Antibiotic stewardship is becoming a “must address” topic in hospitals as many lag behind in the implementation of required national guidelines. According to a study conducted by researchers at Vizient and the Virginia Commonwealth University (VCU) Health System, 17 percent of the 211 hospitals surveyed reported having no formal antibiotic program in place. In addition, nearly half (45 percent) said they did not have a formal written statement of leadership support for antibiotic stewardship.
The study shows the most common implementation gaps are due to a lack of both resources and leadership support to address the overuse of antibiotics. Across the board, there are improvement opportunities for hospitals to mitigate these shortcomings. But while pursuing those opportunities is important, it’s equally crucial to create a culture that is conducive to sustained performance of the core elements of an effective antibiotic stewardship program (ASP).
"It’s imperative to engage a wide range of people in the stewardship program; anyone who interacts with antibiotics, from physicians and clinicians to the bedside nurses to the patients and their families,” said Kristi Kuper, PharmD, BCPS, senior clinical manager, infectious diseases at Vizient. “You want to have everyone thinking about it – that’s how you can effectively integrate stewardship into your hospital’s culture.”
A culture committed to an ASP is defined by:
- Engaged ASP “champions” from all relevant functional areas who are passionate about stewardship
- Processes that include consulting subject matter experts (those who are knowledgeable about the appropriate treatment of infectious diseases
- Communicating with the bedside nurse, who is most familiar with the patient’s immediate clinical status
- Including patients and their families in conversations about treatment and preventing secondary or recurrent infections from developing
- Processes for effective case management at transitions of care
- Demonstration of administrative/leadership support
“The antibiotic stewardship team triages and evaluates the patients who are on antibiotics: whether they are on a single or multiple antibiotics, on antibiotics for a short or long time, are at high risk for developing C. diff., or have already developed it,” Kuper said. “Next is obtaining the perspective of each of the different disciplines, and not just the treating physicians. It also involves having conversations with the clinical pharmacists covering the patient, engaging the bedside nurse who’s taking care of the patient and talking to the patient and/or the family members themselves.”
The stewardship team must provide education to the bedside nurses so they understand what the antibiotic is treating and why it is being used. This helps identify what should they monitor in the patient’s condition and how they can detect an adverse reaction.
Kuper noted, “Engagement and communication from the bedside nurse can provide timely feedback to the rest of the stewardship team, allowing them to take action and address the issue in a timely manner before either resistance to the antibiotic or a secondary infection develops.”
In addition, when reviewing a patient’s antibiotic therapy, the focus should be on the ‘five Ds’ of optimal antibiotic therapy to coordinate an effective treatment plan. This includes consideration of:
- Diagnosis - Does the condition require antibiotic therapy?
- Drug - Is the bacteria susceptible to the selected antibiotic?
- Dose - Is the dose appropriate for the infection severity and underlying organ function, i.e. kidney function?
- Duration - What is the appropriate duration for the antibiotic therapy?
- De-escalation - When can the patient shift from two antibiotics to one, or one to none, or can they go from a broad spectrum to a narrow spectrum agent?
By focusing on each of these, and more importantly discussing them across each functional area of the stewardship team, a hospital begins to implement processes and best practices that help lay the cultural foundation of an effective ASP.
The importance of engaging patients and their families in the culture of stewardship cannot be understated. For clinicians, engagement includes learning how to talk to patients at their level and educating them about the dangers of antibiotic use, and in a manner that is appropriate for their communication level or preferred learning style. For instance, millennials are more likely to respond to information delivered to them via smartphone or video, as opposed to traditional reading material. Patients with literacy issues may respond better to information provided verbally versus in a written form. In any case, engagement must be customized to the patient and is born from establishing effective lines of communication that flows from clinical staff to patient and vice versa.
“Effective communication with the patient is defined as a dialogue, not a monologue,” Kuper said.
Hospitals also need to improve managing antibiotic use at transitions of care.
“Case management is another group that historically hasn’t been extensively involved in the stewardship process, but they should be when the patient is about to be discharged from the hospital,” Kuper said. “Part of the culture of the ASP should be a sense of responsibility for a final evaluation of the patient’s antibiotic history and the development of a treatment plan.”
The final piece to establishing a supportive culture for a successful ASP is securing both buy-in and investment from the C-suite level. This requires leadership to be visible in their support of the ASP and willing to invest in the expertise and other resources needed to do the work effectively. Without this support, the ASP will not become part of the hospital’s culture.
“Don’t make stewardship an island of just a small group of people,” Kuper advises. “Otherwise your stewardship program leaves when the person or people responsible leave their positions. Stewardship needs to be embedded in the hospital’s culture so when people transition in and out of their roles, the program seamlessly moves forward.”