Christin Ko, MD, MBA

Inappropriate antimicrobial use in hospitalized patients is a well‐recognized driver for the development of drug‐resistant organisms and antimicrobial‐related complications such as Clostridium difficile infection (CDI).[1, 2] Infection with C difficile affects nearly 500,000 people annually resulting in higher healthcare expenditures, longer lengths of hospital stay, and nearly 15,000 deaths.[3] Data from the Centers for Disease Control and Prevention (CDC) suggest that a 30% reduction in the use of broad‐spectrum antimicrobials, or a 5% reduction in the proportion of hospitalized patients receiving antimicrobials, could equate to a 26% reduction in CDI.[4] It is estimated that up to 50% of antimicrobial use in the hospital setting may be inappropriate.[5]

Since the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America published guidelines for developing formal, hospital‐based antimicrobial stewardship programs in 2007, stewardship practices have been adapted by frontline providers to fit day‐to‐day inpatient care.[5] A recent review by Hamilton et al. described several studies in which stewardship practices were imbedded into daily workflows by way of checklists, education reminders, and periodic review of antimicrobial usage, as well as a multicenter pilot of point‐of‐care stewardship interventions successfully implemented by various providers including nursing, pharmacists, and hospitalists.[6]

In response to the CDC's 2010 Get Smart for Healthcare campaign, which focused on stemming antimicrobial resistance and improving antimicrobial use, the Institute for Healthcare Improvement (IHI), in partnership with the CDC, brought together experts in the field to identify practical and feasible target practices for hospital‐based stewardship and created a Driver Diagram to guide implementation efforts (Figure 1). Rohde et al. described the initial pilot testing of these practices, the decision to more actively engage frontline providers, and the 3 key strategies identified as high‐yield improvement targets: enhancing the visibility of antimicrobial use at the point of care, creating easily accessible antimicrobial guidelines for common infections, and the implementation of a 72‐hour timeout after initiation of antimicrobials.[7]

Figure 1

In this article, we describe how, in partnership with the IHI and the CDC, the hospital medicine programs at 5 diverse hospitals iteratively tested these 3 strategies with a goal of identifying the barriers and facilitators to effective hospitalist‐led antimicrobial stewardship.

METHODS

Representatives from 5 hospital medicine programs, IHI, and the CDC attended a kick‐off meeting at the CDC in November 2012 to discuss the 3 proposed strategies, examples of prior testing, and ideas for implementation. Each hospitalist provided a high‐level summary of the current state of stewardship efforts at their respective institutions, identified possible future states related to the improvement strategies, and anticipated problems in achieving them. The 3 key strategies are described below.

RESULTS

Participating hospitals included 1 community nonteaching hospital, 2 community teaching hospitals, and 2 academic medical centers. All hospitals used computerized order entry and had prior quality improvement experience; 4 out of 5 hospitals used electronic medical records. Postintervention data on antimicrobial documentation and timeouts were compiled, shared, and successes identified. For example, 2 hospitals saw an increase in complete antimicrobial documentation from 4% and 8% to 51% and 65%, respectively, of medical records reviewed over a 3‐month period. Additionally, cumulative timeout data across all hospitals showed that out of 726 antimicrobial timeouts evaluated, optimization or discontinuation occurred 218 times or 30% of the time.

Each site's key implementation barriers and facilitators were collected. Examples were compiled and common themes emerged (Table 1).

DISCUSSION

We successfully brought together hospitalists from diverse institutions to undertake small tests of change aimed at 3 key antimicrobial use improvement strategies. Following our interventions, significant improvement in antimicrobial documentation occurred at 2 institutions focusing on this improvement strategy, and 72‐hour timeouts performed across all hospitals tailored antimicrobial use in 30% of the sessions. Through frequent collaborative discussions and information sharing, we were able to identify common barriers and facilitators to hospitalist‐centered stewardship efforts.

