Nurse Engagement in Antibiotic Stewardship Programs: A Scoping Review of the Literature

Abstract

Introduction:

Hospital-based antibiotic stewardship programs (ASPs) are an important strategy in combating antibiotic resistance. Four antibiotic stewardship interventions are recommended by the CDC as particularly well-designed to engage nurses. However, there is limited information on whether and how existing hospital-based ASPs reflect these practices.

Purpose:

To describe how nurses are being engaged in hospital ASPs and to what extent this overlaps with the CDC framework.

Methods:

This scoping review included studies published in the last ten years on engaging nurses in hospital-based ASPs. Three databases, PubMed, CINAHL, and Embase, were searched.

Results:

The search yielded 195 unique manuscripts. Ten manuscripts were retained for review detailing how nurses are engaged. One CDC recommended intervention, initiating discussion of antibiotic treatment, appeared in nine studies.

Conclusions:

While hospitals are engaging nurses in antibiotic stewardship programs, their selected approaches do not reflect the full breadth of the opportunities identified by the CDC. More detail as to how exactly nurses engage would also be a useful addition to the literature.

Implications:

More research is needed on nurse engagement on culturing/testing and penicillin allergy evaluation. Standardized measures should be collected and reported to measure the impact of engaging nurses in ASPs.

INTRODUCTION

Health care across the world has entered a post-antibiotic era; people are dying from infections because some organisms have become resistant to antibiotics.¹ In 2019, the Centers for Disease Control and Prevention (CDC) estimated that over 2.8 million antibiotic resistant infections occur in the US each year, resulting in more than 35,000 deaths.¹ In Europe, 33,000 people die from antibiotic resistant infections annually as of 2018.² Estimates also suggest as of 2011 that the annual economic burden of these infections is $55 billion in the US, €1.5 billion yearly in the European Union, and is projected to impose a total burden of $100 trillion globally by 2050 if improvements are not made.^3–5

Antibiotic stewardship programs (ASPs) have emerged as one strategy to decrease the burden of antibiotic resistant infections. ASPs target the appropriate use of antibiotics, including preventing overuse, through multi-level, multi-disciplinary action.^6,7 In 2015, CDC’s National Action Plan for Combating Antibiotic-Resistant Bacteria called for the establishment of ASPs in all acute care hospitals by 2020, naming eight Core Elements for inclusion – hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, education, and CDC support.^6,8 As of 2018, 85% of acute care hospitals in the US reported having all CDC Core Elements for ASPs in place.⁶

In US hospitals, nursing comprises the largest sector of the workforce accounting for 30% of employees worldwide and the largest occupational group in the health sector, accounting for approximately 59% of the health professions.^9,10 As such, the potential impact of nurses to play critical roles in multidisciplinary ASPs is evident. In a 2018 study of inpatient staff nurses, 69.4% of nurses understood what the term “antibiotic stewardship” meant, 54% of nurses perceived that they were already functioning in a stewardship role, and the majority wanted to be more involved in the stewardship process.¹¹ In 2019, the CDC added a new category of nursing-based actions to the Core Elements for Hospital ASPs to reflect the important role that nurses play.⁶ The report identified four opportunities in which hospital leadership may engage nurses in ASPs, including: 1) optimizing testing/diagnostic stewardship [e.g., assessing if a patient might have symptoms that justify a urine culture]; 2) assuring that cultures are performed correctly prior to starting antibiotics; 3) initiating discussions about antibiotic treatment; and 4) improving evaluation of penicillin allergies.⁶ Despite this stronger emphasis on the role of nursing in ASPs, little is understood about if, how, and where hospitals are engaging nurses in ASPs to address this global problem. The aim of this scoping review is to describe how and where (both in the US and internationally) nurses are being engaged in hospital ASPs and determine if and how this reported engagement overlaps with the four CDC opportunities.

METHODS

A scoping review was selected as the most appropriate method to address the study aim as nurse-specific guidelines were published recently. A scoping review allows for the authors to undertake a structured approach to identify types of evidence and knowledge gaps in ASPs related to nurse engagement and provide a descriptive account of the available literature.¹² Using this method we will select the studies, chart the data to extract relevant information, collate, summarize and report the results. IRB approval was not required as this study reviews existing literature.

