A playbook developed by three national organizations and released last week offers numerous options for implementing or enhancing antibiotic stewardship programs (ASPs) in acute care hospitals.
"Antibiotic Stewardship in Acute Care: A Practical Playbook" relies on guidance from more than 25 experts to present tailored solutions for specific contexts and barriers faced by clinicians and pharmacists tasked with minimizing inappropriate or unnecessary antibiotic use.
The Centers for Disease Control and Prevention (CDC) estimates that antimicrobial resistance leads to 2 million illnesses and 23,000 deaths nationally each year, spurring the growth of potentially fatal healthcare-associated infections caused by Clostridium difficile (C diff) and methicillin-resistant Staphylococcus aureus (MRSA).
About 30% to 50% of antibiotics prescribed in hospitals are unnecessary or inappropriate, the playbook says, though types of misuse can vary widely and may include treatment that is not indicated by test results, continuation of therapy when it is no longer necessary, wrong doses, and the use of broad-spectrum drugs to treat susceptible infections.
The 38-page playbook was compiled by the National Quality Forum (NQF), the CDC, and the Hospital Corporation of America (HCA), building on the HCA's launch of its Antimicrobial Management Program at 168 acute care hospitals in 2010. The structure and format of antibiotic use recommendations are based on a 2014 NQF maternal health playbook, which helped reduce early elective deliveries by more than 70% nationwide, according to the authors.
Lists of potential barriers and solutions, measurement case studies, and resource lists walk users through developing flexible and locally specific ASPs that incorporate all seven components of the CDC's 2014 "Core Elements of Hospital Antibiotic Stewardship Programs," listed below:
- Leadership commitment
- Accountability
- Drug expertise
- Actions to support optimal antibiotic use
- Tracking and monitoring antibiotic prescribing, use, and resistance
- Reporting information on improving antibiotic use and resistance
- Education of clinicians and patients and families
The authors cautioned that the book should be used as a menu of options that can be customized to local needs, rather than a list of requirements. Though their guidance is specific to acute care hospitals, they said that the playbook can be applied to proper use of antivirals, antiparasitics, and antifungals, as well as antibiotics.
"Stewardship programs are one of the most critical mechanisms for reducing antibiotic resistance," the authors said.
ASPs need executive support, expert leadership
Dedication of trained staff, adequate funding, and technological resources provides a base on which stewardship programs can begin to monitor antimicrobial misuse and create lasting changes, the authors said.
Commitment from hospitals' executive leadership is critical to the implementation and effectiveness of an ASP and is a key factor in increasing compliance with prescribing recommendations, according to the book. Hospital ASPs should also be guided by a designated leader, ideally an infectious disease physician, and have strong pharmacist involvement. All ASP leaders responsible for outcomes should be well-versed in antibiotic use and treatment of infections, the authors said.
Strategies for sustaining an evidence-based ASP that is accepted by a broad range of providers and executives include, at the most basic level, dedicated salaries for ASP leaders, formal communication from hospital executives in support of the program, collaborative workflows between clinicians and pharmacists, and outreach to pharmacists with post-graduate infectious disease training.
At more intermediate or advanced levels, ASPs should engage providers across disciplines in support of a broad system that targets specialty areas where proper use of antimicrobials could have a large effect (eg, surgery, pediatrics), the authors said. Strategies might include incorporating ASP outcome measures in the facility's strategic plan or quality improvement reports, increasing provider access to microbiology and laboratory data, documenting outcomes in staff performance evaluations, linking antimicrobial use data with C diff infection rates, and providing training opportunities for clinical and pharmacy staff.
Problems with ineffective ASP leadership or with prescribers who resist protocol can be addressed by hospital-wide peer antibiotic prescribing reports, policies that define noncompliance and corrective action, and the use of telemedicine to access off-site antimicrobial expertise, the authors said.
Because hospital leaders may be reluctant to dedicate funding to a new program and providers may resist a change in protocol or oversight, advocacy for ASP support should be tied whenever possible to hospital infection rates (especially for C diff, which must be reported as part of the Centers for Medicare and Medicaid Services' [CMS'] Hospital Inpatient Quality Reporting Program), regulatory and accreditation requirements, quality improvement efforts, and patient narratives.
