Why Nurses Should be Key Participants in ASPs

With more than 3.8 million nurses in the United States, the largest part of the healthcare workforce can be a powerful influence on antimicrobial stewardship efforts. They’re central communicators because they monitor a patient’s status 24/7. Nurses can be a powerful resource during patient-family education to talk to them about appropriate antibiotic use, potential side effects, and just general infection prevention measures. The fact that the nurses spend most of their day with patients is very powerful.

The extent of a nurse’s involvement in ASP activities can change, depending on their scope of responsibilities, skill level, and educational level. For example, the bedside nurse represents several components of antimicrobial stewardship principles in daily care today. That bedside nurse is the primary patient advocate and the monitor for healthcare-associated infections and antimicrobial adverse events. Many of the safety and quality initiatives, including reduction in central line-associated bacteremia, catheter-associated urinary tract infections, C. diff infection surveillance and control, and other bundle measures are, in large measure, operationalized and are being tracked by nursing staff today.

According to a white paper co-authored by the Centers for Disease Control (CDC) and the American Nurses Association, nurses already play an often-unrecognized role in ASP efforts. Some of those functions include:¹

• Obtaining cultures before antibiotics are started, monitoring culture results, and reporting the results to the provider
• Monitoring patients and reporting adverse events to the provider and pharmacist
• Providing medication education to patients and their families
• Taking a patient’s allergy information and recording it in the medical record
• Reviewing antibiotic dose/time orders for accuracy, administering antibiotics, and recording all doses
• Reporting bug/drug mismatches, antibiotic time-outs, and antibiotic de-escalation

“Nurse practitioners,” adds Bonanni, “function similarly to physicians in that they assess, diagnose, and prescribe treatment pathways for patients with infectious diseases.”

The CDC and the Joint Commission have each highlighted the importance of nurses in successful ASPs.^1,2 However, there is still work to be done in helping healthcare organizations recognize the impact nurses can have on AMR efforts and take steps to fully utilize the knowledge, skill, and hands-on patient experience of nurses.

Unfortunately, many healthcare organizations in the US have not clearly defined, or more importantly, recognized the essential role the nurse plays in stewardship.

In a 2018 survey, 69.4% of nurses either agreed or strongly agreed that they understood the term antibiotic stewardship. Most wanted to be more involved in ASP efforts and 54% felt they already were stewards.³

According to the study authors, the overall survey results indicate that while nurses believe they have a role to play in antimicrobial stewardship efforts, they may need enhanced education related to antimicrobials in order to fulfill that role most effectively. Additionally, clinical practice and hospital culture may influence nursing perceptions of their role in antibiotic stewardship.³

Several opportunities exist for enhancing the contributions of nurses to ASPs. Some of these include providing continuing education in infectious disease (including microbiology and pharmacology) and establishing well-defined processes and outcome measures. Some of those outcome measures could be percentage of cultures obtained prior to the first dose of antibiotics, percentage of antibiotics administered in a timely manner, identifying contaminated blood specimens, percentage of bedside rounds that include antibiotic time-outs, and having a percentage of nurses able to verbalize the indication for patients being on antibiotics.

In addition to addressing knowledge gaps for nurses, the CDC/ANA white paper identified other ways hospitals can engage nurses and foster their participation in ASPs.¹ Some of these include developing specific content and messages for nurses as part of any effort to raise awareness about antibiotic use and resistance, encouraging nurse antibiotic stewardship champions at the unit level, and including nurses in stewardship rounds.