Eligibility Criteria

Eligible studies included peer-reviewed, full-text manuscripts published between January 2011 and March 2021 on original research studies or quality improvement initiatives that included nurses in hospital-based ASPs. We selected this 10-year time period to fully capture articles that may address the study aims before and after the publication of the CDC guidelines (as articles may include an activity prior to the CDC formalization of guidance). Articles with a research purpose solely of defining or reviewing the role of the nurse in ASPs or that did not include engagement initiatives were excluded.

The authors chose not to restrict the definition of “engagement” a priori to allow for a wider breadth of literature to be returned during the search process. Instead, we chose to examine it operationally, using the opportunities for engagement set forth by the CDC – optimizing testing, correct culturing, prompting antibiotic treatment discussions, and penicillin allergy evaluation – as a framework for analysis.

Information Sources

Three databases were utilized: 1) PubMed; 2) CINAHL; and 3) Embase. Authors of abstract-only pieces (conference abstracts) were emailed if contact information was available. Only full-text articles were included in the full-text review. The search strategy was developed in consultation with a research librarian at our institution’s health science library. The search strategy was built in a stepwise fashion comparing keywords and their PubMed MeSH counterparts. Boolean operators were added between terms for a final search strategy using key words (“Nursing” OR “Nurse”) AND (“Antibiotic Stewardship” OR “Antibiotic Stewardship”) AND (“Engagement” OR “Involvement”). The search strategy established in PubMed was then translated to the two other databases.

Selection of Sources of Evidence

After the search was completed in each database, results were exported and uploaded to Covidence (Veritas Health Innovation, 2021) for article management and review. The primary author (CTJ) screened the article titles and abstracts for relevance. Reviewing authors (CTJ and LJR) screened the full text for relevance. All articles then received a vote from each reviewer (CTJ, LJR) to include or exclude from the final review. Any conflicts were resolved through meetings to clarify reasons for exclusion/inclusion and until consensus was reached.

A data extraction and charting tool was designed and pilot tested by two authors using two articles to establish usability and consistency in approach. Subsequently, both reviewers extracted data independently for the remaining articles.

RESULTS

Article Selection and Characteristics

The initial search yielded 265 articles, of those, 70 were duplicates. Following removal of duplicates, 195 article title and abstracts were screened for relevance and 25 studies were included for full-text review. During full-text retrieval, 8 abstract-only pieces were excluded. Following full-text review, 7 articles were excluded because nurse engagement was not explicitly included (4), ASP was not implemented (2), and no intervention was identified (1). This yielded 10 articles for data extraction and charting (Figure 1).

FIGURE 1:

PRISMA DIAGRAM

Half of the studies were conducted in the US (n=5)^13–17 and the remaining in Canada (n=2)^18,19, Australia (n=1)²⁰, India (n=1)²¹, and Malawi (n=1)²² (Table 1). All study populations included bedside nurses, with six of the studies targeting bedside and or managerial/charge nurses exclusively.^{13–15,18–20} Gillespie et al. focused on experienced nurses, excluding new graduates.²⁰ Four articles included other clinical personnel – physicians, pharmacists, aides - on the multidisciplinary team in the study.^16,17,21,22 Four of the studies took place in an intensive or critical care setting^13,16,18,19, two in an emergency or trauma setting^17,21, two in a step-down or medical ward^14,22, and four articles did not specify the type of units participating in the study^15,20.

TABLE 1:

Synopsis of Included Studies (n=10)

