case study by James Newton , MD , FACP , FIDSA 1 ; Samantha Robinson , PhD 2
1
Director of Antibiotic Stewardship and Chairman of Infection Prevention and Control , Washington Regional Medical Center , Fayetteville , Ark .
2
Clinical Assistant Professor , Department of Mathematical Sciences , University of Arkansas , Fayetteville , Ark .
Handshake Stewardship in an Adult Critical Care Population
Abstract
Handshake stewardship ( HS ) differs from traditional methods of prospective audit with feedback and antibiotic preauthorization . We describe our experience using HS in an adult critical care population . Intervention acceptance rate was 87.7 %, with an OR = 2.91 ( 99 % CI : [ 2.45 , 3.47 ]). HS is an effective method allowing daily communication and provider education .
Introduction
The Centers for Disease Control and Prevention ( CDC ) recently released antimicrobial resistance data estimating that over three million people may be infected with a hospital-acquired infection , resulting in more than 50,000 deaths annually . 1 In part due to this developing antimicrobial-resistance crisis , the Committee for Medicare and Medicaid Services has required all U . S . hospitals to have an antimicrobial stewardship program ( ASP ) in place no later than March 30 , 2020 . 2 The goals of an ASP are to use the right drug at the right dose for the most effective duration , thus leading to prevention of misuse and unnecessary use of antibiotics . The CDC has published core elements and the Infectious Diseases Society of America ( IDSA ) has published guidelines for the development of an antimicrobial stewardship program . 3 , 4 These organizations place a major emphasis on prospective audit with feedback and antibiotic preauthorization ( henceforth known as traditional stewardship ). 3
Handshake stewardship is a term coined by the antibiotic stewards at Children ' s Hospital of Colorado ( CHCO ). This strategy incorporates a physician-pharmacist team that reviews all prescribed antibiotics at 24 hours and 72 hours , five days weekly . 5 Personal recommendations are then delivered to the individual providers during daily clinical rounds . Hurst and Parker have shown a high intervention acceptance rate 6 and MacBrayne , et al . have shown a 25 % reduction in antimicrobial use over a five-year period using this method of antimicrobial stewardship 7 .
Despite previous research supporting the effectiveness of handshake stewardship at CHCO , there is a paucity of data about the use of this method of antimicrobial stewardship when working with adult patients . The aim of this research brief is to describe our experience with a partial handshake stewardship technique in adults who received care in our critical care units during an eight-year period .
Methods
This study was conducted at Washington Regional Medical Center ( WRMC ), a 425- bed community hospital located in Fayetteville , Ark .. The Washington Regional Antimicrobial Stewardship Program ( WRASP ) was developed and implemented by a board-certified infectious diseases physician ( the “ ASP steward ”) in January 2012 . As part of the implementation process , the ASP steward participated in daily multidisciplinary critical-care rounds five days weekly after chart review of each critical care patient and prior to rounds each day . Through nursing-led patient presentations and a review of all the antimicrobial data available in the medical record , the ASP steward provided recommendations directly to the responsible intensivist or the attending physician for the patients located in the intensive care unit or the coronary care unit .
Available patient data consisted of prescriber acceptance of ASP interventions as well as if handshake stewardship was utilized . Consequently , the total sample of patients were stratified into groups based upon acceptance or rejection of the ASP recommendations by the provider ( compliance and non-compliance ) and further stratified by stewardship type ( handshake or traditional ).
To assess the effect of handshake stewardship on compliance with ASP recommendations , descriptive statistics such as the difference in sample compliance rates and the sample odds ratio ( OR ), where OR compares the odds of compliance given handshake stewardship to the odds of compliance given traditional stewardship , were calculated . Additionally , confidence interval estimates were constructed at the 99 % confidence level . To further assess the statistical significance of the effect of handshake stewardship on compliance , x 2 -Tests were performed , with statistical significance defined as p < 0.01 .
Results
Of 14,234 patient records available between 2012 and 2019 , approximately 16.0 % had received handshake stewardship as a technique for ASP . The overall rate of compliance with ASP recommendations was approximately 73.7 %. To determine the effect of handshake stewardship on compliance with ASP recommendations , this overall rate of compliance was compared for each stewardship type .
The difference in compliance rates between those patients that received handshake stewardship and those patients
274 • The Journal of the Arkansas Medical Society www . ArkMed . org