Antimicrobial Stewards Must Aim for Balance in “Going Beyond the 9 to 5”
Year: 2025
Type: editorial
Abstract: Congratulations to Brace et al. for publication of survey data from 69 United States (US) hospitals in this edition of OFID. This study describes dedicated personnel resource allocation and coverage hours for hospital antimicrobial stewardship programs (ASPs), which updates our understanding from the last major US survey of 244 hospitals by Doernberg et al. in 2018 [1]. Since then, ASPs have matured, survived a pandemic, adopted telehealth practices, and grown system-based programs that spread stewardship expertize across varied and remote settings [2, 3]. Summarized full-time equivalent (FTE) descriptions as presented here can allow stewardship leaders to learn from varied practice models to design what works best for their own institutions and patients. This survey's focus on gathering information for “on call” programs—defined as ASP team activities occurring outside of traditional work hours—is novel. Most responses were from large >500 bed, academic hospitals. Approximately a third (24/69) of surveyed hospitals reported on call activities, including 17/69 (25%) during nights, 22/69 (32%) during weekend days, and 20/69 (29%) during holidays. Nine (13%) reported compensation for on call activities. From these data, we can conclude that on call ASP models are not a standard expectation for inpatient ASPs, even among this sample of large US hospitals. The need for well-designed and resourced ASPs exceeds the work force of infectious diseases (ID) specialists. Brace et al.'s survey of 69 US hospitals including 1 critical access hospital represents a small sample compared to the distribution of hospital-based care in the US. For example, in 2023 the NHSN surveyed 3394 general acute care hospitals and 1286 critical access hospitals [4]. In small hospital settings, dedicated stewardship FTEs are hard to obtain without strategies to share pooled resources or training and delegation of stewardship activities to existing clinical personnel [5, 6]. Attempting to additionally cover off-hours with a centralized stewardship team in such settings is hard to imagine when there is limited or no baseline of dedicated FTE for regular hours. One feasibility study of preauthorization showed that zero community hospital study sites could adopt strict implementation including after-hours coverage [7]. Thus, the finding that large programs with existing dedicated FTE were more likely to offer on call ASP services is no surprise. The most common activity reported by 18 of 24 (75%) hospitals with on call programs was answering ASP/ID questions. Though potentially impactful for individual patients, being available to answer ASP/ID questions at all hours likely has little impact on hospital antibiotic use if implemented without other active interventions. Stenehjem et al.'s landmark, cluster-randomized trial of small community hospitals utilizing centralized expertize provided a 24-hour ID “hotline” in all three models of ASPs tested. However, only hospitals randomized to the most intensive program with centralized experts performing daytime interventions via telemedicine reduced antibiotic use [8]. These findings suggested that 24-hour availability of ID expertize was not the key programmatic intervention. While impacting antibiotic use is important, maintaining the well-being of the antimicrobial stewardship workforce is paramount for enabling long-term success and sustainability. Stewardship champions are faced with the insurmountable task of improving the safe and effective use of antimicrobials in all care areas. Prioritizing the work of the day to enable the greatest impact is a challenge when the number of patients to review outnumbers the minutes in the day. Low-value tasks and those that further moral injury or burnout must be mitigated or avoided. One 2021 survey suggested over one-third of ASP pharmacist and physician respondents met criteria for burnout, with higher rates among pharmacists [9, 10]. IDSA has highlighted the critical shortage of ID physicians, and dwindling match rates have ID fellowship programs searching for ways to keep trainees' well-being a high priority [11]. ASPs that traditionally staffed overnight preauthorization calls with ID fellows have since pivoted to morning reviews and prospective audit and feedback [12, 13]. Adding responsibilities that may increase staff stress and anxiety beyond normal business hours seems unwise in such an environment. Dr. Emily Heil described that antimicrobial stewards are not enthusiastic about offering unsolicited advice and being the “antibiotic police” of their facility [14]. Stewardship pharmacist and thought leader Dr. Debra Goff noted three common themes tied to attrition of stewardship pharmacists: lack of work-life balance, no dedicated time to conduct research, and not feeling appreciated for efforts to improve patient care [15]. Although on call services may be a source of pride and feasible for well-resourced ASPs, there is substantial risk for on call programs to disrupt work-life balance and negatively impact the well-being of stewardship personnel. A major goal for ASPs is to empower primary prescribers to gain knowledge and incorporate stewardship principles into their daily practice, even when not directly intervened upon by the stewardship team. Being a steward is being a motivator, a coach, planting a seed and seeing it grow in colleagues' clinical reasoning patterns. If ASPs are positioned as a fee-for-service program that includes expectations for on call coverage, that role could change. In one-to-one stewardship interventions, we ask questions, provide anticipatory guidance, develop trust, and set up clinical rationales to make it easy to make the next responsible antibiotic decision. Offering advice “for your next patient…” to emphasize a learning point is what handshake rounds are made for, why we see indirect effects with persuasive stewardship strategies, and how we extend influence beyond an individual patient [16–18]. The risk of clinicians forgetting their responsibility for judicious prescribing because they rely on continuous ASP/ID availability and “turn off” their critical thinking could ultimately limit ASP effects. In contrast, seeing the slow progress of learning and behavior change in the clinicians we serve is both sustainable and satisfying. So, when might ASP leaders consider adding on call activities to their program design? We provide a list of proposed benefits and possible risks of on call programs to consider (Table 1), and suggest a thoughtful, Plan-Do-Study-Act approach. First, establish and define clinical scenarios occurring during off-hours that could benefit from stewardship guidance. This might require review of calls or antibiotic decisions during off-hours to recognize gaps and to identify low-value activities. Second, prioritize needs based on patient safety and consider alternative strategies to address them. Third, develop a strategy that balances well-being with access to ID expertize when needed. For example, a tiered approach to preauthorization during overnight hours can allow first doses of restricted drugs with favorable safety profiles for subsequent morning reviews (eg, carbapenems) and reserve calls for more toxic agents where diagnostic reasoning from ID consultants or prompts for surgical consultation are urgent (eg, amphotericin). Fourth, make sure ASP and ID consultant teams discuss and agree that such risks require their input for off-hours scenarios and how to best communicate those rationales to front-line clinicians. Finally, no programmatic decision should be considered a “forever” plan. Reassess and learn with the aim of designing systems-based solutions for off-hours scenarios. Adjust ASP workflow and coverage as primary clinicians' stewardship-focused practice patterns improve, FTEs contract or expand, and ASP priorities evolve. Balancing the Potential Benefits and Risks of On-Call Antimicrobial Stewardship Program Services aThis potential risk must be given exceptional consideration above all other factors. Balancing the Potential Benefits and Risks of On-Call Antimicrobial Stewardship Program Services aThis potential risk must be given exceptional consideration above all other factors. ASP leaders have the expertize to create systems that meet the needs of their patients and clinicians, yet preserve well-being, and create sustainable environments of continued, supportive personal growth. We encourage you to use the data presented here in OFID to reflect on your current approach, learn from your ID community, and further innovate on strategies that create both balance and impact. Financial support. No funding for this work.
Source: Open Forum Infectious Diseases
DOI: 10.1093/ofid/ofaf717
Authors: Rebekah W Moehring, Timothy P Gauthier
Institutions: Duke University, Baptist Health South Florida
Language: English
Subfield: Applied Microbiology and Biotechnology
Field: Immunology and Microbiology
Domain: Life Sciences
Open Access status: gold
Estimated APC paid: $4,053
OpenAlex ID: W4417423152