How to Implement an Antibiotic Stewardship Program

Fall has begun, and with it comes the next phase of Requirements of Participation. Phase 2 of the 2016 Final Rule mandates that all skilled nursing facilities implement an Antibiotic Stewardship Program by November 28, 2017, stating that:

The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

• A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment.
• Written standards, policies, and procedures for the program.

Following closely behind Phase 2 is Phase 3 of the 2016 Final Rule, which mandates that all skilled nursing facilities include an infection preventionist (IP)in their Antibiotic Stewardship Program by November 28, 2019, including:

1. The facility must designate one or more individual(s) as the IP(s) who are responsible for the facility’s IPCP. The IP must:

• Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;
• Be qualified by education, training, experience or certification;
• Work at least part-time at the facility; and
• Have completed specialized training in infection prevention and control.

2. The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

• The facility will conduct an annual review of its IPCP and update their program, as necessary.

The Centers for Disease Control and Prevention (CDC) has developed and recommends these seven core elements of antibiotic stewardship for nursing homes. I recommend you follow their suggested elements as listed below:

1. Leadership Commitment
As with any new process, it is important that the administration provide all of the necessary human, financial and information technology resources in order for the rollout to be successful. The facility leaders should use all means available to let employees, families, and residents know that they are in support of the efforts to decrease and monitor antibiotic use. The facility leaders should also take an active role in supporting the educational process.

2. Accountability
The facility should choose an individual leader to take ownership and accountability for the Antibiotic Stewardship Program outcomes. Many facilities have been very successful with having their medical director fill this role. He or she can set standards for antibiotic prescribing practices and set standards for assessments and monitoring.

An IP will also need to be appointed. Ensure that this individual meets all of the necessary criteria from above. This is the person who is going to drive this process in your facility, so choose someone who is excited about the implementation process.

3. Drug Expertise
Identify a pharmacy leader who can participate as a co-leader for your Antibiotic Stewardship Program. Consider implementing automatic stop orders and automatic alerts for unnecessary duplicate antibiotic orders. Your consultant pharmacist should routinely review microbiology culture results, and review all antibiotic prescriptions as part of their routine drug regimen review.

4. Action
Implementing policies and procedures is a crucial part of your Antibiotic Stewardship Program’s success. Start by implementing one policy to improve your facility’s antibiotic use such as:

• Broad interventions to improve antibiotic use
• Antibiotic “time outs”
• Establish best practices for use of microbiology testing
• Pharmacy interventions to improve antibiotic use
• Develop facility-specific treatment recommendations

5. Tracking
Tracking your progress is going to be instrumental and can be achieved by monitoring specific measures:

• Process measures
• Antibiotic use measures
• Antibiotic outcome measures

Use your measurement outcomes to identify opportunities for improvement. Incorporate them into your quality assurance/ performance improvement process, and begin performance improvement plans if appropriate

6. Reporting
To ensure involvement of your entire facility, you will want to share your progress at regular intervals. This will, in turn, keep the staff engaged and feeling like they are part of the process. Your frontline staff members are your first defense in the war against unnecessary antibiotics.

7. Education
Education can be provided on any platform; handouts, seminars, webinars, emails, etc. The most effective for improving medication prescribing practices is interactive face-to-face workshops. Education should always involve staff, but don’t forget the importance of including residents, families, and volunteers. Everyone must be educated on the importance of the program as well as the risks of non-compliance and benefits of compliance.

Antibiotic overuse and the upsurge in multi-drug resistant organisms is a global challenge. As healthcare providers, we have to act now before it’s too late.

To learn more about creating and antibiotic stewardship program, read our post Antibiotic Stewardship Program: Why Do You Need One.