Each participating hospital medicine program noticed a gradual shift in thinking among their colleagues, from initial skepticism about embedding stewardship within their daily workflow, to general acceptance that it was a worthwhile and meaningful endeavor. We posited that this transition in belief and behavior evolved for several reasons. First, each group was educated about their own, personal prescribing practices from the outset rather than presenting abstract data. This allowed for ownership of the problem and buy‐in to improve it. Second, participants were able to experience the benefits at an individual level while the interventions were ongoing (eg, having other providers reciprocate structured documentation during patient handoffs, making antimicrobial plans clearer), reinforcing the achievability of stewardship practices within each group. Additionally, we focused on making small, manageable interventions that did not seem disruptive to hospitalists' daily workflow. For example, 1 group instituted antimicrobial timeouts during preexisting multidisciplinary rounds with clinical pharmacists. Last, project champions had both leadership and frontline roles within their groups and set the example for stewardship practices, which conveyed that this was a priority at the leadership level. These findings are in line with those of Charani et al., who evaluated behavior change strategies that influence antimicrobial prescribing in acute care. The authors found that behavioral determinants and social norms strongly influence prescribing practices in acute care, and that antimicrobial stewardship improvement projects should account for these influences.[8]

We also identified several barriers to antimicrobial stewardship implementation (Table 1) and proposed measures to address these barriers in future improvement efforts. For example, hospital medicine programs without a preexisting clinical pharmacy partnership asked hospitalist leadership for more direct clinical pharmacy involvement, recognizing the importance of a physician‐pharmacy alliance for stewardship efforts. To more effectively embed antimicrobial stewardship into daily routine, several hospitalists suggested standardized order sets for commonly encountered infections, as well as routine feedback on prescribing practices. Furthermore, although our simplified antimicrobial guideline pocket card enhanced access to this information, several colleagues suggested a smart phone application that would make access even easier and less cumbersome. Last, given the concern about the sustainability of antimicrobial stewardship initiatives, we recommended periodic reminders, random medical record review, and re‐education if necessary on our 3 strategies and their purpose.

Our study is not without limitations. Each participating hospitalist group enacted hospital‐specific interventions based on individual hospitalist program needs and goals, and although there was collective discussion, no group was tasked to undertake another group's initiative, thereby limiting generalizability. We did, however, identify common facilitators that could be adapted to a wide variety of hospitalist programs. We also note that our 3 main strategies were included in a recent review of quality indicators for measuring the success of antimicrobial stewardship programs; thus, although details of individual practice may vary, in principle these concepts can help identify areas for improvement within each unique stewardship program.[9] Importantly, we were unable to evaluate the impact of the 3 key improvement strategies on important clinical outcomes such as overall antimicrobial use, complications including CDI, and cost. However, others have found that improvement strategies similar to our 3 key processes are associated with meaningful improvements in clinical outcomes as well as reductions in healthcare costs.[10, 11] Last, long‐ term impact and sustainability were not evaluated. By choosing interventions that were viewed by frontline providers as valuable and attainable, however, we feel that each group will likely continue current practices beyond the initial evaluation timeframe.

Although these 5 hospitalist groups were able to successfully implement several aspects of the 3 key improvement strategies, we recognize that this is only the first step. Further effort is needed to quantify the impact of these improvement efforts on objective patient outcomes such as readmissions, length of stay, and antimicrobial‐related complications, which will better inform our local and national leaders on the inherent clinical and financial gains associated with hospitalist‐led stewardship work. Finally, creative ways to better integrate stewardship activities into existing provider workflows (eg, decision support and automation) will further accelerate improvement efforts.

In summary, hospitalists at 5 diverse institutions successfully implemented key antimicrobial improvement strategies and identified important implementation facilitators and barriers. Future efforts at hospitalist‐led stewardship should focus on strategies to scale‐up interventions and evaluate their impact on clinical outcomes and cost.

Disclosures: Dr. Flanders reports consulting fees or honoraria from the Institute for Healthcare Improvement, has provided consultancy to the Society of Hospital Medicine, has served as a reviewer for expert testimony, received honoraria as a visiting lecturer to various hospitals, and has received royalties from publisher John Wiley & Sons. He has also received grant funding from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality. Dr. Ko reports consultancy for the American Hospital Association and the Society of Hospital Medicine involving work with catheter‐associated urinary tract infections. Ms. Jacobsen reports grant funding from the Institute for Healthcare Improvement. Dr. Rosenberg reports consultancy for Bristol‐Myers Squibb, Forest Pharmaceuticals, and Pfizer. The funding source for this collaborative was through the Institute for Healthcare Improvement and Centers for Disease Control and Prevention. Funding was provided by the Department of Health and Human Services, the Centers for Disease Control and Prevention, the National Center for Emerging Zoonotic and Infectious Diseases, and the Division of Healthcare Quality Promotion/Office of the Director. Avaris Concepts served as the prime contractor and the Institute for Healthcare Improvement as the subcontractor for the initiative. The findings and conclusions in this report represent the views of the authors and might not reflect the views of the Centers for Disease Control and Prevention. The authors report no conflicts of interest.

