DEPARTMENT OF THE ARMY HEADQUARTERS, UNITED STATES ARMY MEDICAL DEPARTMENT ACTIVITY FORT POLK, LOUISIANA 71459-5110 MEDDAC Regulation 29 August 2017 Number 500a-59 CHAPTER 9 ANTIMICROBIAL STEWARDSHIP PROGRAM (ASP) 1. HISTORY. This regulation was originally imitated on 23 March 2017. Per Joint Commission Antimicrobial Stewardship standard MM.09.01.01 that became effective 01 January 2017. This ASP becomes chapter 9 of the MEDDAC Reg 500a-59 Medication Management. This edition will be the first publication of the ASP. 2. APPLICABILITY. This regulation applies to all Bayne-Jones Army Community Hospital (BJACH) licensed independent practitioners (LIPs) who are credentialed to prescribe antimicrobial medications and to Pharmacy staff who are involved in the dispensing of Inpatient and outpatient prescriptions. 3. PURPOSE. To provide BJACH and its leadership to comply with evidence-based guidelines or best practices regarding antimicrobial prescribing and promote rational and appropriate antimicrobial therapy while improving clinical outcomes while minimizing unintentional side-effects of antimicrobial use, including toxicity and emergence of resistant organisms. 4. REFERENCES. a. Army Regulation 40-3, Medical Dental, and Veterinary Care. b. MEDDAC Regulation 500a-59, Medication Management. c. Jointcommission.org. (2017). Antimicrobial Stewardship-FAQs. Retrieved from https://www.joint commission.org/antimicrobial_stewardship_faqs/. d. CDC.gov. (2015). CDC Recommends All Nursing Homes Implement Core Elements to Improve Antibiotic Use. Retrieved from https://www.cdc. gov/media/releases/2015/p0915-nursing-home-antibiotics.html. e. CDC.gov. (2015). Core Elements of Hospital Antibiotic Stewardship Programs. Retrieved from https://www.cdc.gov/getsmart/ healthcare/ implementation/core-elements.html 1
5. ABBREVIATIONS AND TERMS. a. ASP - Armed Forces Health Longitudinal Technology Application. b. CMO Chief Medical Officer c. DCCS - Deputy Commander for Clinical Services. d. LIP - Licensed Independent Practitioner. e. ASPPC ASP Physician Champion f. PCMH - Patient Centered Medical Home. g. CIPC Chief, Infection Prevention and Control. h. ASP Team ASP subcommittee [ASP PC or CMO or DCCS, Admin, CNO, CIPC Pharmacy Consultant, PCMH Clinical Pharmacist, Lab Rep and others. 6. POLICY: The ASP will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing which may include but is not limited to the following activities: 1. Streamlining or de-escalation therapy 2. Educational activities 3. Antimicrobial management protocols and guidelines 4. Surveillance monitoring 5. Formulary restrictions 7. PROCEDURE: The program assessment and strategic plan is based on the IDSA/SHEA guidelines for Antimicrobial Stewardship. The outcomes and impact of the program shall be tracked and reported to the Medical Staff at a quarterly minimum to include improved utilization of antimicrobials and cost effectiveness. The following activities are to be carried out by the ASP team. 1. Leadership: a. The Chief Medical Officer (CMO) or Deputy Commander for Clinical Services (DCCS) or ASP Physician Champion will: (1). Be committed to supporting BJACH safe and appropriate use of antibiotics (2). Be responsible for implementing and monitoring this program within the BJACH medical staff. (3). Will communicate BJACH s expectations for antibiotic use to prescribing clinicians. 2
b. Review and develop an ASP mission statement 2. Accountability: a. The BJACH ASP Team will be responsible for: i. Review infections and monitor antibiotic usage patterns on a regular basis ii. Obtain and review antibiograms for BJACH organizational trends of resistance iii. Monitor antibiotic resistance patterns (MRSA, VRE, ESBL, CRE etc.) and Clostridium difficile infections. iv. Report on number of antibiotics prescribed (e.g., days of therapy) and the number of residents treated each month v. Include a separate report for the number of residents on antibiotics that did not meet criteria for active infection. b. BJACH Laboratory will provide antibiograms on a regular basis, e.g., annually c. Facility will designate who will collect and review data for clinical and cost efficacy. 3. Drug Expertise: a. Pharmacy Chief or PCMH Clinical Pharmacist will be involved to review and report antibiotic usage data to the ASP Team. b. CMO/DCCS/ASPPC to provide guidance for developing protocols, and assist Clinical Pharmacist or Inpatient Pharmacist and Nursing staff in reviewing antibiotic orders and usage 4. Action a. BJACH ASP Team may consider protocols to address: i. Improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection. ii. Optimizing the use of diagnostic testing 3
iii An antibiotic review process, also known as antibiotic time-out (ATO) for all antibiotics prescribed in the facility. ATOs prompt clinicians to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information available. ATO can be considered a stop order of an antibiotic when diagnostic test results or symptoms of resident do not support the diagnosis of infection. b. A method of flagging residents with multidrug-resistant organisms (MDROs) should be instituted by the laboratory microbiologist 5. Tracking a. CIPC will be responsible for infection surveillance and MDRO tracking b. CIPC will collect and review data such as: i. Type of antibiotic ordered, route of administration, antibiotic costs ii. Whether the order was made by phone, if order was given by attending physician or oncall doctor iii. Whether appropriate tests such as cultures were obtained before ordering antibiotic iv. Whether the antibiotic was changed during the course of treatment c. Pharmacy consultant or PCMH Clinical Pharmacist or Inpatient Pharmacist will review and report antibiotic usage data including numbers of antibiotic prescribed (e.g., days of therapy) and the number of residents treated each month 6. Reporting a. CIPC and/or other members of the ASP team will review and report findings to BJACH Medical Management Committee and to QA committee, who will then provide feedback to BJACH medical staff. b. Feedback will be provided to physicians by the ASP team on their individual prescribing patterns of cultures ordered and antibiotics prescribed, as indicated. 7. Education 4
a. Educational opportunities as identified by the ASP Team, repeated regularly, will be provided for clinical staff as well as patients and their families on appropriate use of antibiotics. FOR THE COMMANDER: APPENDICES: Appendix A - BJACH Pharyngitis Appendix B BJACH antibiograms Appendix C- BJACH Antibiotic susceptibility GERI L. ROBERTSON-FIELD LTC, MS Deputy Commander for Administration DISTRIBUTION: A 5