First Author (Year) & Country	Study Design	Intervention Type & Components	Intervention Population, setting, & n	Outcomes	Key Findings
Fitzpatrick, E. (2021) USA	Quasi-experimental quality improvement	Educational  - 2-hour interactive educational AS session  - Discussion  - Role-playing scenarios  - Mock antibiotic timeout script	Bedside nurses; Surgical ICU; N=44 nurses	- Pre/post-intervention AR/AS areas for nurse participation knowledge surveys	- Statistically significant increase in both AS knowledge and empowerment level of staff RNs (p<.0001)
Gillespie, E. (2013) Australia	Prospective quality improvement study	Educational  - 2 annual IV to PO educational sessions  - Handouts with references  - Infection preventionist resource	Bedside and managerial nurses; Unit setting not published; N=79 nurses	- Pre/post-intervention questionnaire-guided interview - IV line use before/during/after - IV line days - IV line-related SA infections	- Nurses reporting they would question the need for IV antibiotics increased from 14% to 42% (p<.001) - Improved awareness of the risk of development of resistance from 59% (95% CI, 48.7–68.7) to 79%. (p<.0001) - Knowledge of the associated risk of line-related infection with intravenous therapy, increased from 38% to 70% (p<.0001) - 3/6 wards decreased line days - Reduced line-related SA infections from 3 to 2 per year
Ha, D. (2019) USA	Retrospective evaluation of quality improvement study	Rounding  - Time-protected nurse-driven ASP rounds  - RN coordinator/champion for initial education and rounds coaching  - Expert resources: ID Physician, ID Pharmacist, CCNP	Beside nurses; Telemetry step-down; N=867 patient encounters	Primary  - Unit antimicrobial and acid suppressant medication use  - Invasive catheter use Secondary  - Incidence of unit HO-CDI, CAUTI, and CLABSI  - Unit length of stay	- Reductions in antimicrobial use for all antimicrobial groups in aggregate (p=0.03) and in broad-spectrum antibacterial agents predominantly used for community acquired infections (p=0.006) - Urinary catheter use significantly decreased following the intervention (p=0.002) - Reductions in CVC use, PPI use, unit length of stay, HO-CDI, CAUTI, and CLABSI were observed (p>0.05) - Observed enhancement of nurses’ clinical assessment skills and increase in their confidence to facilitate discussions with the AS team - The quantity of these audit-and-feedback interventions trended upward after launching the intervention (by approximately 30% over the intervention period (p>0.05)
Jeffs, L. (2018) Canada	Experimental qualitative quality improvement study	Educational  - Series of learning modules delivered in an interactive, networked Communities of Practice model  - 5 Communities of practice learning sessions for implementation teams to discuss progress, success, factors, and challenges  - Unit specific quality improvement initiatives	Beside and managerial nurses; ICU; N=25 team members	Semi-structured interview with 3 key questions:  - How aware and receptive were nurses of the ASP-SUSTAIN project?  - What strategies did you employ to engage nurses in your ASP-SUSTAIN project?  - What recommendations do you have to improve the ASP-SUSTAIN project?	3 key strategies to engage nurses in ASPs: - Leveraging the interest and passion of nurses - Making the ASP a routine part of practice - Engaging nurses to sustain and spread ASPs by nurse leaders
Monsees, E. (2020) USA	Prospective quality improvement study	Tool-based  - Distribution and implementation of the ADIOS AET Tool with 5 components 1) Presence of antimicrobial, 2) Duration, 3) Indication, 4) Transition from IV to PO, 5) Summary of additional observations  - Pre/post-intervention survey	Bedside nurses; unit setting not published; N=121 nurses	- Nurses’ confidence, satisfaction, and understanding of antibiotic plans of care - Self-reporting of if/how the AET improved nurses’ understanding of the antibiotic plan of care, general use of the tool, and satisfaction with the tool	- Nurses identified discrepancies in antibiotic stop dates (22.8% of submitted AETs) - Nurses found the ADIOS AET to help ask questions and improve confidence to be involved in antibiotic discussions (Average rating of 4, “Agree” on 1–5 scale) - AET use varied by hospital unit (p=0.006) - Anecdotally, the study team observed that units who used the AET more frequently had a higher level of leadership involvement
