The inappropriate use or overuse of antibiotics is a concern in Long Term Care. "Improving the use of antibiotics is an important patient safety and public health issue, as well as a national priority", states the Centers for Disease Control (CDC). Antibiotics, when used appropriately can save lives and have made it possible to treat infections that were once lethal. Antibiotics that are used inappropriately or unnecessarily can place patients at risk. Serious adverse side effects, secondary infections such as Clostridium difficile infection, and antibiotic resistance are just a few of the serious public health concerns associated with antibiotic misuse or overuse.
To address these serious public health concerns, Antibiotic Stewardship Programs (ASPs) have been developed to optimize the treatment of infections while also reducing adverse events associated with antibiotic use. The ASP is focused on helping clinicians improve quality of care and improve patient safety through increased infection cure rates, reduced treatment failures, and increased frequency of correct prescribing for therapy and prophylaxis. In 2014, the CDC recommended that all acute care hospitals implement Antibiotic Stewardship Programs.
The CDC recognizes that addressing the inappropriate use of antibiotics in hospitals is not enough. Antibiotics are used frequently in Long Term Care, and the year 2015 saw the White House spotlighting Antibiotic Stewardship in Long Term Care. In March of 2015, the White House released the National Action Plan for Combating Antimicrobial Resistance, which was a call to action for implementing antibiotic stewardship programs and activities in all healthcare settings, including Long Term Care. In June of 2015, the White House housed a forum on Antibiotic Stewardship, which included several nursing home partner organizations. In July of 2015, CMS proposed new Federal Regulations for Long Term Care facilities including new infection prevention and antibiotic stewardship activities. Clearly, the appropriate management of antibiotics will be a key focus in Long Term Care.
There are challenges that are specific to Long Term Care, such as prescribers often prescribing antibiotics over the phone, without an examination of the patient. Long Term Care documentation is often missing key details regarding the actual infection, and of patient symptoms that led to the call to request antibiotics from the practitioner. At times it can be difficult to obtain the laboratory and diagnostic data that would be used to support antibiotic use. Regulatory guidance in Long Term Care currently exists to promote the appropriate use of antibiotics, including F-441 (Infection Control), F-329 (Unnecessary Drugs), F-332 and F-333 (Medication Errors), and F-428 (Drug Regimen Review). The proposed rule released in July 2015 addresses concerns about antibiotics, including expanding pharmacy medication reviews to include antibiotic use, improved antibiotic protocols, and integrating Antibiotic Stewardship into existing QAPI activities.
To assist Long Term Care providers in their goals for the appropriate use of antibiotics, the CDC released the Core Elements of Antibiotic Stewardship for Nursing Homes in 2015. This guide offers practical strategies for applying the seven Core Elements in nursing homes. 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.
The Seven Core Elements of Antibiotic Stewardship for Nursing Homes include:
- Leadership Commitment: In this step nursing home leadership (consisting of Owners, Administrators, and Regional Level Leaders) publicly commits to improving antibiotic use. This step can include written statements in support of improving antibiotic use that can be shared with staff, residents, and families. Stewardship-related duties should be included in descriptions for the Medical Director, Clinical Nurse Leaders and Consultant Pharmacists. Leaders will communicate with nursing staff and the prescribing clinicians regarding the facility expectations for the use of antibiotics, as well as monitoring and enforcement of stewardship policies. Leaders will use this stance on commitment to create a culture that promotes antibiotic stewardship.
- Accountability: To ensure success of the program, nursing homes will identify individuals who will be accountable for the Antibiotic Stewardship activities. These individuals will have the support of the facility leadership. Important roles that will be empowered are the Medical Director, who will set standards for antibiotic prescribing practices, the Director of Nursing, who will set into practice the standards for assessment, monitoring and communicating critical patient changes, and the Consultant Pharmacist, who will provide oversight through quality assurance activities. Other key roles include the Infection Prevention Program Coordinator, the Consultant Laboratory, and state and local health departments.
- Drug Expertise: Gaining support from individuals that have antibiotic expertise will assist the nursing home in implementing antibiotic stewardship programs. Working with the Consultant Pharmacist, partnering with the hospitals in your area, and developing relationships with infectious disease consultants in your community are all examples of establishing antibiotic expertise.
- Action: Policy and procedure should be revised to reflect prescribing policies and change practices for antibiotic use. It is important that a new policy and procedure is rolled out gradually, to avoid overwhelming staff with new changes in practice. The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A includes practical tips to implement changes in policy and practice.
- Tracking: Tracking data about antibiotic use practices and outcomes related to antibiotics will be critical in measuring the success of the new policy and procedure.
- Reporting: Process measures, use measures, and outcome measures should be utilized to report the results of new practices. The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix B includes examples of measures that can be used to measure prescribing, use, and outcomes of antibiotic use.
- Education: Nurses, residents and families will require education about the goals of antibiotic stewardship intervention and the responsibility of each group for ensuring its implementation. Nursing can learn how to document the clinical symptoms of an infection to decrease the use of antibiotics for asymptomatic bacteremia.
Harmony Healthcare International (HHI) recommends that Antibiotic Stewardship begin in each nursing home. Nursing homes are encouraged to select one or two activities to start with, and over time to integrate additional activities and strategies. Antibiotic Stewardship is an important way to protect patients and to improve clinical care in nursing homes.
The Core Elements of Antibiotic Stewardship for Nursing Homes, as well as a Core Elements Checklist, Appendix A and B, and Antibiotic Stewardship Fact Sheets for residents, family, medical leaders and administrators can be found at: http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.htmlIf you have questions about Antibiotic Stewardship Programs, please contact Harmony Healthcare by clicking here or calling our office at (800) 530-4413.