Implementation and Impact of Antimicrobial Stewardship (AMS) Strategies in Hospital in The Home (HITH)

Introduction

Good afternoon, ladies and gentlemen. My name is Cara, and my current role is as a HITH Nurse Unit Manager at Vitalis. It is an honour to present a topic of utmost significance in today's healthcare industry: Optimizing Antibiotic Use and Enhancing Patient Outcomes in Hospital in The Home (HITH) through Antimicrobial Stewardship (AMS) Strategies.

For several reasons, antimicrobial stewardship (AMS) is essential in today's healthcare environment. First and foremost, it deals with the urgent global health issue of antimicrobial resistance caused by the overuse and abuse of antibiotics, resulting in bacterial strains resistant to drugs and complex diseases (Azim Majumder et al., 2020). AMS also promotes patient safety by minimising unnecessary or overuse of antibiotics and lowering adverse effects, medical expenses, and hospital stays. Thirdly, it supports cost-effective healthcare by avoiding unnecessary antibiotic prescriptions while improving the quality of care (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2018). Lastly, AMS is vital for conserving the efficacy of antibiotics, a finite resource, ensuring judicious use for future generations (Azim Majumder et al., 2020).

Our presentation aims to achieve two main objectives. First, to underscore the significance of AMS in HITH settings, which bring hospital-level care to patients' homes. AMS is essential in HITH to provide effective antimicrobial treatment while minimising overuse risks. Second, we will provide insights and strategies for optimising antibiotic use and patient outcomes in HITH through Antimicrobial Stewardship. We will explore various AMS techniques, guidelines, and best practices that healthcare professionals can employ to ensure responsible antibiotic use in HITH, advancing patient outcomes, reducing healthcare costs, and tackling antimicrobial resistance.

Background

Hospital in The Home (HITH) represents a distinct healthcare paradigm, delivering acute medical care in the comfort of patients' homes, easing the burden on traditional hospitals while enhancing care quality (Kanagala et al., 2023). Antibiotics are integral in inpatient treatment, but their overuse leads to antibiotic-resistant pathogens, jeopardising patient safety. Like conventional hospitals, HITH administers antibiotics, making responsible usage critical (World Health Organisation (WHO), 2021). In 2022, AMS programs were introduced, aligning antibiotic use in HITH with optimal patient outcomes while curbing overuse risks. This includes rigorous patient assessments, precise diagnostics, and education for healthcare professionals and patients to combat resistance and elevate care standards, safeguarding the efficacy of antibiotics for current and future patients (Bankar et al., 2022).

Objectives and Elements

The objectives of our study encompass evaluating the implementation and impact of an AMS program within the HITH model, where 50% of our patient cohort receive IV antibiotic therapy. This entails assessing the influence of the AMS program on antibiotic utilisation and patient outcomes, particularly in cases of complex medical conditions. Importantly, our study aims to ensure strict compliance with the ACHS Clinical Governance Standard and the Partnering with Consumers Standard, reflecting our commitment to maintaining high healthcare standards and engaging patients in their care. Key components of our AMS program involve comprehensive patient assessments, precise diagnostics, healthcare professional and patient education, ongoing monitoring, and the meticulous observance of ACHS standards, collectively serving to optimise antibiotic use and improve the quality of care within the HITH framework.

AMS Strategies

In HITH programs, AMS strategies are pivotal for enhancing patient outcomes through responsible antibiotic use. These strategies involve a comprehensive patient assessment, leveraging evidence-based guidelines to make informed antibiotic decisions (Kakkar et al., 2020). Multidisciplinary collaboration is vital, bringing together diverse healthcare professionals for holistic care, precise diagnostics, and customised antibiotic treatments (Taberna et al., 2020). Regular monitoring tracks antibiotic use and emerging resistance, enabling timely intervention. Educational initiatives and antibiotic formulary restrictions foster responsible antibiotic use (Shrestha et al., 2022). These integrated strategies ensure optimal patient care, reduce overuse, and combat resistance, all critical within the HITH framework.

Program Elements

The AMS program incorporates several key elements, each vital in optimising antibiotic use within healthcare institutions. The Antimicrobial Prescribing Flow Chart is a systematic tool that guides healthcare providers through evidence-based antibiotic prescribing, emphasising clinical conditions, allergies, and resistance patterns (Queensland Health, 2022). Weekly board rounds gather multidisciplinary teams to assess patients receiving antibiotics collaboratively, ensuring informed decision-making and treatment adjustments (Janssen et al., 2023). Patient Antibiotic Education Sheets inform patients and their families about antibiotic therapy, promoting adherence and responsible use (Boiko et al., 2020). Empowering nurses with flow charts and drug formularies facilitates accurate antibiotic administration and compliance with formulary guidelines, enhancing patient safety and care quality (Mula et al., 2020). These elements collectively strengthen AMS programs and patient outcomes.

