SHEA outlines legal considerations for antibiotic stewardship
The Society for Healthcare Epidemiology of America (SHEA) released a white paper outlining strategies for documenting the recommendations of antibiotic stewardship programs (ASP) and clarifying the stewardship team’s role in patient care from a legal and quality improvement standpoint. The white paper, titled “Legal Implications of Antibiotic Stewardship Programs,” was published in the journal, Infection Control and Hospital Epidemiology.
“Antibiotic stewardship has become a critical tool for healthcare systems to slow the emergence of antibiotic resistant bacteria and to improve patient outcomes and safety,” said Keith Hamilton, MD, a member of the SHEA Antimicrobial Stewardship Committee and author of the white paper. “However, it is important to address the legal implications of antibiotic stewardship programs, particularly around concerns about professional liability stewards may have to patients that they do not see or examine with the goal of disseminating best practices and reinforcing the essential roles that these programs play in all healthcare settings.”
The paper provides strategies to address common concerns and perceptions surrounding the legal implications of stewardship programs with the goal of improving the structure and function of the programs, as well as the benefits they provide to patients and patient care.
The guidance, based on expert consensus and a review of case law, addresses documentation, clinical training of stewardship program personnel, tele-stewardship, the use of clinical practice guidelines, and antibiotic stop orders. The authors surveyed SHEA members about concerns around the structure of antibiotic stewardship programs, interventions, and documentation to ensure the guidance reflected realities and concerns from the field.
While there have been no specific lawsuits filed involving ASP, the authors note three important components that should be included in hospitals’ programs to reduce liability and further advance the goals of ASP strategies.
1. Protocols to communicate and resolve differences with treating teams or other stakeholders to help achieve agreement on treatment strategy whenever possible.
2. Documentation practices in electronic health records to provide the basis of recommendations as well as preserve the record of ASP involvement.
3. Standards for credentialing ASP team members based on experience or formal training to ensure team member roles are aligned with expertise, licensure, and scope of practice regulations.
Visit Shea-online.org for the paper.
Stroke evaluations drop by nearly 40% during COVID-19 pandemic
The number of people evaluated for signs of stroke at U.S. hospitals has dropped by nearly 40% during the COVID-19 pandemic, according to a study led by researchers from Washington University School of Medicine in St. Louis who analyzed stroke evaluations at more than 800 hospitals across 49 states and the District of Columbia. The findings, published in The New England Journal of Medicine, are a troubling indication that many people who experience strokes may not be seeking potentially life-saving medical care.
“Our stroke team has maintained full capacity to provide emergency stroke treatment at all times, even during the height of the pandemic,” said lead author Akash Kansagra, MD, an assistant professor of radiology at Washington University’s Mallinckrodt Institute of Radiology (MIR). Kansagra sees stroke patients at Barnes-Jewish Hospital. “Nevertheless, we have seen a smaller number of stroke patients coming to the hospital and some patients arriving at the hospital after a considerable delay. It is absolutely heartbreaking to meet a patient who might have recovered from a stroke but, for whatever reason, waited too long to seek treatment.”
Nearly 800,000 people in the U.S. experience a stroke every year. It is the fifth leading cause of death and the leading cause of long-term disability. With advances in stroke care such as better diagnostic tools, surgeries to remove blood clots or repair broken blood vessels, and clot-busting drugs, people have a better chance of recovering from a stroke today than ever before – as long as they receive treatment promptly. Clot-busting drugs are generally safe only within 4½ hours of symptom onset, and surgeries are only possible within 24 hours of symptom onset. The earlier the treatment is started, the more successful it is likely to be.
Worried by the low numbers of stroke patients being evaluated at Barnes-Jewish Hospital and hearing similar reports from colleagues at other institutions, Kansagra – along with co-authors Manu Goyal, MD, a Washington University assistant professor of radiology and neurology, and statistician Scott Hamilton, PhD, and neurologist Gregory Albers, MD, both of Stanford University – set out to determine how pervasive the problem was.
When patients arrive at a hospital and are showing signs of a stroke, they often get a brain scan so doctors can identify what kind of stroke has occurred and choose the most effective treatment. Many hospitals, including Barnes-Jewish Hospital, use software known as RAPID to analyze such brain scans. Kansagra and colleagues assessed how often the software was used in February, before the pandemic, and during a two-week period from March 26 to April 8, when much of the country was under shelter-in-place orders.
In total, the software was used for 231,753 patients at 856 hospitals. During February, the software was used for an average of 1.18 patients per day per hospital. During the pandemic period, software use per hospital averaged 0.72 patients per day, a drop of 39%.
“Across the board, everybody is affected by this decrease,” said Kansagra, who is also an assistant professor of neurosurgery and of neurology. “It is not limited to just hospitals in urban settings or rural communities, small hospitals or large hospitals. It is not just the old or the young or the people with minor strokes who aren’t showing up. Even patients with really severe strokes are seeking care at reduced rates. This is a widespread and very scary phenomenon.”
