In this article an infectious diseases and antimicrobial stewardship pharmacist discusses five tips for developing localized antimicrobial stewardship guidelines.
Authored by: Timothy P. Gauthier, Pharm.D, BCPS, BCIDP
Article Posted: 12 June 2021
Guidelines for infectious diseases are essential towards directing expected practices and good antimicrobial stewardship. They promote standardization which can enhance patient safety and the delivery of evidence-based care. Guidelines also enable assessments of practices to detect guideline discordance, which allows for identification of areas for improvement.
As part of the “Action” section in the CDC core elements for antimicrobial stewardship, facility-specific treatment guidelines are identified as key tools that institutions can implement to improve antimicrobial use. The CDC even goes beyond just recommending treatment guidelines, suggesting that programs consider diagnostic guidelines as well.
Developing guidelines for infectious disease and antimicrobial stewardship can be a challenge. In the hopes that this article may help others with developing localized antimicrobial stewardship guidelines, the following is provided. I make several mentions of Firstline (formerly Spectrum) in this article, which is an application that can be utilized to mobilize infectious diseases guidelines for use at the point of care.
1. Start at the end
Knowing where you want to go is essential towards figuring out how to get there. Talk to stakeholders to define the format, scope, and expected user(s) for your guideline. Not only will this help create your own expectations, but it will also allow others to begin to form their expectations and in doing so contribute to the development of your plan.
In visualizing an end product, do not seek to blaze a new trail. Many organizations have made their guidelines accessible for free online. Some examples include:
- Greater Los Angeles Veterans Affairs Healthcare System
- Nebraska Medicine
- Northwestern Medicine
- PRISMA Health
- Stanford Medicine
- UCLA Health
For institutions using Firstline, the access they provide to external institutional guidelines is unparalleled as it is not limited to local documents, but documents produced by all of the healthcare systems using the Firstline platform. The PRISMA Health and UCLA Health examples above show how Firstline looks. It’s pretty neat.
2. Open lines of communication and keep them open
Every project is a journey. Along the way unexpected things will come up and the entire process offers learning opportunities. An important component of being successful along any journey is not going it alone.
Early on in the project make time to connect with key players from areas such as emergency medicine, infectious diseases (ID), infection control, performance improvement, critical care, pulmonary medicine, hospitalist service, medical laboratory/ microbiology, informatics, administration, pharmacy, nursing, and others relevant to your topic. At these meetings identify major barriers, key checkpoints, and seek to receive their guidance. Keep an open mind and anticipate that your vision should need to change to align with the needs of your facility. Be sure not to over-commit to anything if you can avoid it, as you may regret it later. Most importantly though, make sure these folks know that you need them on your team to be successful and ensure they know how to access you.
Due to the nature of the guidelines, having a touchpoint with ID at least every-other-week is probably advisable.
3. Obtain local data
We cannot have localized stewardship guidelines if we do not have local data!
Potential data sources are all around you. The antibiogram is likely top of mind, but any antimicrobial consumption data can help. This includes days of therapy, defined daily doses, expenditures, outpatient prescription data, lab test ordering/ use trends, and infection control data on healthcare associated infections.
Beyond targeted data sources, a theme in the world of antimicrobial stewardship is how initiatives must be tailored to the needs of a given institution, so general information is also helpful. What types of procedures are performed, what specialists practice there, and patient populations demographics should be considered. The needs of a 150-bed community hospital with no ICU that serves many elderly patients who have multiple co-morbidities are very different than the needs of a 1000-bed tertiary care hospital with 125 ICU beds that serves a wide array of patients.
As local data are considered be sure to seek validation whenever possible. Data do not have to be perfect, but accurate data better informs decision making. If data are not entirely accurate, at least having the output retain the same limitations over time can allow for detecting variance.
Further, this can also be a “where we are” versus a “where we want to be” type of scenario. If you can be in the know about what data will be available in the future as parallel initiatives are rolled out, that can also be helpful.
4. Develop a Framework and Use Innovative Tools
Having organized records in a logical framework is important for efficiency. This is especially true when working in a team. A good framework is additionally important for succession planning, which should be incorporated into all antimicrobial stewardship endeavors so that in the event an individual leaves their position, it does not render an entire stewardship program non-functional. With stewardship remember it’s about building a program within the structure of the institution rather than building a program around an individual.
Most people are familiar with Microsoft Office tools like Word and PowerPoint. One other option is to utilize a platform like Firstline that offers a custom built tool for creating and distributing guidelines for use at point of care. With Firstline there is no risk of losing work (which I have regrettably had happen with Microsoft Word and can attest it is a nightmare). Firstline also offers a support team to help design guidelines that are easy to use for front-line staff, which really is not achievable with Microsoft Office tools.
5. Organize a reasonable time-table including key checkpoints
There is always a lot going on when you work in the field of antimicrobial stewardship. Staying organized is a constant struggle as acute issues arise, direct patient care needs must be addressed, regulatory preparedness is always a priority, and your work is relevant to everywhere that antibiotics are prescribed (which is probably literally everywhere across your institution). No stress, right?!?
Along with planning your own schedule take into account which committees, workgroups, or task forces a guideline may have to be approved by. You may even consider creating a task force to help facilitate the creation or review of your guideline.
Once you have a time-table with checkpoints, re-assess it periodically as priorities can change along the way.
Recently on Twitter someone was discussing giving their guidelines a catchy name. I believe their name was Guidelines for Optimal Antimicrobial Therapy which gave the acronym GOAT. Imagine needing to “consult the GOAT” before making prescribing decisions. Could be a pretty catchy and fun way to get people interested and using your guideline.
Disclaimer: 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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