A Decade of Handshake Stewardship, a Decade of Progress
Authors: Parker Sarah K , Weber Matthew J , Pearce Kelly , Birkholz Meghan , MacBrayne Christine E 
Published: January 2025

Abstract

Corresponding Author: Sarah K. Parker, MD, Professor, Department of Pediatrics, Section of Infectious Diseases; Children’s Hospital Colorado and University of Colorado School of Medicine; 13123 E 16th Ave, Box B055, Aurora, CO 80045; sarah.parker@childrenscolorado.org; 720-777-8811
Alternate Corresponding Author: Matthew J. Weber, MPH, Department of Pediatrics, Section of Infectious Diseases; Children’s Hospital Colorado and University of Colorado School of Medicine; 13123 E 16th Ave, Box B055, Aurora, CO 80045; matthew.weber@childrenscolorado.org; 720-777-8811
Conflicts of interest/disclosures: Grant from Pfizer Global Bridges to SKP, Contract with Colorado Department of Health and Environment to SKP, both to improve antimicrobial stewardship in the state of Colorado, and do not support this work.

Background
Children’s Hospital Colorado began a Handshake Stewardship program in 2013 that effectively decreased hospital anti-infective use and costs (~$2 million per year) in its pilot year (Hurst et al, PIDJ, 2016; Parker et al, CID, 2017), and continued to improve use over the next 5 years (MacBrayne et. al, CID, 2019). Handshake stewardship is distinguished by: (1) lack of prior authorization; (2) a review of all prescribed anti-infectives; (3) a shared review by the physician and the pharmacist; and (4) a daily, rounding-based, in-person approach to support providers. We sought to reevaluate outcomes after a decade of Handshake Stewardship.

Methods
We retrospectively measured anti-infective (antibiotic, antiviral, antifungal) use hospital-wide by unit and by drug for a 13-year period spanning October 2010 to March 2024; October 2010 to September 2011 was the pre-period without stewardship, and October 2011 to September 2013 the planning period. Handshake Stewardship started in October of 2013. Aggregated monthly use was measured in days of therapy per thousand patient days (DOT/1000 PD). Children’s Hospital Colorado antibiotic DOT was validated using the Children’s Hospital Association Pediatric Health Information System (PHIS) Antimicrobial Stewardship Dashboard annual reports of Standardized Antimicrobial Administration Ratio (SAAR) antibacterials, DOT/1000 PD for 2016-2023.

Results
Hospital-wide mean anti-infective use continues to decrease. Analysis of DOT for the time period demonstrate averages 1060 DOT/1000 PD pre stewardship, 902 DOT/1000 PD post initiation of Handshake Stewardship, and 718 DOT/1000 PD for 2020 to March 2024 (p&lt;0.001, Fig. 1). Children’s Hospital Colorado SAAR antibiotic DOT was 820 DOT/1000 PD pre stewardship, 701 DOT/1000 PD post initiation of Handshake Stewardship, and 525 DOT/1000 PD for 2020 to March 2024 (p&lt;0.001, Fig. 1). These data confirmed in PHIS for the accessible time period of 2016-March 2024. Decreases were observed in almost all units, except the cardiac intensive care unit, and with almost all commonly used anti-infectives. MRSA agents and gram-negative agents decreased over time; use of those agents and overall use were low compared to peer PHIS hospitals.

Conclusions
Handshake Stewardship continues to demonstrate improvements in anti-infective use, albeit at a slower rate. As the program has matured, incremental gains are fostered by this methodology, likely driven by stewardship targeting pathway revisions and dissemination, diagnostic stewardship initiatives, and quality initiatives, like antibiotic durations, etc. Areas for focus also emerged, and initiatives are underway. In-depth analysis and formal statistical evaluation are planned.

Figure: Days of therapy per 1000 patient days for all inpatient units. Anti-infective rate includes all antibiotics, antivirals, and antifungals. Antibiotic rate includes SAAR reported antibacterials.