There’s no reason to believe people suddenly stopped having strokes. And the drop was large even in places where COVID-19 cases were few and hospitals were not overwhelmed, so patients should not have found it unusually difficult to obtain treatment.
“I suspect we are witnessing a combination of patients being reluctant to seek care out of fear that they might contract COVID-19, and the effects of social distancing,” Kansagra said. “The response of family and friends is really important when a loved one is experiencing stroke symptoms. Oftentimes, the patients themselves are not in a position to call 911, but family and friends recognize the stroke symptoms and make the call. In an era when we are all isolating at home, it may be that patients who have strokes aren’t discovered quickly enough.”
Even during a pandemic, it is critically important for people who may be experiencing a stroke to receive care immediately, Kansagra said. The risk of delaying care for a stroke is much greater than the risk of contracting COVID-19.
WHO commemorates smallpox eradication
On May 8, 1980, the 33rd World Health Assembly officially declared: ‘The world and all its peoples have won freedom from smallpox.’ The declaration marked the end of a disease that had plagued humanity for at least 3,000 years, killing 300 million people in the 20th century alone. It was ended, thanks to a 10-year global effort, spearheaded by the World Health Organization (WHO), that involved thousands of health workers around the world to administer half a billion vaccinations to stamp out smallpox.
The US $300 million price-tag to eradicate smallpox saves the world well over US $ 1 billion every year since 1980.
Speaking at a virtual event hosted at WHO-HQ, involving key players in the eradication effort, WHO Director-General, Dr. Tedros Adhanom Ghebreyesus said, “As the world confronts the COVID-19 pandemic, humanity’s victory over smallpox is a reminder of what is possible when nations come together to fight a common health threat.”
Dr. Tedros highlighted that smallpox eradication also offers hope for efforts to eliminate other infectious diseases, including polio, which is now endemic in just two countries. To date, 187 countries, territories and areas have been certified free of Guinea worm disease, with seven more to go. And the fight against malaria has so far resulted in 38 countries and territories certified as malaria-free. In the case of Tuberculosis (TB), 57 countries and territories with low TB incidence are on track to reach TB elimination.
Premier Inc. survey shows hospitals’ COVID-19 testing must triple before surgeries resume
Premier Inc. has released survey results finding that healthcare facilities need to expand their current COVID-19 testing capacity by at least 211 percent in order to even partially resume full services, including elective procedures and diagnostic services.
While survey data indicates that 80 percent of respondents would like to increase their ability to conduct on-site COVID-19 testing, the main factors limiting these efforts are shortages of chemical reagents needed to perform the test (cited by 41 percent of respondents) and shortages of viral swabs (cited by 40 percent).
According to survey data, 81 percent of respondents intend to screen all employees for symptoms of COVID-19, including temperature and other symptom checks before resuming non-emergency procedures. However, given the limitations on testing supplies, only 32 percent said they will be able to proactively administer COVID-19 tests to all front-line healthcare workers, and only 22 percent will be able to test all ancillary employees such as foodservice workers or janitors. Until supplies are more readily available, 44 percent said they would have to limit testing to employees that are symptomatic. Further, 59 percent of respondents said they would have to limit re-testing of front-line workers to only those that show symptoms of having contracted COVID-19.
“A core component of any reopening strategy is broad testing capacity to minimize resurgence of COVID-19,” said Premier President Michael J. Alkire. “However, current restrictions on capacity and shortages of swabs and reagents force health systems to limit testing, prioritizing patients and front-line workers who are symptomatic. Even with these strict conservation protocols, capacity needs to at least triple before enough is available to support even a partial restoration of non-emergency services. This represents a major challenge to patient care, as an inability to offer elective procedures and diagnostics can mean a missed opportunity to detect preventable illnesses early or begin treatments that are necessary for health and wellness.”
For patients, 87 percent of respondents intend to proactively administer COVID-19 tests to any patient admitted for an elective procedure, but only 27 percent said they would be able to proactively test patients undergoing a diagnostic service. Most respondents (54 percent) will continue to bar any family members or other visitors from the facility in order to reduce the risk of spreading infection and conserve available testing.
“Without adequate supplies, health systems are having to make hard choices to be as judicious as possible with their COVID-19 testing capacity,” continued Alkire. “To reach an ideal state where testing is available for all healthcare workers, patients and caregivers, capacity will need to vastly expand. Premier is working proactively to identify additional sources of swabs and reagents to expand needed capacity. At Premier, our goal is to ensure that all our members have the right test, for the right person, at the right time.”
To assist members in their efforts to expand testing, Premier announced the formation of the COVID-19 Testing Advisory Panel. The Advisory Panel is made up of executives from Premier member health systems, large employers and other nationally recognized leaders who will assist in the creation of robust testing plans, assure testing is available for employers, provide recommendations for the best use of available testing technologies, align testing supplies and capacity with anticipated laboratory needs, create best practices and technical assistance to improving testing and surveillance programs, and ensure member access to accurate tests and equipment. hpn