Collaborative Solutions to Antibiotic Stewardship in Small Community and Critical Access Hospitals : Academic Medicine

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Invited Commentaries

Collaborative Solutions to Antibiotic Stewardship in Small Community and Critical Access Hospitals

Bhatt, Jay DO; Smith, Brian MPH; Neuhauser, Melinda M. PharmD; Srinivasan, Arjun MD, MPH, MPA; Moore, Paul DPh; Hyun, David Y. MD

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Academic Medicine 94(10):p 1419-1421, October 2019. | DOI: 10.1097/ACM.0000000000002859
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Inappropriate prescribing of antibiotics creates a significant concern for patient safety and results in the development of antibiotic resistance, a growing public health threat.1,2 Estimates suggest that roughly one-third of antibiotic pre scriptions in hospitals may be in appro priate, and use of broad-spectrum anti biotics in these facilities has increased.3–5 Efforts to ensure appropriate use of antibiotics are critical to mitigate the emergence and spread of antibiotic-resistant bacteria but can be uniquely challenging for small hospitals. Nonethe less, these efforts are important in critical access hospitals as, according to unpublished data from the Centers for Disease Control and Prevention (CDC), these facilities have use rates that are as high as or higher than those of larger hospitals.

Antibiotic stewardship programs (ASPs) in health care settings are designed to optimize the initiation, selection, dosing, and length of treatment for antibiotic therapies, consequently slowing the emergence of antibiotic resistance while minimizing adverse drug events and improving cure rates. In 2014, the CDC called for all hospitals, regardless of size, to implement an ASP. The American Hospital Association (AHA) also has highlighted ASPs as an important approach to optimizing medical resources, improving health outcomes, providing higher-quality care for patients, and lowering health care costs.4,6 In response to increased calls for hospitals to adopt ASPs,7,8 several national policies and resources have been put forth to accelerate implementation of such programs: The CDC developed the “Core Elements of Hospital Antibiotic Stewardship Programs,” which highlights the key components of a successful hospital ASP; the Joint Commission issued new accreditation standards requiring implementation of ASPs in hospitals; and the National Quality Forum issued a “Playbook on Antibiotic Stewardship in Acute Care” that provides detailed examples of successful ASP implementation in acute care settings.9–11

While the number of hospitals with ASPs has increased in recent years, program adoption rates vary by hospital size. According to unpublished CDC data, as of 2016, 64% of acute care hospitals had implemented ASPs that met all 7 of the CDC’s core elements, but that figure represents 82% implementation in hospitals with more than 200 beds compared with 46% of hospitals with fewer than 50 beds. These findings underscore the challenges that lie ahead in expanding antibiotic stewardship efforts in small community and critical access hospitals, which treat underserved patient populations in rural areas and generally have very few beds, limited resources, and staff with multiple functions. Limitations in financial resources, access to experts in infectious disease and antibiotic stewardship, and technological infrastructure to facilitate data collection and analysis can pose significant obstacles to ASP implementation in these settings.

Despite these resource challenges, small hospitals are finding ways to implement successful stewardship programs. In April 2017, the Pew Charitable Trusts, AHA, the Federal Office of Rural Health Policy (FORHP), and the CDC convened facility staff who lead successful stewardship programs in small community and critical access hospitals. The examples and recommendations these participants shared were used to create a guidance document for implementing ASPs in these facilities.12

A central lesson that emerged from this exercise was how organizations outside of small community and critical access hospitals can play a significant role in filling resource gaps and bolstering stewardship efforts. In this Invited Commentary, we outline how academic medical centers, health care systems, state and local health departments, hospital associations, and rural health associations can leverage their existing resources and networks to lead collaborative activities where stewardship tools and expertise can be pooled and shared with smaller hospitals. Expansion of these types of efforts across regions through the leadership of state and local health organizations will be critical to the implementation of stewardship programs in all hospitals, as well as protecting patients from the growing threat of antibiotic resistance. Furthermore, medical schools, academic health systems, and community hospitals are critical venues for medical education. Antibiotic stewardship should be a core component of the curriculum in medical school and residency to help enhance adoption of the core elements among future physicians.

Academic Medical Centers and Health Care Systems

Large hospitals and academic medical centers have many of the resources needed for implementing ASPs, including infectious disease physicians, pharmacists, and data analysis capabilities to measure antibiotic use. These large medical centers, as well as their health care systems, can take the lead in providing on-site stewardship resource support for the development of ASPs in other hospitals, including small and critical access hospitals. An example of this type of collaboration is the Duke Antimicrobial Stewardship Outreach Network at Duke University, which provides stewardship consultation and data support for a network of 28 small community hospitals in Georgia, Florida, North Carolina, South Carolina, Virginia, and West Virginia. It shows that successful partnerships and support for antibiotic stewardship can be achieved even among hospitals that are not owned or operated within the same health system. These collaborative approaches in antibiotic stewardship can help address antibiotic resistance in the region and in the local patient population frequently shared by facilities.13

State and Local Health Departments

Many state and local health departments are already engaged in efforts to support ASPs in acute care hospitals. Health departments have supported ASPs through developing ASP tool kits, organizing learning and training collaboratives for stewardship, and providing technical support for antibiotic use reporting to the CDC’s National Healthcare Safety Network. For example, the Kansas Department of Health and Environment and the California Department of Public Health have created ASP tool kits with detailed information on how to implement or improve the core elements of stewardship.14,15 The Kansas tool kit is specifically focused on implementing ASPs in critical access hospitals.

