Frequently Identified Gaps in Antimicrobial Stewardship Programs in Critical Access Hospitals

Background: Nebraska (NE) Infection Control Assessment and Promotion Program (ICAP) is a CDC funded project. ICAP team works in collaboration with NE Department of Health and Human Services (NEDHHS) to assess and improve infection prevention and control programs (IPCP) in various health care settings including resource limited settings like critical access hospitals (CAH). Little is known about the existing gaps in antimicrobial stewardship programs (ASP) of CAH. Hence, we decided to study the current level of ASP activities and factors associated with these activities in CAH.

Methods: NE ICAP conducted on-site surveys in 36 CAH from 10/2015 to 2/2017. ASP activities related to the 7 CDC recommended core elements (CE) including leadership support (LS), accountability, drug expertise (DE), action, tracking, reporting, and education were assessed using a CDC Infection Control Assessment Tool for acute care hospitals. Descriptive analyses evaluated CAH characteristics and frequency of CE implementation. Fisher’s exact, Mann-Whitney, and Kruskal-Wallis tests were used for statistical analyses examining the association of various factors with level of ASP activities.

Results: The 36 surveyed CAH had a median of 20 (range 10-25) beds and employed a median of 0.4 (range 0.1-1.6) infection preventionist (IP) full time equivalent (FTE)/25-bed. Frequency of CE implementation varied among CAH with action and LS as the most (69%) and least (28%) frequently implemented elements, respectively. Close to half (47%) of surveyed CAH had implemented ≥4 CE but only 14% of facilities had all 7 CE. Median bed size and IP FTE/25-bed were similar among CAH with 0-2, 3-5, or ≥6 CE in place. CAH with LS or accountability for ASP implemented higher median numbers of the remaining CE compared to CAH without LS or accountability (5 vs. 2, p<0.01 and 4 vs. 2, p<0.01, respectively). Facilities with presence of LS, accountability and drug expertise were more likely to have all 4 remaining CE implemented than others (56% vs. 8%, p<0.01).

Conclusion: LS, accountability, and DE are important factors for the implementation of the remaining 4 CE in CAH. Although LS was the least frequently implemented CE, when present was associated with implementation of most of the other CE. Acquiring LS will facilitate implementation of additional ASP efforts in CAH.