In this article an infectious diseases pharmacist identifies and discusses five challenges with creating and managing institutional guidelines for infectious diseases.
Authored By: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP
Article Posted: 21 April 2021
A recent study published in JAMA assessing the appropriateness of antimicrobial prescribing in US hospitals found that more than half of antibiotic prescriptions were not consistent with recommended prescribing practices. This included treatment of common syndromes such as urinary tract infection (UTI) and community acquired pneumonia (CAP). It is a clear sign there is much work to do in the area of institutional guidelines for infectious diseases.
As part of the Core Elements of Antimicrobial Stewardship Programs, the CDC recommends deployment of evidence-based hospital-specific treatment guidelines that focus on common conditions (e.g., UTI, CAP). The Joint Commission looks to the CDC Core Elements documents for guidance and design of regulatory requirements. In turn, it is no surprise Medication Management standard 09.01.01 on antimicrobial stewardship includes element of performance 6 that recommends development of guidelines on antimicrobial use in adults and pediatrics. From a practical and regulatory perspective, institutional guidelines for infectious diseases are important now and will continue to be so into the future.
Over the last 10+ years working in the field of infectious diseases pharmacotherapy and antimicrobial stewardship, I have been engaged to varying degrees with creating and managing institutional guidelines for infectious diseases. In doing so, I have learned much from my peers and experiences. Given the importance of this topic, I thought it might be a good opportunity to detail some lessons learned in this open-access article.
Herein, I identify five challenges with creating and managing institutional guidelines for infectious diseases…
CHALLENGE 1: Getting Staff to Utilize Guidelines in their Workflow
This is listed first, because it is the most important challenge. I cannot over-state the importance of recognizing and working on this item. If hundreds of hours go into making the best guideline on the planet, but nobody uses it, that is the ultimate tragedy. Ask any antimicrobial steward and they will tell you that local guideline adherence can be a common sore point, as reflected by the data in that JAMA article referenced above.
Access should be user-friendly as should the navigation. Posting a document link within the electronic medical record or an institutional page with good traffic is ideal. Take note that such spaces can be coveted and may require informatics/leadership approvals if you don’t yet own space in such an area. Starting a dialogue as early as possible and leveraging collaborator authority can help with obtaining such a space.
For antimicrobial stewardship programs that are ready to level-up their institutional guidelines for infectious diseases, Firstline (formerly Spectrum) is something to check out. Firstline has an app that integrates local guideline documents into a user-friendly interface for mobile and desktop use. They provide analytics that can help with continuous quality assurance aimed at optimizing workflows and improving guideline utilization. Antibiograms can also be hosted on their platform.
CHALLENGE 2: Identifying and Interpreting Data from the Literature
It is reasonable to start or audit an institutional syndrome-specific infectious disease guideline by reviewing current national guidelines (e.g., IDSA) and institutional guidelines posted by local competitors or industry leaders (e.g., Stanford Medicine, Nebraska Medicine). This process will identify reasonable practices, but also bring to light areas where the literature is not as clear or guidelines are lacking strong recommendations. That will trigger a deeper dive into specific elements of the literature to elucidate current practices which may be considered evidence-based. In particular, for syndromes where the guidelines are not recent or do not cover newly-approved drugs (e.g., IDSA skin and soft tissue infection guideline is from July 2014), a more detailed literature search may be needed. While current review articles and google scholar reference tracking may serve helpful, this drill-down process can be labor-intensive and involve a great deal of learning new content.
I have found attending conference talks by leaders in different infectious disease syndromes is one way to help gain a greater understanding of the knowns and unknowns within a given topic. For example the last IDweek I attended prior to the COVID pandemic presented opportunities to learn from key leaders in the areas of CAP and sepsis. In addition to conference talks, continuing education through organizations such as SIDP can be very helpful. Having a general understanding of the challenges ahead through these types of activities is beneficial for identifying a good path forward to reasonably achieve your goal. Then another part of the journey is accepting that you cannot know everything, which is why guideline development (like antimicrobial stewardship) is a team sport.
