A Model for Assessing Antimicrobial Stewardship Practices Using an Innovative Conceptual Framework

BACKGROUND: The Illinois Antimicrobial Stewardship (AMS) Collaborative engaged five Chicago area hospitals in working to improve antimicrobial use. The collaborative was funded by an Affordable Care Act grant and led by the Illinois Department of Public Health in collaboration with the Centers for Disease Control and Prevention (CDC) and expert consultants from one of the CDC Prevention Epicenter sites. Here we share the methods employed by the AMS Collaborative team in developing and applying a standardized framework to assess AMS programs. 

METHODS: In-depth mixed-method assessments at each facility included a pre-collaborative survey of current AMS practices and a review of institutional policies and antibiograms. The collaborative team developed a semi-structured qualitative interview guide that was used to conduct a series of standardized multidisciplinary focus groups at each facility with participation from hospital leadership, pharmacy, medical providers, nursing, information technology, infection control, and other key stakeholders. Participants also completed an organizational culture survey.  The project team then developed a conceptual framework for the establishment and assessment of hospital AMS programs that outlined the rationale for stewardship activities as a way to mitigate harms of antimicrobial use; operational goals of stewardship as ensuring the right diagnosis, right drug selection, right dose, right duration, and right de-escalation; measures of stewardship impact; and essential attributes for successful AMS interventions.                                                                                                                             

RESULTS: The framework served as a guide for presenting facility-specific feedback and recommendations. A common finding was that successful implementation of AMS interventions required consideration of leadership support, financial impact, clinician buy-in, available resources, and impact on work flow. Facilities reported that the act of performing an in-depth multidisciplinary assessment helped increase visibility and support of AMS initiatives while gaining insight into how to make them more successful; this was important to pushing initiatives through the multiple channels needed for implementation at each facility regardless of organizational culture. All sites made improvements to their AMS programs as a result of the assessment and feedback provided.

CONCLUSIONS: Antimicrobial stewardship involves the collaboration of multiple disciplines and the Illinois AMS assessment and conceptual framework can serve as a model for other states. The Collaborative created the term “Antimicrobial Mindfulness” as an umbrella concept for various methods employed to systematically assess and re-assess the appropriateness of  antimicrobial therapy. The next step planned is to assess the feasibility and success of having facilities use the framework to perform an internal review of systems needed to effect change on antimicrobial stewardship practices.