Establishing an AMS program

In residential aged care, this impacts the quality of care for residents and increases the risk of adverse effects. Aged care residents are at greater risk of an infection due to comorbidities, functional decline and a compromised immune status. Living in a communal environment also increases this risk. Residential aged care facilities should aim to reduce the impact of AMR through establishing an antimicrobial stewardship (AMS) program.

What is an AMS program?

An AMS program is a set program of structured activities that promote the appropriate use of antimicrobial medications. The program can be tailored to suit the type of residential aged care facility, whether it is part of a large group of homes or smaller individually owned services. When establishing an AMS program, it’s important to ensure that it covers all of the required areas.

What are the core elements of an AMS program?

An AMS program is a program that follows general rules and requirements that is customised to your facility. The specifics of the program will depend on your facility’s size, structure and needs, but there are some elements that will be present no matter what your facility looks like. The CDC lists the following as core elements of an AMS program:

1.      Leadership commitment  

Commitment by the leadership team is essential. This means that all levels of management, including the governing body (such as the board), have responsibility for supporting and promoting AMS. Regardless of the size of your leadership team and governing body, the following list of measures is necessary to support your program.

• Develop written statements in support of improving antimicrobial usage.
• Incorporate AMS into the overall quality and safety program.
• Communicate to the nursing staff and visiting doctors the expectations of AMS policies and practices they are required to follow.

Leadership commitment should also give you the impetus to undertake a gap analysis. If you’re not sure what this should involve, read our ‘establishing an AMS program’ link below.

2.      Accountability

Accountability is a crucial part of establishing an AMS program. Choosing people who ultimately become responsible for the execution and oversight of the AMS program is the only way to ensure success.

• Delegate responsibility to a dedicated clinical lead to oversee the program. Ideally this would be the infection prevention and control lead in your organisation.
• Key leaders including managers and quality staff are responsible for supporting the clinical lead and driving commitment.

Note that this support must be practical. A signature on a page or agreement during a meeting is not the same as actively supporting the lead in their role. An effective AMS program will most likely require change on and support from multiple levels of management.

This is also a good stage to establish what information should be reported, and to which business area/management level (more on this in step 6).

3.      Expertise and expert buy-in

• Establish links for prescribers to source expert assistance.
• Pharmacists that provide services would be involved in supporting the AMS program and assist with monitoring the usage of antimicrobial medications. This commonly occurs through medication advisory meetings, which are a good venue for discussing the AMS program in general.
• Provide prescribing guidelines such as the Therapeutic Guidelines – Antibiotics to assist prescribers.

4.      Action

The first step of enacting an AMS program is completing a gap analysis. If you haven’t yet done this, there are tips at the end of this post.

• Develop evidence-based AMS policies and procedures.
• Review the existing infection prevention and control program. Infection prevention is vital in avoiding the need for antimicrobial medication and therefore an important part of an AMS program. Infection control measures such as standard and transmission-based precautions, environmental controls and promotion of vaccination for influenza and pneumococcal are all crucial in preventing infections.
• Identify goals and targets based on the results of the gap analysis (see the end of this article), select specific actions, develop a program plan and performance measures to evaluate outcomes of actions implemented.

This is a big step, and possible the first where you will require support from people outside of your regular work area. If you discover issues with your current AMS governance or oversight structure, bring this to the attention of the board.

5.      Tracking

Once action has been taken, the program’s impact needs to be measured. This is done through regular and consistent tracking.

• Selected goals and targets are monitored and measured to establish progress. This includes noting any actions implemented and whether any changes are needed.
• Implementation and monitoring of tracking should be done by the key drivers of the program. Ideally, this should be the clinical lead and management team in coordination with the quality and safety team.

6.      Reporting 

It is crucial that the findings of the AMS program are reported to people who need this information for improvements. This is easier if there is a consistent, standardised plan for collating and sharing this information.

• Develop a communication plan. You will want to let all those involved know how the program is progressing, what has worked well, the program’s achievements and successes, and what can be done to improve it further. This will benefit the ongoing program and commitment by staff and other stakeholders.

Be sure that all the relevant information is being passed to the right teams and business areas. It’s easy to assume that because the information has been collected that it will find its way to the right people; unfortunately this isn’t the case. A regular communication plan makes it easier to remember to relay information, and also allows other parties to plan their responses around the regular communication of new information.

7.      Education

Only when people understand the impact and importance of AMS can they fully commit to your AMS program. Regular education to inform and reinforce the importance of AMS is a critical part of your AMS stewardship.

• Provide education to all staff about the benefits of AMS, how they can contribute and what practices they need to follow. Education can be tailored according to the role of different staff members and what is required according to their responsibilities.
• Provide information sessions for residents and families to assist their understanding AMS and the importance of reducing resistance to antimicrobial medication.
• Each year in November is ‘Antibiotic Awareness Week’. You could use this as an opportunity to have an event in your facility to raise awareness not only for staff but also residents, families and visitors. It could also be a good time to share the progress of your AMS program.

Establishing an AMS program

The most important first step is to do a gap analysis. This will guide you in identifying what areas need improving. To complete a gap analysis you could do one or more of the following:

Your organisation could participate in The Aged Care National Antimicrobial Prescribing Survey (AC – NAPS) which is a standardised surveillance tool used to monitor the prevalence of infections and antimicrobial use in residential aged care facilities. The survey results can guide you in developing an AMS plan and identifying where improvements can be made.

OR

Use an audit tool; the linked tool is from the CDC in the USA and may have some limitations for use in Australia, however it is designed for aged care facilities and could be tailored to the Australian context.

The results of whichever audit you undertake will provide data on where your gaps are and assist with the development of an AMS plan.

Good quality data is crucial in measuring a range of important parameters such as infection rates, microbiology results, use of infection definition criteria, antibiotic usage, prescribing practice and documentation and adverse events.

A comprehensive surveillance system will be of great benefit in collecting continuous ongoing data which needs to be reviewed and evaluated on a regular basis.

Some important initial actions would be to establish goals and targets for the AMS program based on data from survey/audit results.  

Initially start with small, achievable, measurable goals and targets. AMS programs take some time to establish and it is best to start small and then gradually build up the program.  Establish some short-term goals and targets then expand over time. Review the results or outcomes of set goals and targets at regular intervals to measure progress and inform where further improvements and actions are needed.

Further resources

Establishing an AMS program is a big undertaking. While we’ve tried to provide a helpful overview, further information on the core elements of an AMS program can be found at:

• The National Centre for Antimicrobial Stewardship

Antimicrobial stewardship is a big topic, and one that’s constantly changing. We wrote last year about reducing antimicrobial use in aged care based on the 2021 AURA report, which showed the current focus areas for Australian AMS.

If you’re interested in getting on top of AMS in your facility, or if you need help establishing baselines, you can read the Bug Control AMS guide or contact us today to find out how we can help improve infection control in your aged care facility.