When very challenging questions arise, contacting the corresponding author listed on manuscripts is something to consider. I have found these authors are more than happy to provide their current two-cents on various items. I also sometimes will contact peers to better understand non-pharmacy elements that might go into a guideline, for example infection control, microbiology, or nursing content.
CHALLENGE 3: Collecting and Assessing Local Data along with Practice Changing Opportunities
The thing about having an institutional guideline is, well… it needs to be institution-specific!
To compose a document considerate of local strengths and challenges, it can be valuable to gain insights from the microbiology laboratory (e.g., institutional antibiograms, standard testing practices, established turnaround times), quality and performance improvement (e.g., recent regulatory findings, fallouts, existing policy details), infection control (e.g., hospital acquired infection rates), pharmacy administration (e.g., drug inventories, clean room workflows), and others. This type of information is critical for a number of reasons, one example of which is in consideration for the capacity to develop locally validated risk factors for things like pneumonia due to Pseudomonas aeruginosa (as recommended by the IDSA CAP guidelines).
In addition to engaging programatic or operational stakeholders of the institution, the front-line staff are also key to the success of any guideline. I once attended a conference where someone discussed implementation science and antimicrobial stewardship. They talked about “The IKEA Effect.” A person is given a small bag of Lego building blocks and asked to place a value on it. They say $0.75. Someone else builds the Lego pieces into a small helicopter and asks the person to give it a new value. They say $1.25. Then the person valuing it is asked to build the Lego pieces into the small helicopter themself. They are then asked to give the helicopter they built a value. They say $1.50. Involving people in the building process leads them to take ownership and place a higher value on the item. This is relevant to getting people to contribute to local guideline development and for challenge #1 above.
In having conversations with the above individuals, try to identify data sources that may be used as part of continuous quality assurance for the guideline. Once the guideline is established, it will be helpful to have a plan on how and when to re-evaluate it. After all, the key is to improve care, not to just check a box on a list.
CHALLENGE 4: Garnering Stakeholder Support for Guideline Decisions
Depending on the clinical area a guideline touches, there may be approvals needed by a number of stakeholders. The quantity and level of engagement for such individuals inevitably varies by institution and health-system. Additionally, the formal approval [gauntlet] pathway will be governed by local committee structure, which may be quite lengthy.
While the Chief of Infectious Diseases or Chief of Surgery may be key players, do not overlook frontline staff as important stakeholders as well. After all, if they do not support a guideline there is a good chance they will not readily start using it routinely.
Engaging high-level stakeholders early on is important, with in-person discussions being favored over email communication. Engaging frontline staff can be particularly helpful for early identification of controversial items. I have been surprised on more than one occasion about which items turned out to be relatively controversial. Identifying contention points as early as possible helps allow time to come up with resolution options.
CHALLENGE 5: Formatting to Perfection
One challenge with formatting is fitting as much as possible into as few pages as possible. One of my mentors liked to say “KISS” meaning keep it super simple (or something like that 😉). When you work in a field where the answer to every question is “it depends”, keeping it simple can be a major challenge as you also try to keep it accurate. In one instance I wrote a 15-page vancomycin guideline. He told me to make it shorter. The second draft was 8 pages. He told me to fit it on one page. After picking my jaw up off the floor followed by two weeks of back-and-forth, we eventually had a 1-page vancomycin guideline.
There may be an institutional guideline structure that needs to be followed or a format precedent may be have been set by previously developed guidelines. Additionally, leaders may have special requests on what they perceive is the “best” way to present information. In navigating these elements, do not forget about the end-user for whom the document is being developed. It is unfavorable for the user-interface to be overly bulky in text or awkward in flow. Also take note of who the end-user is. Pharmacists versus prescribers versus nurses versus others will generally have different approaches to their work.
Creating and managing institutional guidelines for infectious diseases can be a labor-intensive endeavor that is riddled with challenges. Ultimately it is important work that is essential toward setting practice expectations and improving standardization which supports the best care for patients. I hope this perspective on the topic serves helpful for you and others. If it was, please do share with colleagues who may also find it beneficial to ponder over 🤓
Disclosures: The views and opinions expressed in this article are that of the author and do not necearilly reflect those of any past, current, or potential future employer.
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