MDS Alert

Partner up for stewardship, because it ‘takes a village’ to improve antibiotic use.

Up to 75 percent of antibiotics prescribed to residents in your facility may be unnecessary. Couple that with the increased focus on preventing adverse drug events and how you report them on the MDS, plus the impact on your quality measures, and you need to step up your “antibiotic stewardship” actions pronto.

Why Bother? Antibiotic Statistics are Frightening

On Sept. 15, the U.S. Centers for Disease Control and Prevention (CDC) released the “Core Elements of Antibiotic Stewardship for Nursing Homes,” which it adapted from the “CDC Core Elements of Hospital Antibiotic Stewardship.” The guidance provides step-by-step, practical ways for nursing homes to initiate or expand their antibiotic stewardship activities.

Up to 70 percent of nursing home residents receive one or more courses of systemic antibiotics over the course of one year, and studies have shown that 40 to 75 percent of antibiotics prescribed in nursing homes may be unnecessary or inappropriate, according to the CDC.

Danger: “Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes,” the CDC warns. “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.”

Take 6 Steps to Create an Antibiotic Stewardship Program

In its new antibiotic stewardship guidance, the CDC recommends that all nursing homes take the following steps to improve antibiotic prescribing practices and reduce inappropriate use:

Step 1: Gain Leadership Commitment — Facility leadership, including both owners and administrators, should demonstrate their support and commitment to improving antibiotic use by:

a) Writing statements in support of improving antibiotic use and sharing them with staff, residents and families;

b) Including stewardship-related duties in position descriptions for the medical director, clinical nurse leads, and consultant pharmacists;

c) Communicating with nursing staff and prescribing clinicians the facility’s expectations about antibiotic use and stewardship policies monitoring and enforcement; and

d) Creating a culture that promotes antibiotic stewardship, through messaging, education, and celebrating improvement.

Step 2: Promote Accountability — Identify individuals accountable for the antibiotic stewardship activities who have the support of facility leadership. In particular, empower the:

a) Medical director to set standards for antibiotic prescribing practices for all clinical providers credentialed to deliver care in your nursing home and be accountable for overseeing adherence;

b) Director of nursing to set the practice standards for assessing, monitoring, and communicating changes in a resident’s condition by front-line nursing staff; and

c) Consultant pharmacist to support antibiotic stewardship oversight through quality assurance activities such as medication regimen review and reporting of antibiotic use.

Step 3: Enlist Drug Expertise — Establish access to individuals with antibiotic expertise to implement your antibiotic stewardship activities. For example, nursing homes may:

a) Work with a consultant pharmacist who has received specialized infectious disease or antibiotic stewardship training — for instance, the Making a Difference in Infectious Diseases course (http://mad-id.org/antimicrobial-stewardship-programs) or the Society for Infectious Diseases Pharmacists antibiotic stewardship certificate program (www.sidp.org/page-1442823);

b) Partner with antibiotic stewardship program leads at the hospitals within your referral network; and

c) Develop relationships with infectious disease consultants in your community who are interested in supporting your facility’s stewardship efforts.

Step 4: Change Your Policies and Practices — Implement prescribing policies and change practices to improve antibiotic use. Introduce new policies and procedures that address antibiotic use in a step-wise fashion so staff are not overwhelmed by new changes in practice. Consider the following policy/practice changes:

a) Establish policies that support optimal antibiotic use to ensure that current medication safety policies, including medication regimen review, address the Centers for Medicare & Medicaid Services (CMS) regulations applicable to antibiotic prescribing and use;

b) Enact broad interventions to improve antibiotic use, and standardize the practices applied during the care of any resident suspected of an infection or started on an antibiotic;

c) Employ pharmacy interventions to improve antibiotic use by integrating the dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship in your nursing home; and

d) Use infection- and syndrome-specific interventions by identifying clinical situations that may be driving inappropriate use of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis, and then implement specific interventions to improve use.

Step 5: Track and Report Antibiotic Use and Outcomes — Monitor both antibiotic use practices and outcomes to guide practice changes and track the impact of new interventions. Set antibiotic use and outcome measures like these examples:

a) Track how and why antibiotics are prescribed by performing reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices;

b) Track how often and how many antibiotics are prescribed by reviewing patterns of use and determining the impact of new stewardship interventions; and

c) Track the adverse outcomes and costs from antibiotics by monitoring clinical outcomes such as rates of C. difficile infections, antibiotic-resistant organisms, or adverse drug events to demonstrate that antibiotic stewardship activities are successful in improving patient outcomes.

Step 6: Educate clinicians, nursing staff, and families — Provide antibiotic stewardship education to both nursing staff and clinical providers to ensure that they understand the goal of an antibiotic stewardship intervention and the responsibility of each group for ensuring its implementation.

To view the CDC guidance, go to www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html.