that received traditional stewardship was approximately 16.7 %, with handshake stewardship resulting in 87.7 % compliance and traditional stewardship resulting in 71.0 % compliance . There was a statistically significant difference between the rates of compliance , with the rate of compliance being approximately 14.6 % to 18.7 % higher when handshake stewardship was utilized ( p < 0.0001 ). Furthermore , the observed OR of 2.91 suggested that the odds of compliance with ASP recommendations when handshake stewardship was utilized were approximately three times that of the odds of compliance otherwise ( 99 % CI : [ 2.45 , 3.47 ]). An odds ratio of 1.0 would indicate that there was no statistically significant effect of stewardship type on compliance . The constructed confidence interval for the OR , as well as a x 2 -Test to determine if the OR was significantly greater than 1.0 , suggested that handshake stewardship increases the odds of compliance to ASP recommendations ( p < 0.0001 ).
Discussion
Handshake stewardship has been shown to be an effective strategy that results in high compliance with ASP interventions . 6 , 8 Our retrospective analysis showed comparable results in an adult , critical care population . We showed a nearly three-fold increase in ASP intervention acceptance over an eight-year period in the units where handshake stewardship was utilized . Although this method of stewardship is labor-intensive , the outcomes justify the workload . Additionally , the personal interaction with colleagues allows the ASP steward to be highly visible and that allows ample opportunity for two-way communication and education to explain reasons for decisions leading to the intervention . As Dr . Goff notes , “ communication skills necessary to succeed at ASP are very different than the communication skills on a consult service .” 9 It is never easy to give or accept unsolicited advice in medicine , but daily communication helps build trust that can lead to improved ASP intervention compliance .
Our study is limited by the fact that it is observational and retrospective in nature . The lack of demographics data does not provide an adequate sample comparison . Since handshake stewardship was used only in the critical cares units , this suggests that handshake stewardship should be effective in a patient population that is not critically ill fewer comorbidities . Additionally , because of the lengthy duration of the study , antibiotic days of therapy ( DOT )/ 1000 patient days were not available for the entire study period to determine if there was an impact on decreasing antimicrobial use globally or for specific antimicrobial classes or specific agents . Standard antimicrobial administration ratios ( SAARs ) were only available at our hospital since May 2017 ; therefore , no comparison of SAARs prior to the implementation of handshake stewardship rounds is possible . Because an infectious disease-trained pharmacist was not available for the duration of the study , the impact of a pharmacist could also not be assessed .
Despite limitations , this study confirms that handshake stewardship is a viable , effective , and sustainable alternative to traditional stewardship that leads to a high acceptance rate for ASP interventions in adult critical care patients .
References
1 . 1 . The Centers for Disease Control and Prevention . Antibiotic Resistance Threats in the United States 2019 . Available from : https :// www . cdc . gov / drugresistance / pdf / threats-report / 2019-ar-threats-report
2 . 2 . Centers for Medicare and Medicaid Services . Federal Register 9 / 30 / 2019 . Available from : https :// www . federalregister . gov / documents / 2019 / 09 / 30 / 2019-20736 / medicare-and-medicaid-programs-regulatory-provisions-to-promote-program-efficiency-transparency-and-burden-reduction
3 . 3 . The Centers for Disease Control and Prevention . The Core Elements of Hospital Antibiotic Stewardship Programs : 2019 . Available from : https :// www . cdc . gov / antibiotic-use / healthcare / pdfs / hospital-core-elements
4 . 4 . Dellit TH , Owens RC , McGowan JE , Jr ., Gerding DN , Weinstein RA , Burke JP , et al . Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship . Clin Infect Dis . 2007 Jan 15 ; 44 ( 2 ): 159-77 .
5 . 5 . Hurst AL , Child J , Pearce K , et al . Handshake stewardship : a highly effective rounding-based antimicrobial optimization service . Pediatric Infect Dis J 2016 ; 35:1104-10 .
6 . 6 . Hurst AL , Child J , Parker SK . Interventions and acceptance rates support handshake-stewardship strategy . J Pediatric Infect Dis 2019 ; 8:162-5 .
7 . 7 . MacBrayne CE , Williams MC , Levek C , et al . Sustainability of handshake stewardship : extending a hand is effective years later . Clinical Infectious Diseases , ciz650 , https :// doi . org / 10.1093 / cid / ciz650
8 . 8 . Ekpoji U , Colindres RV , Jump R , et al . Taking off with antimicrobial intervention rounds ( AIR ): successes of a pilot stewardship service at a tertiary-care VA medical center . Open Forum Infect Dis 2018 ; 5 : S95-6 . 9 . 9 . Goff DA , Kullar R . Can the perfect handshake hold the key to success and sustainability of antimicrobial stewardship programs ? Clinical Infectious Diseases , ciz699 , https :// doi . org / 10.1093 / cid / ciz699
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