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In July, 2016 TJC introduced its new standard on antimicrobial stewardship. The standard is contained in the Medication Management chapter (MM.09.01.01) of the Hospital manual and goes into effect January 1, 2017. At first, it might seem that this new standard doesn’t have much relevance for psychiatric hospitals. Antibiotic consumption in psychiatric hospitals is low compared to general hospitals. However, antibiotics have several drug–drug interactions with psychotropic drugs that can lead to adverse events or treatment failure and significantly increase the cost of treatment. Thus, this new standard is relevant for any hospital whose patients are being prescribed antibiotics.

The focus of this new standard is on reducing the use of inappropriate antimicrobials in all healthcare settings due to antimicrobial resistance. The CDC has identified that 20 – 50% of all antibiotics prescribed in acute care hospitals are either unnecessary or inappropriate.


The following is a summary of the key requirements of the standard.

  1. Establish antimicrobial stewardship as an organizational priority.
  • Recommended actions: Review the topic at your P&T Committee, Infection Control Committee, and Medical Staff Executive Committee and begin to develop an action plan. Keep it as a standing agenda item at these meetings to report progress.  Include it as a goal in the 2017 IC Plan and PI Plans.
  1. Educate staff/LIPs involved in antimicrobial ordering, dispensing, administration and monitoring about antimicrobial resistance and antimicrobial stewardship practices.
  • Recommended actions: Develop a training module for relevant staff/LIPs on antimicrobial stewardship and a training plan with an implementation schedule.
  1. Educate patients and families about appropriate use of antibiotics.
  • Recommended actions: Develop some educational material for patients/families. Check out the CDC resource “What’s got you sick?”
  1. Establish an antimicrobial stewardship team with the following members when available in your setting: infectious disease physician, infection preventionist, pharmacist, and practitioner.
  • Recommended actions: Convene a team (a subcommittee of your Pharmacy  Therapeutics Committee or IC Committee) that will take the lead on the antimicrobial stewardship initiative. Recommended members: Medical Director (psychiatrist), internal medicine physician, IC Coordinator, and pharmacist.
  1. Include in the program the following core elements endorsed by CDC:
    • Leadership commitment
    • Accountability (a designated leader for the program)
    • Drug expertise (pharmacist)
    • Action (based on your analysis and best practices)
    • Tracking (data collection)
    • Reporting (relaying the data to MDs and nurses)
    • Education (for prescribers re resistance and optimal prescribing)
  1. Establish organization-approved protocols for antibiotic use.
  • Recommended actions: Research the protocols available and determine which ones are appropriate for your hospital to adopt or adapt.
  1. Report data on the antimicrobial stewardship program.
  • Recommended actions: Start simple. Begin with collecting data on your current antimicrobial prescribing patterns.
  1. Take action on improvement opportunities identified.
  • Recommended actions: Proceed cautiously. Do your research and gather your data and then determine where improvement opportunities exist.


So, don’t delay in paying attention to this new standard. Bring the new requirements to the attention of your clinical leaders and then convene a small workgroup to begin the planning process for how to tackle this important initiative. If you expect to be surveyed in 2017, this topic is sure to be high on the radar for surveyors.

For the full text and all the details see the July 2016 Joint Commission Perspectives article New Antimicrobial Stewardship Standard.