Accreditation Template Vertical

Antimicrobial Stewardship Required Organizational Practice (ROP) Key Facts Antimicrobial Stewardship ROP  Antimicrobial stewardship is a team approach using different initiatives to help use anti-infectives more wisely.  The inappropriate use of antimicrobial agents may have unintended consequences including: o Toxicity o Selection of pathogenic organisms (such as Clostridium difficile) / Opportunistic infections o Development of antimicrobial-resistant organisms (e.g. MRSA, VRE)  The primary focus of an antimicrobial stewardship program is to optimize the use of antimicrobials to achieve the best patient outcomes, reduce the risk of infections, reduce or stabilize levels of antibiotic resistance, and promote patient safety.

I need to know:  Health PEI has a multidisciplinary Provincial Drugs & Therapeutics Antimicrobial Stewardship Subcommittee.  Antimicrobial Stewardship resources are available on the Health PEI website www.healthpei.ca/micro  Examples of the Antimicrobial Stewardship Program’s initiatives include: o Empiric treatment guidelines, most of which are incorporated into PowerPlans o Review (prospective audit and feedback) of all PEI acute care, home care, and ambulatory care patients on meropenem, ertapenem, and imipenem-cilastatin on Tuesdays and Thursdays o Clinical decision support tools in CIS (e.g. Cdiff alert , code sepsis orderable) o Antibiogram, compiled by the Microbiology Division www.healthpei.ca/antibiogram o Educational sessions (e.g. Grand Rounds; province-wide multi-disciplinary events such as Urine Matters, Cough Matters, and Antibiotic Matters) o Formulary work – identified the formulary status of all anti-infectives on the Health PEI Hospital Drug Formulary including restrictions; involved with some anti-infective changes on the PEI Pharmacare Formulary.  An antimicrobial stewardship program survey was sent out to stakeholders and the responses were reviewed. Other antimicrobial stewardship initiatives are audited when appropriate.  The ROP handbook can be found on the Health PEI Staff Resource Centre website http://www.healthpei.ca/src

Related Standard: Medication Management 2.3

Revised June 2017 Required Organizational Practices (ROPs) are identified by Accreditation Canada as evidence based- practices, which reduce harm to patients. They are mandatory practices matched to specific Accreditation Canada Standards that organizations must have in place. There are 33 ROPs identified within Health PEI for the September 2017 survey visit.

Revised June 2017