antibiotic use diagnosis – CAP, UTI, and SSTI. Develop evidence based protocols for each. Review patient treatment plans at 48 hours or when cultures are available to assure proper antibiotic use. Develop an IV to oral conversion timeframe.
- Tracking: Monitor adherence to each of the above referenced treatment protocols by provider and document interventions (conversations/recommendations to providers). Also monitor days of therapy and IV to oral conversions, and cost savings if desired.
- Reporting: Consistent with the tracking, include the data you have tracked as a part of your Pharmacy and Therapeutics committee meetings, QAPI, and report it to hospital leadership and board.
- Education: Ensure any face-to-face education or staff training is documented so you can show your activities. Incorporate ASP principles into orientation for new medical, pharmacy and nursing staff and provide key principles in annual training to staff. Include information on antibiotics in patient education materials.
These are just a few practical strategies to assist organizations to implement an antibiotic stewardship program. Further information may be accessed on the CDC website as well as the CIHQ Resource Library.
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