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Implementation of the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings: 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults—Experiences from 3 institutions
Implementation of the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings: 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults— Experiences from 3 institutions Kristin Brinsley, MPH,a Arjun Srinivasan, MD,a Ronda Sinkowitz-Cochran, MPH,a Rachel Lawton, MPH,a Rosemarie McIntyre, RN, MS,a Gary Kravitz, MD,b Bob Burke, RN, MA, CIC,c Rebecca Shadowen, MD,d and Denise Cardo, MDa Atlanta, Georgia, St. Paul, Minnesota, Boston, Massachusetts, and Bowling Green, Kentucky
Antimicrobial resistance is a growing threat to public health. Health care settings are particularly prone to the spread of antimicrobial-resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum b-lactamase (ESBL)-producing organisms, which contribute to adverse health outcomes and rising costs.1-6 To address this challenge, the Centers for Disease Control and Prevention (CDC) launched the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings (the Campaign) in March 2002. The Campaign was designed as a nationwide effort to facilitate the implementation of educational and behavioral interventions that will assist clinicians in preventing antimicrobial resistance. The Campaign centers on 4 broad strategies—Prevent Infection, Diagnose and Treat Infection Effectively, Use Antimicrobials Wisely, and Prevent Transmission—and includes multiple evidence-based 12-step programs targeting clinicians who treat specific patient populations, including hosFrom the Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, United States Department of Health and Human Services, Atlanta, GAa; Department of Infectious Disease, United Hospital, St. Paul, MNb; Department of Hospital Epidemiology, Boston Medical Center, Boston, MAc; and Department of Infectious Diseases and Epidemiology, The Medical Center at Bowling Green, Bowling Green, KY.d Reprint requests: Kristin Brinsley, MPH, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E68, Atlanta, GA 30333. E-mail: [email protected]. Am J Infect Control 2005;33:53-4. 0196-6553/$30.00 doi:10.1016/j.ajic.2004.12.003
pitalized adults, dialysis patients, surgical patients, hospitalized children, and long-term care residents. At the 14th Annual Society for Healthcare Epidemiology of America (SHEA) Scientific Meeting, the CDC Foundation sponsored a session during which project leads from 3 health care institutions presented their experiences in implementing at least 1 step or a broad strategy of the CDC’s 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults (see Appendix). An expert panel convened by the CDC selected the 3 projects from 21 applications based on creativity to overcome barriers to implementing the 12-step program, the level of staff participation, the progress toward meeting stated objectives, and the use of evaluation techniques. Some applications addressed implementation of specific steps, most commonly ‘‘Break the chain of contagion’’ (4 projects), or ‘‘Vaccinate’’ (3 projects). Two applicants implemented the entire 12-step program. Other applicants focused on implementing 1 or more of the broad strategies; the most common was ‘‘Use Antimicrobials Wisely’’ (3 projects). The 3 selected projects were led by hospital epidemiologists of institutions located in urban settings (in addition to urban campuses, 1 institution also had a rural campus), included both teaching and nonteaching hospitals, and each housed more than 400 beds. Project A included the creation and management of an antibiotic advisory team that identified antibiotic prescribing errors based on hospital pharmacy reports of all patients receiving antibiotics and categorized them in accordance with 8 of the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults. The team issued recommendations, usually placed in the patient charts, to correct the errors, and acceptance 53
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of the recommendations was found to be greater than 90%. The antibiotic advising team estimated that the intervention saved the institution $136,000 annually because of decreased hospital stays as a result of improved antibiotic prescribing practices. Project B consisted of the creation of a task force commissioned by the infection control committee of the institution that utilized the Campaign as its format for intervention. The task force was divided into working groups, 1 for each of the 4 broad strategies of the Campaign, with Prevent Infection being the first strategy to be implemented. The Prevent Infection working group focused on improving inpatient influenza vaccination by issuing program announcements, incorporating reminders into the electronic order entry system, urging nursing leadership to promote vaccination, and ensuring adequate supplies of the vaccine. The number of doses of the vaccine administered served as a measure of the impact of the intervention. Project C integrated the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults into hospital performance improvement efforts. Weekly poster presentations detailing each step of the Campaign along with relevant local information and handouts were exhibited in the doctors’ lounge. Physicians were encouraged to answer questions developed for each step and submit the answers for continuing medical education (CME) credit. Following the weekly poster presentations, a hospital-wide health fair highlighted the 12 steps of the program. A book of the poster presentations was made available for