5 Questions Leaders Should Ask About Antimicrobial Use
Feb. 20, 2018
By Renée Duncan, RN, J.D., CPHRM; Kelly Smith, CPA; and Rebecca Welker, CIA, FHFMA
Antimicrobial stewardship is in the healthcare spotlight and for good reason: Antimicrobial resistance has become a serious threat to patients, communities, and healthcare organizations. The Centers for Disease Control and Prevention estimates that antibiotic-resistant bacteria are to blame for more than 2 million illnesses and 23,000 deaths annually in the United States.1 Without effective antibiotics, medical and surgical treatments or interventions would be seriously compromised.
With the stakes so high, healthcare leaders need to review their organizations’ antimicrobial stewardship programs to make sure they are effective and in compliance with regulatory standards. In this article, clinical risk specialists answer five of healthcare leaders’ most pressing questions about antimicrobial stewardship.
Q: Why should antimicrobial stewardship be a strategic priority?
A: Resistance to antibiotics (drugs that kill or stop bacteria growth) and other antimicrobials (drugs that kill or stop growth of microbes, including bacteria, viruses, fungi, and parasites) is becoming increasingly common among patient populations in the United States and around the world. The World Health Organization reports that globally, 490,000 people developed multidrug-resistant tuberculosis in 2016.2 In addition to causing increased instances of illness and death, antimicrobial resistance is contributing to rising costs for healthcare organizations. The cost of care for patients with resistant infections generally is higher than in cases of nonresistant infections due to longer duration of illness, increased hospital length of stay, and increased medical expenses resulting from additional testing and use of more expensive drugs.
Hospitals and health systems also risk reputational damage should significant patient illnesses or deaths related to antimicrobial-resistant infections affect their organizations. In addition, hospital-acquired conditions such as C-diff (Clostridium difficile) and pneumonia, which often result in poor clinical outcomes and readmissions, can lead to penalties and lost reimbursement in an already challenging financial climate. Evidence suggests that proper use of antibiotics in treating these infections can have a positive impact on the infection rate. Incorrectly prescribed antibiotics, however, have questionable therapeutic benefit and expose patients to potential complications of antibiotic therapy.3
Antimicrobial resistance is truly a population health issue. When antibiotic resistance occurs, it does not affect just one patient – it affects an entire community. High-risk populations, including individuals who are immune-compromised, the elderly, and children, are especially vulnerable, as they may be unable to successfully fight infections.
Q: What is the Joint Commission Antimicrobial Stewardship Standard?
A: Recently, healthcare organizations have been given another reason to move antimicrobial stewardship to the top of their priority lists. Effective Jan. 1, 2017, the Joint Commission issued a new antimicrobial standard that focuses on reducing the risk of overprescribing antibiotics for patients and combating the development of so-called superbugs that are resistant to current medications.
Derived from the Centers for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship Programs, the Joint Commission Antimicrobial Stewardship Standard (MM.09.01.01) applies to hospitals, critical access hospitals, and nursing care centers.4 The standard defines seven core elements of effective antimicrobial stewardship programs.5 Briefly summarized, they are:
- Leadership commitment – dedication of necessary human, financial, and IT resources
- Accountability – appointment of a single leader (such as a physician with infectious disease management experience) to be responsible for antimicrobial stewardship program outcomes
- Drug expertise – appointment of a single pharmacy leader who can dedicate time to improving organizational antimicrobial usage
- Action – implementation of systematic evaluation of ongoing antibiotic treatment needed after a set period of initial treatment
- Tracking – monitoring of the antimicrobial stewardship program, which includes information on antibiotic prescribing and resistance patterns
- Reporting – program reporting to providers, nurses, etc., which includes information on antibiotic use and resistance
- Education – education for practitioners, staff (at hire and annually), and patients about appropriate antimicrobial use
Q: Why is compliance with the Joint Commission Antimicrobial Stewardship Standard vital?
A: Noncompliance can affect an organization’s ability to serve Medicare and Medicaid patients, so there is potentially a lot to lose. Healthcare leaders must be familiar with the standard and play a major role in bringing staff members together to strengthen antimicrobial stewardship programs. Additionally, and most important, patients are safer when they are treated with the most effective antibiotic.
Q: What steps can an organization take to strengthen its antimicrobial stewardship program?
A: Leaders should become familiar with the Joint Commission standard and gain a thorough understanding of the organization’s current state of compliance. Additionally, leaders can focus on the following areas to strengthen an antimicrobial stewardship program6:
- Designate an infectious disease physician champion to implement the program and be its spokesperson.
- Establish antimicrobial stewardship as an organizational priority. Because leaders set the tone throughout an organization, it is important that this message comes from the top.
- Train clinical and nonclinical staff about ordering, dispensing, and administering antimicrobial drugs as well as about monitoring antimicrobial resistance and stewardship practices.
- Train patients and families in both inpatient and outpatient settings about appropriate use of antimicrobial medications, including antibiotics.
- Create and maintain an antimicrobial stewardship multidisciplinary task force that includes infectious disease physicians, infection preventionists, licensed independent practitioners, and pharmacists to monitor the effectiveness of the program. Although not required by the Joint Commission standard, nurses should be included in the task force as vital members of the patient care team.
- Include the Joint Commission’s seven core elements in the organization’s antimicrobial stewardship program.
- Employ organization-approved multidisciplinary protocols such as antibiotic formulary restrictions and preauthorization requirements.
- Collect, analyze, and report data on the organization’s antimicrobial stewardship program.
- Take action on improvement opportunities identified through the antimicrobial stewardship program.
Q: How can a healthcare organization determine whether its antimicrobial stewardship program is effective and compliant?
A: Obtain an independent, objective assessment of the organization’s antimicrobial stewardship program. Having that independent assurance is the most effective way to know if a healthcare organization’s antimicrobial stewardship program is robust enough to comply with the Joint Commission standard and to protect patients and the community from ineffective drug treatment and resistant microorganisms.
1 "Antibiotic Resistance Threats in the United States, 2013," Centers for Disease Control and Prevention, https://www.cdc.gov/drugresistance/threat-report-2013/index.html
2 “Antimicrobial Resistance: Fact Sheet,” World Health Organization, updated January 2018, http://www.who.int/mediacentre/factsheets/fs194/en/
3 Boris D. Lushniak, “Surgeon General’s Perspectives: Antibiotic Resistance: A Public Health Crisis,” Public Health Reports, July-August 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037453/
4 “Antimicrobial Stewardship – FAQs,” The Joint Commission, Jan. 23, 2017, https://www.jointcommission.org/antimicrobial_stewardship_faqs/
5 “Approved: New Antimicrobial Stewardship Standard,” Joint Commission Perspectives, July 19, 2016, https://www.jointcommission.org/new_antimicrobial_stewardship_standard/
6 Ibid; Timothy H. Dellit, Robert C. Owens, John E. McGowan, Dale N. Gerding, Robert A. Weinstein, John P. Burke, W. Charles Huskins, David L. Paterson, Neil O. Fishman, Christopher F. Carpenter, P.J. Brennan, Marianne Billeter, and Thomas M. Hooton, “Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship,” Clinical Infectious Diseases, Jan. 15, 2007, https://academic.oup.com/cid/article-lookup/doi/10.1086/510393