Introduction: Antibiotics are among the most frequently prescribed medications in nursing centers, with up to 70% of nursing home patients receiving one or more courses of systemic antibiotics in a year. Harms from antibiotic overuse are significant for frail and older adults and include the risks of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Actions taken in the Genesis HealthCare Antibiotic Stewardship Program to improve antibiotic use are expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for patients and residents in this setting. The Genesis HealthCare Antibiotic Stewardship Program is based upon the CDC s The Core Elements of Antibiotic Stewardship for Nursing Homes. The Core Elements are: Leadership Accountability Drug Expertise Action Tracking Reporting Education All components of the seven elements do not need to be implemented at the same time. Components in regular type will be part of the initial implementation and those in italics will be phased in. Core Elements of the Genesis HealthCare Antibiotic Stewardship Program: 1. Leadership Commitment: Center leadership (Center Executive Director (CED), Center Nurse Executive (CNE) and Medical Director) commit to improving antibiotic use through dedicating necessary human, financial and technology resources. Genesis Supports Antibiotic Stewardship Statement: As evidence has mounted on the effects of the overuse of antibiotics in recent decades, Genesis HealthCare is committed to appropriate use of antibiotic therapy, now widely known as Antibiotic Stewardship. The harms that the overuse of antibiotic therapy have caused are evidence based and pose particular challenges to our population. Communication among all clinicians is paramount as to when antibiotics are best used and best avoided. As Genesis HealthCare remains committed to quality and excellence in care, Genesis HealthCare leadership supports all efforts to broaden education among staff, clinicians, patients, residents and families regarding the best use of antibiotics. We welcome the opportunity to join the national effort, driven by the Centers for Disease Control, to reduce antibiotic use and become true antibiotic stewards! Each center will discuss antibiotic use and resistance data, compliance with antibiotic use algorithms and results of provider feedback as a standing agenda item in Quality Assurance Performance Improvement (QAPI) meetings monthly. Center leadership monitors whether the Antibiotic Stewardship Program is followed through results of audits and QAPI discussions.
2. Accountability: Identify individuals in the center who will be accountable for the antibiotic stewardship activities. While the Medical Director and Center Nurse Executive are responsible for implementation and monitoring of the Antibiotic Stewardship Program, other members of the inter-professional team also play important roles. Medical Director Communicates expectations to providers regarding antibiotic prescribing practices Acts as resource for nurses, as needed, when communicating with providers Leads discussion of antibiotic use at QAPI meetings Provides and ensures documentation of education given to prescribers (MD, NP, PA) regarding antibiotic stewardship, antibiotic use algorithms and policies to improve antibiotic use Reviews available Center Antibiotic Reporting to: Oversee adherence to antibiotic prescribing practices Evaluate antibiotic use data and ensure best practices (e.g., the right drug at the right dose for the right amount of time) are followed Providers Adhere to expectations and guidelines of the ASP Offer thoughtful diagnosis of infections and judicious use of antibiotics when necessary incorporates use of antibiogram in antibiotic selection Provide appropriate support of clinical staff in use of ASP tools assists in educating nurses and frontline care providers in evaluation and follow up care Document clinical rationale to support the use of antibiotics, especially if using outside of algorithm guidelines Ensure orders for antibiotics contain the dose, duration and indication for use Document conversations with patient and their patient representative regarding the current medical treatment plan and the appropriate use of antibiotics
Center Nurse Executive Antibiotic Stewardship Program (ASP) Ensures that nursing staff evaluate, monitor and communicate changes in a patient s condition that could impact the need for antibiotics Works with Unit Managers/Supervisors to ensure that SBAR is utilized by nurses to communicate relevant clinical data to providers, and that nursing evaluations of patient clinical status and patient response to treatment are documented in PCC Uses her/his influence as a nurse leader to help ensure antibiotics are prescribed only when appropriate Educates Consultant Pharmacist regarding the center s Antibiotic Stewardship Program, policies and antibiotic use algorithms (CNE designee may facilitate education) Collaborates with the center s admission team to ensure appropriate information regarding infection type and antibiotic duration is obtained for new admissions Collaborates with providers and Medical Director regarding patient clinical status and alternative treatment options (i.e.: watchful waiting) if patient does not meet criteria for antibiotic use Nurse Practice Educator/Staff Development Coordinator Educates front line nursing staff and other members of the inter-professional team (i.e.; rehab, recreation and social services) about the importance of antibiotic stewardship and explains program/policies/practices in place to improve antibiotic use Documents and tracks education provided to Nursing Staff (RN, LPN, CNA) Documentation of other IPT members will be tracked by their respective department heads Front-Line Nursing Staff Play a key role in the decision making process for starting an antibiotic. The nurses will: Communicate patient status to providers in a timely manner utilizing SBAR Discuss with providers if the patient meets criteria for antibiotic use or if alternative measures for treatment are warranted (i.e.; watchful waiting, increased hydration) Document in the medical record education regarding antibiotic use and antibiotic stewardship provided to the patient and their patient representative Contact providers for reassessment (time-out) of the ongoing need for and choice of an antibiotic once more data is available including: clinical response