Mula, C.T. (2019) Malawi	Qualitative case study	Discussion/Reflection  - Participant observation of nursing practices  - ASP team focus groups regarding work-arounds  - Purposively selected interviews with nurses	Bedside nurses and aides; Medical; n=23 observed nurses and n=13 focus group nurses	- Identified workarounds in nurse engagement in ASP practices - Perceived issues behind the workarounds - Perceived impacts of workarounds	Workarounds fell into 2 broad categories: - Taking shortcuts by altering a procedure - Using unauthorized process steps or adding new steps to the procedure Workarounds were often related to understaffing or medication shortage - Giving suboptimal antibiotic medication teaching to patients for ease of understanding - One nurse signing for the medication before it is administered and another nurse administering - Doctors prescribing an antibiotic to best suit nurses’ situations/to reduce dose frequency
Raybardhan, S. (2020) Canada	Quasi-experimental quality improvement study	Rounding  - RN prompting to discuss DOT  - PDSA cycles prior to intervention roll-out to refine  - Educational materials  - Supportive DOT lapel buttons  - Rounding “5 whys” tool	Bedside nurses; CCU; n not published	Primary Measures  - Clinical outcome: DOT  - Process outcome: how often the DOT prompts were used in rounds  Balancing Measures  - CCU mortality rate  - LOS  - 48-hour CCU readmissions  - The multiple organ dysfunction score to assess for patient complexity	- 20% reduction in antimicrobial use after implementation of nurse prompting for review of antimicrobial use during rounds - The proportion of relevant cases for which an antimicrobial prompt was provided increased from 21% before the intervention to 48% after the intervention (p<0.001)
Shukla, S. (2020) USA	Prospective quality improvement study	Bundle Intervention  - PDSA cycles  - Charge nurse-led antibiotic time-outs with shift huddles, rounds, and patient & staff education  - Promotion of shorter antibiotic courses for culture-negative sepsis  - Decreasing CLABSI by treating all lines equally	Charge and bedside nurses, physicians, pharmacists; NICU; n not published	Primary Measures  - AUR  - CLABSI rates  - Length of stay  - Cost index Balancing Measures  - Hospital cost  - LOS	- AUR reduction from 330 to 217 DOT per 1,000 patient days, largely driven reduced CLABSI rate - Reduction in yearly CLABSI rate from 2.6 to 1.3 per 1,000 line days - ASP activities led to a narrowing of practice variation and likely contributed to the reduction in CLABSI
Verma, M. (2019) India	Prospective quality improvement study	Bundle Intervention  - Concurrent audit with feedback for incorrectly prescribed antibiotics  - Restrictions on resident prescription/usage for higher level antibiotics  - Education and sensitization activities for residents and nurses: acquainting nurses with dose, duration, and route reviewing; de-escalation of therapy; dose optimization; curb combination therapy; push for oral antibiotics over IV	Bedside nurses and medical residents; Trauma center with orthopedics; n = 695 patients	- Appropriate antibiotic choice, indication, duration, dose, and route - More empirical basis of prescription	- Use of empirical antimicrobial therapy increased significantly (17.5% vs. 7.4%; p<0.001) owing to a higher number of cases with a high likelihood of infection - The number of patients receiving treatment based on CDST results increased (1.3% vs. 2.3%), while prophylactic therapy decreased significantly (91.3% vs. 80.3%; p<0.001) - There was a significant increase in the appropriateness of the duration (81.3% vs. 89.2%; P < 0.001), choice (82.8% vs. 96.36%; p< 0.001), indication (98.7% vs. 100%; p=0.002) and route of administration (89.1% vs. 97.7%; P < 0.001) of antimicrobials
Walters, E. (2019) USA	Prospective quality improvement study	Tool-based (Clinical Decision Support Algorithm for pediatric patients with suspected UTI)  - 5 PDSA cycles  - Multiplatform education for each PDSA cycle included five-minute one-to-one key points, presentations at staff meetings and resident conferences  - Reminders/references involving e-mail, visual cues, posters, badge buddies, and discipline-specific coaching	Bedside nurses, physicians; Emergency Department; n = 458 patients, n = 22 nurses	Key Measures  - Proportion of eligible patients having appropriately ordered and collected urine specimens proportion of patients with suspected UTI receiving algorithm-recommended antibiotics Balancing Measures  - Revisits to our ED related to UTI  - LOS	- Guideline-concurrent specimen collection went from 54.7 to 96.2% - Specimen ordering was standardized, with the correct UA being ordered improving from 54.7% to 96.2% - Of patients receiving antibiotics for suspected UTI, prior to project launch, 6 of 26 received algorithm-recommended first- or second-line antibiotics (23.1%), compared to 57 of 59 (96.6%) after project launch (p < 0.001). - For 2 key measures, improvements have been sustained for over 1 year since completion of the intensive implementation phase

