Bedside Registered Nurse Roles in Antimicrobial Stewardship: A Survey of Acute-Care Hospitals in Los Angeles County

To the Editor—Recent literature suggests that current activities of bedside registered nurses (RNs) can contribute to antimicrobial stewardship; however, roles and capability have not been closely assessed. In November 2015, we surveyed all Los Angeles County (LAC) acute-care hospitals (ACHs) to capture bedside RN roles and to determine the antimicrobial-related education and training hospitals provide them.

An online survey was created in Google forms. In November 2015, we sent invitation links to all LAC ACH nurse education directors or their designees who could best speak to nurse education and competency. Responses were received by mid-January 2016. The Institutional Review Board (IRB) of the LAC Department of Public Health (DPH) designated this survey as IRB exempt. Question formats included multiple choice, select all that apply, or fill in with text. A single question with several subparts comprised the bulk of the survey. Each subpart listed a different activity or knowledge component related to antimicrobials, which respondents identified as “mandatory/required,” “optional/offered,” or “not offered” for bedside RNs in their hospital. We combined responses of “mandatory/required” and “optional/offered” to identify topics that hospitals include in bedside RN knowledge and competency. Additional questions included policies related to antimicrobial administration and orders, as well as communication of results. A response rate of the survey was calculated following guidelines provided by American Association for Public Opinion Research (AAPOR) Standard Definitions. ¹

The rate of response to this survey was 36.6%. The 34 hospitals represented in this survey comprise approximately one-third of LAC’s 93 ACHs. Most surveys were filled out by Nurse Education Directors (n=19); however, additional surveys were completed by nurse education designees such as Clinical Nurse Specialists or Bedside Nurse Educators (n=9), Directors of Nursing (DONs) or Chief Nursing Officers (n=4), or other nurse administrators (n=2).

In 33 hospitals that responded (97%), bedside RNs are required to appropriately assess medication allergies prior to an antimicrobial order. In 5 hospitals (14.7%), physicians’ antimicrobial orders are entered by bedside RNs most of the time, and in 8 hospitals (23.5%), bedside RNs enter those antimicrobial orders about half the time. In 32 hospitals (94.1%), resources are provided for bedside RNs to educate inpatients about appropriate antimicrobial use, and 22 hospitals (64.7%) required this patient education (Table 1). In 31 hospitals (91.1%), bedside RNs are offered education on or are required to understand the relationship between antimicrobial use and antimicrobial resistance.

TABLE 1 Nurse Competency and Education Series (n=34)

^a Mandatory/Required: “If the topic is required for bedside registered nurse (RN) competency/skills labs/mandatory education.”

^b Optional/Offered: “If education on that particular topic is offered to bedside RNs by your facility, but not mandatory.”

^c Not offered: “If the education on that particular topic is not made available to bedside RNs.”

Administering and Evaluating Treatment

Overall, 28 hospitals (82.4%) reported that they educate or require their bedside RNs to be competent in identifying broad-spectrum antibiotics; 28 (82.4%) educate or require competency in interpreting culture/susceptibility results; 30 hospitals (88.2%) educate or require bedside RNs to be competent in monitoring therapeutic levels of antimicrobials; 28 hospitals (82.4%) educate or require competency in antimicrobial treatment specificity.

Survey respondents were asked which members of the patient care team received critical microbiology laboratory results (as defined by the hospital): 31 hospitals (91.1%) reported that the bedside RN was notified, and in 4 (11.8%) of those hospitals, the sole notification was to the bedside RN.

In a “select all that apply” question, we asked respondents to describe how bedside RNs participate in antimicrobial stewardship. Overall, 5 hospitals (14.7%) reported no bedside RN participation in antimicrobial stewardship. In 3 hospitals (8.8%), at least 1 bedside RN is on the antimicrobial stewardship program (ASP) committee; however, in 19 hospitals (55.9%), nursing leadership represents them and no bedside RNs are on the ASP committee. Bedside RNs participate in quality assurance for antimicrobial treatment in 9 responding hospitals (26.5%), and in 3 hospitals (8.8%), they participate on subcommittees that promote antimicrobial stewardship knowledge on their respective units. Finally, in just 1 hospital (2.9%), bedside RNs have an antimicrobial resistance/multidrug-resistant organisms advisory group.

Literature and experience presume that bedside RNs have a central role in entering orders, administering antimicrobials, and evaluating antimicrobial treatment ^{2 – 4} ; however, nursing roles may be different in each hospital. With this survey, we sought to compare the differences of bedside RN engagement in antimicrobial stewardship and to identify existing opportunities within current nursing roles.

Prior to ordering medications, nurses potentially influence prescribers. ⁵ When nurses are educated regarding antimicrobial stewardship and they understand the relationship between antimicrobial use and antimicrobial resistance, they are more likely to question antibiotic orders. ^{6 , 7} The results of this survey demonstrate that bedside RNs frequently enter antimicrobial orders, and thus have at least 1 opportunity to discuss antimicrobial indications with ordering providers. By eliminating untrue allergies, bedside RNs can potentially increase medication options available to inpatients. ⁸ Respondents to the survey confirmed that bedside RNs are required to appropriately assess medication allergies.

Bedside RNs have an important role in the administration and evaluation of antimicrobial treatment, and they frequently serve as a communication hub between the patient, physician, laboratory, and pharmacy. They can initiate or support evidence-based interventions for optimal antimicrobial treatment, such as antimicrobial time-outs. ⁹ Respondents to this survey reported that bedside RNs are trained to recognize broad-spectrum antibiotics, to consult culture/susceptibility results, to monitor therapeutic levels of antimicrobials, and to assess antimicrobial treatment for appropriateness.

This study had limitations. The rate of response to this survey was 37% (n=34). Although the survey questions were specific, a nurse education director unfamiliar with antimicrobial stewardship may have misinterpreted questions related to competency in antimicrobial administration and/or evaluation.

Bedside RNs are the frontline staff who administer antimicrobials, and they access the same information that ASPs use to optimize antimicrobial treatment. By empowering bedside RNs, ASPs can potentially achieve increased compliance to and adherence with antimicrobial stewardship activities across all disciplines.