ongoing CME efforts. Evaluation of Project C was based on outcome data for each step measured over 2 years as part of the hospital performance improvement effort. Several attributes of the Campaign served to facilitate implementation of these projects. First, the Campaign can be tailored to fit the needs of any institution, irrespective of type, size, or affiliation. Second, the Campaign design allows for flexibility in implementation. As was seen in this report, the Campaign can be implemented as a single step, as 1 broad strategy with multiple steps, or in its entirety with all 12 steps. Each presenter also described the evidence base of the Campaign steps as a key aspect in gaining clinician acceptance of their implementation projects. Finally, the presenters noted the fact that development of the Campaign by the CDC enhanced clinician acceptance. These 3 projects show that quality improvement and patient safety initiatives based on the Campaign
framework can be successfully implemented in health care facilities. Infection control professionals are encouraged to take an active role in preventing antimicrobial resistance by implementing evidence-based preventive measures, such as those outlined in the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. To learn more about the Campaign, or for information on how to apply for a scholarship to attend the Association for Professionals in Infection Control 2005 Annual Conference and present your institution’s experiences in implementing the Campaign, please visit the Campaign Web site at www.cdc.gov/drugresistance/healthcare. References 1. Emori TG, Gaynes RP. An overview of nosocomial infection, including the role of the microbiology laboratory. Clin Microbiol Rev 1993;6:428-42. 2. Roth VR, Jarvis WR. Combating antimicrobial resistance in hospitals. Emerg Ther Targets 1999;3:73-88. 3. Manangan LP, Jarvis WR. Prevention of methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), and vancomycin-resistant enterococci (VRE) colonization/infection. Antibiotics for Clinicians 1998;2:33-8. 4. McDonald LC, Jarvis WR. The global impact of vancomycin-resistant enterococci. Curr Opin Infect Dis 1997;10:304-9. 5. Carbon C. Costs of treating infections caused by methicillin-resistant staphylococci and vancomycin-resistant enterococci. J Antimicrob Chemother 1999;44(Suppl A):31-6. 6. Gupta A, Ampofo K, Rubenstein D, Saiman L. Extended spectrum blactamase-producing Klebsiella pneumoniae infections: a review of the literature. Crit Rev Microbiol 2004;30:25-32.
APPENDIX. Twelve steps to prevent antimicrobial resistance among hospitalized adults Strategy: Prevent Infection Step 1. Vaccinate Step 2. Get the catheters out Strategy: Diagnose and Treat Infection Effectively Step 3. Target the pathogen Step 4. Access the experts Strategy: Use Antimicrobials Wisely Step 5. Practice antimicrobial control Step 6. Use local data Step 7. Treat infection, not contamination Step 8. Treat infection, not colonization Step 9. Know when to say ‘‘no’’ to vanco Step 10. Stop treatment when infection is cured or unlikely Strategy: Prevent Transmission Step 11. Isolate the pathogen Step 12. Break the chain of contagion
Antimicrobial resistance is a growing threat to public health. Health care settings are particularly prone to the spread of antimicrobial-resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum b-lactamase (ESBL)-producing organisms, which contribute to adverse health outcomes and rising costs.1-6 To address this challenge, the Centers for Disease Control and Prevention (CDC) launched the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings (the Campaign) in March 2002. The Campaign was designed as a nationwide effort to facilitate the implementation of educational and behavioral interventions that will assist clinicians in preventing antimicrobial resistance. The Campaign centers on 4 broad strategies—Prevent Infection, Diagnose and Treat Infection Effectively, Use Antimicrobials Wisely, and Prevent Transmission—and includes multiple evidence-based 12-step programs targeting clinicians who treat specific patient populations, including hosFrom the Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, United States Department of Health and Human Services, Atlanta, GAa; Department of Infectious Disease, United Hospital, St. Paul, MNb; Department of Hospital Epidemiology, Boston Medical Center, Boston, MAc; and Department of Infectious Diseases and Epidemiology, The Medical Center at Bowling Green, Bowling Green, KY.d Reprint requests: Kristin Brinsley, MPH, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E68, Atlanta, GA 30333. E-mail: [email protected]. Am J Infect Control 2005;33:53-4. 0196-6553/$30.00 doi:10.1016/j.ajic.2004.12.003
pitalized adults, dialysis patients, surgical patients, hospitalized children, and long-term care residents. At the 14th Annual Society for Healthcare Epidemiology of America (SHEA) Scientific Meeting, the CDC Foundation sponsored a session during which project leads from 3 health care institutions presented their experiences in implementing at least 1 step or a broad strategy of the CDC’s 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults (see Appendix). An expert panel convened by the CDC selected the 3 projects from 21 applications based on creativity to overcome barriers to implementing the 12-step program, the level of staff participation, the progress toward meeting stated objectives, and the use of evaluation techniques. Some applications addressed implementation of specific steps, most commonly ‘‘Break the chain of contagion’’ (4 projects), or ‘‘Vaccinate’’ (3 projects). Two applicants implemented the entire 12-step program. Other applicants focused on implementing 1 or more of the broad strategies; the most common was ‘‘Use Antimicrobials Wisely’’ (3 projects). The 3 selected projects were led by hospital epidemiologists of institutions located in urban settings (in addition to urban campuses, 1 institution also had a rural campus), included both teaching and nonteaching hospitals, and each housed more than 400 beds. Project A included the creation and management of an antibiotic advisory team that identified antibiotic prescribing errors based on hospital pharmacy reports of all patients receiving antibiotics and categorized them in accordance with 8 of the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults. The team issued recommendations, usually placed in the patient charts, to correct the errors, and acceptance 53
