January will mark the three-year anniversary of The Joint Commission's antimicrobial stewardship standard for hospitals. The standard requires all accredited hospitals to have a stewardship program in place and to implement interventions to address antimicrobial overuse, educate clinicians, measure progress, and conduct improvement activities. But it doesn't tell them exactly how to run the program or what specific elements to include.
To get a better understanding of advances in antimicrobial stewardship interventions and measures that would be useful for hospitals, The Joint Commission and Pew Charitable Trusts brought together experts and organizations at the Leading Practices in Antimicrobial Stewardship meeting in May 2018.
Stewardship program leaders presented what they thought were the most important (and practical) antimicrobial stewardship activities that all hospitals should be able to implement, and their ideas were summarized in July in The Joint Commission Journal on Quality and Patient Safety. These activities go well beyond the traditional practices of preauthorization or prospective audit and feedback.
David W. Baker, MD, FACP, executive vice president of health care quality evaluation for The Joint Commission, spoke to ACP Hospitalist about the key takeaways and what's next.
Q: What were some of the takeaways from the meeting?
A: One of the things that they talked about is having disease-state guidelines, so at your hospital, these are the antibiotics we should be using for pneumonia or sepsis or urinary tract infections. They emphasized the importance of organizations looking at both national guidelines for that, but then also looking at the antibiotic sensitivity patterns at their individual hospitals and having those, at least for the most common conditions. . . . Some of these hospitals, their biome changes as they start changing their antibiotic use pattern, which you should see. The bacteria that were resistant before, you see their sensitivity re-emerging if you take away the pressure from whatever the drug was that was being used. So it is important for organizations to keep track of their antibiotic sensitivity patterns and adjust their guidelines if there are changes in that.
The second thing they talked about was engaging frontline clinicians. The expression that several of them used that's been in the literature for a few years now is “handshake stewardship.” On a bottom line, this is getting out on the wards and talking to people about issues that may be problematic with the way they're using antibiotics. But the fascinating thing that [the stewardship leaders] all said was how much they learned. The questions that they got from the hospitalists or the nurses or others on these issues were really valuable, and it really helped them think about the issues that they needed to address in a different way. They may need to be changing or making exceptions to some of their guidelines and other things. . . . It's time-intensive for people to go out and have those discussions, but they all felt very strongly that there was tremendous value in that kind of dialogue.
The third intervention that they talked about, we use the shorthand now that's coming in the literature of “diagnostic stewardship,” which basically is to address inappropriate diagnostic testing. The best example of this is the patient who comes in and doesn't have any symptoms of a urinary tract infection but has a urinalysis done that shows bacteria or some white cells, and the patient gets treated with an antibiotic that's both unnecessary to begin with and/or also may not even be the appropriate antibiotic.
The other part we asked people is, “What do you measure, and what do you think every place should be measuring?” They talked about how every hospital should be measuring the days of therapy per 1,000 patient-days. Ideally, if we could wave a magic wand, we'd love to have all hospitals reporting their antibiotic utilization rate to the CDC so that they can get some benchmarks. The other thing they all agreed on was to look at hospital-onset Clostridium difficile rates. If your program is successful, they usually see a significant decline in the C. difficile rate. If you've got a high rate, a lot of the time it's due to inappropriate testing and treatment, but once you take care of that problem—and there are good guidelines for that—then if your C. diff rate isn't declining, then you probably still have a lot of inappropriate antibiotic use.
Q: Did you become aware of any misconceptions about stewardship among clinicians?
A: Quite a few of the experts said that we needed to break down this perception that this is all about cost savings, that administration's pushing this just to be able to save money. They just talked about the improvements in quality of care and safety, but one thing that is a staggering statistic is the CDC estimates that every year, there's about 23,000 who die of infections that would be treatable, but there's no antibiotic to treat them with. Some of the experts say that it's many-fold higher than that. I don't think people know for sure, but say it is 23,000. Everybody needs to understand that inappropriate antibiotic use is going to lead to more resistance, and these multidrug-resistant organisms are just scary. They really want hospitalists and nurses to take this on and be partners, and that's probably the most important message for hospitalists.
Q: What are The Joint Commission's next steps?
A: We would like to see as many [programs] as possible following these leading practices. . . . but everybody needs to recognize we are not at this point in time talking about new requirements. We have support from the Pew Charitable Trusts, and we're working with a collection of experts again to try and understand what the current practices are in hospitals with respect to these leading practices, how many hospitals are actually doing these, and how many hospitals have tried to do these, the barriers that they found, and how can we as a country help organizations overcome those barriers? Then ideally, in the future, we'd like to work with hospitals to try and help them to implement these leading practices.