Febrile #85 – WAAW – Being a Stewie

Andrew walked through the core elements of hospital antimicrobial stewardship:

Hospital leadership commitment

• CMS is clear that institutional leadership (along with Quality Improvement) must address issues identified by the IP and ASP committees; open communication between ASP and hospital leadership helps facilitate this (can be periodic meetings, newsletters/emails, etc.)
  • Important because bigger initiatives and decisions often flounder or are not possible without leadership support
• Hospitals need to fund these positions for them to be successful and showing the improvements your stewardship work achieves is also a great way to justify your compensation
  • Dedicated funding (i.e., salary/pay) and/or dedicated time (i.e., FTE) towards antimicrobial stewardship are great demonstrations of leadership commitment
• Formal statement of support for stewardship is another way to demonstrate leadership commitment
  • Numerous templates/examples from CDC and state health departments

Accountability

• A clear leadership structure is essential (typically physician and pharmacist co-leads but can have a single lead)
  • Roles should be clarified
• An often overlooked point is that the leader(s) must have education, training, or experience in infectious diseases/antimicrobial stewardship as outlined by TJC/CMS
  • Can be “classic” postgraduate training through ID fellowship/ID pharmacy residency or can be through certificate courses plus ongoing CE

Pharmacy expertise

• A pharmacy co-leader of the stewardship program is an essential element
• Because of their positioning in the healthcare system, pharmacists can play a vital role in antimicrobial stewardship.
  • Best situated to have access to/track antimicrobial usage data
  • Already integrated into the Pharmacy and Therapeutics Committee which provides an avenue for reporting and collaboration with leadership/Quality etc.
  • Very familiar with drug-specific information including PK/PD (which can impact dosing optimization and other similar initiatives), drug shortages, formulary information, etc.
  • Work closely with providers, nurses, and other disciplines and can help provide education to frontline staff

Action

• Interventions such as prospective audit and feedback or preauthorization
• Facility-specific treatment guidelines are also a key Action and are required by TJC as of this year (at least 2)
  • Should be based on national guidelines and literature while taking into account local susceptibility data
• Overall this is the “broadest” of the Core Elements because of the sheer amount of different actions and interventions that can be implemented
  • Automatic protocols for renal dosing of abx, IV-to-PO conversions, kinetics-based dosing (great opportunities for pharmacist-driven processes)
  • Antibiotic time out processes, “handshake” rounds, automatic stop dates, treatment order sets
  • Diagnostic stewardship, microbiology lab partnerships for cascade reporting/“nudging” comments
  • Penicillin allergy clarification/challenging/delabeling
  • Can be overwhelming at first, but important to use your tracked data to work on 1-2 key things at a time; parlay small wins into bigger changes

Tracking

• Tracking is a vital aspect to any stewardship program because of its utility in identifying opportunities, tracking progress, and building in accountability. There are numerous different metrics that can be tracked, but one of the most important is antibiotic use. Tracking and reporting antibiotic use to NHSN (National Healthcare Safety Network) is actually a regulatory requirement starting in 2024, and it serves as a great method of tracking your use and establishing some benchmarking and comparisons to similar hospitals. This is especially helpful to track in relation to particular initiatives your stewardship group may have implemented to assess impact. CDC has some great examples of using antibiotic use data to identify an opportunity, develop an intervention, and then track progress using data reported to NHSN.
• Tracking can also encompass other aspects such as number/type of A&F patient interventions, which can be helpful for highlighting the impact of your stewardship group and justifying continued or additional funding/positions. You can also track important outcomes such as incidence of C. diff or MDRO infections, etc.

Reporting

• Reporting is often the back end/actionable side of tracking, where you take the data you’ve deemed most important to track and then relay that back to your frontline staff. This increases transparency and buy-in, especially when paired with reporting/education on ongoing initiatives. It also makes the data more actionable and helps with modifying initiatives that may not be having the impact you expected or highlighting early successes. Another great example of reporting is the annual antibiogram, which informs frontline providers on annual resistance rates for commonly seen organisms.
• Overall, the combination of tracking and reporting help drive the stewardship program forward and work as a great accountability piece.

Education

• Education is a very nebulous topic because of all the forms it can take and the numerous audiences it can apply to. It can include education to prescribers, pharmacists, nurses, or patients/family about resistance, the harms of antibiotics, optimal prescribing, etc. Education can take the form of institutional guidelines, antibiograms, hospital policies, in-service presentations, handouts, you name it. Andrew recommended keeping a log of your education sessions so you can easily demonstrate to surveyors who you educated, when, and how/about what. I also recommend making your workflow more efficient by pairing education with other ongoing initiatives or reporting.