In our first article of the Back to the AMS Basic series, we discussed the importance of inviting other professionals in the hospital to help establish an antimicrobial stewardship (AMS) program. This article will address how to incorporate them into the activities and operation of the AMS program while maintaining compliance with the relevant Joint Commission standards.
A multidisciplinary approach to Antimicrobial Stewardship
The Joint Commission MM.09.01.01 elements of performance 14 requires that the hospital coordinates its antimicrobial stewardship program with the following departments:
- Pharmacy
- Infection prevention and control
- Quality and performance improvement
- Medical staff
- Nursing services
Therefore, we recommend that program leaders ensure the above departments are invited and regularly attend antimicrobial stewardship committee meetings. To adequately satisfy surveyors on their participation, attendance, and the department represented should be noted in the minutes.
Structuring your AMS committee meetings
While the format and frequency of AMS committee meetings are at the discretion of the hospital, we recommend a monthly or quarterly frequency would be ideal to maintain momentum. Smaller facilities may find it useful to combine the AMS committee meetings as part of the larger Pharmacy and Therapeutics Committee (P&T) or the Infection Prevention and Control meeting that are already in existence. Larger facilities, however, may find it useful to keep the AMS committee as a separate meeting.
Once you have gathered the multidisciplinary team to the table, what should you discuss at these meetings? The following are some suggested standing and ad-hoc items that may be incorporated into your meeting:
Antimicrobial usage
Pharmacy should present antimicrobial usage at least quarterly to track the effectiveness of the AMS program. Metrics that may be used include Days of Therapy (DOT) for key antimicrobial class, or antimicrobials of interest. In hospitals that submit antimicrobial use data to NHSN, presentation of Standardized Antimicrobial Administration Ratios (SAAR) may be helpful to benchmark their own statistically adjusted performance to a national database of participating hospitals. AMS leaders may find it helpful to annotate any run charts or trend lines with key dates for which performance improvement (PI) initiatives such as antimicrobial restrictions or time-outs are implemented, so it would be easy to discern the effectiveness of such PI programs.
Antimicrobial resistance
Microbiology laboratory, in collaboration with pharmacy, should produce an annual antibiogram that provides healthcare professionals with susceptibilities of key bacteria to commonly used antimicrobials. In larger facilities, or hospitals with concerning multi-drug resistant organisms, more frequent reporting may be desired. As above, it may be helpful to annotate PI implementation dates to any observed trends to assess their effectiveness and allows for course adjustment if the desired outcome is not achieved.
Adherence to AMS policies and interventions
Data on adherence to established policies and interventions should be tracked and reported regularly to identify areas where non-adherence is occurring and to determine if any potential barriers may need to be removed or mitigated.
Supply chain updates
Naturally, we think of pharmaceutical shortages, but during the COVID-19 pandemic, we witnessed shortages in personal protection equipment and laboratory supplies. The AMS committee can provide a forum for all departments involved in procuring supplies for patient care and protection of staff members to discuss current and projected shortages and utilize the time to devise proactive plans to manage the shortages, such as selecting alternative drugs, batching laboratory testing, or establishing use/test criteria to ensure supplies are being utilized judiciously.
Treatment guidelines update and new research
The AMS committee should also regularly screen the literature and relevant guidelines to determine if any evidence should lead to changes in practice on antimicrobial selection, dosing, or monitoring. Newly approved antimicrobials should also be discussed so that a committee consensus can be formed, and recommendations be made to the P&T committee for consideration of their status on the formulary. This agenda item should also serve as a prompt to review any existing order sets regularly to ensure that empiric antimicrobial suggestions are still appropriate based on the latest evidence and local susceptibilities.
Diagnostic updates
Laboratory directors may share any new diagnostic technology that may improve turnaround time or accuracy and secure the committee’s help to build the business case for bringing such technologies to the hospital. Furthermore, routine reviews of the antimicrobial panels used in automated susceptibility testing equipment can be conducted at the AMS committee to ensure that the antimicrobials tested on the panels are aligned with the formulary and prescribing practices.
Regulatory updates
The quality department may wish to share any upcoming regulatory requirements or changes, such as the addition of AUR submission to NHSN to the Medicare Promoting Interoperability program so that all stakeholders are aware of the changes and ready to implement to protect the organization from non-compliance. Progress on the implementation of any key programs or metrics may also be shared.
Performance Improvement
As part of the accreditation requirements, organizations should have a formal performance improvement program to promote more judicious use of antimicrobials. The AMS committee shall select key improvement goals, based on their relevant metrics, and develop strategies and tactics to achieve such goals. Often these PI initiatives require multidisciplinary participation. Engaging key members of the committee in the selection, planning, and implementation of PI initiatives will increase their likelihood to remain vested in the program throughout the year.
In summary, key agenda items to discuss at the AMS committee is provided below as a guide on how to structure your committee meeting: