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Policy Innovation Profile

State Health Department Support Spurs Development of Many Antimicrobial Stewardship Programs After Passage of Legislative Mandate


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Snapshot

Summary

In response to a State law requiring hospitals to promote appropriate antibiotic use, the Healthcare-Associated Infections Program in the California Department of Public Health provides education, guidance, and other support to hospitals and long-term care facilities that are creating antimicrobial stewardship programs focused on the appropriate use of antibiotics. Support includes recommendations on program elements based on best practices, consultations and education, hospital collaboratives to facilitate sharing of ideas across similar organizations, and creation of common metrics to track and benchmark performance. The initiative has played an important role in convincing many California hospitals to develop antimicrobial stewardship programs.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of hospitals seeking assistance from the statewide initiative and the estimated number that have created antimicrobial stewardship programs in response to the legislation.
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Developing Organizations

Healthcare-Associated Infections Program, California Department of Public Health
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Date First Implemented

2010
February

Problem Addressed

Inappropriate use of antibiotics and other antimicrobial agents can lead to antimicrobial resistance, drug-related adverse effects, and higher costs.1 Antimicrobial stewardship programs can improve the use of antimicrobials by promoting the appropriate selection of agents, dose, duration, and method of administration. Even though guidelines for developing such programs exist, many hospitals do not have these programs in place.2,3

  • Growing problem of antibiotic resistance: Antibiotics have been used liberally for 70 years to treat infectious diseases. As a result of this long-term, widespread use, infectious organisms have adapted over time, making certain antibiotics less effective. Patients infected with antimicrobial-resistant organisms (such as carbapenem-resistant Enterobacteriaceae, vancomycin-resistant Enterococci, methicillin-resistant Staphylococcus aureus, and others) tend to have longer, more expensive hospital stays and face a higher risk of death than patients with other types of infections.4,5 It is estimated that each year, antibiotic-resistant organisms kill 44,000 North Americans.6
  • Unrealized potential of antimicrobial stewardship programs: Antimicrobial stewardship programs have been shown to reduce antibiotic resistance by formally addressing, monitoring, and measuring susceptibility patterns, and promoting strategies to ensure appropriate antibiotic use.7 In fact, a policy statement released jointly by the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society supports the creation of antimicrobial stewardship programs.8 Even though guidelines for creating such programs exist,2 many hospitals and long-term care facilities still do not have them. For example, a California Department of Public Health survey conducted between May 2010 and March 2011 found that 50 percent of the 220 hospital respondents had antimicrobial stewardship programs in place (defined as implementing an antimicrobial stewardship strategy with dedicated personnel), even though legislation passed in 2006 mandated that hospitals monitor antibiotic use and create a committee with oversight responsibilities for this issue by January 2008.9

What They Did

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Description of the Innovative Activity

In response to a State law requiring hospitals to promote appropriate antibiotic use, the Healthcare-Associated Infections Program in the California Department of Public Health provides education, guidance, and other support to hospitals and long-term care facilities that are creating antimicrobial stewardship programs focused on the appropriate use of antibiotics. Support includes recommendations on program elements based on best practices, consultations and education, hospital collaboratives to facilitate sharing of ideas across similar organizations, and creation of common metrics to track and benchmark performance. A description of each of these key elements follows:

  • Passage of law: In 2006, California legislators passed Senate Bill 739, which stipulated that, as of January 1, 2008, the California Department of Public Health requires all general acute care hospitals to evaluate antibiotic use and create a quality improvement committee to monitor oversight responsibilities for this issue.10 Senate Bill 739 also required the California Department of Public Health to implement a program for the statewide surveillance and prevention of health care–associated infections in acute care. The California Antimicrobial Stewardship Program Initiative was developed by the department's Healthcare-Associated Infections Program under these mandates to strengthen and promote optimization of antimicrobial utilization in California health care facilities.
  • Program recommendations based on best practices: The Healthcare-Associated Infections Program Public Health Medical Officer works with hospitals and long-term care facilities to identify barriers, solutions, and best practices related to developing antimicrobial stewardship programs. To date, the Public Health Medical Officer has worked with roughly 125 hospitals and long-term care facilities, and these efforts have identified several strategies that are being promoted throughout the state, including post-prescriptive review with feedback to ensure appropriate prescribing practices, protocols that allow pharmacists to suggest a switch from intravenous to oral antibiotics, and formulary restrictions on select antimicrobials for a particular patient population based on their antimicrobial susceptibility patterns. The ultimate goal is to develop and disseminate a comprehensive set of recommendations on how to implement or strengthen antimicrobial stewardship programs based on a facility's unique attributes and available resources. In a related task, the Healthcare-Associated Infections Program is also involved in defining the key characteristics or metrics of an antimicrobial stewardship program.
  • Consultations and education: The Public Health Medical Officer consults with stewardship teams at individual hospitals to offer advice on program development, review related business plans, and understand facility-specific issues with implementation. She also attends meetings that these teams have with administrators and clinicians, sharing evidence on the program's potential benefits (so as to win their support) and highlighting potential strategies for changing prescribing habits. The same officer also educates leaders of long-term care facilities on the benefits of appropriate antibiotic use, and is working on research to evaluate the efficacy of antimicrobial oversight in the long-term care setting.
  • Regional collaborations: The Public Health Medical Officer organizes collaborations among hospitals with similar challenges (e.g., small and/or rural hospitals, pediatric hospitals, long-term acute care hospitals), allowing them to share best practices. These meetings occur via phone or in person and have variable frequency depending on the interest level of the participants. They provide a forum for these health care facilities to learn from one another (by sharing their policies and procedures as well as their failures) and provide a venue for facilitators to educate an engaged audience based on their interests and challenges.
  • Common performance metrics: A work group consisting of California infectious diseases physicians and infectious diseases pharmacists with expertise in antimicrobial stewardship has developed a list of external benchmarking metrics that facilitate comparisons of antimicrobial use across institutions. The group is also developing a set of internal metrics such as recommended process and outcome measures for hospitals to monitor internally.

Context of the Innovation

The California Department of Public Health is tasked with ensuring the health and well-being of California residents. As part of these efforts, it oversees the state's 383 licensed acute care hospitals and approximately 1,200 licensed long-term care facilities. As stated earlier, given growing concerns about antibiotic resistance in California and across the country, California legislators passed Senate Bill 739 in 2006, which, among many things, stipulated that, as of January 1, 2008, the California Department of Public Health require all general acute care hospitals to evaluate antibiotic use and create a quality improvement committee to monitor oversight responsibilities for this issue.8 Although hospitals were generally aware of this unfunded mandate, they had little guidance on how to comply with it. As a result, the Department of Public Health's Healthcare-Associated Infections Program created this statewide initiative to offer implementation guidance to health care facilities across the state.3

Did It Work?

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Results

This initiative has played an important role in convincing many California hospitals to develop antimicrobial stewardship programs.
  • Widespread interest from hospitals: The Public Health Medical Officer has received inquiries from more than 100 hospitals and long-term care facilities, providing them with assistance. Some of these hospitals already had programs and were trying to improve their implementation and success, while others were attempting to launch new antimicrobial stewardship programs.
  • Program implementation in response to legislation: As part of the same survey conducted between May 2010 and March 2011, the Healthcare-Associated Infections Program found that 22 percent of California hospitals created an antimicrobial stewardship program due to the passage of the law.9 Anecdotal reports indicate that the combination of the legislation and the assistance provided through the statewide antimicrobial stewardship initiative have been instrumental in allowing hospital-based advocates to convince senior leaders of the merits of supporting and sustaining these programs.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of hospitals seeking assistance from the statewide initiative and the estimated number that have created antimicrobial stewardship programs in response to the legislation.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Assigning responsibility for initiative: The Healthcare-Associated Infections Program in the Department of Public Health assigned responsibility for the statewide initiative to the Public Health Medical Officer.
  • Assessing existing programs: The Public Health Medical Officer conducted a voluntary, Web-based survey to assess if hospitals had antimicrobial stewardship programs in place and what strategies they were employing. The survey also assessed barriers to creating stewardship programs. The survey, released on May 1, 2010, was available through March 2011.
  • Building awareness and support: The Public Health Medical Officer contacted antimicrobial stewardship experts across the state, asking for their guidance in developing external and internal metrics for antimicrobial stewardship programs. She made presentations at various pharmacy, infection control, and infectious diseases professional society meetings and also presented at hospital grand rounds and symposia with clinical staff. The goal of these latter efforts was to discuss antimicrobial resistance, highlight the statewide antimicrobial stewardship initiative, and build relationships and support.
  • Identifying vulnerable hospitals: The Public Health Medical Officer identified several categories of hospitals that may require additional assistance in developing an antimicrobial stewardship program, including small and/or rural hospitals and long-term acute care hospitals. She began offering individualized consultation and developed the aforementioned collaboratives that allow them to share ideas and allow a forum for targeted learning.
  • Working with national systems: The Public Health Medical Officer has reached out to medical leaders of health systems that own or manage acute care hospitals in California (such as Kaiser Permanente and Kindred) to explore the possibility of creating system-wide antimicrobial stewardship programs.
  • Working with long-term care facilities: With funding from the Centers for Disease Control and Prevention, the Public Health Medical Officer has initiated a study in three community, stand-alone, long-term care facilities to identify issues related to appropriate antimicrobial use in this setting. This study will eventually yield evidence to inform more general recommendations for the development of antimicrobial stewardship programs in these facilities.

Resources Used and Skills Needed

  • Staffing: The Public Health Medical Officer created and leads the California Antimicrobial Stewardship Program Initiative along with other responsibilities.
  • Costs: Costs include salary and benefits for the time spent by the Public Health Medical Officer on program-related activities.
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Funding Sources

Centers for Disease Control and Prevention; California Department of Public Health
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Tools and Other Resources

Guidelines for developing an antimicrobial stewardship program are available in:
Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Disease Society of American and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis 2007;44:159-77. [PubMed] Available at: http://cid.oxfordjournals.org/content/44/2/159.full.

Recommendations of how to include the infection preventionist in antimicrobial stewardship programs are included in the following:
Moody J, Cosgrove SE, Olmsted R, et al. Antimicrobial stewardship: a collaborative partnership between infection preventionists and health care epidemiologists. Infect Control Hosp Epidemiol. 2012;33:328-330. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Support passage of flexible legislation: While hospitals have a fiduciary responsibility to promote appropriate antimicrobial use as part of efforts to ensure patient safety, a legislative mandate may be required to spur development of formal programs. Ideally, the mandate should be flexible enough to allow hospitals leeway to create programs based on their own circumstances and resources.
  • Identify experts to assist with program activities: Experts from various clinical settings can contribute to specific activities, such as writing guidelines for assisting hospitals in creating antimicrobial stewardship programs and developing performance metrics for benchmarking.
  • Recognize initiative's fit with public health mission: Hospital representatives may question why the public health department is involved in internal hospital program creation. Program developers can emphasize that public health departments have an appropriate and critical role in promoting antimicrobial stewardship. This role is consistent with the core functions and missions of public health, including monitoring and detecting disease trends, educating clinicians and hospital leaders, identifying and disseminating best practices, interpreting laws and regulations that improve public health and patient safety, and implementing innovative solutions to address public health challenges.

