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āElement 1. Leadership CommitmentSNF leadership commitment support helps ensure adequate funding and staffing of the ASP, and facilitates buy-in among clinicians.
Suggestions:
- Create a written statement in support of ASP, including demonstration of adequate funding and staffing resources to support the program
- Establish antibiotic stewardship as a Performance Improvement Program under the facility Quality Assurance-Performance Improvement (QAPI) initiative as recommended by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC)
- Routinely review ASP activities during the facility quality improvement committee meetings
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Webinar recording: Leadership Support for Nursing Home Antimicrobial Stewardship (link opens in YouTube)
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Example 1.1: Statement of Leadership Support (PDF), Sharp Coronado Hospital and Villa Long Term Care
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āElement 2. AccountabilityA SNF leader should be accountable for ASP outcomes and their effectiveness assessed through clear performance standards. ASP leaders serve as liaisons and champions to promote stewardship education and practices across disciplines.
Suggestions:
- Convene a physician-supervised multidisciplinary antibiotic stewardship committee, subcommittee, or workgroup
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āElement 3. Drug ExpertiseSNF should establish access to individuals with antibiotic expertise to implement antibiotic stewardship activities.
Suggestions:
- Obtain ASP support from a physician or pharmacist who has attended specific training on antibiotic stewardship. The trained physician or pharmacist may be consultant pharmacy staff trained or experienced in antibiotic stewardship, an external infectious disease stewardship consultant, or part of the stewardship team at a referral hospital
ASP training is available through various continuing educations programs including those offered by:
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āElement 4. ActionSNF should implement
at least one intervention to improve antibiotic use. New policies and procedures should be introduced in a step-wise fashion so staff become familiar with, and not overwhelmed by, new changes in practice. Prioritize interventions based on the prescribing and resistance patterns or most prevalent antibiotic adverse events (e.g., Clostridioides difficile infections) at the facility.
Suggestions:
- Develop reports summarizing the antibiotic susceptibility patterns observed at the facility (e.g., facility antibiogram)
- Partner with ASP physician or pharmacy consultant to use the antibiogram to reevaluate the antibiotic formulary and develop facility-specific treatment recommendations for common infection syndromes
- Develop a facility-specific algorithm and communication tool for assessing residents suspected of having an infection
- Develop facility-specific algorithms for appropriate diagnostic testing (e.g., obtaining cultures) for specific infections
- Require prescribers to document a dose, duration, and indication for all antibiotic prescriptions
- Implement an antibiotic review process or āantibiotic time outā at 48-72 hours after initiation of antibiotics to reevaluate treatment based on clinical response and culture results
- Implement a process for communicating or ensuring receipt of antibiotic use information when residents are transferred to and from other healthcare facilities
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Webinar recording: Antimicrobial Stewardship Actions and Interventions in the Nursing Home Setting (link opens in YouTube)
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Example 4.1: Antibiogram (PDF), Palomar Health
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Example 4.2: Antibiogram (PDF), Sharp Coronado Hospital and Villa Long Term Care
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Example 4.3: Antibiogram Analysis (PDF), Eden Medical Center / Sutter Health
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Example 4.4: Antibiotic Initiation Guidelines (PDF), Sharp Coronado Hospital and Villa Long Term Care
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Example 4.5: Antibiotic Interventions (PDF), OāConnor Hospital
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Example 4.6: Antibiotic Time Out (PDF), OāConnor Hospital
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Example 4.7: Drug Interaction Progress Note (PDF), OāConnor Hospital
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Example 4.8: Fever/Suspected Infection Treatment (PDF), Sharp Coronado Hospital
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Example 4.9: Infection Assessment (PDF), Palomar Health Long Term Care
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Example 4.10: Pharmacy Communication Sheet for Vancomycin (PDF), OāConnor Hospital
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Example 4.11: Pharmacy Communication Sheet for Narrower Spectrum (PDF), OāConnor Hospital
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Example 4.12: Pharmacy Communication Sheet for Resistant Organism (PDF), OāConnor Hospital
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Example 4.13: Skin and Soft Tissue (SSTI) Treatment Algorithm (PDF), Sharp Coronado Hospital and Villa Long Term Care
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Example 4.14: Stewardship Collaborative Guidelines for SSTI (PDF), Colorado Hospital Association
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Example 4.15: Stewardship Collaborative Guidelines for UTI (PDF), Colorado Hospital Association
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āElement 5. TrackingSNF should monitor both antibiotic use practices and outcomes related to antibiotics to guide practice changes and track the impact of new interventions. Tracking clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether interventions are effective in changing prescribing behaviors.
Suggestions:
- Monitor outcomes of antibiotic use. Options include:
- Rates of
C. difficile infection
- Rates of antibiotic-resistant organisms
- Rates of adverse drug events due to antibiotics
- Monitor measures of antibiotic use.
- Adherence to clinical assessment documentation (e.g., signs/symptoms, vital signs, physical exam findings)
- Adherence to prescribing documentation (e.g., dose, duration, indication)
- Adherence to facility-specific treatment recommendations
- Rates of new antibiotic starts per 1000 resident-days
- Rates of antibiotic days per 1000 resident days.
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āElement 6. ReportingRegular reporting of information on antibiotic use, including adherence to antibiotic prescribing policies, to physicians, nurses, and relevant staff engages and motivates them to meet ASP goals.
Suggestions:
- Regularly provide written summaries of antibiotic stewardship goals, antibiotic use, and outcome measurements to prescribers and nursing staff
- Conduct real-time audits/reviews of individual prescriber practices and provide personalized feedback to clinical providers
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āElement 7. EducationSNF ASP should educate both clinical providers and nursing staff on the rationale and goals of antibiotic stewardship interventions, and the responsibility of each group for ensuring implementation. SNF should also engage residents and their family members in antibiotic use and stewardship education to ensure their support when clinicians make appropriate antibiotic use decisions.
Suggestions:
- Regularly provide education and updates about antibiotic resistance and opportunities for improving use to clinical providers, nursing staff, residents, and families
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