Skilled Nursing Facility Antibiotic Stewardship Program Implementation Toolkit
The skilled nursing facility (SNF) antibiotic stewardship program (ASP) toolkit provides support to California SNFs for the implementation of ASPs, including SB361 requirements and Centers for Medicare and Medicaid Services (CMS) conditions of participation. The toolkit can be used by physicians, pharmacists, infection preventionists, microbiologists, information technology specialists, and any other SNF leadership and support staff seeking guidance, resources, and practical examples for developing ASP practices.
The Centers for Disease Control and Prevention (CDC) recommends that all SNFs take steps to improve antibiotic prescribing practices and reduce inappropriate use by implementing an antibiotic stewardship policy or procedure.
ASPs can both optimize the treatment of infections and reduce adverse events associated with antibiotic. The programs help clinicians improve the quality of patient care and improve patient safety through increased infection cure rates, reduced treatment failures, and increased frequency of correct prescribing for therapy and prophylaxis.
Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for nursing home residents.
Examples of policy
- Example 0.1 Title
- Example 1.2 Title
The following is based on the CDC “Core Elements of Antibiotic Stewardship for Nursing Homes, and includes specific examples of implementation recommended by the Healthcare-Associated Infections (HAI) Program Advisory Committee.
Element 1. Leadership Commitment
Leadership support is critical to the success of antibiotic stewardship programs.
- [Evidence/statement to support the following:] Create a written statement in support of ASP from SNF leadership (both governing entity and administration) and provide evidence of adequate budget/staffing to support the program.
- [Evidence/statement to support the following:] Establish antibiotic stewardship as a Performance Improvement Program (POP) under the facility Quality Assurance-Performance Improvement (QAPI) initiative as recommended by the Centers for Medicare & Medicaid Services (CMS) / the Centers for Disease Control and Prevention (CDC). Routinely review ASP activities during the facility quality improvement committee meetings.
Element 2. Accountability
Appointing a leader who is responsible for program outcomes and whose effectiveness is assessed through clear performance standards, provides accountability for antibiotic stewardship.
The ASP committee oversees organization-wide efforts to promote and evaluate the appropriate use of antibiotic agents. Ideally, the committee membership should include physician stakeholders who act as liaisons and champions to promote stewardship education and practices among their various services and disciplines.
- [Evidence/statement to support the following:] Convene a physician-supervised multidisciplinary antibiotic stewardship committee, subcommittee, or workgroup.
Element 3. Drug Expertise
Formal training in infectious diseases or antibiotic stewardship benefits stewardship program leaders. Facilities have achieved success by hiring additional full- or part-time staff or partnering with off-site expertise and hospitalists to develop and manage stewardship programs.
Appointing a pharmacist leader to partner with the ASP leader provides the expertise and accountability needed for a high-quality program.
Criteria for a pharmacy leader should include expertise in antibiotic use, training in stewardship, leadership skills, respect from peers, and good team skills.
- [Evidence/statement to support the following:] Formal training in antibiotic stewardship benefits ASP leaders. Obtain ASP support from a physician or pharmacist who has attended specific training on antibiotic stewardship. Training requirements may be met through several continuing education training programs offered by the Centers for Disease Control and Prevention (CDC), the Society of Healthcare Epidemiology of America (SHEA), Infectious Disease Society of America (IDSA), or other recognized professional organization, or post-graduate training with concentration in 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.
Examples of antibiotic stewardship education and training courses:
Element 4. ActionImplementing at least one intervention to improve antibiotic use is critical for an effective ASP. The interventions should align with local needs and have measurable outcomes which the ASP monitors and reports to hospital leadership and providers.
- [Evidence/statement to support the following:]
- Develop reports summarizing the antibiotic susceptibility patterns (e.g., facility antibiogram), partner with ASP physician or pharmacy consultant to use these data to reevaluate antibiotic formulary and inform common infection syndromes, and develop facility-specific treatment recommendations for infections.
- 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 / “antibiotic time out” at 48-72 hours to reevaluate treatment based on clinical response and culture results.
- Implement a process for communicating or receiving antibiotic use information when residents are transferred to and from other healthcare facilities.
Element 5. Tracking
Measurement is critical to identify opportunities for improvement and assess the impact of improvement efforts. For antibiotic stewardship, measurement may involve evaluation of both process and outcome measures.
Monitoring antibiotic prescribing and resistance patterns is critical to identify opportunities for improvement and to assess the impact of improvement efforts. Systematic collection of antibiotic use and resistance data allows facilities to assess, monitor, and improve prescribing practices.
- [Evidence/statement to support the following:] Monitor measures of antibiotic use including:
- Rates of C.difficile infection
- Rates of antibiotic-resistant organisms
- Rates of adverse drug events due to antibiotics
- 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.
Element 6. ReportingRegular reporting of information on antibiotic use and resistance to physicians, nurses, and relevant staff serves as a key element of a successful ASP.
- [Evidence/statement to support the following:] 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.