Helsejuni 28, 2023

Establishing program scope and responsibilities for an effective antimicrobial stewardship program

Etter: Steve Mok, PharmD, MBA, BCPS, BCIDP
HL-Insights High-Angle-View-Of-Doctors-With-Laptop-And-Digital-Tablet-In-Meeting
A key element of an effective antimicrobial stewardship program (ASP) is the development of key responsibilities and how to document and measure those responsibilities.

In structuring your Antimicrobial Stewardship Program for success, we discussed the importance of securing interdisciplinary support to build out your antimicrobial stewardship (AMS) program at your hospital.  In this article, we will review the key responsibilities of the AMS program and how to document and measure them to achieve compliance with relevant accreditation standards.

This topic most closely aligns with the Accountability component of the CDC’s Core Elements of Hospital Antimicrobial Stewardship and The Joint Commission MM.09.01.01 Elements of Performance 12.  One of the key tenets of EP12 is that the program must be based on nationally recognized guidelines to monitor and improve use of antibiotics.  AMS leaders can build their programs based on widely recognized sources such as the CDC Core Elements and Infectious Diseases Society of America (IDSA) guidelines on antimicrobial stewardship to meet this EP.

Develop an AMS policy and procedure document

Like any formal interdisciplinary program, a policy and procedure document should be developed and approved by applicable committees to establish the legitimacy and recognition of the AMS program. In addition to being a best practice, the policy and procedure document may be examined by accreditation bodies during a facility survey and provide a framework to adjudicate any potential issues or disputes. The policy should also include the scope, activities, and responsibilities of the AMS program and should address the following:

Program leadership

Who will lead the program, and what are their responsibilities.

Program goals

While prevention of antimicrobial resistance is an overarching goal of most AMS programs, it would be helpful to discuss how improvement targets are selected.

AMS activities

How the program documents its systemic activities and patient-specific interventions.

Metrics

How antimicrobial use is monitored, and how does the program measure its progress toward its stated goals.

Competency-based training and education

How the program delivers such training to key staff, including medical staff, on the application of AMS guidelines and policies.

Antibiotic Stewardship Program leadership

Once you have secured support and consensus on building an AMS program, a leader or co-leaders must be appointed to oversee the program.  The leader can be either a physician or a pharmacist, although many programs have co-leaders consisting of physicians and pharmacists. The leader should have a working knowledge of the principles of antimicrobial use, experience in process improvement, and strong communication skills. While it's preferred that the leader has formal infectious diseases residencies/fellowships, the reality is that there are not enough ID-trained physicians and pharmacists in the US to serve every hospital. Pharmacists may gain experience by attending webinars, reading articles, and applying those key lessons in their day-to-day responsibilities or completing short, formal concentrated trainings with Society of Infectious Diseases Pharmacists certificate or Making a Difference in Infectious Diseases program.*

*Note: Wolters Kluwer does not endorse any specific antimicrobial stewardship training program; these example programs are provided purely as a resource.

The process of nominating program leadership should be documented in the AMS policy.

Program goals aligned to Core Elements of Antimicrobial Stewardship

The overarching goals of the AMS program typically include:

  • Optimize antimicrobial use to improve patient outcomes and minimize adverse events
  • Prevent the development of antimicrobial resistance
  • Reduce the usage of unnecessary antimicrobials

These goals should serve as the guideposts in designing activities and interventions during the day-to-day operation of the AMS program. In addition, programs should have key strategic priorities set for each year so that the program maintains focus. Hospitals operate with thin margins and lean staffing in these challenging times. Therefore, it is important to deploy the resources to key areas without being distracted.  The policy should spell out the process for selecting these key strategic priorities each year.  Some examples of how to select such priorities include:

  • Comparing antibiograms of this current period with the previous period to identify key organisms with decreasing susceptibilities
  • Targeting antimicrobial uses with the highest NHSN Standardized Antimicrobial Administration Ratios (SAAR)
  • Collaborating with infection preventionists to identify hospital-acquired infections of the highest concern
  • Reviewing patient safety reporting databases to identify antimicrobials with the highest number or incidence of adverse events
  • Discussing with medical staff and analytics department to identify infection-related diagnoses with the highest, unexpected mortality or complications

The annual strategic priorities should be selected in a formalized process, such as scoring, FMEA (Failure Modes & Effects Analysis), or committee consensus, and documented in AMS committee minutes.  The annual strategic priorities should be communicated to the medical and other relevant staff.

Broad Spectrum HAI Agents
SAAR by Antimicrobial CategorySentri7's Saar Benchmarking Dashboard

AMS program activities and key metrics

Once your program has selected the key strategic priorities and goals for the program, you should design activities to help you accomplish said goals.  The tactical activities can be divided into system-level activities or patient-level activities.  System-level activities may include interventions such as antimicrobial restriction, the introduction of new diagnostic testing, reflex culture of urine, etc., where formalized programs are implemented to improve antimicrobial use.  This level can be particularly effective if the AMS program has few personnel to conduct the day-to-day review of antimicrobial orders.  However, implementing system-level interventions may take longer to align stakeholders.

Patient-level activities include review of patient-specific antimicrobial orders, relevant information in the electronic health records, and providing real-time feedback on the appropriateness of therapies, dosing, and monitoring plans.  While this type of activity is more time-consuming, having a one-on-one “handshake stewardship” conversation with the patient’s prescriber provides the AMS leader an opportunity to educate providers about best prescribing practices and the importance of antimicrobial stewardship. In return, AMS leaders may glean additional information that may not be apparent in the electronic health records and ultimately alter the treatment recommendations.

AMS leaders should align the activities to match the stated priorities and goals. Whatever interventions and activities are selected, it is important to document how and when the intervention was implemented so that key metrics (e.g., carbapenem days of therapy, Pseudomonas susceptibility to a certain antimicrobial) can be annotated in the correct timescale for analysis to determine if the intervention is achieving the desired outcome. 

Days of Therapy
DOT by Spectrum of ActivitySentri7's Antimicrobials Stewardship Dashboard - Days of Therapy (DOT)

 

Susceptibility Trend from Antibiogram

Sentri7's Susceptibility Trend from Antibiogram

AMS program education

In order to improve antimicrobial use and stewardship and to satisfy the requirements of The Joint Commission EP 12, AMS leaders should provide competency-based training to relevant staff. While the EP does not specify a timeframe, it is considered a best practice to incorporate this training as part of the orientation course and recurrent annual competency training. Documentation of completion of such requirements is essential during accreditation surveys, and many hospitals employ a learning management platform to host such education. AMS leaders will find that Infection Preventionists often already have such annual training and documentation processes implemented, so it may be beneficial to consult with them to see how you may append your AMS training to their current training curriculum.  AMS leaders may also consult the following resources in developing their education materials:

The IDSA has maintained a useful resource site that provides a sample policy template that can be adopted by your hospital.

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Steve-Mok
Steve Mok, PharmD, MBA, BCPS, BCIDP
Manager of Pharmacy Services and Fellowship Director
Dr. Steve Mok has over a decade of experience in the areas of antimicrobial stewardship, infectious diseases and clinical pharmacy management. He has practiced in a variety of settings.
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