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Virtual Antimicrobial Stewardship in a Hospital Setting During a Pandemic


A group of medical professionals seen on a video call on a laptop computer

By Tracy N. Zembles, PharmD, BCPS-AQ ID

Antibiotics are essential to effectively treat infections in hospitalized patients, however, an estimated 30-50% of antibiotic use in hospitals is either unnecessary or inappropriate. When used incorrectly, antibiotics offer little benefit and expose patients to adverse reactions and increased risk of acquiring an antibiotic-resistant infection. 

“Handshake stewardship” is a unique method of antimicrobial stewardship which is characterized by:

  • lack of prior authorization
  • shared review of prescribed antimicrobials by a physician/pharmacist
  • daily, rounding-based, in-person approach to supporting providers

This method is considered a leading practice by The Joint Commission and has been incorporated into the Centers for Disease Control and Prevention’s (CDC) updated Core Elements for Hospital Antimicrobial Stewardship. 

COVID-19 Pandemic
In an article from the March 2021 issue of The Joint Commission Journal on Quality and Patient Safety, my colleagues and I discuss handshake stewardship during the COVID-19 pandemic. 

In early 2020, COVID-19 was declared and the CDC issued recommendations to limit face-to-face contact to reduce spread (hereafter called “social distancing”). Social distancing changed nearly every human interaction, including handshake stewardship. Hospitals advised personnel not directly caring for patients to work from home when possible. With little notice, antimicrobial stewards were faced with the challenge of creating a remote work environment that would continue to support optimal antimicrobial utilization. 

Challenges Related to the Elimination of Handshake Stewardship

This new normal resulted in the elimination of the handshake stewardship model described above. This change posed significant challenges such as:

  • inability to develop relationships
  • lack of a collaborative approach
  • difficulty providing education
  • inability to “read the room” and determine if the timing of the discussion was occurring at an appropriate time for both parties

Success of the handshake method is largely driven by interpersonal communication skills and a sense of connectedness between the antimicrobial stewardship team and clinicians. If the value of handshake stewardship relies on face-to-face contact to build rapport, establish trust, and develop relationships for future collaboration, how can handshake possibly be done virtually?

Providing Virtual Handshake Stewardship 
To successfully continue handshake stewardship in the era of social distancing, teams must find ways to enhance the personal connection via virtual communications. Some options include:

  • introductions at various hospital staff meetings 
  • creation of virtual meetings to discuss patients and/or deliver educational content 
  • embracing electronic communication and encouraging questions and/or follow up
  • emailing colleagues as appropriate to foster collaboration efforts on future guidelines and/or projects
  • utilizing technology for virtual check-ins to stay connected with all members of the stewardship team and to provide peer support

Pivoting Duties
In addition to the typical antimicrobial stewardship work, some teams have been required to pivot duties to include “COVID-19 stewardship,” including:

  • managing formulary requests and/or restrictions (e.g., remdesivir)
  • managing drug shortages related to the pandemic
  • developing treatment pathways for patients hospitalized with COVID-19
  • ensuring patients are not receiving unnecessary antibiotics
  • identifying opportunities to conserve personal protective equipment

Back to Normal?
Though it is unknown when teams can return to “normal operations,” some antimicrobial stewardship teams have been granted a return to some form of in-person rounds, with masking requirements and socially distanced interactions. This return to in-person rounds is a priority for successful programs, not only to improve efficiency and teaching opportunities, but for personal job satisfaction. 

Though some teams have been able to return to in-person rounds, the lessons learned from nearly a year of virtual stewardship may be helpful to teams when remote work may be necessary in the future.

Tracy N. Zembles, PharmD, BCPS-AQ ID, is an Antimicrobial Stewardship Pharmacist in the Department of Enterprise Safety at Children’s Wisconsin in Milwaukee.