Name: Jo McEwen, Advanced Nurse Practitioner, Antimicrobial Stewardship
Provide a brief overview of your project?: Multidisciplinary antimicrobial stewardship programmes are essential in optimising antimicrobial use and treatment outcomes whilst minimising associated collateral damage. Many antimicrobial stewardship initiatives have primarily targeted doctors and pharmacists, however the potential contribution that nurses could make in this area has not yet been explored.
Within the healthcare setting, nurses account for the greatest proportion of the workforce, however, previous antimicrobial stewardship initiatives have failed to acknowledge the vital influential role the profession can have in driving forward change and improvement management. Nurses are central to the delivery of patient care across all care settings and are therefore the professionals most likely to identify and intercept errors; ultimately preventing harm from coming to patients.
To ensure that this finite resource remains effective for future generations antimicrobial stewardship programmes need to embrace a multi-professional approach and identify contemporary methods of delivery.
The primary aim of this initiative was to enhance nursing knowledge around antimicrobial stewardship by focusing on the key areas of nursing influence. A secondary focus was to encourage appropriate urine sampling in the older adult population and those with indwelling urinary catheters through promotion of the Scottish Antimicrobial Prescribing Group (SAPG) UTI management resources.
Educational programmes were delivered to all community hospital nursing teams in NHS Tayside over a 12 month period. Each community hospital received 4 education sessions which consisted of an introductory presentation on the role of the nurse in antimicrobial stewardship and 3 sessions dedicated to clinical based scenarios to enable implementation of the areas of nursing influence into clinical practice. All of the community hospitals specialise in the care of the older adult; therefore the SAPG UTI decision aids were heavily promoted within the clinical based scenarios.
To assess nursing knowledge, questionnaires were distributed prior to the delivery of the educational programme and again on completion.
The numbers of urine samples sent for culture from each community hospital were obtained from the local laboratory on a monthly basis during the intervention phase. Retrospective data was obtained from the laboratory for the six months prior to the intervention to determine impact.
List any supporting partners or organisations worked with: NHS Tayside Antimicrobial Management Team
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category?: This project inspired the development of the “areas of nursing influence in antimicrobial stewardship” which identifies where nurses can actively contribute toward optimising patient care outcomes and minimising the incidence of antimicrobial resistance through nursing practice. The areas of nursing influence were adapted from those mentioned by Edwards et al., (2011). The areas of nursing influence can be separated into “Medicine Management” and “Nursing Management” roles and responsibilities such as:
• Prescribing in line with recommended guidelines –non medical prescribers
• Monitor duration of therapy
• Promote appropriate route of administration
• Timing of antimicrobial administration
• Participation in therapeutic drug monitoring
• Check allergy status
• Contribute to preparing patient for Out-patient parenteral antimicrobial therapy (OPAT)
• Adherence to infection prevention and control standards both national and local
• Provision of essential nursing care including nutrition, hydration and prevention of pressure ulcers
• Appropriate sampling
• Review microbiology results
• Nursing assessment
• Health Promotion
• Discharge Planning
An additional element which spans across both medicines and nursing management is:
• Patient education, awareness and involvement in antibiotic use
Comparison between the pre-intervention and post-intervention questionnaire demonstrates an improvement in nursing knowledge in relation to antimicrobial stewardship and infection management. This was statistically significant in nine of the fourteen questions (p=< 0.05) although an increase was observed across all questions.
Three additional questions were added to the post intervention questionnaire to determine impact on practice. 100% of the nurses involved felt that the programme was beneficial for their nursing practice and 96% felt more confident in their ability to manage infections following the educational sessions. The third question asked nurses to demonstrate where they had used the areas of nursing influence in clinical practice. Examples of this include:
• Promoting duration of therapy
• Adding stop dates to prescriptions
• Questioning need for prescription
• Checking lab sensitivities
• No longer using urinalysis in the diagnosis of UTI in elderly
• Sampling in context of patients signs/symptoms of infection
As a direct result of theoretical application to clinical practice there was a statistically significant reduction in urine samples submitted for culture after the intervention, from mean 20.9 to 14.9 per 1000 OBD per month (difference 6.0, t-test p=0.009).
