Background: Growing antimicrobial resistance, C. difficile infection and cost have triggered a greater reliance on antimicrobial stewardship. Most stewardship models rely upon a central team, often led by ID specialists, to oversee prescribing in an institution. However, there are limitations to this paradigm.
Purpose: We believe opportunities exist for hospitalists to drive stewardship by integrating the process into existing care models supported by interdisciplinary rounding (IDRs). We piloted such a model of stewardship at our 850 bed quaternary care hospital.
Description: Our medicine units’ IDR teams are comprised of nurses, case managers, advanced care practitioners (ACPs) (or medicine residents) and clinical pharmacists. Hospitalists provide oversight of these teams, though, the attending-of-record for a patient is often different than the IDR hospitalist.
The process, promoted on four geographic medicine units, emphasizes: 1. antimicrobial de-escalation based on culture data, 2. reduction in excess duration of antimicrobials, and 3. discontinuation of antimicrobials when a source of infection is not identified. Clinical pharmacists monitor antimicrobial use and culture results, and communicate data to the unit ACPs or medicine residents. Teams regularly investigate opportunities to apply stewardship interventions to maximize antibiotic utilization. Stewardship recommendations from the IDR team are communicated to the attending-of-record who chooses whether to adopt them.
We surveyed staff that comprise IDR teams to understand how subgroups rated the impact of the initiative and the degree to which stewardship discussions occur at IDRs. We hypothesized that our process would: 1. promote awareness and a culture shift in prescribing, 2. not present a significant time burden to IDR teams, and 3. lead to high rates of acceptance of stewardship recommendations by the attending-of-record.
Conclusions: All subgroups comprising IDR teams reported a high occurrence rate of stewardship discussions at IDRs. Subgroups affirmed the value of stewardship in their individual prescribing, and the impact was rated at the highest level by ACPs. The majority of IDR team members believed the process was not too burdensome to regularly incorporate it into the daily workflow. Recommendations for de-escalation have been accepted at high rates. Overall antimicrobial utilization, year-to-date, has decreased 2.5% in 2018 vs. 2017.
In summary, our hospital has traditionally engaged in antimicrobial stewardship via a central team working to optimize narrow spectrum prescribing. However, several limiting factors highlighted opportunities to systemically integrate stewardship into daily workflow by leveraging the value of hospitalists and IDR teams. Our process has provided value to team members, generated recommendations that are widely accepted and is not perceived to hamper the productivity and efficiency of IDRs. These observations suggest a role for this stewardship scheme in care models that rely upon IDRs.