Methods

Our study employed a retrospective methodology, focusing on the HITH model's AMS practices. Data collection involved extracting relevant information from patient records, encompassing medical histories, clinical assessments, antibiotic prescriptions, and treatment durations for patients receiving antibiotics in HITH during a specified timeframe. We evaluated the appropriateness of antibiotic prescribing, patient outcomes, and adherence to AMS guidelines and conducted a cost analysis. This allowed us to assess the impact of AMS strategies on antibiotic utilisation and patient care, including their effectiveness in ensuring responsible antibiotic use, enhancing patient outcomes, and addressing the pressing issue of antibiotic resistance within the HITH model.

Results

Our study yielded crucial findings, foremost among them being the marked improvements in antibiotic utilisation practices within the HITH setting through integrating AMS strategies. Implementing evidence-based guidelines, prescribing flow charts, and the multidisciplinary collaboration facilitated by weekly board rounds led to more reasonable and tailored antibiotic use, significantly reducing unnecessary prescriptions. We will underscore the significance of early adverse event identification through a case study where AMS practices allowed prompt recognition and adjustment of a patient's treatment plan during a board round, ensuring patient safety. Additionally, patient antibiotic education sheets effectively empowered patients, enhancing adherence and fostering responsible antibiotic use, ultimately contributing to improved patient outcomes. These findings emphasise the pivotal role of AMS in elevating patient care standards.

Case Study

In our case study, Mrs. Smith, a 68-year-old HITH patient with a urinary tract infection, experienced a critical incident demonstrating the value of AMS strategies. During a weekly board round, healthcare professionals noted her worsening condition, including fatigue, dizziness, and abnormal blood pressure. Empowered by AMS practices, they recognised these as potential adverse events related to antibiotic therapy. Promptly, the antibiotic regimen was adjusted, and liver function was monitored closely. This swift intervention led to Mrs. Smith's recovery, emphasising the importance of AMS in early adverse event identification, safeguarding patient well-being, and reinforcing the significance of responsible antibiotic use within HITH settings.

Patient Outcomes

AMS substantially impacts patient outcomes, as reflected in various statistics. Firstly, responsible antibiotic use, guided by AMS strategies, has reduced the average length of antibiotic treatment, minimising the risk of antibiotic resistance and side effects (Azim Majumder et al., 2020). Additionally, AMS has contributed to a decline in readmission rates due to treatment failures, as seen in a study by Mauro et al. (2021), where readmission rates for antibiotic-sensitive infections reduced from 24.9% to 9.3% over thirty days. Lastly, the incidence of antibiotic-related adverse events has decreased as timely intervention, and adverse event monitoring has improved through AMS, ensuring patient safety and reducing complications (Bauer et al., 2019).

Discussion

Our study underscores the paramount significance of AMS within HITH settings. Tailored regimens promote patient health and align with global efforts against antibiotic resistance by reducing the average length of antibiotic treatment through responsible prescribing practices. Shorter treatment durations curtail the risk of overexposure, addressing the driver of resistance development. The notable drop in readmission rates underscores AMS's pivotal role in ensuring treatment efficacy, conserving healthcare resources and alleviating patient financial burdens. Moreover, reducing antibiotic-related adverse events accentuates AMS's importance in enhancing patient safety, with proactive monitoring and timely interventions being critical components. In the HITH model, AMS is an essential guardian of patient safety, reducing healthcare costs and aiding in the fight against antibiotic resistance while providing hospital-level care in the comfort of patients' homes.

Conclusion

Key takeaways from our study highlight the transformative impact of Antimicrobial Stewardship (AMS) in Hospital in The Home (HITH) settings. AMS strategies optimise antibiotic use, resulting in informed, tailored, and effective treatment, curbing overuse and minimising risks. Patient outcomes are notably enhanced with reduced treatment durations, lower readmission rates, and fewer antibiotic-related adverse events due to proactive monitoring and timely intervention. Moreover, AMS contributes to cost-efficiency by reducing unnecessary healthcare expenses and prolonged hospital stays. To ensure patients experience high-quality care in their homes, protect patient safety, lower healthcare costs, and fight antibiotic resistance globally, it is crucial to integrate AMS into HITH programs.