Cite 3 examples within the project which highlight promotion of the protection of antibiotics?: Nurses are the constant in the delivery of patient care, therefore, as a profession they are ideally placed to enhance antimicrobial management within the multidisciplinary team. By raising awareness among the largest professional workforce within healthcare, the principles of antimicrobial stewardship can be applied to the roles and responsibilities of nurses to optimise infection management within clinical settings.
Through the inclusion of nurses into antimicrobial stewardship programmes and providing education, justification and rationale for practices, nurses become more confident within their ability to manage infection which in turn increases their likelihood of entering into a multi-professional discussion and challenging unnecessary or inappropriate prescribing.
This study demonstrates that by providing nurses with targeted educational support they can directly contribute towards a reduction in inappropriate urine sampling; promote duration of therapy and direct therapy by reviewing laboratory results. This will ultimately reduce unnecessary antibiotic prescribing and reduce patient harm.
Key outcomes of project?:
How is the project to be developed in the future?: This project will be developed further and delivered to other clinical areas. The focus of the areas of nursing influence will vary depending on specialty for example within an acute ward the focus could be IV to Oral switch or timing of administration.
Moving forward it is the intention to include an optional improvement project towards the end of the programme to promote ownership of antimicrobial stewardship practice within nursing teams.
Name: Hayley Wickens
Organisation: University Hospital Southampton NHS Foundation Trust
Name: Hayley Wickens
Provide a brief overview of your project?: Specialist Antimicrobial Stewardship (AMS) nursing posts are still relatively rare in England, however studies have highlighted the potential for nurses to have a positive impact in this field, promoting rational antibiotic use and appropriate clinical review of patients on antibiotics. As the nursing role expands, nurses have more autonomy to aid in decision-making about patient care. We therefore employed a specialist nurse to join our pharmacy/microbiology-led AMS team, with a key objective to empower our nursing colleagues in the wider Trust to take up a role in AMS. The post-holder aimed to achieve this through provision of education and role-modelling for colleagues.
The AMS team collaboratively set some objectives for this educational programme, focussing on 3 key aspects of AMS: IV to oral switch, promotion of clinical review at 48-72h after empiric antimicrobials were prescribed, and increasing the documentation of stop dates in the medical notes, in accordance with DH Start Smart then Focus guidance. We also aimed to improve levels of basic antimicrobial knowledge in the nursing team, to underpin the specific prompts described above, and to introduce nurses to the local antibiotic guideline smartphone app, ‘Microguide’, which supports decision-making around e.g. IV-oral switch and treatment duration.
The AMS nurse received specialist training, and then disseminated this by running a variety of educational workshops, nurse induction sessions, ward rounds and ad-hoc discussions on wards, often working in tandem with our Sepsis educational team. Education sessions were developed with the pharmacy team, and included an overview of AMS, local and global antimicrobial resistance trends, and how nurses can influence prescribing and management of patients receiving antibiotics. Nursing students and healthcare assistants were included. The formal education package compromised of a power point presentation lasting thirty minutes, followed by an interactive discussion. We also implemented display boards in ward areas with high antibiotic use, highlighting nursing roles in AMS and sepsis, and provided training for Infection Prevention Link nurses to help disseminate the message further.
Over an initial 3 month period, 125 staff participated in educational workshops, accompanied ward rounds or ad hoc teaching sessions. We conducted pre- and post-workshop questionnaires, which showed increases in knowledge around AMS, and confidence in ability to prompt the clinical review of patients on antibiotics. Informal feedback suggested that the participants particularly valued that the education was provided on a peer-to-peer basis, highlighting the value of the AMS nurse in the stewardship team.
