Antimicrobial Stewardship: How to Extend a Solid Handshake

As a core strategy of antimicrobial stewardship (AS), prospective audit with feedback (PAF) is a widely implemented strategy to assess the appropriateness of prescribed antimicrobials. This review typically occurs 48 to 72 hours after initiation of the antimicrobial with recommendations communicated electronically or via phone. Handshake stewardship (H-AS) is an innovative approach developed by the Children’s Hospital of Colorado (CHCO) that prioritizes face-to-face communication and engages frontline providers into the PAF process.

Specifically, it focuses on a lack of restriction and preauthorization, reviewing all antimicrobials at two time points (24 and 48-72 hours), and a rounding-based, in person approach to feedback by an infectious disease (ID) pharmacist-physician team.¹

To effectively implement H-AS, it is helpful to first establish an interprofessional collaboration with providers. AS representatives can attend scheduled departmental meetings to boost the presence of the AS team and develop the key relationships necessary to ensure the success of H-AS. Educating providers on this process can increase awareness and intentions of H-AS helping address hesitations of involved team members. It is also crucial to collaborate with other team members such as nursing, non-ID pharmacists, and advanced practice providers to enhance the efficacy and sustainability of H-AS interventions.

Strong interpersonal communication skills are also essential to the success of H-AS. Use of motivational interviewing techniques and active listening have been shown to facilitate face-to-face communication of AS recommendations in a non-confrontational manner.² The language and timing of interventions should be tailored based on type of provider (i.e., intern vs. attending) and/or specialty (i.e., medical vs. surgical team).³ Discussing recommendations in the presence of the entire medical team can allow for extensive open dialogue with bi-directional feedback and real-time education.⁴ This can help strengthen rapport with providers and may enhance the acceptance of AS interventions.

In institutions with limited resources, modified forms of H-AS can be performed. If stewards are unable to audit all antimicrobials on a regular basis, prioritizing the review of distinct antimicrobials and continued use of preauthorization may be necessary. CHCO noticed that after the introduction of H-AS, the hesitance to obtain authorization and follow up ID consultations had significantly decreased.⁵ In addition, smaller AS teams or non-ID pharmacists can consider focusing on specific patient care teams (e.g., intensive care units, general pediatrics), targeting specific infectious indications (e.g., Staphylococcus aureus infections, candidemia), and/or limiting the number of rounding days. If in person rounds are not possible, Zembles et al describes virtual H-AS using methods such as virtual meetings, electronic communication, and email. Although it resulted in less interventions and limited interactions, it still constitutes a valid alternative to rounding based H-AS.⁶

H-AS describes an approach to AS that encourages more open-ended conversations, increased visibility of the AS team, and shared decision making to optimize antimicrobial use in hospitalized patients. Although H-AS has been deemed a leading practice, implementation of adapted versions of H-AS may be needed based on an institution’s circumstances and resources.

References

1. Hurst AL, Child J, Pearce K, et al. Handshake stewardship: a highly effective rounding-based antimicrobial optimization service. Pediatr Infect Dis J 2016; 35:1104–10.
2. Goff D, Reed W, Naumovski S, et al. Approaches to modifying the behavior of clinicians who are noncompliant with antimicrobial stewardship program guidelines. Clin Infect Dis 2016;63(4):532-538.
3. Charani E, Ahmad R, Rawson TM, et al. The differences in antibiotic decision-making between acute surgical and acute medical teams: an ethnographic study of culture and team dynamics. Clin Infect Dis 2019;69(1):12-20.
4. Foral PA, Anthone JM, Destache CJ, et al. Education and communication in an interprofessional antimicrobial stewardship program. J Am Osteopath Assoc 2016;116:588–93.
5. Messacar K, Campbell K, Pearce K, et al. A handshake from antimicrobial stewardship opens doors for infectious disease consultations. Clin Infect Dis. 2017;64(10):1449-1452. doi:10.1093/cid/cix139
6. Zembles TN, MacBrayne CE, Mitchell ML, Parker SK. Lessons learned from virtual handshake stewardship during a pandemic. Jt Comm J Qual Patient Saf. 2021;47(3):198-200. doi:10.1016/j.jcjq.2020.10.006