Nursing Home Quality Care Collaborative Learning Series

Working to improve the quality of care delivery to nursing home residents.

Antibiotic Stewardship

Perhaps the single most important action needed to greatly slow down the development and spread of antibiotic-resistant infections is to change the way antibiotics are used. Reducing inappropriate and unnecessary use of antibiotics would help greatly in slowing down the spread of resistant bacteria. This commitment to always use antibiotics appropriately and safely—only when they are needed to treat disease, and to choose the right antibiotics and to administer them in the right way in every case- is known as antibiotic stewardship

Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of bacterial infections while reducing the adverse events associated with antibiotic use. Any action to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in nursing homes

Stewardship activities include limiting the use of antibiotics when they are not needed, and minimizing the frequency, duration, and number of antibiotics prescribed.

Stewardship can improve the outcomes for residents who need antibiotics and prevent the unintended consequences of antibiotic use such as side effects, the development of antibiotic resistant bacteria, and the replacement of normal bacteria with those which cause infections, such as C. difficile. Many residents with C. difficile infection (CDI) have had exposure to antibiotics within 28 days prior to the onset of symptoms. CDI risk increases with taking multiple antibiotics or taking long courses of an antibiotic. Antibiotic stewardship can be an effective prevention strategy for the reduction of CDI.

The information describes antibiotic stewardship and how it helps to prevent antibiotic resistance and problems associated with antibiotic use. The information includes core elements of an antibiotic stewardship program (leadership, commitment, accountability, drug expertise, actions to improve antibiotic use, tracking, reporting, and education) and the need for community-wide efforts. Consider the practical aspects of stewardship, and think about what it looks like in your organization.

"Antibiotic Stewardship in Long Term Care" Webinar, presented by Teresa Lubowski  Pharm D, Task Lead for Outpatient Antibiotic Stewardship for IPRO,  provides key information related to Antibiotic Stewardship and establishing an Antibiotic Stewardship program. This is a November 28th Phase 2 requirement of the CMS Final Rule to Reform the Requirements for Long Term care Facilities.

Presentation Slides

How can you use this information?

The information focuses on antibiotic stewardship in the nursing home setting. The material is intended to be useful for guiding individual practice and as an educational resource for staff involved in the care of nursing home residents. Nursing home leaders can review the content in this session and decide which components would be helpful to staff in their facility.

What is antibiotic stewardship and why is it important?

  • Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of bacterial infections while reducing the adverse events associated with antibiotic use.
  • Any action to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in nursing homes.

Is antibiotic stewardship required in nursing homes?

The Centers for Medicare & Medicaid Services (CMS) published a final rule titled Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities on October 4, 2016. The final rule requires an antibiotic stewardship program that includes antibiotic use protocols and systems for monitoring antibiotic use and recording incidents identified under the facility's infection prevention and control program (IPCP) and the corrective actions taken by the facility

Specifically, the IPCP would:

  • include infection prevention, identification, surveillance, and antibiotic stewardship;
  • require each facility to periodically review and update its program;
  • require performance of an analysis of the resident population and facility;
  • designate an infection prevention and control officer(s) (IPCO);
  • integrate the IPCO with the facility’s quality assurance and performance improvement (QAPI) program;
  • establish written policies and procedures for the IPCP; and
  • provide the IPCO and facility staff with education or training related to the IPCP.

What are the elements of an antibiotic stewardship program in long-term care?

Here is a summary of the core elements for antibiotic stewardship in nursing homes:

  • Leadership commitment:
    • Demonstrate support and commitment to safe and appropriate antibiotic use in your facility.
  • Accountability:
    • Identify physician, nursing, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities in your facility.
  • Drug expertise:
    • Establish access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship for your facility.
  • Action:
    • Implement at least one policy or practice to improve antibiotic use.
  • Tracking:
    • Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in your facility.
  • Reporting:
    • Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff.
  • Education:
    • Provide resources to clinicians, nursing staff, residents, and families about antibiotic resistance and opportunities for improving antibiotic use.

Take Home Message

  • Antibiotic stewardship helps reduce inappropriate antibiotic use. Inappropriate use causes development of resistant bacteria which can be very difficult and costly to treat.
  • There are strategies that nursing homes can implement to be good stewards of antibiotics. These strategies can be implemented in a step-wise fashion.
  • Everyone in the nursing home plays a role in how antibiotics are used and in preventing antibiotic resistance.
  • Teamwork is required to support the judicious use of antibiotics – key players include prescribing providers, nurses, pharmacists, infection control practitioners, laboratory technicians, and residents and families.
  • Nursing homes need to work together to support prescribing providers in judiciously using antibiotics.

Resources

Agency for Healthcare Research and Quality (AHRQ) Nursing Home Antimicrobial Stewardship Guide

Center for Disease Control (CDC) Long Term Care Facilities: The core elements of antibiotic stewardship for nursing homes.

National Nursing Home Quality Improvement Campaign

Advance Appendix PP – Phase 2  (Effective 11/28/17) State Operations Manual
Antibiotic Stewardship Program (ASP) §483.80(a)(3) pg 655

Infection and Antibiotic Tracking

Being mindful that many facilities have individuals with multiple responsibilities (i.e. both infections and antibiotic use), a MONTHLY INFECTION AND ANTIBIOTIC TRACKING FORM has been developed to streamline the tracking, analysis and monitoring of these two major areas of importance.

This monthly tracking form provides an organized tool to maintain “real-time” information for both infections and antibiotic utilization. The tracking form itself is in an Excel format for universal use. All data entry is completed and maintained on one tab/sheet within the file. All data is instantaneously summarized, analyzed and graphed for not only the entire facility, but also for up to 10 “user-defined” units or locations.

The initial set-up of the tracking form allows for the entry of up to 25 different prescribers on a separate tab/sheet that instantly flows to the prescriber “dropdown” choices on the data entry sheet.

This prescriber assignment allows the tracking form to offer “prescriber-specific” antibiotic use summaries and graphs that may be printed for separate review and conversation with the appropriate parties.

The tracking sheet also calculates appropriate rates based on resident days. There is an option to provide “location-specific” resident days to have the tracking form also calculate both infection and antibiotic use rates for each “user-defined” location.

Webex "IPRO Infection and Antibiotic Tracking Tool"

  • WMV Format: this version will be downloaded to your computer

To request this tracking forms, simply contact david.johnson@area-i.hcqis.org 
It would be helpful if you would provide your facility name and location along with specific tool you are requesting

 

Contact Us

New York

Pauline Kinney, RN, MA, LNHA, RAC-CT
Senior Director, Health Care Quality Improvement
Tel: (516) 209-5402
Fax: (516) 326-0434
pauline.kinney@area-I.hcqis.org

Maureen Valvo, RN, BSN, RAC-CT
Senior Quality Improvement Specialist
Tel: (516) 209-5308
Maureen.valvo@area-I.hcqis.org

David L. Johnson, NHA, RAC-CT
Senior Quality Improvement Specialist
Tel: (518) 320-3516
David.johnson@area-I.hcqis.org

Dan Yuricic, MA
Senior Quality Improvement Specialist
Tel: (516) 209-5458
Danny.yuricic@area-I.hcqis.org

IPRO Nursing Home Team
ipronursinghometeam@ipro.org

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