Experts identify steps to improve hospital stewardship programs

Medical consult in hallway
Medical consult in hallway

Ridofranz / iStock

A panel of experts in antibiotic stewardship has identified steps that hospitals can take to improve their antibiotic stewardship programs (ASPs), highlighted by two emerging strategies that go beyond current guidelines.

The two strategies—handshake stewardship and diagnostic stewardship—were identified by participants in a May 2018 meeting convened by the Joint Commission, a nonprofit organization that accredits US hospitals, and the Pew Charitable Trusts. The Centers for Disease Control and Prevention (CDC), the American Hospital Association, the National Quality Forum, and other stakeholders also took part in the meeting.

Participants also recommended measures for assessing whether a hospital's stewardship activities are effectively ensuring that antibiotics are being used appropriately.

The conclusions from the meeting were reported in a paper yesterday in the Joint Commission Journal on Quality and Patient Safety.

More specifics needed

The meeting was convened following a survey of hospitals conducted in the 16 months after the Joint Commission began requiring hospitals to have an ASP in January 2017. That survey found that only 75 of 1,992 (3.8%) of hospitals cited deficiencies in their stewardship programs. The results confirmed that most hospitals were committed to stewardship, but raised concern among Joint Commission leaders that their ASP standards weren't specific enough.

The current Joint Commission standards call for hospitals to use the CDC's Core Elements of Hospital Antibiotic Stewardship Programs as a guide for stewardship activities. But while this document lays out seven necessary structural and organizational components for hospital ASPs (leadership commitment, accountability, drug expertise, action, tracking, reporting, and education), it does not recommend specific strategies or best practices for hospitals to follow.

David Hyun, MD, co-author of the paper and senior officer with Pew's antibiotic resistance project, said the stewardship standards were focused on getting stewardship programs in place, and have helped accelerate the implementation of ASPs in hospitals across the country. The results of the survey, however, indicated that more emphasis is now needed on specific types of interventions and activities that hospitals can perform to reduce antibiotic use and slow the emergence of antibiotic resistance.

"There was a recognition that this was an opportunity to further evolve from where we are under the current standards, to provide some specificity, so that we can start assessing not only the presence of a stewardship program, but also the quality," Hyun told CIDRAP News.

To identify some best practices, Pew and the Joint Commission brought in stewardship leaders from hospitals and health system across the country to discuss the ASP activities they believe should be foundational elements for any hospital. In addition, they were asked to identify the activities that have been most important for their program's success, and for any novel strategies that should be further explored.

Foundational and emerging strategies

The two stewardship interventions implemented by all panelists were strategies recommended in the very first ASP guidelines, published in 2007 by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. These strategies are preauthorization, which requires providers to seek approval before using certain antibiotics, and prospective audit and feedback, a practice in which an independent provider reviews a patient's antibiotics and gives input to the clinical team. Prospective audit and feedback was singled out at the meeting as fundamental to the success of hospital stewardship programs.

But handshake stewardship, which involves more active engagement between ASP team members and frontline providers, was cited by several of the panelists as an emerging strategy that has become a key component of their success. In this strategy—which was first coined and described in a 2016 paper by clinicians and pharmacists at Children's Hospital Colorado—a stewardship team conducts daily rounds with clinical teams, reviews all prescribed antibiotics, and communicates any feedback face-to-face.

The benefit of this approach, Hyun explains, is that it incorporates stewardship into daily patient care, and provides an opportunity for more consistent and predictable two-way interactions between the stewardship team and providers.

"In the traditional model, when the stewardship program is only calling up the provider when there's a problem in a prescribing pattern, the dynamic is more of a one-way conversation," he said, with the person on the ASP team telling the clinician how they can improve their prescribing.

"But with a daily interaction approach, you're going to have days when there is no problem to discuss, and it creates a more collaborative opportunity, where the stewardship team can hear the feedback coming from the provider side," Hyun added. And that type of consistent dialogue can encourage more buy-in among providers, creating an environment in which they are more likely to accept recommendations.

"The buy-in and the collaborative approach are so important in the success of stewardship in general," he said.

Addressing routine and inappropriate use of diagnostic tests was the other emerging strategy emphasized by participants at meeting, because performing these tests when they aren't needed can lead to misinterpretation of results and ultimately to inappropriate antibiotic use. An example is testing for a urinary tract infection when the patient shows no signs or symptoms of an infection. Unnecessary testing for Clostridioides difficile was also cited as high priority target for diagnostic stewardship.

"This is something that's been getting a lot more attention in the last few years," Hyun said. "If the utilization of these diagnostic tests can be optimized, that alone could potentially lead to a significant decrease in inappropriate and unnecessary antibiotic use."

Participants also noted the importance of strong leadership and financial support for ASPs, community engagement, and collaboration between medical facilities that serve the same patient populations.

Stewardship measurements

In addition, the experts identified three key measures for assessing a hospital's stewardship activities: total antibiotic use (expressed as days of therapy per 1,000 patient-days), rates of hospital-acquired C difficile, and adherence to clinical practice guidelines. Measuring prescribing patterns of individual physicians and total antibiotic duration were also considered, but panelists noted that many hospitals may not have the data-analytics resources required to perform such analysis.

Hyun said the next step will be to get a better understanding of how many hospitals are currently using these strategies and measurements, how feasible it is to implement them in all US hospitals, and how they can be adapted to hospitals with fewer resources.  "For all the ideas and activities that were raised, there needs to be a continuous recognition that one size does not fit all," he said.

See also:

May 21 Jt Comm J Qual Patient Saf paper

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