Sustainability of Handshake Stewardship: Extending a Hand Is Effective Years Later

Abstract

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.

Antibiotics: how can we make it as easy to stop as it is to start?

“…Secondly, feedback delivered verbally and in the presence of a stewardship physician during in-person rounds was more likely to be accepted than those delivered by a pharmacist alone or in writing. This is consistent with prior studies underscoring the importance of face-to-face clinicianesteward interactions on both recommendation adherence and antibiotic consumption [5,7,8]. Further, because physicians are generally seen as team leaders and final decision makers by their colleagues in the clinical setting, their presence on stewardship rounds may serve as tacit validation of pharmacist-delivered recommendations.…”

Implementation and evaluation of clinical pharmacy services through quality improvement in a Tertiary Hospital in Malawi

“…While pharmacists had a primary responsibility to document the recommendations in the patient chart, they were also encouraged to discuss recommendations collaboratively with the medical team during rounds. It may be that towards the end of the implementation period, most recommendations were accepted because they were being made through shared decision making, which is a key component of interprofessional collaboration 48,49 . Importantly, quality improvement approaches may help to stimulate interprofessional collaborative practice 50 .…”

Antibiotic Stewardship (ABS) in der stationären Kinder- und Jugendmedizin

“…Idealerweise führt das ABS-Team Visiten auf den Stationen mit hoher Antibiotika-Verordnungsdichte durch; solche Visiten können die Tür für eine weiterführende infektiologische Beratung öffnen, sofern ein pädiatrischer Infektiologe nicht ohnehin bei diesen Visiten anwesend ist. Im Rahmen des Konzepts "Prospective Audit and Feedback" werden Diagnostik und Therapie fallbezogen auf Augenhöhe besprochen und nach Möglichkeit optimiert ("Handshake Stewardship") [9,10]. Dabei sind die ABS-Ärzte in der Regel beratend tätig (wie andere Konsiliardienste auch); das heißt, die medizinisch-klinische Verantwortung für den Patienten verbleibt beim zuständigen Oberarzt.…”

“…Damit Empfehlungen umgesetzt werden, muss das ABS-Team fachlich und auch in der Kommunikation mit den behandelnden Ärzten überzeugen [10]. Manche Berater fürchten sich dabei aus juristischen Erwägungen davor, deutlich Stellung zu beziehen (defensiver Ansatz), z.…”