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Let’s Manage the Antibiotic Misuse

Regulatory Compliance Part 2:

The misuse of antibiotics in hospitals is prevalent.  It is estimated that up to 50% of antibiotic use is unnecessary or inappropriate leading to increased costs, adverse medication effects, rise in C. Difficile, and increased resistances. In June 2015, The White House organized a forum on Antibiotic Stewardship bringing together over 150 health care organizations and other stakeholders, to create and implement programs which decrease the misuse of antibiotics and the accompanying problems associated with the misuse.

The Joint Commission (TJC) has developed an antimicrobial stewardship program for hospitals including critical access hospitals, nursing care centers, ambulatory health care, and office based surgery practices.  The new medication management standard (MM.09.01.01) became effective January 1, 2017.

The eight elements of performance for MM.09.01.01 include:

  1. Leaders establish antimicrobial stewardship as an organization priority.
  2. The organization educates staff and licensed independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and antimicrobial stewardship practices. Education occurs upon hire and periodically thereafter.
  3. The organization educates patients, and their families as needed, regarding the appropriate use of antimicrobial medications, including antibiotics.
  4. The organization has an antimicrobial stewardship multidisciplinary team that includes the following members, when available:
    • Infections disease physician
    • Pharmacist
    • Infection preventionist(s)
    • Practitioner
  5. The organization’s antimicrobial stewardship program includes the following core elements:
    • Leadership commitment- dedicating necessary human, financial, and information technology resources
    • Accountability: Appointing a single leader responsible for program outcomes
    • Drug expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use
    • Action:  Implementing recommended actions after a set period of initial treatment
    • Tracking:  Monitoring the antimicrobial stewardship program
    • Reporting: Regularly reporting information on the antimicrobial stewardship program to doctors, nurses, and relevant staff
    • Education:  Educating practitioners, staff, and patients on the antimicrobial program
  6. The organization’s antimicrobial stewardship program uses organization-approved multidisciplinary protocols.
  7. The organization collects and analyzes data on its antimicrobial stewardship program, including antimicrobial prescribing and resistance patterns.
  8. The organization acts on improvement opportunities identified in its antimicrobial stewardship program.

The requirements have been published in the 2017 Comprehensive Accreditation Manual for the Critical Access Hospital, Hospital, and Nursing Center Accreditation Programs.  Click here for a quick overview of the Antimicrobial Stewardship Standard and the other important TJC updates.

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