Uptake of Antibiotic Stewardship Programs in US Acute Care Hospitals: Findings From the 2015 National Healthcare Safety Network Annual Hospital Survey

Abstract

To assess uptake of the Centers for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship Programs, we analyzed stewardship practices as reported in the 2015 National Healthcare Safety Network’s Annual Hospital Survey. Hospital uptake of all 7 core elements increased from 40.9% in 2014 to 48.1% in 2015.

antibiotic stewardship, National Healthcare Safety Network (NHSN), core elements, healthcare survey, acute care

Antibiotic stewardship programs (ASPs) improve patient outcomes and reduce unintended consequences related to antibiotic use, including Clostridium difficile and antibiotic resistance [1, 2]. In 2014, the Centers for Disease Control and Prevention (CDC) issued a Vital Signs report encouraging all US hospitals to implement ASPs and released the Core Elements of Hospital Antibiotic Stewardship Programs to support this implementation [3]. In 2016, the National Action Plan for Combating Antibiotic Resistant Bacteria (CARB) set a goal for all acute care hospitals to have ASPs in place by 2020 [4], and ASPs based on the CDC core elements became a Joint Commission requirement in 2017 [5]. CDC monitors uptake of hospital ASPs with the National Healthcare Safety Network (NHSN) Annual Hospital Survey. The survey affords an opportunity to assess national progress and identify opportunities to better support ASP implementation. Questions based on CDC’s core elements were added to the survey in 2015 to assess activities in calendar year 2014 and were posed again in 2016 [6]. In 2014, 40.9% of hospitals reported having an ASP with all 7 core elements [7]. This number was initially reported at 39.2% but was revised based on reclassification of one of the questions, as detailed below. Here, we report the results for hospital ASPs in calendar year 2015.

METHODS

Each year, healthcare facilities participating in NHSN’s Patient Safety Component are required to complete the Annual Hospital Survey. Hospitals document facility demographics, laboratory practices, infection control practices, and infrastructure and implementation of ASPs [8]. Survey responses are self-reported by a hospital’s infection preventionist, though survey instructions request assistance of pharmacy and other ASP staff be sought to complete stewardship-related questions. The survey contains 12 questions that explore uptake of the 7 core elements: (1) leadership, (2) accountability, (3) drug expertise, (4) tracking, (5) actions, (6) reporting, (7) education. Details on how questions were developed can be found in the 2014 survey report [7].

Methods relating to analysis of the 2015 survey were consistent with 2014 methods [7], with 1 exception. In 2014, audit with feedback interventions were counted as a criteria toward core element 5, “actions.” However, after further consideration, it was noted that audit with feedback interventions are also used to report prescribing information to providers and should therefore count toward element 6, “report,” as well. As a result, in 2015, hospitals reporting audit with feedback met both act and report elements. Applying this methodology to 2014 survey data increased the percentage of hospitals reporting all 7 elements from 39.2% to 40.9%.

To better understand how presence of certain facility characteristics and stewardship practices were related to a hospital’s ability to meet all 7 core elements, univariate and multivariate analyses were conducted using forward stage-wise log binomial regression and assessed using likelihood ratio tests and Akaike information criteria statistics in SAS version 9.3 (SAS Institute, Cary, North Carolina).

RESULTS

Overall, 4569 acute care hospitals responded to the 2015 survey, an increase of roughly 400 hospitals compared to 2014; the majority of new respondents were critical access hospitals (CAHs), which increased in number by 39%. Hospitals reported an average bed size of 164 (interquartile range, 31–131).

Reported implementation of each individual element ranged from 66%, for education, to 95%, for actions to improve use (Table 1). There were increases in each individual element, ranging from 1%, for actions, to 8%, for leadership support. Of the 4569 respondents, 2199 (48.1%) reported uptake of all 7 core elements (Table 1). Of the 4069 hospitals responding in both 2014 and 2015, the percentage meeting all 7 increased from 41.2% in 2014 to 49.8% in 2015; 14.8% of these 4069 reported increases of ≥2 core elements. More hospitals with >200 beds (66.1%) met all 7 elements compared to those with 51–200 beds (49.6%) and ≤50 beds (31.1%), and fewer CAHs (≤25 beds) met all 7 (26.3%) compared to other facility types (Table 1). Few hospitals reported diminished uptake, with 1.2% of facilities reporting a drop of ≥3 core elements.

Table 1.

Characteristics of US Acute Care Hospitals Reporting Implementation of all 7 of the Centers for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship Programs^a, National Healthcare Safety Network, 2014–2015, and Number and Percentage of Hospitals Reporting Uptake of Individual Core Elements

Characteristic	2014b (n = 4184)		2015 (n = 4569)
	No. of Respondents	Meeting All 7 Core Elements	No. of Respondents	Meeting All 7 Core Elements
Overall	4184	1710 (40.9)	4569	2199 (48.1)
Facility type
Children’s hospital	76	38 (50.0)	79	42 (53.2)
General acute care hospitalc	3385	1510 (44.6)	3537	1877 (53.1)
Surgical hospitald	146	49 (33.6)	152	69 (45.4)
Critical access hospital	577	113 (19.6)	801	211 (26.3)
Bed size
>200 beds	1320	771 (58.4)	1361	899 (66.1)
51–200 beds	1571	634 (40.4)	1634	811 (49.6)
≤50 beds	1293	305 (23.6)	1574	489 (31.1)
Teaching status
Major teaching (major, graduate)	1121	621 (55.4)	1248	791 (63.4)
Nonteaching/ undergraduate	3063	1089 (35.6)	3321	1408 (42.4)
Core element	2014b		2015
	No. Meeting Each Core Element	Percentage Meeting Each Core Element	No. Meeting Each Core Element	Percentage Meeting Each Core Element
Leadership	2508	59.9	3092	67.7
Accountability	3016	72.1	3499	76.6
Drug expertise	3648	87.2	4084	89.4
Act	3926	93.8	4334	94.9
Track	3318	79.3	3707	81.1
Report	3466	82.8	3929	86.0
Educate	2589	61.9	3018	66.1

Data are presented as No. (%) of hospitals reporting meeting each core element.

