When infectious disease specialist Sarah Parker, MD, was hired to create an antimicrobial stewardship program at Children’s Colorado in 2011, there were several aspects of the typical model she didn’t like.
Antimicrobial stewardship programs are supposed to help measure and improve how providers prescribe antimicrobials. But restrictions on the drugs that providers can order and the typical preauthorization process often undermine the program’s goals.
“Including caveats didn’t seem like the best way to support our providers,” says Dr. Parker, “so we made some modifications, and we implemented what we call Handshake Stewardship.”
The result of those modifications is an 86% acceptance rate, the percentage of Children’s Colorado providers who agree to modify their prescription order based on the stewards’ recommendations. It’s an incredibly high acceptance rate.
Removing the barriers
Prior to rolling out Handshake Stewardship, Dr. Parker talked with providers both at Children’s Colorado and across the country about antimicrobial stewardship programs. What she found was that when there are obstacles, providers find workarounds.
“They’d order a combination of unrestricted drugs that would mimic the effect of the restricted drug,” she says. “Or they’d wait to order a drug until after the steward was off duty.”
As for preauthorization? When providers have to wait for the steward to call them back with an authorization code, it causes an unnecessary delay in patient care.
If Dr. Parker was going to make an antimicrobial stewardship program work at Children’s Colorado, those two things would have to go.
Two stewards: A physician and a pharmacist
Another novel aspect of Handshake Stewardship is that both a physician and a pharmacist review antibiotic orders.
“That’s essential,” says Dr. Parker. “Most stewardship programs only have a physician as backup, but because we have both, we often have complementing feedback.”
They review between 60 and 120 orders a day, and they take turns looking at the orders so that both of them review each one.
It’s much easier and more effective to communicate a recommendation to a provider when you can do it in person, says Dr. Parker.
“With our rounding-based feedback approach, we’re able to teach a lot more,” she says. “We don’t usually just talk to one person, it’s the whole team that’s there, from the beginner med student all the way up to the attending.”
It allows for more comfortable back-and-forth dialogue about topics like toxicity, affordability for the patient’s family, and why de-escalation or escalation of the drug could be important for the patient’s safety. It also gives the stewards more situational awareness. They can read the room and adjust their approach accordingly — something they can’t do over email or phone.
Dr. Parker says that’s likely why Handshake Stewardship has the acceptance rate it does. “In-person interaction is something so simple that no other stewardship program is doing, and our providers really appreciate it.”
A model that’s catching on
Handshake Stewardship is now considered a national model, lauded by The Joint Commission and the Centers for Disease Control and Prevention.
As such, it’s been implemented at institutions like Vanderbilt, Children’s Hospital of Philadelphia, University of Minnesota, Seattle Children’s Hospital and Children’s Mercy — to name a handful.
It’s spread more widely than they likely know, Dr. Parker says, and that’s why her team continues to collect data.
“Programs often have to justify themselves,” she says. “So we’ve published information on the acceptance rate, the cost savings, the sustainability of the model and much more to make it easier for institutions to implement.”