Sustaining This Innovation

  • Encourage hospitals to use mandate to justify funding: Hospital-based champions can use the legislative mandate to convince leaders of the need to allocate funds to antimicrobial stewardship programs. In California, many hospital-based pharmacists, infectious diseases physicians, and infection preventionists successfully used this strategy.
  • Use data to win over key stakeholders: Presenting data on the growing problem of antimicrobial resistance and the need to use available antimicrobials appropriately can help win support for an antimicrobial stewardship program from both hospital-based administrators and clinicians, especially in light of few novel antimicrobial agents in the pipeline.
  • Monitor impact over time: Continued enthusiasm and support for antimicrobial stewardship programs depend on their ability to improve resistance patterns, patient safety, and quality, which may secondarily reduce health care costs. Consequently, efforts should be made to support hospitals in monitoring their impact. In particular, there is a need to develop and promote use of common process and outcomes measures that allow for such internal monitoring and for comparisons of performance across institutions.

Additional Considerations

As of April 2012, California is the only state to require general acute care hospitals to evaluate and oversee the appropriate use of antibiotics. It is also the only state to have launched a statewide antimicrobial stewardship program initiative.

More Information

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Contact the Innovator

Lynn Janssen, MS, CIC, CPHQ
Program Chief
Healthcare-Associated Infections Program
California Department of Public Health
850 Marina Bay Parkway, Bldg. E, 1st Floor
Richmond, CA 94804
Phone: (510) 412-6060
E-mail: lynn.janssen@cdph.ca.gov

Innovator Disclosures

Ms. Janssen has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Program Web site: http://www.cdph.ca.gov/programs/hai/Pages/AntimicrobialStewardshipProgramInitiative.aspx.

Trivedi K. California’s Model for Antimicrobial Stewardship: Legislation, Consultation, and Accountability. Alliance for the Prudent Use of Antibiotics Newsletter. 2010;28(1). Available at: http://www.tufts.edu/med/apua/news/news-newsletter-vol-29-no--1-2.shtml.

Trivedi K. The Path of Least Resistance: Antimicrobial Use Optimization. California Association of Long-Term Care Medicine. December 2011.

Policy Statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33(4):322-327. [PubMed]

Moody J, Cosgrove SE, Olmsted R, et al. Antimicrobial stewardship: a collaborative partnership between infection preventionists and health care epidemiologists. Infect Control Hosp Epidemiol. 2012;33(4):328-330. [PubMed]

Footnotes

1 Trivedi K. The Path of Least Resistance: Antimicrobial Use Optimization. California Association of Long-Term Care Medicine. December 2011.
2 Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Disease Society of American and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis 2007;44:159-77. [PubMed] Available at: http://cid.oxfordjournals.org/content/44/2/159.full.
3 California Department of Public Health. The California Antimicrobial Stewardship Program Initiative. 2010. Available at: http://www.cdph.ca.gov/programs/hai/Pages/AntimicrobialStewardshipProgramInitiative.aspx.
4 Centers for Disease Control and Prevention. Antibiotic/Antimicrobial Resistance. October 4, 2011. Available at: http://www.cdc.gov/drugresistance/index.html.
5 Roberts RR, Hota B, Ahmad I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009;49:1175-1184. [PubMed]
6 Evenson B. Antibiotic-resistance deaths out of control. The National Post-Canada. Available at: http://www.rense.com/general29/asani.htm.
7 Infectious Diseases Society of America. Antimicrobial Stewardship Programs, National Campaigns Curb Usage. ISDA News. November 2008;18(11). Available at: http://news.idsociety.org/idsa/issues/2008-11-01/5.html.
8 Policy Statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33(4):322-327. [PubMed]
9 Trivedi Kk, Rosenberg, J. The state of antimicrobial stewardship programs in California. Infect Control Hosp Epidemiol. 2013;34(4): 379-384.
10 California Department of Health Care Services. Senate Bill No. 739. Available at: http://www.dhcs.ca.gov/provgovpart/initiatives/nqi/Documents/SB739.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
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Original publication: June 06, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 02, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 04, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.