Removing Antimicrobial “Pebbles” – Helping You and Helping Our Community

Column Author: Annie Wirtz, PharmD, BCPPS | Adjunct Clinical Associate Professor of Pharmacy, University of Missouri-Kansas City School of Pharmacy

Elizabeth Monsees, PhD, MBA, RN, CIC, FAPIC | Senior Director, Infection Prevention & Stewardship Integration and Assistant Professor, UMKC School of Medicine

Column Editor: Rana El Feghaly, MD, MSCI | Director, Clinical Services | Director, Outpatient Antibiotic Stewardship Program | Associate Professor of Pediatrics, UMKC School of Medicine

With the rising threat of multidrug-resistant organisms, harm from antibiotic use, and a limited pipeline of new and novel antibiotic agents, antimicrobial stewardship programs (ASPs) are vital to health care systems to achieve safe care for all patients. What was previously thought of as an inpatient-only initiative, antimicrobial stewardship is rapidly expanding into different venues (i.e., outpatient settings) and domains (e.g., diagnostic stewardship).¹ Efforts are being made to involve all disciplines in some form of stewardship work to extend reach.

However, within health care, burnout is at an all-time high, making it challenging for ASPs to engage other disciplines. Health care workers must be thoughtful in deciding which additional tasks they take on in order to ensure efforts are value-added and sustainable. The Center for Wellbeing at Children’s Mercy was recently awarded Silver recognition from the American Medical Association as a Joy in Medicine™ organization. One strategy enacted by the Center is having a systemwide approach available to all health care workers to identify and mitigate “pebbles in the shoe” or frustrating factors within the workplace. Such methods may reduce burnout by enhancing team members’ sense of accomplishment, satisfaction and engagement, and most importantly by removing barriers to getting work done more easily.² Concentrating on the work that a team feels is valuable and important to prioritize versus work that feels just time consuming, distracting or of low value is also known as “focusing on your Blue Chips.”³

The safe and appropriate use of antimicrobials is applicable to all, with most health care professionals either prescribing, administering, dispensing or consuming them at some point. Many “pebbles in the shoe” relate to antimicrobials that arise for frontline providers in day-to-day practice. Based on our personal experience, we feel that mitigating antimicrobial “pebbles” can have benefits in two main ways: extending the reach of stewardship by engaging frontline providers in efforts to improve antimicrobial issues and addressing burnout with work that is valuable and impactful to many. Below we describe two examples of “pebbles” identified and addressed by frontline providers at Children’s Mercy in conjunction with the ASP team.  

“Pebble”: Antimicrobial Waste. In 2019, during rounds, the ASP initiated a conversation with frontline nurses about their involvement in antimicrobial use. One nurse, working on a postoperative floor, shared that many unused doses of cefazolin were being discarded upon patient discharge. The nurse was bothered about these wasted hospital supplies, employee time and money. Our ASP recognized that cefazolin had been previously plagued by medication shortages. ASP began assessing hospital-wide antimicrobial waste and discovered that in 2018, 18,501 antimicrobial doses were wasted, amounting to $252,810 in drug cost alone. Cefazolin was a top contributor and was frequently wasted on the floor of the nurse who identified the problem. Our ASP engaged local leaders, who identified reasons for wasted antimicrobial doses and brainstormed efforts to reduce waste, specifically focusing on postoperative cefazolin doses. We discovered an issue with the electronic health record at the point of pharmacist verification that led to extra cefazolin doses being dispensed. Additionally, ordering prolonged courses of postoperative antimicrobials also contributed to waste. With quality improvement efforts and multidisciplinary engagement, we were able to reduce the odds of wasting a postoperative cefazolin dose by 16%.¹ Because of this nurse’s recognition of a “pebble” within her area of work, we were able to unearth and mitigate a large antimicrobial stewardship problem that was meaningful to frontline providers.

“Pebble”: Penicillin Allergy. Another “pebble” related to antimicrobials is penicillin allergy reconciliation. Often, penicillin allergies are not clarified fully and details about the reaction remain unknown. The presence of a penicillin allergy limits antimicrobials available for use, requiring use of more costly, difficult to find, or less ideal alternatives.⁴ Carter et al. engaged nurses in improving documentation of penicillin allergies, a major role that nurses play in optimizing antibiotic therapy and of equal measure an activity nurses felt motivated to improve. Nurses used the mnemonic STORY (Symptoms, Timing, Onset, Resolution, Yet again), which was felt to improve documentation, communication and allergy assessment.⁵ Nurses at the Children’s Mercy East Urgent Care reported a similar “pebble,” recognizing that often families will report side effects to penicillin as adverse drug events or allergies. Over the past couple of years, urgent care nurses and prescribers have partnered with ASP to develop a survey to assess comfort with identifying allergies, designed an interactive educational module to boost knowledge of penicillin allergies, and developed an algorithm to distinguish true allergies from side effects, including scripted language to enhance conversation with families and prescribers. The local urgent care leaders were instrumental in supporting engagement by all team members and empowering them to refine processes that stand in the way of way of actions they believe are correct. Through this work, we hope to be able to improve documentation of penicillin allergies and improve appropriate antimicrobial use.

Overall, there are many opportunities to get involved in stewardship work, but we recognize the competing priorities, demands, and risk of burnout facing health care workers. While you may not have the time, resources or energy to conduct large antimicrobial stewardship projects, we ask you to recognize and think about ways to mitigate even the small antimicrobial “pebbles” within your practice. In doing so, we feel this will extend stewardship reach and bring a sense of accomplishment, satisfaction and engagement to health care – helping you and helping our community.

References:

1. Monsees E, Wirtz AL, Krein S. Stewardship 2.0: embracing elements of implementation science to enhance everyday antimicrobial stewardship efforts. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e149. doi:10.1017/ash.2023.413
2. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Institute for Healthcare Improvement; 2017.
3. Keenan J. Culture conversation: blue chips. University of Nebraska Medical Center. March 31, 2021. https://www.unmc.edu/newsroom/2021/03/31/culture-conversation-blue-chips/
4. Shah NS, Ridgway JP, Pettit N, Fahrenbach J, Robicsek A. Documenting penicillin allergy: the impact of inconsistency. PLoS One. 2016;11(3):e0150514.
5. Carter EJ, Schramm C, Baron K, Zolla MM, Zavez K, Banach DB. Perceived usefulness of a mnemonic to improve nurses’ evaluation of reported penicillin allergies. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e124. doi:10.1017/ash.2023.177