additional diagnostic information alternate explanations for the status change which prompted the antibiotic start Consultant Pharmacist During monthly Medication Regimen Review (MRR): Reviews antibiotic courses for appropriateness of administration and/or indication Reviews microbiology culture data to assess and guide antibiotic selection for patient Monitors for adverse drug events from antibiotics Assists with monitoring provider compliance with proper documentation of antibiotic orders dose, duration and indication (in order and pharmacy label), and antibiotic use algorithms May provide education to nurses on provider considerations when selecting antibiotics (i.e.; for UTI, IV vs PO) Participates in quarterly QAPI - reporting on center s antibiotic utilization Infection Preventionist Monitors and supports antibiotic stewardship activities through rounds, review of provider orders, PCC documentation and available PCC/pharmacy/lab reports Tracks antibiotic starts through use of line listings and pharmacy reports Reviews antibiotic resistance patterns: Monitors HAI MDROs on Monthly Line Listings and Infection Control Report looking for increased rates and/or trends Compares with center antibiogram to look for commonalities Laboratory Provides antibiograms to centers Alerts center if certain antibiotic resistant organisms are identified (i.e.: CRE) Provides education, as needed, about laboratory testing and proper specimen collection
3. Drug Expertise: Establish access to individuals with antibiotic expertise to implement antibiotic stewardship activities. Receiving support from infectious disease consultants and consultant pharmacists with training in antibiotic stewardship can help a nursing home reduce antibiotic use and experience lower rates of positive C. difficile tests. Besides the use of our consultant pharmacists who have received training in antibiotic stewardship; a center may also: Partner with a stewardship team at referral hospital Establish a relationship with an external infectious disease/stewardship consultant 4. Action: Policy and Practice Changes - Implement prescribing policies and change practices to improve antibiotic use. Require prescribers to document dose, duration, and indication for all antibiotic prescriptions Utilize a standard assessment and communication tool for patients suspected of having an infection SBAR Communicate or request antibiotic use information when patients are transferred to/from other healthcare facilities Utilize reports summarizing the antibiotic susceptibility patterns (i.e.: center antibiogram) Utilize Genesis-specific algorithms for assessing and treating patients including optimizing diagnostic tests for specific infections Implement antibiotic time-out Consultant Pharmacist During each monthly drug regimen review, reviews the medical records of patients that have been prescribed or are taking an antibiotic. The Pharmacist will document in a written report any irregularities noted during the drug regimen review that lists at a minimum, the patient s name, the relevant drug, and the irregularity identified, to be sent to the attending physician and the center s Medical Director and Center Nurse Executive Provide patient -specific treatment recommendations for infections (i.e.: change treatment vs start treatment)
Review antibiotic agents listed on the antibiotic algorithms 5. Tracking: Monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions Monitor measures of antibiotic use by auditing available reports and patient medical records for adherence to: Clinical evaluation documentation (i.e.: signs/symptoms, vital signs, physical exam findings) Prescribing documentation (dose, duration, indication) Genesis-specific algorithms for assessing and treating patients including optimizing diagnostic tests for specific infections Monitor if cultures obtained before antibiotics initiated, if indicated, and if antibiotics changed during course of treatment Monitor rates of new antibiotic starts/1,000 resident-days through use of EOM and/or pharmacy reports or line lists Monitor antibiotic days of therapy/1,000 resident-days through use of pharmacy reports Perform point prevalence surveys of antibiotic use through use of EOM and/or pharmacy reports Monitoring outcomes of antibiotic use: Monitor rates of C. difficile infection through use of line listings and Monthly Infection Control Report Monitor rates of antibiotic-resistant organisms through use of Monthly Infection Control Report and MDRO specific line listings If new MDROs, drill down as to which specific MDRO, compare with antibiogram, location on units, types of patients Monitor rates of adverse drug events due to antibiotics through use of RMS
6. Reporting: Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Share center-specific reports on antibiotic use and outcomes with clinical providers and nursing staff (i.e.: through QAPI, staff meetings, center postings) Measures of antibiotic use at the center Measures of outcomes related to antibiotic use (i.e., C. difficile rates) Report of center antibiotic susceptibility patterns (within last 18 months) 7. Education: Provide personalized feedback on antibiotic prescribing practices (to clinical providers) Educational programs will be provided to both nursing staff and clinical providers on the goals of the antibiotic stewardship program, and the responsibilities of each group. Centers will engage patients and their patient representatives in educational opportunities regarding antibiotic use and stewardship to encourage their support of providers when making appropriate antibiotic use decisions. The engagement of patients and their patient representatives will reduce the perception that their expectations may be a barrier to improving antibiotic use. The Corporate Infection Control Practice Council will provide centers with educational resources regarding antibiotic resistance, the opportunity for improving antibiotic use, to educate patients and their patient representatives, and for the NPE/SDC in educating nursing and other interprofessional staff Centers will provide/make available to patients and their patient representatives educational materials regarding antibiotic use and antibiotic stewardship (i.e.: Get Smart, CDC resources for patients and families)