Angela M. Jackley, RN, is the Healthcare-Associated Infections and Antimicrobial Resistance Program Coordinator for the South Dakota Department of Health. Her responsibilities include oversight and coordination of efforts to reduce healthcare-associated infections, multi-drug resistant outbreaks, and improve antimicrobial susceptibility patterns.

In December of 2012, South Dakota experienced an outbreak of Carbapenem-resistant Enterobacteriaceae (CRE). An astute infection preventionist alerted us to over a dozen cases of carbapenem resistance over a six month period. As a result, the South Dakota Department of Health (SDDOH) aligned with statewide healthcare facilities to address the outbreak. Our agency hosted experts from the Centers for Disease Control and Prevention to discuss CRE epidemiology and prevention and antimicrobial stewardship with physicians, infection preventionists, and healthcare executives. Following the seminar, the South Dakota Secretary of Health personally invited multi-disciplinary stakeholders across South Dakota to prevent future drug-resistant outbreaks by improving prescribing practices.

South Dakota is a rural state with fewer than 900,000 people living across 77,000 square miles, requiring resourcefulness when problems arise. Often, the same leaders participate on issues ranging from Ebola preparation and response to H1N1 outbreaks and multi-drug resistance.  This familiarity and collaboration provides us the opportunity to establish mutually beneficial associations which often includes providing resources, training, or technical support. These long-standing relationships afford us the opportunity to directly involve people with the ability to make decisions on behalf of a healthcare system.

In 2013 we formed an antimicrobial stewardship workgroup that includes members from South Dakota’s Quality Improvement Organization, hospital association, long-term care association, Indian Health Service, and the Board of Pharmacy, along with individual pharmacists, microbiologists, infection preventionists, and healthcare system infectious disease physicians. Gathering the right people to partner with us proved effortless; however, we faced immediate challenges in 2013 when our coalition did not receive programmatic funding for stewardship. The SDDOH experienced difficulties hosting meetings without funding and relied upon volunteer efforts.

Healthcare systems alleviated a share of the burden and hosted meetings when we in the SDDOH were unable. During the meetings, the workgroup identified the need to structure the group’s activities according to the Core Competencies for Public Health Professionals, specifically focusing on policy development. Each statewide partner assessed their roles and responsibilities. Our workgroup established a plan in year one to implement or expand stewardship activities in the flagship hospitals, followed by expansion into critical access hospitals and clinics over the following 24 months. We asked hospitals without formal programs to review their internal data and determine the right measures to implement stewardship activities utilizing existing tools, including the Antibiotic Stewardship Driver Diagram and Change Package. Competing healthcare systems assisted one another and shared existing practices, protocols, and formularies.

SDDOH appealed to organizations asking them to sponsor antimicrobial stewardship education during their annual meetings. We produced statewide and regional antibiograms to serve as a baseline for future efforts to improve the susceptibility of important healthcare-associated pathogens. We created an inter-facility transfer form and streamlined CRE screening criteria for patients upon admission to hospitals.

The last several years have yielded numerous accomplishments including a 50% reduction in CRE within the first year, conducting train-the-trainer programs, adding CRE as a reportable condition, and sharing data on drug-resistant organisms. Achievements beyond CRE include a hospital systems expansion of stewardship into 21 critical access hospitals, daily telemedicine rounds offered to clinics by infectious disease physicians, and a 40% reduction in prescribing fluoroquinolones, which contribute to antibiotic resistance. In addition, one system implemented use of clinical decision support tools in 100% of their clinics. The workgroup authored pediatric upper respiratory guidelines and improved susceptibility patterns across the state.

The workgroup members provide educational offerings, support to hospitals starting stewardship programs, and subject matter expertise with goals to accomplish more. The new Centers for Medicare and Medicaid Services stewardship regulations provide an opportunity to expand stewardship into long-term care but require additional resources to implement activities. The workgroup combined resources with the hospital association and quality improvement network to address this barrier. The new projects, meant to expand stewardship into nursing homes, will concentrate on prescribing practices related to Clostridium difficile and asymptomatic bacteriuria.

The rural nature and limited resources in South Dakota demand innovation and commitment. Our leadership remains dedicated to enhancing the health of patients and continually strives to improve susceptibility patterns throughout the state. Working together, one day at a time, the challenge is transforming into a success story that we can be proud of, and a vast opportunity to improve the health of patients in South Dakota.