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A Challenge to Hospital Leadership

Donald A. Goldmann, MD; Robert A. Weinstein, MD; Richard P. Wenzel, MD; Ofelia C. Tablan, MD; Richard J. Duma, MD; Robert P. Gaynes, MD; James Schlosser, MD; William J. Martone, MD; Workshop to Prevent and Control the Emergence and Spread of Antimicrobial-Resistant Microorganisms in Hospitals; Jacques Acar, MD; Jerry Avorn, MD; John Burke, MD; John Boyce, MD; Jean Carlet, MD; Julia Garner, RN, MN, CDC; Mary J. Gilchrist, PhD; Elaine Larson, RN, PhD; James Lee, MD, PhD; Mark A. Malangoni, MD; Edward McSweegan, PhD; John McGowan, MD; Armando D. Meza, MD; Joel Moses, MD; Carole Patterson, RN, MN; Bruce C. Perry, MD, MPH; Barbara Russell, RN, MPH; Jerome Schentag, PharmD; Albert T. Sheldon, Jr, PhD; Jane Siegel, MD; Ken Spitalny, MD; James Tenney, MD; Fred Tenover, PhD, CDC; Ralph Timperi, PhD; Jan Maarten van den Berg, MD

JAMA. 1996;275(3):234-240.

Abstract
Objective.
—To provide hospital leaders with strategic goals or actions likely to have a significant impact on antimicrobial resistance, outline outcome and process measures for evaluating progress toward each goal, describe potential barriers to success, and suggest countermeasures and novel improvement strategies.

Participants.
—A multidisciplinary group of experts was drawn from the following areas: hospital epidemiology and infection control, infectious diseases (including graduate training programs), clinical practice (including nursing, surgery, internal medicine, and pediatrics), pharmacy, administration, quality improvement, appropriateness evaluation, behavior modification, practice guideline development, medical informatics, and outcomes research. Representatives from appropriate federal agencies, the Joint Commission on Accreditation of Healthcare Organizations, and the pharmaceutical industry also participated.

Evidence.
—Published literature, guidelines, expert opinion, and practical experience regarding efforts to improve antibiotic utilization and prevent and control the emergence and dissemination of antimicrobial-resistant microorganisms in hospitals.

Consensus Process.
—Participants were divided into two quality improvement teams: one focusing on improving antimicrobial usage and the other on preventing and controlling transmission of resistant microorganisms. The teams modeled the process a hospital might use to develop and implement a strategic plan to combat antimicrobial resistance.

Conclusions.
—Ten strategic goals and related process and outcome measures were agreed on. The five strategic goals to optimize antimicrobial use were as follows: optimizing antimicrobial prophylaxis for operative procedures; optimizing choice and duration of empiric therapy; improving antimicrobial prescribing by educational and administrative means; monitoring and providing feedback regarding antibiotic resistance; and defining and implementing health care delivery system guidelines for important types of antimicrobial use. The five strategic goals to detect, report, and prevent transmission of antimicrobial resistant organisms were as follows: to develop a system to recognize and report trends in antimicrobial resistance within the institution; develop a system to rapidly detect and report resistant microorganisms in individual patients and ensure a rapid response by caregivers; increase adherence to basic infection control policies and procedures; incorporate the detection, prevention, and control of antimicrobial resistance into institutional strategic goals and provide the required resources; and develop a plan for identifying, transferring, discharging, and readmitting patients colonized with specific antimicrobial-resistant pathogens.

(JAMA. 1996;275:234-240)

Author Affiliations
Hôpital Saint-Joseph, Paris, France; Brigham and Women's Hospital, Boston, Mass; LDS Hospital, Salt Lake City, Utah; Society for Healthcare Epidemiology of America and Miriam Hospital, Providence, RI; Hôpital Saint-Joseph, Paris, France; Atlanta, Ga; American Society for Microbiology and Veterans Administration Medical Center, Cincinnati, Ohio; Georgetown University School of Nursing, Washington, DC; VA Medical Center, Minneapolis, Minn; Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio; National Institutes of Health, Bethesda, Md; Grady Memorial Hospital, Atlanta, Ga; R. E. Thomason General Hospital, El Paso, Tex; Arnot Ogden Medical Center, Elmira, NY; Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill; The Southeast Permanente Medical Group Inc, Atlanta, Ga; Association of Professionals in Infection Control and Epidemiology, Chicago, Ill; Millard Fillmore Hospital, Buffalo, NY; Food and Drug Administration, Rockville, Md; American Academy of Pediatrics, Pediatric Infectious Diseases Society of America, and University of Texas Southwestern Medical Center, Dallas, Tex; Council of State and Territorial Epidemiologists and New Jersey State Health Department, Trenton, NJ; Clinical Research, Bristol-Myers-Squibb Pharmaceutical Research Institute, Wallingford, Conn; Atlanta, Ga; Association of State and Territorial Public Health Laboratory Directors and Massachusetts Department of Health, Jamaica Plain, Mass; Centraal Begeleidingsorgaan voor de Intercollegiale, Toetsing, the Netherlands

From the Departments of Medicine and Quality Improvement, Children's Hospital, Boston, Mass (Dr Goldmann); Division of Infectious Diseases, Cook County Hospital, Chicago, Ill (Dr Weinstein); Division of General Medicine, University of Iowa Hospitals and Clinics, Iowa City (Dr Wenzel); Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga (Drs Tablan, Gaynes, and Martone); National Foundation for Infectious Diseases, Bethesda, Md (Dr Duma); and Cambridge (Mass) Hospital and Institute for Healthcare Improvement, Boston, Mass (Dr Schlosser).

Footnotes
A complete list of the workshop participants appears at the end of this article.

The workshop, Antimicrobial Resistance in Hospitals; Strategies to Improve Antimicrobial Use and Prevent Nosocomial Transmission of Antimicrobial-Resistant Microorganisms, was held on September 12-14, 1994, in Atlanta, Ga, under the joint sponsorship of the Centers for Disease Control and Prevention and the National Foundation for Infectious Diseases.

Reprint requests to Division of Infectious Diseases, Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (Dr Goldmann).

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