Inappropriate antimicrobial use in hospitalized patients is a well‐recognized driver for the development of drug‐resistant organisms and antimicrobial‐related complications such as Clostridium difficile infection (CDI).[1, 2] Infection with C difficile affects nearly 500,000 people annually resulting in higher healthcare expenditures, longer lengths of hospital stay, and nearly 15,000 deaths.[3] Data from the Centers for Disease Control and Prevention (CDC) suggest that a 30% reduction in the use of broad‐spectrum antimicrobials, or a 5% reduction in the proportion of hospitalized patients receiving antimicrobials, could equate to a 26% reduction in CDI.[4] It is estimated that up to 50% of antimicrobial use in the hospital setting may be inappropriate.[5]

Since the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America published guidelines for developing formal, hospital‐based antimicrobial stewardship programs in 2007, stewardship practices have been adapted by frontline providers to fit day‐to‐day inpatient care.[5] A recent review by Hamilton et al. described several studies in which stewardship practices were imbedded into daily workflows by way of checklists, education reminders, and periodic review of antimicrobial usage, as well as a multicenter pilot of point‐of‐care stewardship interventions successfully implemented by various providers including nursing, pharmacists, and hospitalists.[6]

In response to the CDC's 2010 Get Smart for Healthcare campaign, which focused on stemming antimicrobial resistance and improving antimicrobial use, the Institute for Healthcare Improvement (IHI), in partnership with the CDC, brought together experts in the field to identify practical and feasible target practices for hospital‐based stewardship and created a Driver Diagram to guide implementation efforts (Figure 1). Rohde et al. described the initial pilot testing of these practices, the decision to more actively engage frontline providers, and the 3 key strategies identified as high‐yield improvement targets: enhancing the visibility of antimicrobial use at the point of care, creating easily accessible antimicrobial guidelines for common infections, and the implementation of a 72‐hour timeout after initiation of antimicrobials.[7]

Figure 1

In this article, we describe how, in partnership with the IHI and the CDC, the hospital medicine programs at 5 diverse hospitals iteratively tested these 3 strategies with a goal of identifying the barriers and facilitators to effective hospitalist‐led antimicrobial stewardship.

METHODS

Representatives from 5 hospital medicine programs, IHI, and the CDC attended a kick‐off meeting at the CDC in November 2012 to discuss the 3 proposed strategies, examples of prior testing, and ideas for implementation. Each hospitalist provided a high‐level summary of the current state of stewardship efforts at their respective institutions, identified possible future states related to the improvement strategies, and anticipated problems in achieving them. The 3 key strategies are described below.

RESULTS

Participating hospitals included 1 community nonteaching hospital, 2 community teaching hospitals, and 2 academic medical centers. All hospitals used computerized order entry and had prior quality improvement experience; 4 out of 5 hospitals used electronic medical records. Postintervention data on antimicrobial documentation and timeouts were compiled, shared, and successes identified. For example, 2 hospitals saw an increase in complete antimicrobial documentation from 4% and 8% to 51% and 65%, respectively, of medical records reviewed over a 3‐month period. Additionally, cumulative timeout data across all hospitals showed that out of 726 antimicrobial timeouts evaluated, optimization or discontinuation occurred 218 times or 30% of the time.

Each site's key implementation barriers and facilitators were collected. Examples were compiled and common themes emerged (Table 1).

DISCUSSION

We successfully brought together hospitalists from diverse institutions to undertake small tests of change aimed at 3 key antimicrobial use improvement strategies. Following our interventions, significant improvement in antimicrobial documentation occurred at 2 institutions focusing on this improvement strategy, and 72‐hour timeouts performed across all hospitals tailored antimicrobial use in 30% of the sessions. Through frequent collaborative discussions and information sharing, we were able to identify common barriers and facilitators to hospitalist‐centered stewardship efforts.

