In 2017 The Joint Commission issued a new medication management standard (Standard MM.09.01.01 EP 7) for acute-care hospitals (ACHs) that required the implementation of an antibiotic stewardship program (ASP) that follows the Center for Disease Control and Prevention’s (CDC) 7 core elements of hospital ASPs.1, 2 The ACHs report core-element achievement through the National Healthcare Safety Network’s (NHSN) Patient Safety Component Annual Survey. This survey assesses facility characteristics, infection control practices, laboratory practices, and antibiotic stewardship practices. Among these questions, 16 assess stewardship practices. Based on the 2015 NHSN survey results, 48.1% of hospitals nationwide had implemented all 7 core elements, and the implementation of each individual element ranged from 66% to 95%.Reference O’Leary, van Santen and Webb3 Hospital infection preventionists usually complete the NHSN survey and are instructed to obtain input from stewardship personnel. To gain more detailed information on ASPs statewide and to validate the NHSN survey results, the Tennessee Department of Health (DOH) developed a survey targeting antibiotic stewardship physician or pharmacist champions in the ACH setting.
Methods
We developed a detailed, 76-question survey about hospital ASPs using examples listed in the National Quality Partners Playbook: Antibiotic Stewardship in Acute Care.4 We identified key stewardship contacts at each hospital and distributed the survey electronically via Research Electronic Data Capture (REDCap) in June 2017.Reference Harris, Taylor and Thielke5 To attain achievement of each individual core element in the DOH survey, at least 1 intervention had to be reported as “actively implemented.” Results from our survey were compared to the CDC’s determination of core-element achievement from the 2016 NHSN annual hospital survey completed in the first quarter of 2017. An ACH was included in the comparative analysis if a hospital representative had completed both surveys. McNemar’s test was used to compare total and individual core-element achievement between the 2 surveys. Analyses were performed using SAS version 9.4 software (SAS Institute, Cary, North Carolina).
Results
Of 109 ACHs that completed the 2016 NHSN annual hospital survey, 90 (83%) also completed the DOH survey. The median bed size for participating hospitals was 109 (range, 1–737): 12% had >400 beds; 48% had between 101 and 400 beds; 21% had between 50 and 100 beds; and 19% had <50 beds. In addition, 29% were teaching hospitals, and 58% of those were major teaching hospitals. ASPs were led by pharmacists in 41% of responding hospitals; 11% of ASPs were led by physicians, and 44% were co-led. Based on our survey, 89% of ACHs met all 7 core elements, whereas 68% had achieved all 7 core elements according to the NHSN survey (P < .05) (Fig. 1). Moreover, 50 of 90 ACHs (66%) matched perfectly on all core elements when assessed on both surveys. Individual core-element concordance between the 2 surveys ranged from 86% (for education) to 100% (for action). On 35 occasions, the DOH survey showed core-element achievement and the NHSN survey did not: education (n = 11), tracking (n = 7), leadership (n = 7), reporting (n = 5), accountability (n = 3), drug expertise (n = 2). On 8 occasions, the NHSN survey showed core element achievement and the DOH survey did not: reporting (n = 3), education (n = 2), accountability (n = 2), drug expertise (n = 1).
Percent of hospitals achieving each core element by NHSN Annual Hospital Survey, 2016, and the Tennessee Department of Health survey, 2017. *P < .05.
Discussion
Assessing core element achievement by ACHs is an important measure of stewardship progress at the facility level, regionally, and statewide. In our analysis of individual core elements, we found high concordance between the NHSN survey and our more detailed DOH survey. However, only 66% of facilities matched completely. This finding may be explained in part by timing of the surveys, targeting facility stewardship personnel, and capturing more granular data on the facility’s interventions. A qualitative assessment of ASPs was beyond the scope of this study.
Unpublished studies have previously attempted to validate the NHSN survey’s stewardship questions.Reference Janelle, Spencer and Hoxworth6–Reference Haque and Alvarez8 Haque and AlvarezReference Haque and Alvarez8 found high concordance between 2 surveys that assessed core-element achievement in Virginia hospitals, but they also found significant differences in specific core-element achievement. Kuper et alReference Kuper, Van Santen and Pakyz7 also compared a separate stewardship survey to questions from the NHSN survey in 2015 and found similar percentages of hospitals meeting all 7 core elements, but individual responses differed based on respondent position.
The primary strengths of our study include the high response rate and the number of interventions offered to meet individual core element achievement. The level of detail obtained has allowed us to target educational outreach efforts based on Tennessee specific findings and needs.
Participation in our survey was voluntary. Facilities that did not complete our survey may have lacked strong stewardship programs, potentially overestimating true statewide progress toward full achievement. We did have a high response rate, and we included only NHSN Survey data for the concordance analysis from those facilities that completed both surveys.
Although there was generally good agreement between our survey and the NHSN annual survey, we did identify discrepancies between them. Targeting stewardship champions as respondents and offering more options for intervention likely explains the conflicting results; most of the discordant results occurred when our survey showed achievement and the NHSN survey did not. Our survey provided more opportunity for ACHs to describe components of their ASPs. The NHSN has updated the stewardship questions for the 2018 annual hospital survey; these more detailed questions should allow for greater depth of understanding of a facility’s ASP and a better assessment of core-element achievement at the local, state, and national levels.
Author ORCIDs
Christopher Evans, 0000-0001-9276-5067
Acknowledgments
The Tennessee Department of Health would like to acknowledge and thank all the stewardship pharmacists, physicians, and infection preventionists that participated in this survey.
Financial support
Support for this project was provided by the Epidemiology and Laboratory Capacity Cooperative Agreement (Federal grant no. NU50CK000386-05-00).
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2019.92.
