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Prepare Your Facility for the Antibiotic Stewardship Program – Part 1

The Antibiotic Stewardship Program (ASP) is a new regulation that comes with Phase 2 of the Mega Rule and goes into effect on November 28, 2017.

This new regulation will involve major changes to your process and several new duties for your staff. And it could also affect your F-tags –  if not implemented properly, you could be cited under multiple tags, and penalized accordingly.

So if your facility leadership has not yet begun to prepare for the ASP, it’s high time to consider it.

What is the Antibiotic Stewardship Program?

Antibiotic stewardship is “a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms,” according to the Association for Professionals in Infection Control and Epidemiology (APIC).

Antibiotic stewardship is not a cookie-cutter program. It’s one that needs to be adapted to each healthcare setting in which it’s implemented. There will never be one universally correct antibiotic to prescribe for a urinary tract infection, for instance. Why? Because the bacteria found in each healthcare facility are unique to that setting, so the antibiotics used to treat them may be different across the board.

In other words, your stewardship program will be like a fingerprint of your facility. Each one will be unique.

So How Do I Implement a Unique ASP in My Facility?

Step 1: Choose and train your champion

The champion will be responsible for facilitating the program within your facility. This could be your medical director, the director of nursing services, the infection preventionist, or a nurse or physician. Whoever is selected to be the champion of the program, that person needs to become very familiar with the CDC Core Elements of Antibiotic Stewardship in Nursing Homes, says Linda Behan, BSN, RN, CWCN, CIC, and director of infection prevention and control at Genesis HealthCare. (Genesis implemented antibiotic stewardship in October 2016.)

“They need to understand what each element is all about, what is involved with each element, which members of the team need to be involved, and what their roles and responsibilities will be,” says Behan.

Step 2: Assemble your team

Depending on the size of your facility, says Behan, an ideal ASP committee would include a physician, a member of the nursing department, a pharmacist, a staff member from the lab, a staff member from information technology, and someone in risk management. However you may have to adjust this team depending on your resources.

Then, team members should start meeting on a regular basis (Behan says her team meets monthly). Following this, any team members who aren’t familiar with the core elements of the program should be educated.

Step 3: Conduct a gap analysis and set a timeline

A gap analysis of your current processes is a good idea because it helps you identify where you already have systems in place that you can utilize for the ASP, and where you have gaps you need to fill. Behan suggests using the CDC checklist to guide you through this process.

Once you figure out how your systems need to be updated, set a timeline for how you will roll out the ASP.

Once you have your timeline, you can start developing any materials, such as training materials and program forms, that you need for your ASP.

Step 4: Assess and Make Any Necessary Changes

Implementation of the steps is not the finish line of this process. As with any new system you integrate into your facility, you need to constantly stay on top of whether the system is working properly, and make changes as necessary.

“You need to evaluate as you introduce each piece of it,” says Behan. “Is it working? What are some barriers that still need to be overcome to get it into place? That’s the process to get this stewardship program really up and running.”


In Part 2 of this blog, you’ll get more details on what the workflow for the Antibiotic Stewardship Program will look like, the significance of an antibiogram for your facility, as well as additional resources to help you create a successful ASP.

Getting started is half the battle– so start choosing your team, get your analysis going, and look at any changes you might need to make first.


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