Q&A: Clinical nurses’ involvement in antimicrobial stewardship
Well-funded and well-rounded antimicrobial stewardship programs are critical in the fight against antimicrobial resistance, and including clinical nurses in antimicrobial stewardship interventions could help expand resources, researchers said.
Although the specific responsibilities for clinical nurses in antimicrobial stewardship programs have been outlined by the CDC and the American Nurses Association (ANA), there is not a great deal of information, evidence or data in the literature concerning prescribers’ attitudes toward the involvement of clinical nurses in antimicrobial stewardship efforts, according to William G. Greendyke, MD, assistant professor of medicine at Columbia University Irving Medical Center and associate hospital epidemiologist at New York-Presbyterian Hospital, and colleagues.
Between July 2017 and March 2018, Greendyke and colleagues conducted focus groups with prescribers from two tertiary-care academic medical centers in New York City. We spoke with Greendyke about what the focus groups revealed about prescribers’ attitudes toward nurses’ involvement in antimicrobial stewardship efforts and barriers to an effective partnership between nurses and prescribers. – by Marley Ghizzone
Q: How do prescribers view the role of the nurse in antimicrobial stewardship programs?
A: Historically, nurses have not routinely played a significant role in antimicrobial stewardship programs. However, many people have pointed out that bedside nurses are the most numerous frontline personnel within the health care system and could be a significant untapped resource for antimicrobial stewardship programs to partner with. In our study, we interviewed prescribers (physicians and nurse practitioners) to solicit their general thoughts regarding nurses and stewardship, as well as specific nurse-initiated antimicrobial stewardship recommendations from the CDC and the ANA. In general, prescribers viewed nurses as valuable partners who often had a deep breadth of experience for certain aspects of antimicrobial stewardship and were very much in favor of using that experience to further stewardship goals. For instance, one pediatrician reflected on a bedside nurse’s ability to recognize red man syndrome in a patient receiving vancomycin, notify the prescriber and reassure a panicky parent. Such active involvement among nurses may result in the downstream improvement of antibiotic prescribing.
Q: What interventions did prescribers support, and what barriers to an effective partnership between prescribers and nurses did you identify?
A: Providers were most in favor of interventions that could potentially be easily implemented within the structure and workflow of a given unit. For instance, in our medical ICU, nurses are well-integrated into daily rounding with the physician team, and a hypothetical intervention regarding a nursing-initiated antibiotic timeout was well-received among prescribers there. It seemed to me that one reason for this was the existence of a forum for nurses to have these conversations with physicians during rounds.
The other factor I noticed was that prescriber groups were enthusiastic about interventions that addressed an unmet need on a given unit. An intervention that nurses prompt prescribers to switch from an IV to [oral] antibiotics was thought to be very helpful on the pediatric ward, where nurses are keenly aware of patients’ ability to tolerate oral intake and regularly discuss their assessments with prescribers. Conversely, in the medical ICU, a critical care clinical pharmacist performs this role already when rounding with the prescriber team, and the role of nurses performing this intervention was felt to be extraneous.
Q: Are these findings generalizable to other hospitals?
A: One limitation is that our focus groups were performed at only two hospitals on a single campus. That said, we interviewed a variety of prescribers at various training levels and specialties. Across the board, nearly everyone welcomed nurses taking on an increased role in antimicrobial stewardship. What that increased role may look like varied significantly across the prescriber groups we interviewed and would likely look different depending on a hospital’s stewardship needs.
Q: Do they support changing antimicrobial stewardship guidelines?
A: I sensed that prescribers would welcome changing stewardship guidelines to recommend greater nursing involvement. The threat of growing antimicrobial resistance and the efforts of our local stewardship team have convinced prescribers that antimicrobial stewardship plays a vital role in providing safe and effective care to patients. I think prescribers would welcome partnership with any discipline that helps forward these goals. I sensed that prescribers would be reluctant to change guidelines in an overly prescriptive way; it was clear that nursing-driven stewardship interventions should take into account the culture of a local unit.
Q: What is the biggest takeaway from the study?
A: With antimicrobial stewardship now being a Joint Commission standard for all hospitals, it will be important for everyone to think strategically about how best to implement stewardship in all inpatient settings. Clinical nurses spend more time at an individual patient’s bedside than any other member of the health care team, and antimicrobial stewardship programs should not overlook what nurses can bring to the table. Although needs may vary between units, antimicrobial stewardship programs should examine how nurses may be able to extend their reach and influence among prescribers.
Disclosures: The authors report no relevant financial disclosures.