Enhancing Patient Safety Through an Antibiotic Stewardship Program in Long Term Care

Antibiotic resistance is a critical global health threat, and optimizing antibiotic use in healthcare settings is a national priority. An antibiotic stewardship program is a structured approach designed to improve antibiotic utilization, ensuring that these medications are used appropriately and effectively to treat infections while minimizing adverse effects and combating resistance. The Centers for Disease Control and Prevention (CDC) emphasizes the importance of antibiotic stewardship programs (ASPs) in all healthcare facilities, including long-term care settings like nursing homes. While the CDC has outlined core elements for hospitals, these principles are equally vital and adaptable for implementation in long term care facilities.

Nursing homes are significant sites of antibiotic use. Studies reveal that a substantial proportion of nursing home residents, as high as 70% annually, receive at least one course of systemic antibiotics. This high usage, coupled with evidence suggesting that a considerable percentage (40–75%) of antibiotic prescriptions in these settings may be unnecessary or inappropriate, raises serious concerns. Overuse of antibiotics in frail, older adults in long-term care facilities carries substantial risks. These include severe Clostridium difficile infections causing debilitating diarrhea, increased adverse drug events and harmful drug interactions, and the heightened risk of colonization and infection with antibiotic-resistant organisms.

This article will delve into the practical application of the CDC’s Core Elements of Hospital Antibiotic Stewardship within nursing homes. It will provide actionable strategies for initiating or expanding antibiotic stewardship activities, tailored to the unique challenges and resources of long-term care facilities. Recognizing that resources and staffing may differ from acute care hospitals, this guide encourages a phased implementation, starting with one or two key activities and gradually integrating further strategies from each core element. Every step taken to enhance antibiotic use is a stride towards reducing harm, curbing resistance, and ultimately improving the health outcomes for residents in long term care.

Core Elements of Antibiotic Stewardship in Nursing Homes: A Summary

To effectively implement an Antibiotic Stewardship Program In Long Term Care, it’s essential to focus on key areas. These core elements, adapted from the CDC guidelines, provide a framework for building a robust and effective program:

• Leadership Commitment: Demonstrating visible support from leadership is crucial for prioritizing and resourcing antibiotic stewardship initiatives.
• Accountability: Designating individuals responsible for leading and overseeing stewardship activities ensures focused effort and progress.
• Drug Expertise: Access to specialized knowledge in antibiotic use, often through consultant pharmacists or infectious disease specialists, is vital for informed decision-making.
• Action: Implementing concrete policies and practices aimed at improving antibiotic prescribing and utilization is the core of the program.
• Tracking: Monitoring antibiotic use and related outcomes provides data to assess the program’s impact and identify areas for improvement.
• Reporting: Regularly communicating data on antibiotic use and resistance to relevant staff fosters awareness and encourages engagement in stewardship efforts.
• Education: Providing ongoing education to clinicians, nursing staff, residents, and families ensures a shared understanding of antibiotic stewardship and its importance.

Leadership Commitment: Setting the Stage for Antibiotic Stewardship

Strong leadership commitment is the bedrock of a successful antibiotic stewardship program in long term care. Nursing home leaders, including owners, administrators, and corporate leadership if applicable, must actively champion and demonstrate their dedication to improving antibiotic use. This commitment can be shown through several key actions:

• Formal Statements of Support: Develop written statements that clearly articulate the facility’s commitment to antibiotic stewardship and optimal antibiotic use. Share these statements with staff, residents, and their families to communicate the importance of this initiative facility-wide.
• Integrating Stewardship into Job Roles: Incorporate antibiotic stewardship responsibilities into the position descriptions of key personnel such as the medical director, director of nursing, clinical nurse leaders, and consultant pharmacists. This formal integration ensures accountability and dedicated effort.
• Clear Communication of Expectations: Communicate the facility’s expectations regarding antibiotic use to all prescribing clinicians and nursing staff. This includes outlining stewardship policies, monitoring processes, and enforcement mechanisms to ensure consistent adherence to best practices.
• Cultivating a Stewardship Culture: Actively foster a culture that values and promotes antibiotic stewardship through consistent messaging, educational initiatives, and recognition of successes. Celebrate improvements in antibiotic use to reinforce positive changes and encourage ongoing participation.

Alt Text: Nursing home administrator and medical director reviewing antibiotic stewardship program data, demonstrating leadership commitment to improving antibiotic use in long term care facility.

Accountability: Defining Roles and Responsibilities

Establishing clear accountability is essential for driving an effective antibiotic stewardship program in long term care. Nursing homes need to identify specific individuals who will be responsible for leading and overseeing antibiotic stewardship activities, ensuring they have the full support of facility leadership. Key roles for accountability include:

• Empowering the Medical Director: The medical director plays a pivotal role in setting standards for antibiotic prescribing practices for all clinicians within the nursing home. They should be empowered to oversee adherence to these standards, review antibiotic use data (as detailed in the Tracking and Reporting section), and ensure that best practices are integrated into resident medical care.
• Empowering the Director of Nursing: The director of nursing is crucial in establishing practice standards for nursing staff regarding resident assessment, monitoring, and communication of changes in condition. Nurses and nurse aides are often the first to observe signs of potential infection and their accurate and timely communication is vital for appropriate antibiotic decisions. Nursing leadership’s emphasis on antibiotic stewardship greatly influences the nursing staff’s role in this process.
• Engaging the Consultant Pharmacist: The consultant pharmacist is a valuable resource for antibiotic stewardship oversight. Their expertise can be leveraged through quality assurance activities, such as medication regimen reviews and reporting on antibiotic utilization data, contributing significantly to the program’s effectiveness.

