Background
Children’s Hospital Colorado created a unique method of antimicrobial stewardship, called handshake stewardship, that effectively decreased hospital anti-infective use and costs in its pilot year (2013). Handshake stewardship is distinguished by: (1) the lack of prior authorization; (2) a review of all prescribed anti-infectives; (3) a shared review by the physician and the pharmacist; and (4) a daily, rounding-based, in-person approach to supporting providers. We sought to reevaluate the outcomes of the program after 5 years of experience, totaling 8 years of data.
Methods
We retrospectively measured anti-infective (antibiotic, antiviral, antifungal) use hospital-wide by unit and by drug for an 8-year period spanning October 2010 to October 2018. Aggregated monthly use was measured in days of therapy per thousand patient days (DOT/1000 PD). The percentage of children admitted ever receiving an anti-infective was also measured, as well as severity-adjusted mortality, readmissions, and lengths of stay.
Results
Hospital-wide mean anti-infective use significantly decreased, from 891 (95% confidence interval [CI] 859–923) in the pre-implementation phase to 655 (95% CI 637–694) DOT/1000 PD in post-implementation Year 5; in a segmented regression time series analysis, this was a rate of -2.6 DOT/1000 PD (95% CI -4.8 to -0.4). This is largely attributable to decreased antibacterial use, from 704 (95% CI 686–722) to 544 (95% CI 525 –562) DOT/1000 PD. The percentage of children ever receiving an anti-infective during admission likewise declined, from 65% to 52% (95% CI 49–54). There were no detrimental effects on severity adjusted mortality, readmissions, or lengths of stay.
Conclusions
The handshake method is an effective and sustainable approach to stewardship.
The handshake stewardship approach is an effective strategy for an antimicrobial stewardship program, as demonstrated by the widespread and significant decrease in antimicrobial use after implementation.
Implementation of a unique in-person pediatric antimicrobial stewardship program was associated with a significant increase in infectious disease consultations at a quaternary care children's hospital. This study demonstrates that antimicrobial stewardship programs support, and do not compete with, infectious disease programs.
saturation group. It is known that SGA infants have higher mortality and worse outcomes compared with AGA infants of the same gestation. 3 Furthermore, growth restriction has been shown to increase the risk of pulmonary hypertension in the setting of bronchopulmonary dysplasia. 4-6 These reports mirror our finding of bronchopulmonary dysplasia as a leading mortality cause in the SGA cohort. We view these analyses as hypothesis generating. These results must be confirmed in other oxygen targetting studies. An important opportunity to do this is in the planned Neonatal Oxygenation Prospective Meta-analysis, which includes data from 4800 infants with a prespecified analysis by growth status. We speculate that SGA infants may experience hypoxia in utero that destabilizes respiratory control or affects pulmonary vascular resistance, increasing vulnerability to lower saturation targets.
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