Abbreviation List: ICU (intensive care unit); AR (antibiotic resistance); AS (antibiotic/antimicrobial stewardship); RN (registered nurse); IV (intravenous); PO (oral); SA (staphylococcus aureus); ASP (antibiotic/antimicrobial stewardship program); ID (infectious disease); CCNP (critical care nurse practitioner); HO-CDI (hospital-onset clostridium difficile infection); CAUTI (catheter-associated urinary tract infection); CLABSI (central line associated-bloodstream infection); CVC (central venous catheter); PPI (proton pump inhibitor); ADIOS (antimicrobial, duration, indication, oral, suggestions); AET (Antibiotic Engagement Tool); DOT (duration of therapy); PDSA (plan-do-study-act); CCU (critical care unit); LOS (length of stay); NICU (neonatal intensive care unit); AUR (antibiotic usage rate); UTI (urinary tract infection); CDST (culture and drug susceptibility testing); UA (urine analysis); ED (emergency department)

There was marked heterogeneity in subjects sampled and size. Four studies defined their sample as nurses and specified the number participating, ranging from 13 to 121.^13,15,20,22 Three studies defined their sample to be patients or patient encounters and included the size, ranging from 458 – 867 patients/encounters.^14,17,21 One study defined their sample as four multidisciplinary teams totaling 25 members.¹⁸ Two studies defined their sample as the unit in aggregate and did not specify the number of staff or patients making up the analytic sample.^16,19 Nine out of ten studies ^13–21 reviewed had a quality improvement design, with three studies describing their design as either experimental or quasi-experimental.^13,18,19 One study, Mula et al., employed a qualitative case study design to understand nurse workarounds to stewardship practices.²²

Synthesis of Results

First, categorical themes were created to chart the methods study authors employed in ASP initiatives: 1) educational; 2) rounding; 3) tool- or algorithm-based; 4) implementation bundle; and 5) discussion/reflection. (Table 1) Three studies employed an education-based intervention to engage nurses in ASPs activities, ^13,18,20 two studies reported a rounding intervention to engage nurses, ^14,19 two centered their intervention on a tool- or algorithm-based care activity cluster, ^15,17 two studies included implementation bundles of varying size and components, ^16,21 and one article utilized a practice discussion- and reflection-based approach.²² Next, the extent and methods that each study addressed one or more of the four CDC opportunities (optimizing testing, performing cultures correctly, initiating discussions about antibiotic treatment, and improving evaluation of penicillin allergies) for nurse engagement were assessed. While most opportunities were represented in at least one article, none of the articles explicitly discussed including accurate assessments of penicillin allergies in their initiatives.

Optimizing Testing

Two studies described initiatives designed to optimize testing techniques and encourage diagnostic stewardship.^13,17 Fitzpatrick et al. included content on avoiding inappropriate culturing orders.¹³ Walters et al. included education and supporting materials to both physicians and nurses on proper ordering of a urinalysis and culture, a “quick pick order list” to narrow ordering down to only urinalysis and culture, and development of “SmartPhrases” to facilitate documentation of collection method.¹⁷

Performing Cultures Correctly

Three studies included initiatives to assure that cultures are performed correctly and before starting antibiotics.^13,15,17 Fitzpatrick et al. provided tips on proper culture techniques and timing to nurses during a 2-hour interactive session.¹³ Monsees et al. encouraged nurse investigation into culture results for any patient with antibiotics ordered using education on the reverse side of the “ADIOS Antibiotic Engagement Tool (AET)” and assessed nurse confidence in assuring that cultures are obtained prior to starting antibiotics pre- and post-intervention through surveys.¹⁵ Using a clinical decision support algorithm, Walters et al. addressed correct culturing practices through coaching of nurses on culturing methods for children based on toilet training status and standardized patient education on collecting clean catch specimens.¹⁷

Initiating Discussions About Antibiotic Treatment

Nine studies reported initiatives for engaging nurses in ASPs by involving them with antibiotic discussions or prompting discussions about antibiotic treatments. The ADIOS AET from Monsees et al. was designed for nurses to use to initiate discussions about antibiotic treatment during care transitions, operationally defined as a transfer of a patient’s care between services, a patient admission, and a patient discharge. ¹⁵ Shukla et al. utilized charge nurses to lead nursing-based ASPs and discussions about antibiotic treatment.¹⁶ During charge nurse-led antibiotic timeout “clinical huddles”, the charge nurses reviewed antibiotic therapy, provided recommendations and guidelines on antibiotics prescription, promoted shorter antibiotic courses for culture-negative sepsis, and reviewed indications for antibiotic usage in the neonatal intensive care unit.¹⁶ Fitzpatrick et al. educated the nurses on participating in rounds and initiating in antibiotic discussions by and starting antibiotic timeouts.¹³

