Hospitalists in several programs around the country were asked to focus on a few key improvement strategies that are believed to improve use. For instance, when guidelines give a range of duration of dosing, physicians often lean toward the higher end (when the range is seven to 21 days, the default was typically closer to 21), even when that might not be necessary in a given situation. So, more specific guidelines for common situations were applied.
Hospitalists also worked to improve documentation to make antibiotic use more visible at the point of care: which drug it is, when it was started, what day of therapy it is that day, how many more days are left.
An antibiotic “timeout” at 48 to 72 hours was implemented to determine whether the treatment course should be maintained, changed, or eliminated.
The idea was for hospitalists to track this as part of the usual care process.
“We didn’t want people to create whole new systems to do these things,” says Dr. Flanders, who has consulted with SHM for its stewardship initiative. “We wanted people, for example, to use their multidisciplinary rounds that they were already having to just add one thing to the checklist.”
The process was shown to be workable. All steps of the stewardship protocol were performed 70% of the time after the initiative began, compared with just 20% of the time before it began, Dr. Flanders says. Additionally, about 25% of patients had a “significant and important” change made to their antibiotic treatment following the “timeout.”
Success generally comes from starting small, from starting with a focused approach to something that you know is a problem in your facility. When you try to delve into everything all at once, you can very quickly get overwhelmed. —Arjun Srinivasan, MD, associate director for healthcare-associated infection prevention programs, CDC
“During this timeout, a lot of action happened,” Dr. Flanders says. More study is needed to show exactly how much of a change occurred and whether it led to cost savings, he says, but “I suspect it will.”
Much-Anticipated Partnership
Arjun Srinivasan, MD, associate director for healthcare-associated infection prevention programs at the CDC, says he is eager to continue to work with SHM on its antibiotic stewardship efforts, but he cautions that hospitalists should not try to do too much too quickly in implementing change.
“Success generally comes from starting small, from starting with a focused approach to something that you know is a problem in your facility,” Dr. Srinivasan says. “When you try to delve into everything all at once, you can very quickly get overwhelmed.”
Although smaller centers might have less manpower and face a bigger challenge in leading a stewardship program, it can be done, he says.
“We see some very small hospitals that have fantastic stewardship programs and some very small hospitals that are struggling,” he says. “We know it’s doable across the spectrum of the sizes of hospital.”
Hospitalists, he adds, “are the tip of the spear. They are probably prescribing most of the antibiotics [for inpatients] … and diagnosing most of the infections. So arming them with the information they need, working with them to develop a process that makes prescribing optimal and most efficient is obviously hugely beneficial.
“You’re going to have a tremendous impact by reaching that particular group.”
Tom Collins is a freelance writer in South Florida.
References
- Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. May 7, 2015. Accessed October 6, 2015.
- Agwu AL, Lee CK, Jain SK. A World Wide Web-based antimicrobial stewardship program improves efficiency, communication, and user satisfaction and reduces cost in a tertiary care pediatric medical center. Clin Infect Dis. 2008 Sep 15;47(6):747-753.
- Valiquette L, Cossette B, Garant MP, Diab H, Pépin J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis. 2007;45 Suppl 2:S112-S121.
- Slayton RB, Toth D, Lee BY, et al. Vital signs: estimated effects of a coordinated approach for action to reduce antibiotic-resistant infections in health care facilities – United States. MMWR Morb Mortal Wkly Rep. 2015;64(30):826-831.