To further bolster antibiotic stewardship efforts, nursing homes should collaborate with existing resources and key partners:

• Infection Prevention Program Coordinator: Infection prevention coordinators possess crucial expertise and data for guiding antibiotic stewardship strategies. They can track antibiotic initiations, monitor adherence to evidence-based guidelines for infection management, and analyze antibiotic resistance patterns within the facility. With adequate training, time, and resources to analyze infection surveillance data, these coordinators become invaluable in supporting stewardship activities.
• Consultant Laboratory: Nursing homes can leverage their contracts with laboratory services to enhance antibiotic stewardship. This includes requesting reports on antibiotic-resistant organisms, educational support for staff on diagnostic testing (e.g., C. difficile testing), and creating antibiograms summarizing antibiotic susceptibility patterns. Antibiograms are particularly useful in guiding empiric antibiotic selection and monitoring resistance trends.
• State and Local Health Departments: State and local health departments often offer valuable educational resources and support for antibiotic stewardship and infection prevention through their Healthcare-Associated Infection (HAI) Prevention programs. Nursing homes should utilize these resources to enhance their stewardship programs.

Alt Text: Director of nursing and consultant pharmacist discussing antibiotic use data and strategies for accountability within the antibiotic stewardship program in a long term care setting.

Drug Expertise: Accessing Specialized Knowledge for Optimal Antibiotic Use

Ensuring access to individuals with specialized antibiotic expertise is a cornerstone of a successful antibiotic stewardship program in long term care. Support from infectious disease consultants and consultant pharmacists with focused training in antibiotic stewardship can significantly improve antibiotic use and reduce C. difficile infection rates in nursing homes. Strategies to enhance drug expertise include:

• Partnering with Consultant Pharmacists with Specialized Training: Seek out consultant pharmacists who have completed specialized training in infectious diseases or antibiotic stewardship. Relevant training programs include the Making a Difference in Infectious Diseases (MAD-ID) antibiotic stewardship course and the Society for Infectious Diseases Pharmacists antibiotic stewardship certificate program.
• Collaborating with Hospital ASP Leaders: Establish partnerships with antibiotic stewardship program leaders at local hospitals, particularly those within your resident referral network. Hospital ASPs may offer mentorship, resources, and collaborative opportunities.
• Developing Relationships with Infectious Disease Consultants: Cultivate relationships with infectious disease consultants in your community who are interested in supporting antibiotic stewardship efforts in your facility. These experts can provide guidance on complex cases, policy development, and staff education.

Alt Text: Consultant pharmacist reviewing a resident’s medication chart and discussing antibiotic options with a physician, demonstrating drug expertise in antibiotic stewardship within a long term care facility.

Action: Implementing Policies and Practices to Improve Antibiotic Use

Taking concrete action through policy and practice changes is the active component of an antibiotic stewardship program in long term care. Introducing new policies and procedures should be a phased process to ensure staff adaptation and avoid overwhelming them. Prioritize interventions based on the specific needs of your facility and share successes to motivate staff and clinicians. Key policy and practice changes include:

Policies Supporting Optimal Antibiotic Use

• Leveraging Existing Medication Safety Policies: Ensure that current medication safety policies, especially those related to medication regimen review mandated by Centers for Medicare and Medicaid Services (CMS) regulations, are effectively applied to antibiotic prescribing and use.

Broad Interventions for Antibiotic Use Improvement

• Standardizing Infection Management Practices: Implement standardized practices for managing residents suspected of infection or those already on antibiotics. This includes enhancing the evaluation and documentation of clinical signs and symptoms of infection, optimizing the use of diagnostic testing to confirm infections and identify pathogens, and implementing an antibiotic review process, often called an “antibiotic time-out,” for all antibiotic prescriptions. Antibiotic time-outs provide a structured opportunity to reassess the continued need for and appropriateness of the antibiotic when more clinical information becomes available.

Pharmacy Interventions for Stewardship

• Integrating Pharmacists into the Clinical Team: Incorporate dispensing and consultant pharmacists as integral members of the clinical care team to support antibiotic stewardship. Pharmacists can contribute by ensuring appropriate antibiotic ordering, reviewing culture results, and developing antibiotic monitoring and infection management guidelines in collaboration with nursing and medical leadership.

