Toolkit 2: Monitor and Sustain Stewardship

Toolkit Effectiveness

This toolkit is based on similar toolkits used in hospitals and nursing homes, but it has not been tested.

One of the tools, the Quarterly Prescribing Profile, is based on a tool used in a randomized controlled trial in eight long-term care facilities. Doctors in the experimental group received an antibiotic guide and a copy of their antibiotic prescribing profile for the previous 3 months. Nonadherent antibiotic prescriptions declined by 20% in the experimental group as compared to 5% in the control group.¹

Overview of the Toolkit

How Is Monitoring Helpful and Why Should a Nursing Home Use This Toolkit?

Monitoring antibiotic use helps a nursing home assess progress in utilizing the right antibiotics and avoiding unnecessary antibiotics. Communicating the results to staff, residents, and prescribing clinicians is helpful to show progress and as a reminder that stewardship is an ongoing effort.

What Is Included in the Monitoring Toolkit?

This toolkit provides sample tools that can be adapted for collecting data and creating reports about antibiotic usage in the nursing home. These tools are meant to be used by the antimicrobial stewardship program team as models of what tracking may look like. The team should modify these tools to reflect the goals and work practices of the nursing home.

Monitoring tools are useful for tracking antibiotic use, allowing the nursing home to see whether use is increasing, declining, or staying the same over time. Secondly, the tools can be used to help decide whether all of the antibiotics being prescribed are necessary. Finally, the toolkit includes tools to summarize and report findings. This toolkit includes the following tools:

• Suggested agenda for the antimicrobial stewardship program team to discuss monitoring and which tool or tools to use (tool 1) (PDF | Word)
   
• Tool options for monitoring
  • Antibiotic Use Tracking Sheet (tool 2) (PDF | Word | Excel)
  • Sample Monthly Summary Reports to review progress (tool 3) (PDF | Word | Excel)
  • Quarterly or Monthly Prescribing Profile to report findings back to prescribing clinicians (tool 4) (PDF | Word)

How Is the Toolkit Implemented?

Implementing the toolkit involves five steps:

1. Convene a meeting of the antimicrobial stewardship program team to discuss how and what to monitor. The agenda (tool 1) provides a suggested list of topics for the antimicrobial stewardship program team to discuss in determining what to focus on and how best to monitor the success of the stewardship program. These discussions will help the team determine which tools to use and how to implement them in each nursing home.

   Monitoring can also help a nursing home reach quality improvement and infection control goals. The nursing home’s quality improvement team and infection control specialist should be included in discussions so that work can be coordinated.
    
2. Use the Antibiotic Use Tracking Sheet. The tracking sheet (tool 2) is designed to bring together all the data about infections, lab results and x rays, organisms, names of prescribing clinicians, and antibiotic therapies, as well as track whether or not appropriate follow-up communication with residents and/or prescribing clinicians has occurred. The tool is provided in several modifiable formats for printing on paper and as an electronic spreadsheet file. Due to space limits, the smaller versions of the tool track less information than the larger versions. However, these versions are just examples and this tool should be adapted by the antimicrobial stewardship program team to suit each nursing home.

   Nursing homes are already collecting some of this information in infection control logs and medical charts, so the next step to using this tool is figuring out how to blend it into existing practices. The process of filling out the Tracking Sheet should fit into the normal workflow and division of duties in the nursing home. A designated staff person should be responsible for completing the Tracking Sheet and nursing staff must have a logical and convenient way of reporting information required (e.g., by dropping off copies of diagnostic forms or antibiotic orders).

   Data can be collected on a weekly or monthly basis and can be used to create monthly, quarterly, or annual cumulative reports. By bringing the data together in one tool, the Tracking Sheet allows the antimicrobial stewardship program team to see trends and patterns in infections and antibiotic use that might not be noticed otherwise.
    
3. Use and evaluate progress through the Monthly Summary Reports. The Monthly Summary Report tools (tool 3) provide suggested categories of information that could be tallied on a monthly basis. These tools are examples and will need to be adapted by the antimicrobial stewardship program team to suit the goals of the nursing home. For example, each team will need to consider how to report on residents who receive antibiotics more than once in a month.

   The ability to see a month-to-month comparison of these totals over time allows the antimicrobial stewardship program team to evaluate whether antibiotic use is increasing, decreasing, or staying the same over time. This helps the nursing home show whether the stewardship program is having an impact.

   It may also allow the antimicrobial stewardship program team to measure progress toward more specific goals. For example, has there been a decrease in treatment of residents who do not meet the diagnostic criteria? Is there decreased use of particular antibiotics that may be of concern (e.g., fluoroquinolones)? Being able to monitor changes in these measures allows the antimicrobial stewardship team to identify where action may be needed to improve the use of antibiotics.
    
4. Communicate results to prescribing clinicians. Information from the monthly summary reports should be shared with prescribing clinicians as appropriate. The antimicrobial stewardship program team should discuss the information to be shared and the best way to share it.

   For nursing homes that choose to use an antibiogram and/or track compliance with the diagnostic criteria, the Quarterly or Monthly Prescribing Profile tool (tool 4) provides a sample format for providing a regular report of prescribing data to clinicians. This tool would accompany a copy of the antibiogram, or the criteria or protocol for initiating antibiotic use in the nursing home.

   It is important that this report be accurate, so this form should be used only if the nursing home is consistently and systematically collecting the information needed to create the report. If the nursing home is using a computer system to track this information, providing this type of report may be something the antimicrobial stewardship program team can do fairly easily. If the nursing home is collecting this information manually, adequate staff time must be available for creating this type of report.
    
5. Review and update guidelines. Check annually to see whether the guidelines regarding antibiotic use (e.g., indications for urinary tract infections) have changed. For the most up-to-date guidelines, review the Centers for Disease Control and Prevention (CDC) Web site.

¹Monette J, Miller MA, Monette M, et al. Effect of an educational intervention on optimizing antibiotic prescribing in long-term care facilities. J Am Geriatr Soc. 2007 Aug;55(8):1231-5. PMID: 17661962.

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