Faculty Member Works to Avert a Global Health Crisis
School of Nursing faculty Dr. Rita Olans takes a lead role in including nurses in national efforts to prevent antimicrobial resistance.
People in the coming years who will have surgery, go through cancer treatment, or give birth may be in trouble due to the rise in bacteria that don’t respond to antibiotics.
With World Antibiotic Awareness Weeks being observed November 11-17, School of Nursing Assistant Professor Rita Olans, DNP, CPNP-PC, APRN-BC, continues to be one of several health care professionals sounding the alarm about how decades of over-prescribing antibiotics combined with increasingly resistant bacteria could become a world-wide problem unless practices change soon.
“This is a looming crisis,” says Dr. Olans, who is leading efforts to increase the role of nurses - who comprise 80 percent of the country’s health care workers - in antimicrobial stewardship efforts. “The truth is that despite all we are doing on stewardship, the bacteria will continue to mutate. Current antibiotic use is putting this mutation of bacteria ‘on steroids,’ making multi-drug resistance to existing antibiotics much faster and deadlier. We have to do something about how we approach the infectious patient quickly because if we don’t there is the possibility that without effective antibiotics, surgery becomes more risky, chemotherapy becomes more risky, and even giving birth becomes more risky.”
According to the Centers for Disease Control, each year in the United States at least 2 million people become infected with bacteria that are resistant to antibiotics. At least 23,000 people die each year as a direct result of these infections, while many more people die from other conditions that were complicated by an antibiotic-resistant infection. The CDC says antibiotics are among the most commonly prescribed drugs used in human medicine, but estimates up to 50% prescribed for people are not needed or are not optimally effective as prescribed. In the U.S. 70% of all antibiotics are given to animals. Antimicrobial stewardship, says Olans, requires a “one world approach’.
The World Health Organization continues to urge countries to restrict the routine use of antibiotics given animals to promote growth and prevent diseases during food production. This is another major effort underway in antimicrobial stewardship efforts as antibiotic use in animals further escalates the rise of antibiotic resistance in bacteria.
It was 2011, and Olans had just enrolled in the MGH Institute’s Doctor of Nursing Practice program after four years of STD, TB, and HIV prevention work in the Virgin Islands with her husband, Richard. Richard Olans, the co-chair of antimicrobial stewardship at Hallmark Health Systems, was talking with a colleague about national efforts to make stewardship the norm for all hospitals when she cut into the conversation.
“You need to get nurses involved,” she told them. “Nurses monitor patients 24/7. They do the triage and take the cultures. They take that all-important allergy history. It is the nurse that puts the infectious patient in isolation. This is standard nursing practice, so why aren’t nurses included in the planning?”
Alfred DeMaria Jr., MD, the colleague with whom Dr. Olans’ husband had been speaking with, is medical director and state epidemiologist at the Massachusetts Department of Public Health. “Rita had this insight that became obvious to us once she identified it,” Dr. DeMaria says. “No one had talked to nurses about the whys and wherefores of stewardship. It was just assumed that nurses would do these things.”
Olans has made the inclusion of nurses in antimicrobial (more commonly known as antibiotic) stewardship programs a cornerstone of her professional work. Using the topic as her capstone project to complete her DNP, she increasingly has pursued her mission to ensure that nurses have a seat at the table as experts work to figure out how to prevent a looming crisis of multidrug resistance.
“Part of what drug companies are in business for is to make money for their shareholders, and they do that making chronic disease drugs rather than antibiotic. The problem with antibiotics is that bacteria could become multi-resistant to the antibiotic by the time it comes to market,” says Olans, who has taught at the IHP's School of Nursing since 2012.
Antibiotics revolutionized medicine in the 1940s, providing a cure for infections like tuberculosis and gonorrhea and making complex procedures like organ transplant and open-heart surgery possible. But over time, antibiotics’ healing powers have waned through widespread misuse and overutilization. Superbugs, resistant strains of bacteria impervious to available treatments, have become a serious global threat, responsible for 2 million infections and 23,000 deaths in the U.S. each year. The United Nations has compared antibiotic resistance to a slow-motion tsunami. Meanwhile, pharmaceutical companies are devoting ever-fewer resources to developing new antibiotics, citing rising costs and an inability to produce a drug that rapid bacterial mutations don’t render obsolete by the time it is developed.
“This is a looming crisis,” Olans says, her normally smiling face becoming serious. “We have to do something about this quickly because if we don’t there is the possibility that without effective antibiotics, surgery becomes more risky, chemotherapy becomes more risky, and even giving birth becomes more risky.”