Infection and Syndrome Specific Interventions

• Targeting Common Inappropriate Antibiotic Uses: Identify specific clinical scenarios that frequently lead to inappropriate antibiotic use in your facility, such as the treatment of asymptomatic bacteriuria or the use of urinary tract infection prophylaxis. Develop and implement targeted interventions to address these specific issues and improve antibiotic use in these situations.

Alt Text: Nursing staff and physician collaboratively reviewing antibiotic prescribing guidelines and policies as part of implementing actionable strategies within a long term care antibiotic stewardship program.

Tracking and Reporting Antibiotic Use and Outcomes: Measuring Impact and Guiding Improvement

Monitoring both antibiotic use practices and patient outcomes is crucial for guiding practice changes and evaluating the effectiveness of your antibiotic stewardship program in long term care. Data on adherence to antibiotic prescribing policies and antibiotic utilization should be regularly shared with clinicians and nurses to maintain awareness and track progress. Clinician feedback and response to this data are essential for gauging the effectiveness of the reporting and feedback mechanisms in changing prescribing behaviors. Examples of key measures include:

Process Measures: Assessing Adherence to Prescribing Guidelines

• Medical Record Reviews: Conduct periodic reviews of resident medical records for new antibiotic starts. Assess whether the clinical evaluation, prescription documentation, and antibiotic selection align with facility antibiotic use policies and best practices. Trended over time, these reviews can reveal whether antibiotic prescribing policies are being consistently followed.

Antibiotic Use Measures: Quantifying Antibiotic Consumption

• Tracking Antibiotic Usage: Monitor the overall amount of antibiotics used in your nursing home to identify patterns of use and assess the impact of stewardship interventions. Measures can include prevalence surveys (providing a snapshot in time) and ongoing tracking of nursing home-initiated antibiotic starts and days of therapy (DOT). The choice of measure should align with the specific intervention being implemented. For example, interventions aimed at shortening antibiotic duration might not change antibiotic start rates but would reduce DOT.

Standardized antibiotic use data collection from nursing homes is vital for both individual facility improvement and broader public health efforts. The increasing adoption of electronic health records in nursing homes facilitates the integration of pharmacy and laboratory data, making antibiotic use and resistance data more accessible for stewardship purposes. The CDC’s National Healthcare Safety Network (NHSN) is developing an Antibiotic Use (AU) reporting option specifically for nursing homes, which will allow for standardized electronic submission of antibiotic use data, enabling benchmarking and comparative analysis.

Antibiotic Outcome Measures: Assessing Clinical and Economic Impact

• Monitoring Adverse Outcomes: Track clinical outcomes such as C. difficile infection rates, antibiotic-resistant organism infections, and adverse drug events. Improvements in these outcomes can demonstrate the positive impact of antibiotic stewardship activities on patient safety and well-being. Nursing homes already tracking C. difficile and certain antibiotic-resistant bacteria (e.g., MRSA, CRE) for infection prevention programs can submit this data to the CDC’s NHSN Laboratory-identified event reporting module for long-term care facilities.

Alt Text: Infection preventionist presenting data on antibiotic use trends and C. difficile infection rates to the quality improvement team, illustrating tracking and reporting within a long term care antibiotic stewardship program.

Education: Fostering a Culture of Informed Antibiotic Use

Providing comprehensive antibiotic stewardship education is essential for clinicians, nursing staff, residents, and families in antibiotic stewardship program in long term care. Effective educational programs should clearly articulate the goals of stewardship interventions and the specific responsibilities of each group in ensuring successful implementation. A variety of educational methods can be employed, including flyers, pocket guides, newsletters, and electronic communications. However, interactive academic detailing, such as face-to-face workshops, has been shown to be most effective in improving medication prescribing practices.

Sustaining improvements in antibiotic use requires ongoing education and feedback for providers. Studies have demonstrated that combining education with feedback on prescribing practices leads to sustained reductions in antibiotic use. Providing feedback on individual physician prescribing patterns and adherence to guidelines has also been shown to significantly reduce inappropriate antibiotic prescriptions.

Engaging residents and their families in antibiotic stewardship education is crucial for ensuring their support and understanding of appropriate antibiotic use decisions. Open communication and education can address potential misconceptions and reduce the perception that resident or family expectations might be a barrier to optimal antibiotic stewardship in nursing homes.

Alt Text: Pharmacist conducting an educational session with nursing staff on appropriate antibiotic use and stewardship principles within a long term care facility.

Conclusion: Embracing Antibiotic Stewardship for Enhanced Long Term Care

The Core Elements of antibiotic stewardship provide a robust framework applicable to both hospitals and nursing homes. This guide offers practical examples of how nursing home leadership, clinicians, and staff can implement these elements to effectively monitor and improve antibiotic use. Nursing homes are encouraged to begin with one or two manageable activities and gradually expand their efforts, incorporating new strategies over time to achieve continuous improvement in antibiotic stewardship. By committing to implementing antibiotic stewardship policies and practices, long term care facilities can significantly enhance patient safety, improve clinical care, and contribute to the broader fight against antibiotic resistance. Start your antibiotic stewardship journey today to safeguard your residents and the future effectiveness of antibiotics.

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