MDS Alert

Hint: Take a multilevel approach to staff education and commitment.

The mandating of an antibiotic stewardship program was one of the big changes in last November's Phase 2 Requirements of Participation. Make sure your facility is measuring up to the mandated changes and big picture goals for antibiotic use in long-term care.

Nuts and bolts

The Centers for Disease Control and Prevention (CDC) estimates that up to 70 percent of nursing home residents nationwide are prescribed a course of systemic antibiotics annually, according to the CDC Core Elements of Antibiotic Stewardship for Nursing Homes fact sheet. Of those antibiotics prescribed, the CDC estimates that 40-75 percent of those are unnecessary or otherwise inappropriately prescribed.

"This is a totally unacceptable statistic," says Linda Elizaitis, president and CEO of CMSCompliance Group in Melville, New York.

Besides the alarming rate of prescriptions, unnecessary antibiotics have a significant negative effect on residents - and even the population at large. "Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms," the CDC fact sheet says.

Revisit antibiotics protocols

In the six months since the new regulations went into effect, all facilities should have antibiotic stewardship as an established part of their policies and routines. "At this point in time, every nursing home should have developed and implemented protocols for how it treats infections as well as establishing criteria for what is an actual infection, including ensuring that the appropriate antibiotic is prescribed," Elizaitis says. "Treating prophylactically with any antibiotic until the facility gets a culture result that is specific to identify the organism is not the standard of practice that should be followed."

CMS intended to forestall this common practice with its new antibiotic stewardship requirement. "When CMS revised and added new regulations to the Requirements of Participation, the Agency added a requirement for Antibiotic Stewardship under regulatory tag F881, which became effective Nov. 28, 2017. The regulation specifically outlines what should be happening in a nursing home related to antibiotic use," Elizaitis says.

The CDC provides both a summary and an in-depth description of the steps all facilities should take or already have in place, starting with a top-down approach of a commitment from leadership.

Don't panic if your facility isn't yet at the point where you'd like to be. "Nursing homes are encouraged to work in a step-wise fashion, implementing one or two activities to start and gradually adding new strategies from each element over time. Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting," the CDC says in The Core Elements of Antibiotic Stewardship for Nursing Homes.

Focus on education

But be wary of the ways in which you implement the various facets of the antibiotic stewardship program. A lack of investment in training could undermine all of your facility's efforts and cost you in citations. "While there are many components to a sound and comprehensive Antibiotic Stewardship Program, a significant vulnerability lies in an under-educated staff, resident population and their families," Elizaitis says.

In fact, a focus on residents' families may be the lynchpin in a successful program. With our culture believing for so long that antibiotics could fix anything, many people expect a prescription even when the diagnosis wouldn't call for antibiotics.

Elizaitis recommends really hammering out the language and conversations your staff might have with residents and their families. "An emphasis needs to be placed on providing education that the target audience can understand. We need to know how to explain to the concerned daughter why mom does not need an antibiotic to be prescribed simply because when mom had certain symptoms in the past, an antibiotic was always prescribed," she says.

Ensure leadership's commitment - and management accountability

One of the core elements of the CDC's program is securing leadership's commitment to cutting down on antibiotic usage. Their recommendations include attaching leaderships' names to written statements encouraging more appropriate antibiotic use, rewriting pertinent job descriptions to include antibiotic stewardship responsibilities, communicating expectations with staff and following up with monitoring and enforcement, and creating a culture that encourages education and celebrates improvement.

It's important that the "business" side of leadership -  all the way up the ladder - is vocal about their commitment to the change in company policies and protocols. But look to the medical leadership to really set the tone for the new culture your facility will need to create in order to have a successful antibiotic stewardship program.

"As the overseer of the facility's resident care protocols, the medical director should be working with all attending medical practitioners regarding their responsibility to prescribe antibiotics responsibly. The medical staff should also be working closely with the consultant pharmacist to order appropriately if there is a question of what course of action to take," Elizaitis says.

And don't forget about nurses. They'll best be able to implement both management's expectations and report back on the realities of what's going on with individual residents. "Nursing is a key component of a strong antibiotic stewardship program, whether providing education, monitoring for adverse drug events or interactions, or compiling data on infections and antibiotic use for review and assessment by the infection control or QAPI Committee," Elizaitis says.

Remember: "A sound antibiotic stewardship program is a requirement that needs to remain on the radar screen of all administrators, since their leadership commitment is a necessary component of such a program's success," Elizaitis says.