Misuse Runs Deep
The roots of antibiotic misuse stretch far and wide, into physician’s offices and nursing homes. But some of the most lethal forms of resistance proliferate in hospitals. Up to half of all patients in U.S. hospitals receive antibiotics, but the Centers for Disease Control and Prevention has determined that more than a third of those prescriptions are inappropriate or unnecessary. “The organisms we’re most concerned about, the ones that have no treatment options, occur in hospitals,” says Arjun Srinivasan, MD, the CDC’s associate director for health care-associated infection prevention programs in its Division of Healthcare Quality Promotion.
This is where antimicrobial stewardship comes in. It is an interdisciplinary approach that engages key players throughout the hospital— infectious disease specialists, pharmacists, microbiologists, physicians, and today nurses— to ensure antibiotics are used thoughtfully, with a close eye on patients’ changing conditions, to prevent resistant strains from developing or spreading.
In 2015, Olans drew on her capstone research in an article for nurse educators. Her co-authors included DeMaria, School of Nursing faculty colleague Dr. Patrice Nicholas, and Diane Hanley, associate chief nursing officer at Hallmark. Later that same year, Olans, her husband, and DeMaria published an article, “The Critical Role of the Staff Nurse in Antimicrobial Stewardship—Unrecognized, but Already There,” in the journal Clinical Infectious Diseases. It caught the eye of Dr. Srinivasan.
“I read her article and thought it was fantastic,” says Srinivasan, who was heading up a two-year project with the National Quality Forum to develop recommendations for hospitals to implement antimicrobial stewardship programs. “We’d engaged pharmacists, physicians, infectious disease specialists, but not nurses. The article did a wonderful job outlining all the things nurses were already doing on a daily basis.”
Srinivasan emailed Olans and subsequently invited her to Washington, D.C. to participate in a meeting, which culminated in the creation of the National Quality Forum’s landmark “Playbook: Antibiotic Stewardship in Advanced Care.” Olans continues to consult to the National Quality Forum and their most recent publication, “National Quality Forum Long-Term Care Playbook” addresses the reality that 50-70% of all residents of nursing homes will take an antibiotic in the next year. Yet, as much as 75% of the antibiotics prescribed in this setting are inappropriately prescribed.
Spreading the Word
Dr. Olans continues to collaborate and spread the word that nurses are an important part of our nation’s stewardship efforts. In 2018, she collaborated with Columbia University School of Nursing for a poster at the Infectious Diseases Society of America meetings. She was invited to the Joint Commission as part of a Technical Expert Panel for a combined Centers for Disease Control and Prevention, American Hospital Association, PEW Charitable Trust and National Quality Forum conference on defining antimicrobial stewardship in the hospital setting.
Dr. Olans is conducting a webinar for more than 1,000 participants sponsored by healthcare performance improvement company Vivient, Inc during World Antibiotic Awareness week and will be speaking with nurses in Massachusetts through a webinar in December and conference in March, 2019.
She also has spearheaded efforts by 35 nurses around the company to write the CDC/ANA joint white paper defining nurses’ role in antimicrobial stewardship, spoken to the Pew Charitable Trusts and the Colorado Hospital Association about nurses’ roles in stewardship programs, presented at the annual conference of the Association for Professionals in Infection Control and Epidemiology, led a meet-the-professor session at the annual scientific meeting of the Infectious Diseases Society of America, and spoke at the annual meeting of the Society of Healthcare Epidemiology of America.
In addition, she has joined forces with the American Nurses Association, which had been doing its own work to raise awareness around antibiotic resistance. “Dr. Srinivasan brought Rita’s work to the ANA’s attention,” says Sharon Morgan, the ANA’s senior policy advisor. Morgan considers Olans a kindred spirit: “We are both very interested and outspoken about how nurses can be a bridge between all aspects of care.” With funding from the CDC, the ANA convened an antimicrobial stewardship working group and is using Olans’ work as a framework to better define nurses’ contributions to stewardship efforts.
Dr. Olans says that all of this momentum, is good news for health professionals and their patients. “Every time I give a talk, I close it with a photo of my grandson,” says Olans. “Antibiotic resistance is not just a health hazard, it threatens our future. It is going to take every health professional, whether working in acute, long-term care or outpatient care, to address this crisis. This is a local, national, and global imperative. We need to make sure future generations will have ways to manage infections successfully.”