Ha et al. educated nurses on antibiotic rounding and included coaching and semi-weekly rounding coordination support from a nurse champion as well as an infectious disease pharmacist, infection preventionist, and critical care nurse practioner.¹⁴ Raybardhan et al. also incorporated rounding, focusing on nurse-prompted duration of therapy discussions.¹⁹ The nurses were provided education on antimicrobial reassessment and provided with information on common critical care unit antimicrobials as well as a standard script to introduce duration of therapy discussions during daily rounding.¹⁹

Verma et al. provided education and guides to nurses on reviewing antibiotic therapy details, policy and how to discuss therapy with the treating physician.²¹ Similarly, Gillespie et al. aimed two annual “switch to oral” educational sessions at empowering nurses to influence antibiotic management, and to question medical staff about the need for continued antibiotic use in each patient.²⁰ Jeffs et al. educated four implementation teams on QI methods, collaboratives, Communities of Practice, and insights from previous literature on ASPs.¹⁸ The implementation teams focused on initiatives to improving communication around antibiotic therapy changes and appropriateness and debriefed to evaluate themes of success.¹⁸ Mula et al. used direct observation of nurse practices by other medical team members around four types of antibiotic management encounters – nurses’ shift change handover reports, antibiotic preparation, antibiotic administration, and ward rounds.²² After data collection, the researchers held focus groups with team members and purposive interviews with nurses for feedback, reflection and discussion on antibiotic workarounds.²²

Finally, we examined how the different interventions described in the literature overlap with the CDC opportunities for nursing engagement in ASPs (Figure 3). We found that interventions that utilized an education or tool-based intervention included more than one engagement opportunity whereas other intervention approaches (rounding, bundles, and discussion) focused on a singular opportunity to engage nurses in ASPs.

FIGURE 3:

Evidence Chart – Study intervention type by CDC opportunity for nurse engagement in ASPs (n=10)

Note: For simplicity, only the first author’s last name and publication year are used to identify paper.

Abbreviations: CDC – Centers for Disease Control and Prevention; ASPs – antibiotic stewardship programs

We also found that the outcomes that researchers used to evaluate the effectiveness of their interventions varied widely. Four studies focused on more subjective outcomes such as pre/post intervention surveys or guided interview themes.^13,15,18,22 Five looked at objective outcomes such as IV line days, healthcare-associated infections, duration of therapy, charting/order patterns, and length of stay.^{14,16,17,19,21}. The only article to combine both subjective self-report data and objective aggregate care outcome statistics in a mixed-methods approach was that by Gillespie et al.²⁰ (Table 1).

LIMITATIONS

As this scoping review included peer-reviewed literature only, it is possible some quality improvement initiatives have been reported outside of the peer-reviewed literature, thus selection bias may exist. In addition, an inherent limitation of scoping review methodology is the absence of formal study quality appraisal as the intent is to gather information from a broad range of study designs. Finally, while the CDC participates in global antibiotic resistance initiatives and contributes to standards beyond US borders, we recognize that they are a US-based agency and the opportunities for engagement might not reflect practice in hospital settings outside of the US.

DISCUSSION

This scoping review provides an overview of the available evidence to answer the questions “how are nurses being engaged in hospital ASPs?” and “do these strategies target or include CDC opportunities for nurse engagement?” The available evidence suggests a growing focus on antibiotic stewardship as an important target of quality improvement programming and global interest in engaging nurses in ASPs.

A disappointing finding was the inclusion and description of nurse involvement in ASPs. Multi-disciplinary articles that were included in this review tended to have limited information on the extent of nurse involvement in the APSs and/or included few-to-no metrics measuring the independent effect of the nurse participation within the initiative.^17,21 We don’t know if this reflects the actual program realities, or merely how it is reported in the peer reviewed literature. There are currently no national or global measures available on nursing participation on ASPs and the metrics and incentives for including nurses remain undefined.²³

Through data charting we found that encouraging nurses to initiate discussion around proper antibiotic use is the most frequently used approach in hospital ASPs. One promising strategy reported appears to be the initiation of “timeouts”, which have been identified by the CDC as effective antibiotic stewardship.^11,14 These timeouts are designed facilitate the transition from broad-spectrum antibiotics, usually initiated empirically, to more targeted therapies, by having a structured discussion on antibiotic choice on at a designated point in time (e.g., the third calendar day of treatment).