Each participating hospital medicine program noticed a gradual shift in thinking among their colleagues, from initial skepticism about embedding stewardship within their daily workflow, to general acceptance that it was a worthwhile and meaningful endeavor. We posited that this transition in belief and behavior evolved for several reasons. First, each group was educated about their own, personal prescribing practices from the outset rather than presenting abstract data. This allowed for ownership of the problem and buy‐in to improve it. Second, participants were able to experience the benefits at an individual level while the interventions were ongoing (eg, having other providers reciprocate structured documentation during patient handoffs, making antimicrobial plans clearer), reinforcing the achievability of stewardship practices within each group. Additionally, we focused on making small, manageable interventions that did not seem disruptive to hospitalists' daily workflow. For example, 1 group instituted antimicrobial timeouts during preexisting multidisciplinary rounds with clinical pharmacists. Last, project champions had both leadership and frontline roles within their groups and set the example for stewardship practices, which conveyed that this was a priority at the leadership level. These findings are in line with those of Charani et al., who evaluated behavior change strategies that influence antimicrobial prescribing in acute care. The authors found that behavioral determinants and social norms strongly influence prescribing practices in acute care, and that antimicrobial stewardship improvement projects should account for these influences.[8]

We also identified several barriers to antimicrobial stewardship implementation (Table 1) and proposed measures to address these barriers in future improvement efforts. For example, hospital medicine programs without a preexisting clinical pharmacy partnership asked hospitalist leadership for more direct clinical pharmacy involvement, recognizing the importance of a physician‐pharmacy alliance for stewardship efforts. To more effectively embed antimicrobial stewardship into daily routine, several hospitalists suggested standardized order sets for commonly encountered infections, as well as routine feedback on prescribing practices. Furthermore, although our simplified antimicrobial guideline pocket card enhanced access to this information, several colleagues suggested a smart phone application that would make access even easier and less cumbersome. Last, given the concern about the sustainability of antimicrobial stewardship initiatives, we recommended periodic reminders, random medical record review, and re‐education if necessary on our 3 strategies and their purpose.

Our study is not without limitations. Each participating hospitalist group enacted hospital‐specific interventions based on individual hospitalist program needs and goals, and although there was collective discussion, no group was tasked to undertake another group's initiative, thereby limiting generalizability. We did, however, identify common facilitators that could be adapted to a wide variety of hospitalist programs. We also note that our 3 main strategies were included in a recent review of quality indicators for measuring the success of antimicrobial stewardship programs; thus, although details of individual practice may vary, in principle these concepts can help identify areas for improvement within each unique stewardship program.[9] Importantly, we were unable to evaluate the impact of the 3 key improvement strategies on important clinical outcomes such as overall antimicrobial use, complications including CDI, and cost. However, others have found that improvement strategies similar to our 3 key processes are associated with meaningful improvements in clinical outcomes as well as reductions in healthcare costs.[10, 11] Last, long‐ term impact and sustainability were not evaluated. By choosing interventions that were viewed by frontline providers as valuable and attainable, however, we feel that each group will likely continue current practices beyond the initial evaluation timeframe.

Although these 5 hospitalist groups were able to successfully implement several aspects of the 3 key improvement strategies, we recognize that this is only the first step. Further effort is needed to quantify the impact of these improvement efforts on objective patient outcomes such as readmissions, length of stay, and antimicrobial‐related complications, which will better inform our local and national leaders on the inherent clinical and financial gains associated with hospitalist‐led stewardship work. Finally, creative ways to better integrate stewardship activities into existing provider workflows (eg, decision support and automation) will further accelerate improvement efforts.

In summary, hospitalists at 5 diverse institutions successfully implemented key antimicrobial improvement strategies and identified important implementation facilitators and barriers. Future efforts at hospitalist‐led stewardship should focus on strategies to scale‐up interventions and evaluate their impact on clinical outcomes and cost.

Disclosures: Dr. Flanders reports consulting fees or honoraria from the Institute for Healthcare Improvement, has provided consultancy to the Society of Hospital Medicine, has served as a reviewer for expert testimony, received honoraria as a visiting lecturer to various hospitals, and has received royalties from publisher John Wiley & Sons. He has also received grant funding from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality. Dr. Ko reports consultancy for the American Hospital Association and the Society of Hospital Medicine involving work with catheter‐associated urinary tract infections. Ms. Jacobsen reports grant funding from the Institute for Healthcare Improvement. Dr. Rosenberg reports consultancy for Bristol‐Myers Squibb, Forest Pharmaceuticals, and Pfizer. The funding source for this collaborative was through the Institute for Healthcare Improvement and Centers for Disease Control and Prevention. Funding was provided by the Department of Health and Human Services, the Centers for Disease Control and Prevention, the National Center for Emerging Zoonotic and Infectious Diseases, and the Division of Healthcare Quality Promotion/Office of the Director. Avaris Concepts served as the prime contractor and the Institute for Healthcare Improvement as the subcontractor for the initiative. The findings and conclusions in this report represent the views of the authors and might not reflect the views of the Centers for Disease Control and Prevention. The authors report no conflicts of interest.

