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Antibiotic Stewardship Programs in U.S.

Acute
Care Hospitals: Findings From the 2014 National
Healthcare Safety Network Annual Hospital
Survey

Francine Celera, Valentina Chawdhury, Jennifer Diaz, Cindy Mahoney, Marwa Mohamed
Learning Objectives
• Understand the variation in Antibiotic Stewardship Programs (ASPs)
by hospital characteristics and state.
• Explore the association between infrastructure (support, staffing)
and ASP implementation (actions, tracking, reporting, and
education).
Article Citation
• Antibiotic Stewardship Programs in U.S. Acute
Care Hospitals: Findings From the 2014
National Healthcare Safety Network Annual
Hospital Survey
• This is the first comprehensive national
assessment of antibiotic stewardship practices
in the United States.
Ice Breaker Activity

1. What are antibiotics used for?


2. 30% of antibiotics prescribed are often unnecessary and
misused. T F
3. Outpatient antibiotic prescriptions are written to treat patients
with acute respiratory conditions, such as sinus infections,
middle ear infections, pharyngitis, viral upper respiratory
infections. T F
Introduction
• Objective- The study’s objective is to use the National
Healthcare Safety Network data to identify the self-
reported implementation of antibiotic stewardship
programs (ASP) in the United States using the Center of
Disease Control (CDC) core elements of Hospital ASP
framework.

• Hypothesis- Using the comprehensive national


assessment will increase antibiotic stewardship practices
in the United States and will serve as a basis for utilization
of antibiotic stewardship programs in the future.
Who Are They?
• People- Medical staff, specifically doctors who are prescribing
antibiotics.
Patients, to prevent antibiotic resistance.

• Where -Hospitals in the United States

• Time- Responses to survey were from 2014


Method (1)
• Design-2014 National Healthcare Safety Network (NHSN) Annual
Hospital Survey, univariate analyses, and multivariate model.
• Population Sample- Pharmacists responsible for outcome of patients:
1,540 (36.8%), Physicians 1,258 (30.1%), Other 926 (5.2%)
Education provided to staff: 2,589 (61.9%).
• Quantitative- Overall, 4,184 acute care hospitals responded to the
NHSN Annual Hospital Survey: 3385 (81%) general acute care
hospitals, 577 (14%) critical access hospitals, 146 (3%) surgical
hospitals, and 76 (2%) children’s hospitals.
Method (2)

• Data Source
• Primary Data
• Instrument: Patient Safety Component Annual Hospital Survey was included
within the National Healthcare Safety Network (NHSN) application.
• Included questions on facility demographics, laboratory practices, infection control
practices, and activities of ASPs.
• Questions were piloted by the Georgia Department of Public Health as a pre-assessment
survey given to hospital pharmacists attending a stewardship training workshop.
• Survey completed by infection preventionist(s), pharmacists and/or physicians who
focus on infectious diseases.
Statistical Analysis
• Univariate analyses was conducted
• single variable doesn't deal with causes or relationship. Ex. age
• describe the data and find patterns that exist within.
• Data collected and analyzed were at state and national level
• excluded inpatient rehabilitation, long-term acute care hospitals, and
psychiatric hospitals.
● Hospitals were categorized by bed size, type of facility(general acute
care, surgical, children’s hospital), surgical hospitals, major teaching
status that included graduate medical education programs and
physicians in training or teaching medical students.
● Each of the 7 core elements were reviewed individually and then
the proportion of facilities that met all 7 core elements were
calculated and arranged by facility type, medical school, and state.
● All statistical analyses were conducted using SAS version 9.3
Findings
• Descriptive Findings
• Hospital characteristics
• overall 4,184 acute care hospitals responded: 81% general acute care
hospitals, 14% critical access hospital, 3% surgical hospitals, and 2% childrens
hospital.
• ASP practice
• Overall 60% reported hospital leadership commitment.
• The primary leader was more likely to be a pharmacist (37%)than a physician
(30%).
• 87% report that at least one pharmacist responsible for improving antibiotic
use.
• 94% of all hospitals reported having specific practices to improve prescribing
• 51% of hospitals reported all four core implementation elements (action,
tracking reporting, and education).
Findings
• Hospitals meeting ALL ASP elements
• 39% of US acute care hospitals reported implementing all core elements.
● Individual variable analyses
○ varied by facility type: 50% for children’s hospital, 43% general acute care
hospital, 33% surgical hospital, and 18% critical access hospital.
○ Hospitals with more than 200 beds more likely to report all core elements:
56% compared to 39% of hospitals with 51-200 beds.
○ hospitals with less than 50 beds were less likely to report leadership
support (40%) or antibiotic stewardship education, 46%.
● In 11 states 50% or more hospitals reported meeting all 7 core
elements in 2014: California was one of them.
● Non Descriptive Findings
○ The strongest predictor for meeting all core elements was written support
from the facility administration
Study Strengths

