General Management and Implementation Issues
Auditing and Feedback
- Real-time auditing helps optimize therapy on an individual-patient basis.
- Constructive and patient-specific feedback from experts in antimicrobial therapy is essential.
- The optimal method of communicating the recommendation to the provider—that is, feedback—must be defined.
- Match the mode of communication to the level of acuity and complexity.
- Passive education about appropriate antimicrobial use can include grand rounds, newsletters, and written guidelines.
- Passive education should be distinguished from active education that occurs in the context of auditing and feedback or preauthorization for specific patients.
- Education about the program itself should not be overlooked.
- A public, up-to-date Web site is an excellent way to inform providers about their institutional antimicrobial stewardship program and offers easy access to information about current strategies:
- Guidelines must be regularly re-evaluated and, if necessary, revised to reflect recent developments reported in the scientific literature.
Application of Information Technology
- Applications on the Web or on personal digital assistants can greatly facilitate rapid updating and dissemination of information compared with paper-based sources.
- Computerized physician order entry further expands the potential for intervening at the time of prescribing.
- Examples of tools are stop-order reminders and/or flags, order sets containing prophylaxis and treatment recommendations, assistance with dosing, information about formulary availability, and approval criteria for restricted antibiotics.
- Many commercially available clinical decision support systems integrate electronic medical records and can facilitate both back-end and front-end approaches to providing real-time, patient-specific recommendations, although they cannot replace clinical judgment.
Specific Antimicrobial Issues
Restriction and/or Preauthorization
- Formulary based restriction: Agents that are entirely unavailable
- Criteria-based restriction: Agents that are available for only certain indications
- Preauthorization-based restriction: Agents that are available only after approval by some authority
- Antimicrobial intravenous-to-oral switch can achieve substantial economic benefits.
- Program staff should consider which drugs to target, criteria for switching, and how the switch is performed.
- Third-party payer criteria for inpatient status may not be affected by intravenous-to-oral switching.
De-escalation or Streamlining
- De-escalation or streamlining is a subclass of auditing and feedback that focuses on changing from initial broad-spectrum (often combination) empiric therapy to a narrower-spectrum (often monotherapy) agent when culture identification and susceptibility results become available.
- Its role in limiting use of broad-spectrum antimicrobials can be fraught with complications.
- Successful strategies must offer clear, predefined criteria for narrowing or discontinuing antimicrobials, while allowing for clinical judgment.
Table 1. Antimicrobial Stewardship Strategies with Associated Barriers and Solutions
|Strategy||Barriers to Effective Implementation||Potential Solutions|
|Auditing and feedback||Problems in identifying patients who are receiving suboptimal therapy||Use rules-based computer systems that combine pharmacy and microbiologic data to flag patients of interest. Manually review antimicrobial order sheets. Review microbiologic data to identify targeted organisms.|
|Difficulty communicating recommendations to providers||Approve policy delineating appropriate means of communicating recommendations.|
|Lack of clarity in appropriate methods for providing feedback||Create nonpermanent forms for written communication in the medical record.|
|Medicolegal concerns about providing feedback in the medical record||Time communication for greatest likelihood of impact (eg, before rounds). Hold intermittent, regularly scheduled antibiotic rounds between the stewardship team and staff from services that heavily use antimicrobials.|
|Restriction and/or preauthorization||Perceived challenge to physician autonomy||Have an approved policy by the medical executive committee. Grant time-restricted approvals (eg, for 24-72 hrs) to balance physicians’ and stewardship concern. Regularly review the use of restricted agents to evaluate their continued restriction.|
|Integration of restriction policies into workflow||Use computerized physician order-entry systems to give restriction notifications automatically. Use dedicated pagers for restricted agents to minimize delays in authorization. Establish clear procedures for authorization after hours.|
|Prescriber education||Lack of knowledge about the role of stewardship programs||Hold antimicrobial stewardship grand rounds to explain the program and provide hospital-specific data.|
|Guideline implementation||Poor knowledge of, and adherence to, guidelines for antimicrobial use||Disseminate information in printed handbooks, integrate it in order sets, and provide easy access on Internet or intranet. Involve opinion leaders from multiple specialties in developing guidelines.|
|Application of information technology||Considerable investment of financial and human resources||Emphasize its importance in patient safety and the potential to avoid substantial costs.|
|Intravenous-to-oral switch||Identification of eligible patients||On a daily basis, review patients receiving intravenous forms of highly bioavailable antimicrobials. Develop criteria to help clinicians determine candidacy for switch (eg, body temperature, white blood cell count).|
|De-escalation or streamlining||Unwillingness of providers to de-escalate or streamline||Refer to studies that demonstrated safety of|
de-escalation or streamlining when resistant organisms were not identified.
|Dosage optimization||Nursing concerns regarding administration and drug incompatibility||Create protocols for administration and list compatible drugs. Consider extended infusion instead of continuous infusion.|