Stories about drug-resistant infections can help executives and providers understand the effects an ASP might have on care and safety, while integrating stewardship education and resistance data into grand rounds or continuing clinical education in the context of individual infections can enhance prescriber compliance with new or unfamiliar protocols, the authors said. Educational programs like the American Board of Internal Medicine Foundation's "Choose Wisely" campaign create opportunities for clinicians and patients to discuss appropriate antibiotic use and engage patients in stewardship advocacy.
Prescribing, tracking, and documenting antibiotic use
Because antibiotic misuse can occur in a variety of contexts, ASP leaders are often encouraged to take a broad approach toward prescribing, treatment tracking, and reporting behaviors. The playbook, however, encourages ASP leaders to begin building a cohesive system for responsible antimicrobial use with one bacterium or drug that presents a particular problem for the hospital (eg, focusing on community-acquired pneumonia during the winter months) before expanding the program.
At a basic level, changing antimicrobial use patterns entails reviewing clinicians' orders for certain protected drugs; documenting diagnostic testing, dose, drug type, and duration of treatment in a standardized way; ensuring that prescribers stop antibiotic treatment when it is no longer warranted; and issuing regular reports on hospital antibiotic use, the authors said. Numerous systems to document antibiotic use measures and outcomes have been developed in recent years, most notably the National Healthcare Safety Network's Standardized Antimicrobial Administration Ration (SAAR), which provides a risk-adjusted measure comparing observed and expected use for different antibiotics.
At a more advanced level, ASPs should conduct sequential testing of antibiotic resistance patterns across the hospital, monitor 30-day readmission rates for pneumonia and C diff infections, provide guidance on automatic changes from intravenous to oral antibiotics, advise on dose adjustments in cases of organ dysfunction, develop treatment protocols for possible sepsis, begin using rapid diagnostic methods (eg, biomarkers, rapid pathogen identification assays), and disseminate reports with provider-level information on antibiotic use and areas for improvement, the authors said.
"ASPs can optimize treatment of infections and antibiotic use—with the goal to provide every patient with the right antibiotics, at the right time, at the right dose, and for the right duration—to reduce adverse events associated with antibiotics and improve patient outcomes," the playbook says.
The authors wrote that ASP leaders may become overwhelmed by the scope of a program that attempts to target numerous aspects of inappropriate antimicrobial use and should be encouraged to start small and prioritize areas of greatest impact. Fractured information-sharing between hospital specialty areas may be mended by sharing data and program successes across disciplines. Consistent and frequent reporting of results and the integration of patient stories into documentation can help demonstrate the effects on safety and quality of care made by even a small stewardship program.
National trend toward hospital ASP compliance
A number of proposed standards and patient safety reports have recently included antibiotic use in acute care hospitals as a measure of quality improvement, heightening the need to develop innovative strategies (eg, accreditation, public reporting, incentives) to hasten compliance with proper prescribing and tracking practices, the authors noted.
In November 2015, the Joint Commission released a proposed standard delineating eight antibiotic stewardship requirements for hospitals. CMS has introduced a proposed rule to include hospitals' antimicrobial prescribing data in its Hospital Inpatient Quality Reporting Program, which would offer providers the ability to compare prescription practices on a national level, the authors said. In addition, the Leapfrog Group will begin publicly reporting hospital compliance with the CDC's seven core ASP elements in its 2016 Hospital Survey.
The playbook is intended to provide avenues for hospitals intent on building a locally specific and effective ASP that meets new requirements, though the authors acknowledge that significant work is still required in developing provider-level quality measures, discovering new and effective antimicrobial therapies and diagnostics, and increasing surveillance of resistant organisms. Despite these needs, ASP efforts, even at the most basic level, should be a priority for all acute care hospitals, the playbook says.
"Investment in antibiotic stewardship programs has been demonstrated to improve patient outcomes, reduce antibiotic resistance, and save lives as well as reduce healthcare costs," the authors said.
See also:
NQF Antibiotic Stewardship Playbook home page
May 25 "Antibiotic Stewardship in Acute Care: A Practical Playbook"
CDC Core Elements of Hospital Antibiotic Stewardship Programs