• The survey was given to small and large hospitals, in which it gave
representation to all acute care hospitals in the United States.
• It was the largest and the first comprehensive national assessment
of antibiotic stewardship practices in the US and will serve as a
baseline for ASPs implementation in the future.
Study Limitations
• The data was self reported, in which the responses were not
verified externally
• Results could have varied in both direction
• A respondent infection preventionist working on the survey without
consulting others could have been unaware of stewardship activities, thus
providing low results.
• A respondent may have curved their responses in placing more of a socially
desirable answer, thus leading to a higher results.
• The survey did not measure effectiveness of the program
Study Implications
• Infrastructure (staff and support) and
implementation (actions, tracking, reporting
and education) elements working together¹
• State-based efforts in advancing antibiotic stewardship.
• Policy Action - 2009 mandate in CA for hospitals to engage in efforts to improve
antibiotic use.²
• Implementation of mandated ASP programs and promotion of ASPs as essential part to prevent
antibiotic resistance.
• Importance of key stakeholders to identify gaps and make commitments to
improve stewardship.
• CDC (and other partners) take steps to help hospitals implement programs³
• General implementation guidance to all hospitals may be useful
• Direct outreach and discussions to provide examples and offer key lessons
Discussion
• What stood out
• In eleven states, 50% or more of hospitals reported meeting all 7 core elements
in 2014
• California had the highest percentage of hospitals reporting all 7 elements, this
could be due to California’s 2009 mandate requiring antibiotic stewardship
programs.
Discussion
• What did not stand out
• Because the survey only assessed CDC core elements, there could be
stewardship program that are successful, but that do not have all seven
elements implemented.
• Anything new
• With access to this new data and information, results demonstrate the need
for states to implement and continue stewardship programs.
• Continuation of survey will continue to provide information on any gaps and
current status of the program.
How Content Relates to Epidemiology
• This article targets infectious diseases in epidemiology.
• The importance of utilizing an instrument was discussed in class as
well as within the article.
• 2014 National Healthcare Safety Network Annual Hospital Survey
• Improving antibiotic prescribing is a key prevention strategy for
resistance, Clostridium difficile, and other adverse effects.
• Findings suggest that many hospitals need to add infrastructure and
measurement support to their current actions to improve antibiotic use.
Conclusion
• This study provides important new info on current status and
implementation gaps in antibiotic stewardships¹
• ASPs will be key to improving prescribing to improve patient outcomes and
combating resistance.
• Antibiotic stewardship can benefit from the model of infection control where
a strong program fits within:
• A broader context of measurement
• Improvement interventions
• Policy actions
• CDC intends to use data to better assess impact of stewardship program
elements.
• CDC committed to ongoing work with partners to help all hospitals implement
effective ASPs and help monitor progress
Reference
Pollack, L. A., Van Santen, K. L., Weiner, L. M., Dudeck, M. A., Edwards, J. R., &
Srinivasan, A. (2016). Antibiotic Stewardship Programs in U.S. Acute Care
Hospitals: Findings From the 2014 National Healthcare Safety Network Annual
Hospital Survey. Clinical Infectious Diseases, 63(4), 443–449. https://doi-
org.libproxy.lib.csusb.edu/10.1093/cid/ciw323