^aCenters for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. Available at http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html.

^b2014 results include audit with feedback as a possible criteria toward meeting core element “report.” For this reason, results provided here may differ from results previously published.

^cGeneral acute care hospitals, for this analysis, include the following hospital types: general acute care hospitals, military hospitals, oncology hospitals, Veterans Affairs hospitals, women’s hospitals, women’s and children’s hospitals.

^dIncludes surgical and orthopedic hospitals.

There was considerable variability in reported uptake of core elements at the state level. An interactive map with state-specific uptake results can be viewed via CDC’s Antibiotic Resistance Patient Safety Atlas [9]. In 2015, hospitals in Vermont continued to report lowest uptake of all 7 elements at 7%, while hospitals in Utah reported highest uptake at 77%, with California (70%), North Carolina (67%), and Rhode Island (67%) not far behind. Six states (Rhode Island, Hawaii, West Virginia, Utah, Colorado, Connecticut) and the District of Columbia reported increases of 20% or more from 2014 to 2015.

Univariate analyses indicated that larger bed size (quintiles) and teaching status were statistically significantly associated with a hospital reporting all 7 elements. Hospitals falling in the first quintile (≥270 beds) were 2.4 (95% confidence interval [CI], 2.2–2.7) times more likely to report all elements compared to hospitals in the fifth quintile (≤25 beds) (P < .0001). Hospitals reporting “major” or “graduate” teaching status, indicating the presence of medical training programs, were 1.5 (95% CI, 1.4–1.6) times more likely to report all 7 elements compared to those reporting “undergraduate” or “nonteaching” status (P < .0001). All individual stewardship practices mentioned in survey questions were statistically significant predictors of a hospital meeting all 7 core elements (all P < .0001).

In a multivariate analysis, written support, salary support, teaching status, and bed size (quintiles) were independent predictors of a hospital meeting all 7 core elements, with written support from facility administration being the strongest predictor (adjusted risk ratio [RR], 6.1 [95% CI, 5.3–7.1]; P < .0001).

DISCUSSION

In 2015, 48% of acute care hospitals in the United States reported implementing an ASP with all 7 CDC Core Elements of Hospital ASPs, a 7% increase from 2014. The increase comes despite the fact that >200 CAHs, the group with the lowest uptake, began survey participation in 2015. Very few hospitals lost ground on the core elements, suggesting that once programs begin, there is momentum to sustain them. While the improvement is encouraging, achieving the 100% goal by 2020 will require faster progress.

State-level data continue to show variability, which should inform actions at the state level. For example, Intermountain Healthcare, the largest healthcare system in Utah, has been actively engaged in promoting ASPs in its hospitals, and 95% reported implementing all elements in 2015 [10]. This model of engaging healthcare systems might work well in other states. State policies can also drive action. California, with legislation requiring hospitals to have ASPs, maintains a high rate of implementation at 70%. Missouri passed similar legislation in 2016 and its uptake of core elements is anticipated to quickly increase [11].

While progress was made from 2014 to 2015, there were a number of developments in 2016 that should promote more rapid uptake of hospital ASPs moving forward. All states and several cities are receiving support to address antibiotic resistance through funding provided to CDC by Congress in 2016. Health departments will focus on a range of activities to better detect and respond to antibiotic resistance, prevent spread of resistant organisms, and improve antibiotic use through stewardship. In 2016, The Joint Commission issued a new accreditation standard that requires all accredited hospitals to have ASPs with core elements in place by January 2017 [5]. As the organization that accredits roughly 80% of all acute care hospitals, this standard should have significant impact. Finally, also in 2016, The Centers for Medicare and Medicaid Services (CMS) issued a proposed revision to the hospital Conditions of Participation that would require all hospitals receiving payments from CMS to have an ASP [12].

As was the case in 2014, smaller hospitals, especially CAHs, had the lowest rates of uptake, a gap that widened in 2015. ASPs in small hospitals face unique challenges, such as limited access to pharmacy staff. Fortunately, >200 CAHs did report successful implementation of all elements. CDC is currently partnering with state health departments, the Pew Charitable Trusts, and the American Hospital Association to learn and disseminate best practices for implementing ASPs in small hospitals.

Written support for ASPs from facility administration, the “leadership” commitment core element, remains a strong predictor of having all 7 elements. The strength of this association, a 6-fold increase in adjusted risk of having all elements, underscores the importance of ensuring that hospital leadership is strongly supportive of stewardship programs.

This annual survey has limitations. Most important is that data are self-reported and are not validated. Year-to-year comparisons must be interpreted with caution as hospitals enter and leave the survey each year. However, an analysis of hospitals reporting data in both years showed similar results to overall findings reported here. We also do not know how uptake of core elements correlates with important stewardship outcomes such as antibiotic use, resistance, and Clostridium difficile infection. CDC works with a variety of partners to address this important issue.

Hospitals in the United States are making progress toward a national goal of universal presence of ASPs, but faster progress is needed. Efforts to support smaller hospitals will be especially important. CDC continues to work with many partners to support hospitals in their efforts to improve antibiotic use to protect patients.

Notes

Disclaimer. The findings and conclusions of the report are those of the authors and do not necessarily represent the official position of the CDC.

Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.