Antibiotic stewardship programs in hospitals have become a critical priority to stave off multidrug-resistant organisms. However, when public health officials initially began sounding the alarm about the issue, some infection preventionists — and certainly bedside nurses — felt this was not in their sphere of influence.
The common reaction, somewhat understandably, was that antibiotic stewardship should be the purview of physicians and pharmacists who prescribe and handle the drugs.
“When we first started our antimicrobial stewardship program, I asked myself the same question of why I needed to be involved,” said Chris Shakula, MS, RN, CNS-BC, CIC, an IP at Franciscan Health Hospital in Crown Point, Indiana. “In my role as an infection preventionist I do not prescribe medications, so why did I need to be involved and did I really need one more item added to my list of things to do? As I learned more about antibiotic stewardship, I realized how important it was for me and for nurse leaders to be engaged.”
Speaking at a recent webinar held by the American Nurses Association and the CDC, Shakula also stressed her new appreciation for the role of the bedside nurse in antibiotic stewardship.
“I have learned how much nurses are already doing at the bedside related to antimicrobial stewardship,” she said. “We need to let management know why nurses need to be involved.”
Indeed, many basic elements of nursing influence whether antibiotics will be prescribed appropriately and discontinued when medically indicated.
“Proper specimen collection is a topic I cover in our nursing education,” Shakula said. “Several nurses didn’t realize how much is affected by culture results. Those results may affect whether or not a patient receives an antibiotic. They may affect the length of stay of a patient if additional testing is needed.”
This point was underscored with clinical detail by co-speaker Barbara A. S. Gilbert, MSN, RN, CIC, an IP who represented the Academy of Medical-Surgical Nurses in the webinar.
“Obtain appropriate cultures using proper techniques before starting antibiotics,” she emphasized. “For example, for blood cultures, disinfect the bottle top with 70% isopropyl alcohol. Clean the puncture site with alcohol, followed by chlorhexidine gluconate, and allow it to dry. Then collect the appropriate quantity of blood — for adults that’s 10 ccs to 20 ccs for each blood culture set.”
For sputum cultures, she said, “Have patient rinse with water to remove excess oral flora; instruct them to cough deeply and collect and transport in a sterile container.”
Such clinical minutiae and raised awareness at the beside is a long way from the typical top-down approach of issuing guidelines and telling everyone to comply.
In that respect, with nurses as the target audience, the ANA/CDC antibiotic stewardship webinar is a step in the much-desired direction of making infection prevention the responsibility of the entire staff.
The webinar was based in part on an ANA and CDC joint white paper that stressed the importance of getting bedside nurses engaged in antibiotic stewardship.
One of the overall goals in nursing education is to teach prevention of antibiotic resistance as part of basic clinical practice.
“Under this model, microbiology and pharmacology principles that are the foundation of antibiotic stewardship would seem less divorced from the daily care of patients,” the ANA/CDC paper states.1
“Prevent infections from the get-go by following infection control practices like hand hygiene, and [removing] invasive devices such as central lines — even peripheral IVs — and urinary catheters as soon as possible when no longer needed,” Gilbert said. “I tell patients and family members that any invasive device is an opportunity for germs to jump in. The sooner we can get rid of them, the better.”
Educate patients and their families about preventing infections, keeping scrapes and wounds clean, and managing chronic conditions, she added. “Tell them when antibiotics are not necessary, especially if they demand them,” Gilbert said. “Tell them to complete antibiotics once prescribed, and not to share antibiotics or take those not prescribed to them.”
In addition, take a detailed allergy history of patients, she said, noting that penicillin allergies may be a red flag for the subsequent appearance of antibiotic-resistant organisms, longer hospital stays, and increased costs.
Ensure antibiotics are started promptly and reviewed once culture results are available, she advised. Talk to the clinical team about antimicrobial usage, including de-escalation of drugs and changing from IV to oral antibiotics, she said.
“Medication administration is important,” Gilbert said. “As an example, I remember when a provider ordered an IV medication for a patient with C. diff. Medication for C. diff works better if it goes through the gut [orally].”
Nurses should review microbiology results and sensitivities for ordered antibiotics.
“Is the bacteria sensitive to the prescribed antibiotic?” she said. “Similarly, nurses should try to be aware of the indication and intended duration of antibiotics.” Notify the physician or a pharmacist of any adverse effects or if the patient refuses to take antibiotics, she said.
“Verify the antibiotic schedule when the patient transfers,” Gilbert said. “Make sure that this is part of your patient handoff.”
Involving Nurse Leaders
Representing the National Association of Clinical Nurse Specialists, Shakula reviewed some of the reasons antibiotic stewardship is a critical issue for nursing and healthcare leaders.
Antibiotic stewardship is a patient safety issue, she said, noting that the indiscriminate use of drugs drive increases in a host of multidrug-resistant organisms, from MRSA to some of the emerging gram-negative pathogens such as carbapenem-resistant Enterobacteriaceae (CRE).
Another patient safety issue that is somewhat unique to antibiotics is that misuse of antimicrobials in one patient may select out resistant organisms that spread to another patient.
“Most treatment or actions in healthcare only affect one patient, but antibiotics affect everyone,” Shakula said.
“The patient taking the antibiotic may not be the only one affected by it. Resistant organisms can be spread from person to person by poor hand hygiene and by inanimate objects that are not cleaned and disinfected appropriately,” she added.
Antimicrobial resistance also affects nursing workflow, even if it is something as basic as having to put a patient on an IV antimicrobial medication versus an oral pill, she said.
“Patients that are on antibiotics that are not de-escalated in a timely fashion may have longer hospital stays,” she added. “Patients with contaminated specimens may have longer hospital stays and be exposed to antibiotics that aren’t needed.”
Nursing involvement in antibiotic stewardship also is being required by several regulatory and accrediting bodies, she emphasized. These include The Joint Commission and the Healthcare Facilities Accreditation Program.
“Antimicrobial stewardship is also part of pay for performance and value-based purchasing [by] the Centers for Medicare & Medicaid Services,” Shakula said.
“The CMS has a proposal to make antimicrobial stewardship a Condition of Participation. Some insurance companies have also added it as an indicator on which they base payment.”
Through the clinical and patient care work they do every day, “nurses are already a part of antimicrobial stewardship,” she said.
“Leaders need to ensure they are engaged in antimicrobial stewardship programs and understand why their participation is vital.”
On this point, Gilbert added, “Be at the table of the antimicrobial stewardship committee. Invite yourself if you need to.”
- ANA, CDC. Redefining the Antibiotic Stewardship Team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the Role of Registered Nurses in Hospital Antibiotic Stewardship Practices. 2017: https://bit.ly/2IIYIoG.