Inappropriate antimicrobial use in hospitalized patients is a well‐recognized driver for the development of drug‐resistant organisms and antimicrobial‐related complications such as Clostridium difficile infection (CDI).[1, 2] Infection with C difficile affects nearly 500,000 people annually resulting in higher healthcare expenditures, longer lengths of hospital stay, and nearly 15,000 deaths.[3] Data from the Centers for Disease Control and Prevention (CDC) suggest that a 30% reduction in the use of broad‐spectrum antimicrobials, or a 5% reduction in the proportion of hospitalized patients receiving antimicrobials, could equate to a 26% reduction in CDI.[4] It is estimated that up to 50% of antimicrobial use in the hospital setting may be inappropriate.[5]

Since the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America published guidelines for developing formal, hospital‐based antimicrobial stewardship programs in 2007, stewardship practices have been adapted by frontline providers to fit day‐to‐day inpatient care.[5] A recent review by Hamilton et al. described several studies in which stewardship practices were imbedded into daily workflows by way of checklists, education reminders, and periodic review of antimicrobial usage, as well as a multicenter pilot of point‐of‐care stewardship interventions successfully implemented by various providers including nursing, pharmacists, and hospitalists.[6]

In response to the CDC's 2010 Get Smart for Healthcare campaign, which focused on stemming antimicrobial resistance and improving antimicrobial use, the Institute for Healthcare Improvement (IHI), in partnership with the CDC, brought together experts in the field to identify practical and feasible target practices for hospital‐based stewardship and created a Driver Diagram to guide implementation efforts (Figure 1). Rohde et al. described the initial pilot testing of these practices, the decision to more actively engage frontline providers, and the 3 key strategies identified as high‐yield improvement targets: enhancing the visibility of antimicrobial use at the point of care, creating easily accessible antimicrobial guidelines for common infections, and the implementation of a 72‐hour timeout after initiation of antimicrobials.[7]

Figure 1

In this article, we describe how, in partnership with the IHI and the CDC, the hospital medicine programs at 5 diverse hospitals iteratively tested these 3 strategies with a goal of identifying the barriers and facilitators to effective hospitalist‐led antimicrobial stewardship.

METHODS

Representatives from 5 hospital medicine programs, IHI, and the CDC attended a kick‐off meeting at the CDC in November 2012 to discuss the 3 proposed strategies, examples of prior testing, and ideas for implementation. Each hospitalist provided a high‐level summary of the current state of stewardship efforts at their respective institutions, identified possible future states related to the improvement strategies, and anticipated problems in achieving them. The 3 key strategies are described below.

RESULTS

Participating hospitals included 1 community nonteaching hospital, 2 community teaching hospitals, and 2 academic medical centers. All hospitals used computerized order entry and had prior quality improvement experience; 4 out of 5 hospitals used electronic medical records. Postintervention data on antimicrobial documentation and timeouts were compiled, shared, and successes identified. For example, 2 hospitals saw an increase in complete antimicrobial documentation from 4% and 8% to 51% and 65%, respectively, of medical records reviewed over a 3‐month period. Additionally, cumulative timeout data across all hospitals showed that out of 726 antimicrobial timeouts evaluated, optimization or discontinuation occurred 218 times or 30% of the time.

Each site's key implementation barriers and facilitators were collected. Examples were compiled and common themes emerged (Table 1).

DISCUSSION

We successfully brought together hospitalists from diverse institutions to undertake small tests of change aimed at 3 key antimicrobial use improvement strategies. Following our interventions, significant improvement in antimicrobial documentation occurred at 2 institutions focusing on this improvement strategy, and 72‐hour timeouts performed across all hospitals tailored antimicrobial use in 30% of the sessions. Through frequent collaborative discussions and information sharing, we were able to identify common barriers and facilitators to hospitalist‐centered stewardship efforts.