Many of the state and local activities are funded through the CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement. Most of these efforts are collaborations between the health department, hospital association, and academic partners. Tailoring this support from state partners to fit the needs of small community and critical access hospitals can further support implementation and operation of ASPs. By providing education and technical assistance specific to small hospitals and facilitating partnerships between hospitals and public health stakeholders, state and local health departments can help coordinate and consolidate resource support for ASP development in their region.

Hospital Associations

Hospital associations can lead collaborative antibiotic stewardship efforts as part of their initiatives to improve quality of care and patient safety. Several hospital associations have undertaken stewardship projects that have shown to be valuable resources for small community and critical access hospitals, especially for those that are not part of larger health care systems. The Colorado Hospital Association started its Antimicrobial Stewardship Collaborative in 2015, providing on-site and remote consultations with infectious disease physicians and pharmacists, educational webinars and meetings, and data collection and analysis tools for 27 hospitals including 10 critical access hospitals.16 Similar models can be employed by other hospital associations trying to improve health care safety and quality performance for their members.

Hospital associations also can help their member hospitals meet regulatory standards pertaining to antibiotic stewardship by informing them of new rules or changes to existing regulations and providing education and technical assistance. An example of this can be found in Missouri, where the Missouri Hospital Association has created an Antibiotic Stewardship Immersion Project to help participating hospitals meet new regulatory requirements for ASPs outlined by the Joint Commission Antibiotic Stewardship Standards and Missouri statute.17,18 This project provides individualized guidance for hospitals on how to implement specific stewardship interventions through quarterly virtual meetings, monthly coaching calls, and on-site visits.

The AHA’s not-for-profit research and education affiliate, the Health Research & Educational Trust, has provided educational materials for member hospitals, including webinars providing examples of ASP implementation and guides highlighting best practices in reducing hospital-acquired infections and promoting patient safety and quality.19–21 These ASP resources can be tailored toward small and critical access hospitals and applied to meet the unique needs of these settings.

FORHP and State Flexibility Grant Programs

FORHP administers the Medicare Rural Hospital Flexibility Grant (FLEX) program, which provides rural-specific technical assistance and resources for quality improvement initiatives and programs to over 1,340 critical access hospitals. Funds through the FLEX program are then administered by state FLEX programs across the 45 states that have critical access hospitals to coordinate and support capacity building and technical assistance for individual facilities.22

Starting in 2018, the FLEX program will include the implementation of ASPs as a required element for quality improvement reporting by participating critical access hospitals.23 This policy inclusion will help prioritize ASP development for hospital leadership while also mobilizing resources for these settings to support implementation of ASPs. Both FORHP and state FLEX programs can work with critical access hospitals participating in the FLEX program to provide technical and regulatory assistance.


Although ASPs are effective at improving antibiotic prescribing and reducing resistance, there is a disparity in implementation rates by hospital type, with smaller hospitals lagging behind larger ones. Consequently, the goal of reducing inappropriate antibiotic use cannot be fully realized until the barriers holding back implementation in these settings are overcome. By collaborating with small community and critical access hospitals, academic medicine, medical education, public health agencies, hospital associations, and health care systems can help organizations fill their resource gaps for implementing ASPs while supporting their efforts to establish effective and comprehensive programs. These partnerships will be vital in reaching the national goal of developing successful stewardship programs in every acute care hospital, ultimately slowing the threat of antibiotic resistance and improving patient outcomes.


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14. Kansas Department of Health and Environment. Antimicrobial Stewardship Programs: A Toolkit for Critical Access Hospitals in Kansas. 2016. Topeka, KS: Kansas Department of Health and Environment; Accessed June 21, 2019.
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16. Colorado Hospital Association. Colorado Hospital Association’s Antimicrobial Stewardship Collaborative. 2015. Greenwood Village, CO: Colorado Hospital Association; Accessed June 21, 2019.
17. Missouri Hospital Association. Antibiotic Stewardship Immersion Project. 2016. Jefferson City, MO: Missouri Hospital Association; Published 2016. Accessed June 21, 2019.
18. Missouri Senate Bill No. 579. February 3, 2016. Accessed June 21, 2019.
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20. Health Research & Educational Trust, American Hospital Association. The secret of getting ahead is getting started. Published June 1, 2017. Accessed June 21, 2019.
21. Health Research & Educational Trust. Clostridium difficile infection change package: 2017 update. Published 2017. Accessed June 21, 2019.
22. U.S. Department of Health and Human Services. Medicare Rural Hospital Flexibility Grant Program. Published 2017. Accessed June 21, 2019.
23. Federal Office of Rural Health Policy. MBQIP measures: Flex project period: FY2018–2021. Published 2017. Accessed June 21, 2019.