Standard 3: Preventing and Controlling Healthcare Associated Infections
3.14 Antimicrobial stewardship - in small health service organisations (less than 50 beds)
Action
3.14.1 An antimicrobial
stewardship program is in place
TRIM: 74777 | Updated 19 December 2013
Requirements
Can the facility show:
Explanatory notes
 a baseline assessment to
provide a snapshot of current
resources and activity to
support an Antimicrobial
Stewardship (AMS) program

A summary or “map” of current governance arrangements, policies, processes and
resources that can be used to support AMS. A baseline assessment can be used to
understand the local context for implementation and identify actions required for
implementing a program.
 a team or committee relevant
to facility size and structure,
with terms of reference

The team may be established within a facility (onsite) or as part of a Local Hospital
Network/ District committee, depending on the local circumstance

The AMS team should work with relevant individuals, such as the person responsible
for infection prevention and control or quality and safety, to encourage coordination
and reduce duplication of effort

The AMS team should also have links with any relevant existing committees or
groups, such as committees responsible for drug and therapeutics and infection
prevention and control

The AMS team will reflect the size of the facility and complexity of services offered.
Examples of team composition include:
o
a medical practitioner, the facility manager and a pharmacist (if available) or
nurse
o
a group of interested clinical staff and a member of the facility management
o
visiting clinicians and/or pharmacists that have expressed an interest in
supporting AMS
o
an existing committee such as one responsible for drug and therapeutics, or
infection prevention and control.
3.14 Antimicrobial stewardship - in small health service organisations (less than 50 beds)
Action
(Continued)
Requirements
 A governance structure for
AMS that includes
communication lines with the
AMS team and roles and
responsibilities of
executive/management in
supporting the team and
stewardship activities
 a program plan that includes
actions for implementation
and timeline
Explanatory notes

The governance structure should incorporate formal structural alignment of the AMS
team to relevant committees and be endorsed by the hospital executive

While specialist infectious disease clinicians, medical microbiologists and
pharmacists may not be onsite in a small facility, access to and involvement of these
experts will assist in an effective AMS program

Hospital or relevant network district governance arrangements should include
processes for seeking external specialist advice to support the local AMS team in the
program plan. For example, it may be possible to have a dedicated AMS pharmacist
and/or a specialist clinician responsible for coordinating stewardship activities across
a number of facilities, working in collaboration with local teams/committees.
To establish arrangements for external specialist advice, the program plan
should include documented strategies for negotiating such advice,
incorporating actions, responsibilities, timelines and a process to review
progress. Progress towards implementation should be monitored.
The AMS program plan will provide detail of how the program will be implemented, and
may be at facility or network/district level. It is essentially an action plan that describes
who/which group will be responsible for what actions, when each of the actions will be
put into place, the resources required and measures to be used to monitor progress.
The priorities should be guided by the results of the baseline assessment.
 a policy that specifies
prescribing clinicians should
follow Therapeutic Guidelines:
Antibiotic (or state based
guidelines based on
Therapeutic Guidelines:
Antibiotic)
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3.14 Antimicrobial stewardship - in small health service organisations (less than 50 beds)
Action
3.14.2 The clinical workforce
prescribing antimicrobials have
access to current endorsed
therapeutic guidelines on
antibiotic usage
3.14.3 Monitoring of antimicrobial
usage and resistance is
undertaken
Requirements
 prescribing clinicians have
access to Therapeutic
Guidelines: Antibiotic (may
include printed/hard copy or
electronic)
 a system for monitoring
antimicrobial usage is
documented and included in
the AMS program plan
 a system for monitoring
resistance is documented and
included in the program plan
 results of usage and
resistance monitoring are
reported to and reviewed by
the relevant committees
Explanatory notes

Therapeutic Guidelines: Antibiotic or state based endorsed guidelines

Monitoring antimicrobial usage and resistance is critical to understanding
antimicrobial prescribing trends and resistance patterns and should be addressed
within the program plan

The methods of monitoring antimicrobial usage should be relevant to the size and
complexity of the facility. Examples could include:

o
Reviewing the list of stock ordered and used each month, as well as reviewing
monthly expenditure of antimicrobials (the supplying pharmacy should be able to
provide usage reports)
o
Monitoring antimicrobial usage in a high risk area, in relation to a specific
procedure, clinical condition, or of high risk or broad spectrum antimicrobials and
later generation antimicrobials (e.g. 3rd and 4th generation cephalosporin and
quinolones). High use or high expenditure can provide a ‘flag’ for facilities to
undertake a more detailed analysis of usage such as a clinical audit/drug use
evaluation.
Methods of monitoring resistance should also be relevant to the facility and could
include:
o
Undertaking surveillance by reviewing the incidence of HAI in a targeted area, or
reviewing targeted organisms such as MRSA, VRE or ESBL.
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3.14 Antimicrobial stewardship - in small health service organisations (less than 50 beds)
Action
3.14.4 Action is taken to improve
the effectiveness of antimicrobial
stewardship
Requirements
 the AMS program plan
includes details of how
program effectiveness will be
monitored and reviewed
 the plan includes strategies to
reduce inappropriate use of
antimicrobials and optimise
their use
For further information please contact:
Australian Commission on Safety and Quality in Health Care
Phone 1800 304 056
http://www.safetyandquality.gov.au
Explanatory notes


Monitoring program effectiveness can be achieved through
o
Expanding usage monitoring to include high risk antimicrobials, or broad
spectrum antimicrobials and later generation antimicrobials (e.g. 3rd and 4th
generation cephalosporin and quinolones)
o
Identification and review of adverse events/incidents related to antimicrobial
prescribing
o
Effectiveness can be measured by reviewing usage reports, conducting audits or
using indicators from Quality Use of medicines Indicators for Australian Hospitals
o
Review of Staphylococcus aureus Bacteraemia rates (i.e. data collected for the
MyHospitals website) and documentation of actions taken to improve.
Strategies to reduce inappropriate use of antimicrobials in small facilities could
include :
o
Implementing antibiotic guidelines for common conditions such as community
acquired pneumonia
o
Implementing antibiotic guidelines for surgical prophylaxis
o
Developing a process to provide feedback to prescribers
o
Reviewing duration of use
o
Implementing an ‘IV to oral’ policy
o
Including in the program plan future actions for education programs to
incorporate content on AMR and AMS for relevant staff (consider available online programs such as antimicrobial prescribing modules
www.nps.org.au/health_professionals/online_learning, and ACSQHC
Antimicrobial stewardship for nurses e-learning module (latter currently under
development).
Strategies and resources to assist health care facilities with the
implementation of antimicrobial stewardship programs can be found in the
Commission publication Antimicrobial Stewardship in Australian Hospitals
2011, available at: http://www.safetyandquality.gov.au/our-work/healthcare- 4
associated-infection/antimicrobial-stewardship/