Antibiotic stewardship bundle for the C-Suite

For the past seventy years antibiotics have been used to treat patients who have infectious diseases, greatly reducing the extent of their illness and death.

However, overuse has led to development of bacterial resistance, making the drugs less effective.  Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die as a direct result of these infections. Drug resistance has become a critical patient safety issue, accordingly.¹

The goal of antibiotic stewardship programs (ASP)

Antimicrobial Stewardship programs (ASP) have been implemented in hospitals nationwide to promote the appropriate use of antibiotics in order to reduce the rate of developing resistant organisms. These programs are reporting success in reducing resistance, in addition to the incidence of infections caused by multidrug-resistant organisms and the associated healthcare costs. The appropriate use of antibiotics further serves to reduce the incidence of Clostridium difficile infections caused in part by the disruption of helpful intestinal bacteria by administration of antibiotics. In general, a successful ASP supports improved patient outcomes, reduced healthcare costs, and improved patient satisfaction, all of which are goals that align perfectly with hospital executives in the C-suite.²

Key roles to ensure a successful antibiotic stewardship program:

Strong support from a member of the C-suite, acting as a champion, is often the most important factor in securing the success of any patient safety program, including Antibiotic Stewardship. This individual is typically positioned to ensure that adequate resources are allocated for developing and executing an ASP, most commonly by a physician specialized in Infectious Diseases (“ID”) in partnership with a pharmacist.^3,4 In best practice models the Pharmacist is provided with specialized training in order to function optimally in collaboration with the ID physician. ⁵ In addition, a committee is often convened to provide oversight of the ASP based on clinical guidelines such as the CDC Core Elements of Antimicrobial Stewardship. ⁶ The C-suite champion is also positioned to advocate for the time and resources required for the operation of this multi-disciplinary committee.  In addition to human resources, the C-suite champion can facilitate funding for the acquisition of tools to optimize outcomes of the ASP, such as rapid diagnostic technology. New rapid diagnostic tests can reduce from days to hours the time required between specimen collection and test result.  This can tremendously reduce the incidence of inappropriate antibiotic administration for viral infections and reduce the use of empiric broad spectrum antibiotics for bacterial infections in the place of targeted treatment as directed by test results.⁷ Improved outcomes, reduced costs, reduced length of stay (LOS), reduced readmissions, and better regulatory and quality scores (e.g. Joint Commission, HEDIS) are goals shared by the ASP and the C-suite. ⁸ To round out the ASP team, the Nursing, Laboratory, and Infection Prevention departments provide further assistance to ensure success of the ASP.  For example, nurses may contribute by incorporating an assessment of antibiotic necessity during daily nursing huddles and rounds, just as they currently perform daily assessment of urinary catheter necessity.⁹ The Laboratory can provide antimicrobial resistance pattern and trend reports.  The foundational work of the IP Director and/or IP department focused on prevention of healthcare associated infections (HAI) provides the ultimate support for ASP.  For every infection prevented, there is one less course of antibiotics administered and alleviation of the associated resistance pressure and cost.

An ASP bundle for the C-Suite Champion:

The Institute of Healthcare Improvement (IHI) developed the concept of “bundles” to support more reliably delivered high quality care for patients.  A bundle is a structured way of standardizing the processes of care to improve patient outcomes.  When performed collectively and reliably, a small set of evidence-based practices (generally three to five) demonstrably improve patient outcomes. The power of a bundle comes from the body of science behind it with consistent and uniform bundle execution.¹⁰

To help simplify the key contributions of the C-suite ASP champion, a bundle might be useful.  This C-suite “ASP Champion Bundle” might ideally be comprised of the following four elements:

1. Convene an ASP Oversight Committee guided by the CDC Core Elements of Antimicrobial Stewardship with an ID Physician and Pharmacist co-leads. Other members should include representatives from C-suite, nursing, laboratory and infection prevention departments.
2. Ensure adequate dedicated ID Physician and Pharmacist time for the work of the ASP.
3. Support the budget and plan for ID training for the Pharmacist (for example http://www.proce.com/SIPD-ASP).
4. Support the budget and plan for Laboratory to acquire any necessary tools including rapid diagnostic technology to optimize therapy to improve patient outcomes.

Conclusions

Hospital antibiotic stewardship programs are successful when well-supported by the C-suite, and executed by an expert pharmacist in collaboration with an Infectious Disease physician.  A multi-disciplinary ASP committee is commonly leveraged to oversee the ongoing operation and outcomes of the ASP with support provided by key stakeholders including Laboratory, Nursing, and the IP departments.  To help communicate, simplify and standardize the key contributions of the C-suite ASP Champion, a bundle may be a useful tool as detailed above.

For more information, please visit Accelerate Diagnostics’ website.

References

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2. Barlam TF, Cosgrove SE, Abbo LM, et al. “Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America”. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2016; 62(10):e51-e77.
3. Srinivasan A. “Engaging hospitalists in antimicrobial stewardship: the CDC perspective. Journal of hospital medicine: an official publication of the Society of Hospital Medicine”.Jan 2011; 6 Suppl 1:S31-33.
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6. Pollack LA, Srinivasan A. “Coreelements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention”. Clin Infect Dis. 2014 Oct 15; 59 Suppl 3:S97-100. 
7. Messacar K, Parker S, Todd J, Dominguez S. “Implementation of Rapid Molecular Infectious Disease Diagnostics: the Role of Diagnostic and Antimicrobial Stewardship”. J Clin Microbiol. 2017 Mar; 55(3): 715–723.
8. Schafer J, Hennessey M. “Four steps managed care can take to promote antimicrobial stewardship”. Managed Healthcare Executive April 13, 2017.
9. Manning ML, Pfeiffer J, Larson EL. “Combating antibiotic resistance: The role of nursing in antibiotic stewardship”. Am J Infect Control.2016 Dec 1; 44(12):1454-1457.
10. Resar R, Pronovost P, Haraden C, Simmonds T, et al. “Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia”. Joint Commission Journal on Quality and Patient Safety. 2005; 31(5):243-248.