Unfortunately, other CDC opportunities were identified less often, indicating gaps in evidence, and perhaps practice. In descending frequency, performing cultures correctly was a focus in three studies, optimizing testing was a focus in two, and assessing for a penicillin allergy was not a focus in any paper. This is a missed opportunity. Ten percent of patients report a penicillin allergy, but only 1% of the population is actually allergic.²⁴ Improved evaluations for penicillin allergies have the potential to both lower costs and improve outcomes. Antibiotics for patients with penicillin allergies cost between 63% and 158% more than for those without an allergy.²⁵ One healthcare system saw a savings of $2 million when it began assessing for penicillin allergies more rigorously.²⁵ Further, patients who report a penicillin allergy often have longer hospital stays, which may be due in part to unnecessary exposure to antibiotics associated with Clostridium difficile and vancomycin-resistant enterococcus.²⁶

Despite these findings, it is important to acknowledge the limitations of the studies addressing this emerging field of inquiry and included in this review. Many of the interventions were relatively short in duration, 1 – 15 months, or did not publish details on duration and by nature of design we cannot infer these interventions will lend to sustainable practice change. In addition, half of the interventions were primarily aimed at the individual, such as education or reflection, and education is a weaker intervention in terms of sustainable practice change compared to interventions that change the work and/or are at the system-level. Further, outcomes like knowledge, satisfaction, and empowerment are weaker measures compared to clinical process and outcome measures where the work of the nurse can be quantified in terms of the health and safety of the patient. These papers and this review has laid a foundation for future work to address the nature and duration of the interventions, issues of sustainability, and key process and outcome measures.

CONCLUSION

Hospital-based nurses are uniquely situated to make a substantive impact on reducing antibiotic resistance, not only for their individual patients but also for the broader population. The role of nurses in ASPs varies and includes leading specific interventions or having an engaged presence on an interdisciplinary team. This review shows promising impact in targeted opportunities to prompt antibiotic discussions, though negligible impact in opportunities to optimize testing, perform cultures correctly and improve penicillin allergy evaluations. Additionally, no national or global measurement for nurse participation and engagement in ASPs exists. Healthcare administrators and policy makers can leverage the role of the nurse more effectively through targeted and purposeful structure to positively impact patient safety and healthcare quality as it relates to antibiotic stewardship.

FIGURE 2:

CDC Nurse Engagement Opportunities and Study Interventions (n=10)

Abbreviations: ICU (intensive care unit); IV (intravenous); QI (quality improvement) CCU (critical care unit); NICU (neonatal intensive care unit)

IMPLICATIONS.

This scoping review demonstrates existing gaps in research for engaging nurses in hospital ASPs, namely in culturing/testing practices and penicillin allergy evaluation. It also highlights the contributions that nurses are currently making in ASPs globally and the potential for increasing impact with increasing engagement. Additionally, meaningful measurements of nurse-engagement in hospital-based ASPs are needed to fully understand the impact and potential for nursing measures to reduce antibiotic resistance.

Biographies

Cara Thurman Johnson, MPH, BSN, RN is a senior research coordinator for the AHRQ R18 Simulation to Improve Infection Prevention and Patient Safety at Columbia University School of Nursing in New York, NY. Her research interests are in infection prevention, antibiotic resistance, and healthcare epidemiology. Her clinical experience is in adult medical-surgical and oncology nursing. (cbt2119@cumc.columbia.edu)

Laura J. Ridge, PhD, RN, ANP-BC, AAHIVE is a Postdoctoral Fellow in the University of Michigan School of Nursing’s T32 training program in Complexity: Innovations in Promoting Health and Safety. Her interests focus on patient and healthcare worker safety in the United States and West Africa. The Michigan School of Nursing is in Ann Arbor, Michigan.

Amanda J. Hessels, PhD, MPH, RN, CIC, CPHQ, FAPIC, FAAN is jointly appointed as Assistant Professor at Columbia School of Nursing in New York, NY and a Nurse Scientist at Hackensack-Meridian Health in Wall Township, NJ. She is the Principal Investigator of the AHRQ-funded project Simulation to Improve Infection Prevention and Patient Safety (1R18HS026418). Her research interests are in organizational climate, errors of omission, infection prevention and occupational health and safety.