54
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of the recommendations was found to be greater than 90%. The antibiotic advising team estimated that the intervention saved the institution $136,000 annually because of decreased hospital stays as a result of improved antibiotic prescribing practices. Project B consisted of the creation of a task force commissioned by the infection control committee of the institution that utilized the Campaign as its format for intervention. The task force was divided into working groups, 1 for each of the 4 broad strategies of the Campaign, with Prevent Infection being the first strategy to be implemented. The Prevent Infection working group focused on improving inpatient influenza vaccination by issuing program announcements, incorporating reminders into the electronic order entry system, urging nursing leadership to promote vaccination, and ensuring adequate supplies of the vaccine. The number of doses of the vaccine administered served as a measure of the impact of the intervention. Project C integrated the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults into hospital performance improvement efforts. Weekly poster presentations detailing each step of the Campaign along with relevant local information and handouts were exhibited in the doctors’ lounge. Physicians were encouraged to answer questions developed for each step and submit the answers for continuing medical education (CME) credit. Following the weekly poster presentations, a hospital-wide health fair highlighted the 12 steps of the program. A book of the poster presentations was made available for ongoing CME efforts. Evaluation of Project C was based on outcome data for each step measured over 2 years as part of the hospital performance improvement effort. Several attributes of the Campaign served to facilitate implementation of these projects. First, the Campaign can be tailored to fit the needs of any institution, irrespective of type, size, or affiliation. Second, the Campaign design allows for flexibility in implementation. As was seen in this report, the Campaign can be implemented as a single step, as 1 broad strategy with multiple steps, or in its entirety with all 12 steps. Each presenter also described the evidence base of the Campaign steps as a key aspect in gaining clinician acceptance of their implementation projects. Finally, the presenters noted the fact that development of the Campaign by the CDC enhanced clinician acceptance. These 3 projects show that quality improvement and patient safety initiatives based on the Campaign
framework can be successfully implemented in health care facilities. Infection control professionals are encouraged to take an active role in preventing antimicrobial resistance by implementing evidence-based preventive measures, such as those outlined in the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. To learn more about the Campaign, or for information on how to apply for a scholarship to attend the Association for Professionals in Infection Control 2005 Annual Conference and present your institution’s experiences in implementing the Campaign, please visit the Campaign Web site at www.cdc.gov/drugresistance/healthcare. References 1. Emori TG, Gaynes RP. An overview of nosocomial infection, including the role of the microbiology laboratory. Clin Microbiol Rev 1993;6:428-42. 2. Roth VR, Jarvis WR. Combating antimicrobial resistance in hospitals. Emerg Ther Targets 1999;3:73-88. 3. Manangan LP, Jarvis WR. Prevention of methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), and vancomycin-resistant enterococci (VRE) colonization/infection. Antibiotics for Clinicians 1998;2:33-8. 4. McDonald LC, Jarvis WR. The global impact of vancomycin-resistant enterococci. Curr Opin Infect Dis 1997;10:304-9. 5. Carbon C. Costs of treating infections caused by methicillin-resistant staphylococci and vancomycin-resistant enterococci. J Antimicrob Chemother 1999;44(Suppl A):31-6. 6. Gupta A, Ampofo K, Rubenstein D, Saiman L. Extended spectrum blactamase-producing Klebsiella pneumoniae infections: a review of the literature. Crit Rev Microbiol 2004;30:25-32.
APPENDIX. Twelve steps to prevent antimicrobial resistance among hospitalized adults Strategy: Prevent Infection Step 1. Vaccinate Step 2. Get the catheters out Strategy: Diagnose and Treat Infection Effectively Step 3. Target the pathogen Step 4. Access the experts Strategy: Use Antimicrobials Wisely Step 5. Practice antimicrobial control Step 6. Use local data Step 7. Treat infection, not contamination Step 8. Treat infection, not colonization Step 9. Know when to say ‘‘no’’ to vanco Step 10. Stop treatment when infection is cured or unlikely Strategy: Prevent Transmission Step 11. Isolate the pathogen Step 12. Break the chain of contagion