Starting a Stewardship Program | Emory School of Medicine

Antibiotic Stewardship refers to a set of commitments and actions designed to “optimize the treatment of infections while reducing the adverse events associated with antibiotic use.”

Rationale

Over the last decade, antimicrobial resistance (AMR) in healthcare settings has become an increasing public health crisis in the United States. Nursing homes and other long-term care facilities (LTCFs) are especially vulnerable to AMR-related problems due to their often frail and/or immunocompromised patient population, high antibiotic prescription rates, and potential for facility-wide outbreaks.

In September 2014, then President Barack Obama initiated the US Government response to this challenge by signing Executive Order 13676: Combating Antibiotic-Resistant Bacteria, outlining steps for implementing the National Strategy on Combating Antibiotic-Resistant Bacteria, which was subsequently published in 2015. The unifying theme of the national strategy is the concept of antibiotic stewardship, which refers to a set of commitments and actions designed to "optimize the treatment of infections while reducing the adverse events associated with antibiotic use."

From the agency Core Elements of a Stewardship Program Explore the full text guide from the CDC

With the national priority on AMR established, the Centers for Medicare and Medicaid Services (CMS) have published specific regulations requiring LTCFs to address AMR in their facilities and the Centers for Disease Control and Prevention (CDC) has provided implementation guidance for LTCFs, with a focus on 7 Core Elements of Antibiotic Stewardship in Nursing Homes.

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Core Elements

Leadership commitment

Support and direction from an organization's leadership creates a culture that places value on stewardship activities, empowering healthcare workers and staff to take ownership over their roles in the development of safer community for their patients.

Accountability

Everyone in the organization has a role in an antibiotic stewardship, and the program is only as effective as it's weakest link. Installing mechanisms that hold stakeholders accountable for their roles will ensure that program activities are prioritized and accomplished as designed.

Drug expertise

Optimized prescription practices are the bedrock of a stewardship program - relying on evidence-based practices to narrow the gap of preventable infections and slow the development of drug-resistance. Stakeholders with subject matter expertise will be a central resource for every stewardship effort.

Action

With adequate planning and stakeholders engagement, the next step is to implement the practices set out in the stewardship plan. Stewardship is an active and ongoing endeavor, and requires a proactive response to affect the desired improvement.

Tracking

Ongoing measurement of key indicators provides a crucial assessment of a stewardship program's progress and effectiveness. Without these insights, optimization of antibiotic use among a patient population will fail - lacking the ability to iteratively assess and improve upon program weaknesses.

Reporting

Data equity and transparency can build trust with both patients and stakeholders, and thus improve an organization's authority and credibility. Reporting is not only important for those involved in the stewardship program, but also to help build more robust analytical datasets for researchers to continue to identify causal mechanisms and inform better policy.

Education

New policies and practices introduced by the stewardship program will ultimately require many of the stakeholders in an organization to learn and apply new treatment guidelines. An educated workforce and an informed patient population will create less resistance to change and will benefit from having a more robust understanding of their own health or treatment strategy.

Getting started

There are steps your facility can take right away to start the journey towards a robust stewardship program.

Commitment materials

Commitment materials can be used to develop a stewardship-minded culture in your organization. EASIL has developed posters targeted for residents that discuss:

Additionally, upon admission, your organization can provide each resident with a personalized commitment letter demonstrating your dedication to their health and the health of the entire community.

Policy template

Antibiotic stewardship will look slightly different in every organization, but it begins from a standard set of principles. EASIL has developed a template policy document that can serve as a first draft for your organization's official program.

Gap analysis tools

Where are your organization's stewardship painpoints? Use this EASIL-designed gap analysis tool to identify what area's in your policy and practice are stewardship-oriented and which are in need of reform. Also see another excellent tool for gap analysis from the Minnesota Department of Health, one of EASIL's many collaborators.

Agency for Healthcare Research and Quality

AHRQ provides toolkits for minimum criteria for prescribing antibiotics, as well as educating and engaging residents and family members. These include tools to help:

Next Steps Build your program

Stewardship programs, especially in the LTCF setting, should be implemented in a stepwise fashion - slowly introducing new practice updates one after another so that your organization has time to adjust accordingly.

Specific Actions to Improve Antibiotic Use