Future directions

AMS strategies have a bright future thanks to prospective research and advancements. The prompt identification of resistance patterns can be improved using sophisticated data analytics and predictive algorithms. Based on unique genetics, pharmacogenomics delivers customised antibiotic therapy. With the expansion of virtual healthcare, AMS integration into telemedicine is essential. Rapid pathogen identification for customised therapy is made possible by innovative diagnostic technologies. Technologies for patient participation, such as wearables and smartphone apps, provide patients more control over their care. Collaboration on a global scale is essential to combating antibiotic resistance. Research in these fields will strengthen AMS initiatives, ensuring efficient antibiotic use and battling resistance in a healthcare environment that is constantly changing.

References

Australian Commission on Safety and Quality in Health Care (ACSQHC). (2018). Antimicrobial Stewardship in Australian Health Care. https://www.safetyandquality.gov.au/sites/default/files/migrated/Chapter1-Evidence-for-antimicrobial-stewardship.pdf

Azim Majumder, M. A., Rahman, S., Cohall, D., Bharatha, A., Singh, K., Haque, M., & Gittens-St Hilaire, M. (2020). Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health. Infection and Drug Resistance, 13, 4713-4738. https://doi.org/10.2147/IDR.S290835

Bankar, N. J., Ugemuge, S., Ambad, R. S., Hawale, D. V., & Timilsina, D. R. (2022). Implementation of Antimicrobial Stewardship in the Healthcare Setting. Cureus, 14(7). https://doi.org/10.7759/cureus.26664

Bauer, K. A., Kullar, R., Gilchrist, M., & File Jr, T. M. (2019). Antibiotics and adverse events: The role of antimicrobial stewardship programs in ‘doing no harm’. Current Opinion in Infectious Diseases, 32(6), 553-558. https://doi.org/10.1097/QCO.0000000000000604

Boiko, O., Gulliford, M. C., & Burgess, C. (2020). Revisiting patient expectations and experiences of antibiotics in an era of antimicrobial resistance: Qualitative study. Health Expectations, 23(5), 1250-1258. https://doi.org/10.1111/hex.13102

Janssen, R. M., Oerlemans, A. J., Van der Hoeven, J. G., Oostdijk, E. A., Derde, L. P., Ten Oever, J., Wertheim, H. F., Hulscher, M. E., & Schouten, J. A. (2023). Decision-making regarding antibiotic therapy duration: An observational study of multidisciplinary meetings in the intensive care unit. Journal of Critical Care, 78, 154363. https://doi.org/10.1016/j.jcrc.2023.154363

Kakkar, A. K., Shafiq, N., Singh, G., Ray, P., Gautam, V., Agarwal, R., Muralidharan, J., & Arora, P. (2020). Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems. Frontiers in Public Health, 8. https://doi.org/10.3389/fpubh.2020.00140

Kanagala, S. G., Gupta, V., Kumawat, S., Anamika, F., McGillen, B., & Jain, R. (2023). Hospital at home: Emergence of a high-value model of care delivery. The Egyptian Journal of Internal Medicine, 35(1). https://doi.org/10.1186/s43162-023-00206-3

Mauro, J., Kannangara, S., Peterson, J., Livert, D., & Tuma, R. A. (2021). Rigorous antibiotic stewardship in the hospitalized elderly population: Saving lives and decreasing cost of inpatient care. JAC-Antimicrobial Resistance, 3(3). https://doi.org/10.1093/jacamr/dlab118

Mula, C. T., Middleton, L., Muula, A., Solomon, V., & Varga, C. (2020). Nurses’ role in antibiotic stewardship at medical wards of a referral hospital in Malawi: Understanding reality and identifying barriers. International Journal of Africa Nursing Sciences, 15, 100311. https://doi.org/10.1016/j.ijans.2021.100311

Queensland Health. (2022). Antimicrobial: Prescribing, Management and Stewardship. https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/ams/proc_01036.pdf

Shrestha, J., Zahra, F., & Cannady Jr, P. (2021). Antimicrobial stewardship. https://europepmc.org/article/NBK/nbk572068

Taberna, M., Moncayo, F. G., Jané-Salas, E., Antonio, M., Arribas, L., Vilajosana, E., Torres, E. P., & Mesía, R. (2020). The Multidisciplinary Team (MDT) Approach and Quality of Care. Frontiers in Oncology, 10. https://doi.org/10.3389/fonc.2020.00085

World Health Organisation. (2021). Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance

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