A high-performing antimicrobial stewardship program (ASP) has been proven to provide much value to a healthcare organization. Nevertheless, many hospitals still struggle to implement a sustainable program. While these organizations have a general understanding of how to appropriately use antimicrobials and a desire to improve stewardship, implementation delays remain. The reasons for these delays vary by institution, but most are caused by a lack of some combination of personnel, funds, expertise and priority.
It's time for hospitals to navigate through those implementation barriers. Antimicrobial stewardship programs, which historically have been weakly regulated, are becoming a higher priority on both the state and federal level due to new regulations in place.
In the future, ASPs will become more highly regulated, and accreditation bodies may even require a high-performing ASP before conferring institutional accreditation.
On September 17, 2014, the California Legislature passed Senate Bill 1311, which added to the state's Health and Safety Codes regarding health facilities. It requires by July 2015 that all general acute care hospitals adopt and implement an antimicrobial stewardship policy in accordance with federal government and professional organization guidelines. The bill also requires the establishment of a physician-supervised multidisciplinary antimicrobial stewardship committee with at least one physician or pharmacist who has had specific training related to antimicrobial stewardship. The bill will further require the general acute hospital to report antimicrobial stewardship program activities to each appropriate hospital committee that is undertaking clinical quality improvement activities.1
The federal government has not been silent on the issue of ASPs. On September 18, 2014, a Presidential Executive Order (EO) was issued entitled "Combating Antibiotic-Resistant Bacteria." This EO requires federal agencies to review existing regulations and to propose new ones or other actions that have the effect of requiring hospitals to implement "robust stewardship programs that adhere to best practices; agencies will also be required to define, promulgate and implement stewardship programs in other settings such as long-term care facilities and outpatient settings."2
Successful ASP implementation
Fortunately, the Centers for Disease Control (CDC)3 and the Infectious Diseases Society of America (IDSA)4 offer help to guide hospitals during this process, including these strategies, among others, for successful ASP implementation:
There should be a formal written statement of support from leadership on the importance of improving antibiotic use through a high-performing ASP. The hospital should budget for activities that advance the ASP, including salary support, training, expert personnel, and IT software.
There should be a physician champion who is responsible for the ASP outcomes.
A trained pharmacist to lead the AS program is critical to long-term program sustainability.
Formulary restrictions development
Antimicrobial restriction, either through formulary limitations or requiring preauthorization and justification, is the single most effective way to achieve control of antimicrobial use.
Implementing an ASP becomes less intimidating if it's scaled and phased in over time. For example, formulary restriction might start with phase 1 P&T policy development; phase 2 drug-use approval process and phase 3 pharmacy MUE tracking.
An automated surveillance system helps all stakeholders better understand and analyze key data, both in real-time and in aggregate. Such systems offer a combination of surveillance and clinical decision support tools to help support an excellent ASP. These programs will play an increasingly large role in future antimicrobial stewardship programs.
Where could your ASP use improvement?
- The California Legislature Senate Bill No. 1311 text.
- The White House, Office of the Press Secretary. Executive Order-Combating Antibiotic-Resistant Bacteria.
- CDC. Checklist for Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- IDSA/SHEA Guidelines for Antimicrobial Stewardship Programs. http://www.journals.uchicago.edu/doi/pdf./10.1086/510393