Getting Started: A Gap Analysis Tool for Antimicrobial Stewardship Programs Page 1 of 7

Getting Started: A Gap Analysis Tool

for Antimicrobial Stewardship Programs

Accreditation Canada’s Required Organizational Practices (ROP) requires hospitals to have an

antimicrobial stewardship program (ASP) in place for inpatient acute care, inpatient cancer, inpatient

rehabilitation and complex continuing care services. The five tests for compliance are as follows:

An antimicrobial stewardship program has been implemented (Major)

The program specifies who is accountable for implementing the program (Major)

The program is inter-disciplinary, involving pharmacists, infectious diseases physicians, infection

control specialists, physicians, microbiology staff, nursing staff, hospital administrators, and

information system specialists, as available and appropriate (Major)

The program includes interventions to optimize antimicrobial use such as audit and feedback, a

formulary of targeted antimicrobials and approved indications, education, antimicrobial order

forms, guidelines and clinical pathways for antimicrobial utilization, strategies for streamlining

or de-escalation of therapy, dose optimization, and parenteral to oral conversion of

antimicrobials (where appropriate) (Major)

The program is evaluated on an ongoing basis, and results are shared with stakeholders in the

organization (Minor)

Some hospitals may feel overwhelmed by the prospect of establishing an ASP that meets the above

criteria. The following checklist includes activities that are considered to be ASP related and is based on

the ROP by Accreditation Canada, Public Health Ontario core antimicrobial strategies and the Centers for

Disease Control core elements of antimicrobial stewardship programs checklist. It provides facilities

who may feel they have no ASP in place or are in the early stages of program development a way to

gauge whether activities they are currently performing or administrative controls they have in place are,

in fact, part of a functioning ASP.

After completion of this checklist, you may determine that:

your facility has the necessary ASP elements in place to meet the criteria

or

you need to implement additional elements to meet the criteria and/or advance your program.

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A Gap Analysis Checklist YES NO Staff/persons involved Comments

Administrative Controls

Senior leadership support for antimicrobial stewardship

May include a formal statement of support, financial support for antimicrobial stewardship activities and/or other types of support

Committee exists that looks at antibiotic usage

Committee is multi-disciplinary and includes membership from:

Required:

- Physician(s) group - Pharmacy

Suggested:

- Infection prevention and control - Microbiology - Information technology - Nursing - Senior leadership/hospital administrators

Committee has established short term and long term goals for improving antimicrobial use

Antimicrobial Stewardship Activities

Formulary-related strategies

Formulary review/streamlining

A formulary is in place and there is a regular process of formulary review.

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A Gap Analysis Checklist YES NO Staff/persons involved Comments

Formulary automatic substitution/therapeutic interchange policies

The process whereby an order for a specific drug or dosing regimen is automatically changed or substituted according to preapproved procedures and conditions, without needing to consult the prescriber.

Formulary restriction

Restricted dispensing of targeted antimicrobials on the hospital’s formulary, according to approved criteria. The use of restricted antimicrobials may be limited to certain indications, prescribers, services, patient populations or a combination of these.

Structural/Process strategies

General antimicrobial order forms

Forms used to single out and highlight prescriptions for anti-infectives as a way of improving specific or overall antimicrobial use.

Automatic stop orders

Automatically applied stop dates for antimicrobial orders when the duration of therapy is not specified. Can be individualized for specific antimicrobial classes, routes of administration and/or indications.

Clinical strategies

Prospective audit with intervention and feedback

Formal assessment of antimicrobial therapy with recommendations to the prescribing service when therapy is considered suboptimal.

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A Gap Analysis Checklist YES NO Staff/persons involved Comments

Dose optimization

Review and individualization of antimicrobial dosing based on the characteristics of the patient, drug, and infection.

Therapeutic drug monitoring (with feedback)

Measurement and interpretation of serum drug concentrations to maximize efficacy and minimize toxicity.

De-escalation and streamlining

Changing broad-spectrum or multiple antimicrobials to narrow or target therapy, or discontinuing antimicrobials based on culture and susceptibility results.

Prescribing Guidance strategies

Empiric antibiotic prescribing guidelines

Multidisciplinary, evidence-based recommendations using local susceptibility data to standardize and improve the selection of initial therapy for common infectious diseases.

Disease-specific treatment guidelines/pathways/ algorithms and/or associated order forms

Evidence-based practice recommendations that incorporate local resistance patterns and institution-specific formulary antimicrobials into a guideline, treatment pathway, algorithm and/or order form.

Intravenous to oral conversion

Promoting the use of oral antimicrobial agents instead of intravenous administration when clinically indicated.

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A Gap Analysis Checklist YES NO Staff/persons involved Comments

Prescriber education

Education (formal or informal) to inform and engage prescribers and other health care professionals in stewardship activities and to improve antimicrobial prescribing.

Microbiology-related strategies

Antibiograms

A summary of the cumulative susceptibility of bacterial isolates to formulary antibiotics in a given institution or region. Its main functions are to guide choice of empiric therapy and track resistance patterns.

Infection Prevention and Control Activities

Ventilator-associated pneumonia surveillance

Catheter-associated urinary tract infection surveillance

Central line-associated blood stream infection surveillance

Metrics and Evaluation

There are one or more established metric(s) to evaluate antibiotic usage, for example:

- Defined daily dose (DDD) - Days of therapy (DOT) - Length of therapy (LOT) - Antimicrobial expenditures - Grams of antimicrobials dispensed/administered

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A Gap Analysis Checklist YES NO Staff/persons involved Comments

Process measures to evaluate activities are in place (if applicable):

- Proportion of suggestions that are accepted - Adherence to prescribing guidance (including empiric

guidelines, pathways/algorithms/order forms)

Outcome measures to evaluate are in place:

- Clostridium difficile infection rates - Trends in resistance rates - Length of stay - Mortality rates - Re-admission rates due to infection

Reporting within the institution

There is an established strategy to feedback results of the ASP to stakeholders in the organization

Updated July 2016

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References

1. Accreditation Canada. Required organizational practices: Handbook 2017. [Internet]. Ottawa, ON:

Accreditation Canada; 2016 [cited 2017 July 8]. Available from:

https://accreditation.ca/sites/default/files/rop-handbook-2017.pdf

2. Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al; Infectious Diseases

Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of

America and the Society for Healthcare Epidemiology of America guidelines for developing an

institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–77.

Available from: http://cid.oxfordjournals.org/content/44/2/159.long

3. Centers for Disease Control and Prevention. Checklist for core elements of hospital antibiotic

stewardship programs [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 2015 [cited

2016 May 18]. Available from:

http://www.cdc.gov/getsmart/healthcare/implementation/checklist.html

Disclaimer

This document may be freely used without permission for non-commercial purposes only and provided that

appropriate credit is given to Public Health Ontario. No changes and/or modifications may be made to the

content without explicit written permission from Public Health Ontario.

Citation

Ontario Agency for Health Protection and Promotion (Public Health Ontario). Getting Started: A Gap

Analysis Tool for Antimicrobial Stewardship Programs. Toronto, ON: Queen’s Printer for Ontario; 2016.

©Queen’s Printer for Ontario, 2016

For further information

Antimicrobial Stewardship Program, Infection Prevention and Control, Public Health Ontario.

Email: asp@oahpp.ca

Public Health Ontario acknowledges the financial support of the Ontario Government.