Each participating hospital medicine program noticed a gradual shift in thinking among their colleagues, from initial skepticism about embedding stewardship within their daily workflow, to general acceptance that it was a worthwhile and meaningful endeavor. We posited that this transition in belief and behavior evolved for several reasons. First, each group was educated about their own, personal prescribing practices from the outset rather than presenting abstract data. This allowed for ownership of the problem and buy‐in to improve it. Second, participants were able to experience the benefits at an individual level while the interventions were ongoing (eg, having other providers reciprocate structured documentation during patient handoffs, making antimicrobial plans clearer), reinforcing the achievability of stewardship practices within each group. Additionally, we focused on making small, manageable interventions that did not seem disruptive to hospitalists' daily workflow. For example, 1 group instituted antimicrobial timeouts during preexisting multidisciplinary rounds with clinical pharmacists. Last, project champions had both leadership and frontline roles within their groups and set the example for stewardship practices, which conveyed that this was a priority at the leadership level. These findings are in line with those of Charani et al., who evaluated behavior change strategies that influence antimicrobial prescribing in acute care. The authors found that behavioral determinants and social norms strongly influence prescribing practices in acute care, and that antimicrobial stewardship improvement projects should account for these influences.[8]

We also identified several barriers to antimicrobial stewardship implementation (Table 1) and proposed measures to address these barriers in future improvement efforts. For example, hospital medicine programs without a preexisting clinical pharmacy partnership asked hospitalist leadership for more direct clinical pharmacy involvement, recognizing the importance of a physician‐pharmacy alliance for stewardship efforts. To more effectively embed antimicrobial stewardship into daily routine, several hospitalists suggested standardized order sets for commonly encountered infections, as well as routine feedback on prescribing practices. Furthermore, although our simplified antimicrobial guideline pocket card enhanced access to this information, several colleagues suggested a smart phone application that would make access even easier and less cumbersome. Last, given the concern about the sustainability of antimicrobial stewardship initiatives, we recommended periodic reminders, random medical record review, and re‐education if necessary on our 3 strategies and their purpose.

Our study is not without limitations. Each participating hospitalist group enacted hospital‐specific interventions based on individual hospitalist program needs and goals, and although there was collective discussion, no group was tasked to undertake another group's initiative, thereby limiting generalizability. We did, however, identify common facilitators that could be adapted to a wide variety of hospitalist programs. We also note that our 3 main strategies were included in a recent review of quality indicators for measuring the success of antimicrobial stewardship programs; thus, although details of individual practice may vary, in principle these concepts can help identify areas for improvement within each unique stewardship program.[9] Importantly, we were unable to evaluate the impact of the 3 key improvement strategies on important clinical outcomes such as overall antimicrobial use, complications including CDI, and cost. However, others have found that improvement strategies similar to our 3 key processes are associated with meaningful improvements in clinical outcomes as well as reductions in healthcare costs.[10, 11] Last, long‐ term impact and sustainability were not evaluated. By choosing interventions that were viewed by frontline providers as valuable and attainable, however, we feel that each group will likely continue current practices beyond the initial evaluation timeframe.

Although these 5 hospitalist groups were able to successfully implement several aspects of the 3 key improvement strategies, we recognize that this is only the first step. Further effort is needed to quantify the impact of these improvement efforts on objective patient outcomes such as readmissions, length of stay, and antimicrobial‐related complications, which will better inform our local and national leaders on the inherent clinical and financial gains associated with hospitalist‐led stewardship work. Finally, creative ways to better integrate stewardship activities into existing provider workflows (eg, decision support and automation) will further accelerate improvement efforts.

In summary, hospitalists at 5 diverse institutions successfully implemented key antimicrobial improvement strategies and identified important implementation facilitators and barriers. Future efforts at hospitalist‐led stewardship should focus on strategies to scale‐up interventions and evaluate their impact on clinical outcomes and cost.

Disclosures: Dr. Flanders reports consulting fees or honoraria from the Institute for Healthcare Improvement, has provided consultancy to the Society of Hospital Medicine, has served as a reviewer for expert testimony, received honoraria as a visiting lecturer to various hospitals, and has received royalties from publisher John Wiley & Sons. He has also received grant funding from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality. Dr. Ko reports consultancy for the American Hospital Association and the Society of Hospital Medicine involving work with catheter‐associated urinary tract infections. Ms. Jacobsen reports grant funding from the Institute for Healthcare Improvement. Dr. Rosenberg reports consultancy for Bristol‐Myers Squibb, Forest Pharmaceuticals, and Pfizer. The funding source for this collaborative was through the Institute for Healthcare Improvement and Centers for Disease Control and Prevention. Funding was provided by the Department of Health and Human Services, the Centers for Disease Control and Prevention, the National Center for Emerging Zoonotic and Infectious Diseases, and the Division of Healthcare Quality Promotion/Office of the Director. Avaris Concepts served as the prime contractor and the Institute for Healthcare Improvement as the subcontractor for the initiative. The findings and conclusions in this report represent the views of the authors and might not reflect the views of the Centers for Disease Control and Prevention. The authors report no conflicts of interest.