Antibiotic Stewardship Drivers and Change Package
Primary Driver 1: Timely and Appropriate Initiation of Antibiotics
|Secondary Driver||Key Change Concepts||Specific Change Ideas|
|Promptly identify patients who require antibiotics||Develop a standardized process to identify patients who require antibiotics||
|Promptly identify patients who require antibiotics||Create standardized protocols for ordering and obtaining cultures and other diagnostic tests prior to initiating antibiotics||
|Do not give antibiotics with overlapping activity or combinations not supported by evidence or guidelines||Develop a way to inform clinicians about unnecessary combinations of antibiotics, including “double coverage(4)”||
|Determine and verify antibiotic allergies and tailor therapy accordingly||Choose antibiotic based on patient allergies||
|Consider local antibiotic susceptibility patterns in selecting therapy||Develop a standardized process for antibiotic selection||
|Start Treatment Promptly||Develop processes that support prompt treatment of patients requiring antibiotics||
|Ensure antibiotics are readily available||
|Specify expected duration of therapy based on evidence and national and hospital guidelines||Incorporate evidence-based guidelines for duration of antibiotics into standard protocols and/or computerized decision support||
- Refers to: The Improvement Guide— A Practical Approach to Enhancing Organizational Performance (2nd Edition). Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers; 2009.
- Refers to: “Antibiotic” is used throughout the change package to support specific efforts to improve patient care and decrease costs related to antibiotic utilization. Appropriate use of other antimicrobials, such as antifungal agents, should also be considered.
- Refers to: Clinical pathways are used throughout the change package as a method for translating clinical practice guidelines into a clear paper or computerized document specifying key actions that need to be performed at specific times. These pathways are intended to provide real-time decision support at the point of care to facilitate implementation of evidence-based guidelines. They should be developed with multi-disciplinary input to ensure that providers can utilize them within their normal work flow. Three key components of successful pathways include:
- Clearly specified key evidence-based actions;
- Timing of these actions; and
- Documentation of deviations or variations in care, including opt-out provisions.
- Refers to: “Double coverage” or “combination therapy” refers to the practice of intentionally administering antibiotics with overlapping spectra of activity.
- Refers to: Consider keeping frequently used antibiotics available in the ED and on the floor. It is important that antibiotics stored at the point of care—in the ED or the OR—are maintained and restocked. Ensure that there is documentation of administration of antibiotics obtained from local stocks.
- Refers to: Two standard opt-out provisions to allow for provider discretion are:
- Permit physicians to opt out of the standard duration of treatment, but require documentation of the rationale whenever prescribing against evidence-based guidelines;
- Permit physicians to opt out of automatically discontinuing therapy based on local policy (e.g., prophylactic antibiotics for surgery), but require documentation of the rationale.
- Refers to: De-escalation refers to the practice of changing to more targeted therapy and/or discontinuing empirical therapy based on clinical criteria and culture results.
- Refers to: Establish process for prompt notification of culture and antibiotic susceptibility results. For the purposes of this change package “cultures” is being used as a general term that reaches beyond the strictest definition to include results of rapid diagnostic tests, including viral tests.