The growth of antibiotic-resistant pathogens is a major public health and patient safety concern, and while the threat isn’t new, various government bodies and agencies have recently placed a renewed focus on tackling this issue.
On Jan. 1, 2017, the Joint Commission released a new Medication Management (MM) standard that stipulated all hospitals seeking accreditation should have in place an active Antimicrobial Stewardship Program (ASP). Up until now, the decision to implement an ASP – a program designed to improve and measure the appropriate use of antimicrobials and ultimately decrease the spread of infections caused by drug-resistant organisms – has been largely at the discretion of each individual hospital and healthcare organization. The introduction of this new standard gives greater incentive to hospitals to prioritize the implementation of an ASP to effectively meet the Joint Commission accreditation requirements.
With this increased attention, and the potential for more oversight in the future, it is critical hospitals understand how to implement a successful ASP.
Creating a strong ASP team
Integral to any successful ASP is a highly intricate and multidisciplinary team that should be made up of representatives from four specific groups: providers (including, if available, an infectious disease physician), clinical pharmacists (with infectious disease training), infection prevention specialists, and members of the C-Suite. Other members of the team include representatives from Environmental Services, the Laboratory, IT representatives and of course, nurses.
The core elements of an ASP
Healthcare organizations should consider these core elements to develop a successful ASP and ensure they meet the Joint Commission standards, and as a step in the right direction for any future requirements of other governing bodies:
- Leadership commitment from administration: Hospitals must establish a formal expression of support for the stewardship program and note it as an organizational priority. A physician is best placed to lead the ASP team; however, it is encouraged that a pharmacist act in a co-leader position. While this isn’t a requirement, the pharmacist, as the medication expert, is uniquely suited to best promote and monitor the optimal use of antimicrobials.
- Educating providers on antibiotic use and resistance: The goal of the ASP is not to restrict the practice of medicine, but rather to optimize it. Changing prescriber practices and habits can be challenging, which is why clinicians must be fully engaged in, and supportive of, efforts to improve antimicrobial use in the healthcare system. Education can come in many forms including feedback from patients or peers, as well as formal guideline courses and training.
- Antibiotic use tracking: To gather a holistic view of how and when antibiotics are being utilized, ongoing monitoring of prescribing and resistance patterns is critical.
- Regular reporting on antibiotic use and resistance: Antimicrobial utilization tracking by way of Days of Therapy is likely to be the avenue which the Joint Commission, and perhaps the CDC, will shortly require hospitals to report on. Days of Therapy is calculated when a patient receives at least one dose of a single agent on a given day or if a single agent is administered on a given day regardless of the number of doses or strength. Other forms of reporting can include antibiograms (used to assess local susceptibility rates and monitor resistance trends), antimicrobial expenditures, and medication use evaluations on targeted therapy.
- Specific improvement intervention. Subsequent to meticulous and long-term monitoring, tracking and analysis, the team will be empowered to act, through a variety of passive and active interventions that can be broken down into two methods; before medication is ordered and afterward. This will help hospitals measure impacts on their healthcare system.
- The cornerstone of the active front-end, “before” method is antimicrobial restriction. While ‘restriction’ may carry negative connotations, it simply means the high-cost or broad-spectrum antibiotics are no longer offered or specific criteria must be met before these agents can be utilized. Given these antibiotics commonly have the largest risk of adverse events for patients, this practice is a proactive way to prevent the agent being prescribed at all, or over-prescribed and will assist to reduce the development of multi-drug resistant organisms.
- The second method can involve antimicrobial streamlining and/or dose optimization. This involves the pharmacist’s reviewing patient data to identify opportunities to simplify routes of administration (for example switching to oral medications), lowering the dosage or moving to a single-agent therapy.
Implementing a successful ASP is a significant undertaking and doesn’t happen overnight. Referring to the core elements will put any organization on the right path to either implement or refine their own individual programs.
Julie Rubin, PharmD, BCPS, is the director of clinical services for CompleteRx, a leading pharmacy management company. She has 20 years of clinical pharmacy experience, advising hospital and health executives across the country on critical issues including how to implement a successful Antimicrobial Stewardship Program, and is board certified in pharmacotherapy.