Antibiotics now give us the ability to treat common types of infections that were once lethal; however, they can be detrimental when used inappropriately. According to the Centers for Disease Control and Prevention (CDC), 70% of nursing center residents receive one or more courses of systemic antibiotics per year and 40%-75% of antibiotics prescribed may be unnecessary or inappropriate. Some of the risks associated with inappropriate use of antibiotics include increased morbidity and mortality, increased risk of hospitalization, increased risk of C. difficile infection, and increased treatment costs. Overuse can also lead to antibiotic resistant organisms, for which there are limited treatment options.
In response, the CDC began urging health care facilities to implement an antibiotic stewardship program (ASP) with the goal of optimizing the treatment of infections while reducing the adverse events associated with antibiotic use. Both the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (TJC) have also recognized the importance of antibiotic stewardship and now require implementation of an ASP in accordance with the CDC core elements of antibiotic stewardship as of November 2017 for CMS and January 2018 for TJC. There are seven core elements of an ASP according to the CDC publication, The Core Elements of Antibiotic Stewardship for Nursing Homes:
- Facility leadership commitment to safe and appropriate antibiotic use;
- Appropriate facility staff accountable for promoting and overseeing antibiotic stewardship;
- Accessing pharmacists and others with experience or training in antibiotic stewardship;
- Implementing policies or practices to improve antibiotic use;
- Tracking measures of antibiotic use in the facility (i.e., one process and one outcome measure);
- Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff; and
- Educating staff and residents about antibiotic stewardship.
To assist nursing centers with starting an ASP in accordance with the CDC core elements, the Agency for Healthcare Research and Quality (AHRQ) has developed a detailed toolkit, Start an Antimicrobial Stewardship Program, which emphasizes four steps to implementing an ASP.
Identify champions and gather a team
Establish a multidisciplinary team consisting of staff with varying responsibilities such as charge nurses, the director or assistant director of nursing, the medical director, the infection preventionist, and an information technology staff member (if an electronic medical record is used). The team may also include consulting pharmacists, prescribing clinicians, and/or resident or family representatives. Two champions should be appointed to ensure program leadership through times of staff turnover, to promote the importance of the program, and to be accountable for outcomes. Champions should be responsible for developing agendas and policies, and leading trainings. Other team members can be assigned responsibilities such as assisting with developing training, the implementation of new tools, abstracting data for monitoring, and reporting data.
Conduct a readiness assessment
The purpose of the readiness assessment is to determine what resources the program will need and how ready the organization is to take on new interventions. It takes into account each nursing center’s unique characteristics and can help to determine which stewardship goals are reasonable. The assessment also helps to select and prioritize specific interventions. A step-wise implementation is encouraged in which only one or two interventions are rolled out at a time.
Plan for intervention
Based on the readiness assessment, the team can develop a plan including a timeline, responsibilities and a schedule for team meetings. When planning the timeline for the project, consider time for training staff, developing policies, and informing all parties involved with the process. Developing new policies and procedures that support the selected interventions will help hardwire and sustain the ASP. Meetings leading up to implementation should include a review of the purpose of the program, discussion of the tools that will be implemented, how the workflow will be adjusted to incorporate new tools, and a projected budget. Also discuss what materials need to be developed to support implementation as well as methods to communicate information about the intervention to staff, prescribing clinicians, and other facilities as necessary.
Introduce new policies and procedures to staff
New policies and procedures should answer the questions of who, what, when, where, why, and how. Prior to implementation, policies and procedures should be shared with staff via clear and easy-to-understand methods. A statement of the organization’s commitment to quality of care as well as the purpose, scope and goals of the program should be expressed in the policy. Additionally, details regarding when the program will start and who will be involved should be included. Procedures should include the goals of specific interventions, what tools will be used to support the intervention, how the intervention will be implemented, and the staff responsible for the intervention. Depending on the scope of the new procedures, staff training may also be necessary.
As with any successful QAPI project, there should be a plan for monitoring and sustainment, which will also be addressed by the ASP team. The team should discuss what to monitor, who will collect the necessary data, how often the data will be collected, and the data source. Both process measures and outcome measures should be collected to adequately demonstrate progress of the ASP. To ensure that the ASP will be sustained, ongoing evaluation and reassessment based on feedback from staff as well as process and outcome measures is vital. By using quality improvement tools such as the plan-do-study-act (PDSA) model, continue to adapt and modify the program as necessary. Most importantly, celebrate successes as they occur to keep staff engaged.
- The Core Elements of Antibiotic Stewardship for Nursing Homes. Atlanta, GA: US Department of Health and Human Services, CDC; 2015.
- Implement, Monitor, and Sustain an Antimicrobial Stewardship Program. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD.