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Appendix
Appendix
2018-2022 LEAP Experiential Curriculum
Public health
• Supporting literature
Antimicrobial stewardship
• Experiences
• Core
• Shadowing of key health department personnel (e.g., HAI coordinators, medical directorate, public health outbreak personnel, stewardship personnel) – Arrange to shadow department personnel while active in the field or while coordinating meetings. Ideally, one or more days a week should be spent at the DOH site so that the fellow can be integrated into developing situations. Key learning points include how the HAI program is structured at the health department; what types of funding streams a health department utilizes and how different funding is utilized; and what role CDC plays in health department funding and programming.
• Programmatic advisory councils (e.g., HAI advisory council, stewardship advisory council) – Learn what kind of information the advisory councils track and how they use that information to inform public health department activities.
• Facility infection control assessment and response visits and debriefs (i.e., site visits) – Observe how an ICAR functions, what types of information and issues are identified by the state surveyors and what kinds of recommendations are made in response. It is advisable to attempt to observe more than one ICAR visit and to visit different types of health care facilities.
• Facility types:
• Acute care hospital
• Critical access hospital
• Ambulatory surgical center or other outpatient setting
• Long-term care facility
• Hemodialysis facility
• Reportable disease reviews (CRE, CRAB, Candida auris, COVID-19, XDRO TB, STIs) – Attend meetings where reportable diseases are discussed to learn how the health department approaches tracking and management of concerning infectious and communicable pathogens.
• Public health lab visits and meetings – Attempt to join any scheduled visits to the DOH’s affiliated public health lab. Learn what kinds of activities the lab does, what kinds of services it provides to facilities around the state and how it determines what kinds of tests to use and in which circumstances (such as when PFGE or whole genome sequencing is appropriate for clonal analysis).
• Supplemental
• Outbreak investigations (community or health care associated) – Learn how the health department assists hospitals in outbreak investigations. If possible, it is very instructive for the fellow to assist as a liaison between the health department members and hospital epidemiology/infection control staff at the hospital.
• Educational collaboratives in which the health department is involved – Participate in activities such as COVID-19 outbreak mitigation, CDI prevention collaboratives, HAI or MDRO prevention collaboratives, antimicrobial resistance prevention collaboratives and antimicrobial stewardship collaboratives. Learn how varied the expertise among health care settings is, and what the health department does to try and disseminate knowledge and set standards. It is recommended that if there are opportunities to create and present information to collaborative members, the fellow should participate in these activities.
• CDC. Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics. Third Edition. U.S. Department of Health and Human Services; 2006.
• Experiences
• Core
• Core stewardship program work meeting – Participate in the regular workgroup meeting for the stewardship program at your hospital. Key learning points include how stewardship programs monitor antimicrobial use in the hospital, how the efficacy of interventions is monitored, how antimicrobial use concerns by leadership are addressed by an ASP and what day-to-day activities a stewardship program engages in.
• Prospective antimicrobial use reviews and feedback interventions – Participate in prospective auditing of antimicrobial use. Learning points include how to communicate stewardship recommendations with various types of providers.
• Antimicrobial use reports – Assist in the creation and compilation of internal antimicrobial use and antimicrobial stewardship program activity reporting. Learning points include which metrics are used and how metrics of antimicrobial use and patient day denominators are collected and compiled, and what other kinds of data are collected and tracked by an ASP, including (if relevant) antimicrobial resistance data or antibiogram data, intervention tracking and national reporting.
• Antimicrobial use guidelines (or clinical treatment guidelines) – Participate in the creation of new antimicrobial use guidelines or clinical treatment guidelines. Learning points include what kind of data goes into compiling a new treatment guideline, what the process is for approving and disseminating this type of guideline, and how to utilize pharmacokinetic and pharmacodynamic information to inform recommendations.
• Antimicrobial stewardship educational efforts – Participate in antimicrobial stewardship educational lectures or other educational efforts. Learning points include how to most effectively convey stewardship recommendations.
• Antimicrobial stewardship and microbiology joint meetings – Learn how the ASP program works with microbiology to influence susceptibility reporting (tiered susceptibility reports/tiered resistance testing), rapid diagnostic reporting and diagnostic stewardship (if any). What role does the lab play in hospital formulary review and antimicrobial approvals, creation of the hospital antibiogram, specialized testing and susceptibility reporting for newly introduced antimicrobial agents.
• Supplemental
• Approval of restricted antimicrobials (if not already involved) – Note: The fellow should not be unduly burdened by antimicrobial approval duties. However, a minor amount of exposure to the process and demands of antimicrobial approval is not inappropriate. Learning points include what kinds of clinical data are required to make properly informed decisions on approval, communication strategies to increase provider acceptance of recommendations, how to appropriately document an intervention and what types of strategies can be used when a requested antimicrobial is not appropriate. We strongly recommend that complicated cases undergo debriefings between the fellow and a more experienced stewardship physician/pharmacist to discuss points of contention and refine techniques.
• Clinical decision support meetings – Participate in any meetings that the ASP program has with clinical decision support, especially if involving the design or monitoring of CDS stewardship interventions. Learning points include what limitations are inherent in clinical decision support systems and how to build in tracking metrics to monitor use of clinical decision support.
• Pharmacy and therapeutics meeting – Participate in the ASP-related sections of the P&T meeting in order to learn what types of concerns are brought up regarding the use of antimicrobial pharmaceuticals or antimicrobial use policies, and what the approval process is like.
• Participate in formulary review – Learn what criteria are necessary for formulary substitution of agents, and when an agent can be removed from formulary or restricted to specific providers.
• IDSA Core Antimicrobial Stewardship Curriculum, developed to provide infectious diseases (ID) fellows with foundational education and training in antimicrobial stewardship. https://academy.idsociety.org/content/core-antimicrobial-stewardship-curriculum-fellows (paid option)
• IDSA Advanced Antimicrobial Stewardship (AS) curriculum provides the knowledge and skills to become a leader in antimicrobial stewardship. https://academy.idsociety.org/content/advanced-antimicrobial-stewardship-curriculum-self-study#group-tabs-node-course-default1 (paid option)
• Supporting literature
• Core Elements of Hospital Antibiotic Stewardship Programs From the Centers for Disease Control and Prevention: 2019.
https://www.cdc.gov/antibiotic-use/hcp/core-elements/hospital.html
• CDC Training Course on Antimicrobial Stewardship. https://www.cdc.gov/antibiotic-use/hcp/training/index.html
• Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016 May 15;62(10):e51–77.