List any supporting partners or organisations worked with: Antimicrobial Stewardship Team, Sepsis Team, Infection Prevention and Control Team, Nursing Education Team – all at UHS
Our AMS nurse also attended the Nursing Summit on Antimicrobial Stewardship, hosted by Imperial College and the National Institute for Health Research in January 2017 to share and develop her ideas, and also has discussed her work with peer AMS nurses at Nottingham University Hospital, Sheffield Teaching Hospitals, Imperial College Healthcare and NHS Tayside.
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category?: In the first three months of this project (Jan-Mar 2017), 125 nurses and healthcare assistants, who would not otherwise have received any specific training on AMS, have taken part in education sessions led by our specialist AMS nurse. 60 of these staff took part in a pre-course quiz identifying their baseline knowledge, and at this point the majority (92%) stated that they had not heard of AMS: in this post-course quiz, 88% of respondents were able to provide a correct free-text definition of AMS. Pre-course, 63% thought antibiotic resistance was a serious problem in the UK, and 58% thought resistance was a problem at our hospital; after the education, these figures increased to 74% and 71% respectively. We also asked attendees pre-and post-course how confident they would feel in asking a doctor to review an antibiotic prescription. Prior to the course, 25% rated themselves as ‘not at all confident’, 33% ‘somewhat confident’ and 35% ‘very confident: after the course, these percentages were 5%, 40% and 50% respectively, showing a self-reported increase in confidence. Correct answers to factual question about AMR increased from 10% to 76% between pre-and post-course questionnaires.
After the training, participants were asked to use their newly-acquired knowledge by writing down the ways in which nurses could contribute to AMS. Here are a selection of responses:
“By monitoring the use of antibiotics and requesting review when necessary.”- band 5 nurse.
“Challenging the medical staff, chasing the microbiology results and checking blood results.”- band 5 staff nurse
“ Asking the doctors to review the patients on antibiotics. Ensuring the antibiotics are given at the correct time, dose and route. Ask doctors, if possible to switch from IV to oral options.”- band 5 nurse.
“Regular review of patients (signs of infection) and of appropriate prescribing of antibiotics. Switching from IV to oral.”- band 5 nurse.
“Challenge doctors to do three day review. Send samples. Check results.”- band 7 nurse.
“Ask doctors to review IV antibiotics after 3 days. Prompt IV to oral switch.”- band 5 nurse
“Don’t let the patient have antibiotics for more than 72 hours without a review!”- band 6 nurse.
Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:
Key outcomes of project?: 1. We have established a role of an AMS specialist nurse within our AMS team, focussing on peer-education and behaviour change amongst nursing staff. The AMS nurse acts as a role model and delivers formal and informal education on AMS for ward-based nursing staff, promoting 72h clinical review of antimicrobials, appropriate iv-oral switch, and prescribing of appropriate antimicrobial course lengths.
2. 125 nurses and healthcare assistants received formal training on antimicrobial stewardship, over a 3 month period, increasing their knowledge base and empowering them to prompt clinical review of antimicrobials.
3. Following the success of this role in the first three months, the Trust Executive have agreed to fund the post on an ongoing basis.
How is the project to be developed in the future?: Our project has only been running for three months, however the Trust Executive has been sufficiently impressed to fund the AMS nurse post for a further year. We are going to use this opportunity to continue empowering nurses around the organisation to take a role in AMS.
A follow-up piece of work is underway to assess whether these nurses have increased their number of interventions after receiving AMS training, and to assess any barriers to this. We are also monitoring antimicrobial prescribing in the areas where nurses have received training to observe for any impact.
Furthermore, we are in the process of incorporating AMS into the training programme and competency documentation that need to be completed by nurses entering the Trust. We have engaged with nursing and education leads within the organisation who have agreed on the increasing importance of AMS in nursing practice.
Name: Kiran Hewitt, Deputy Chief Pharmacist
Provide a brief overview of your project?: Improvement of Antimicrobial Stewardship and NICE Compliance across a mental-health and community-health NHS Trust
Berkshire Healthcare NHS Foundation Trust is a mental-health and community-health NHS Trust serving the county-wide population of Berkshire. AMS was not a priority area for the organisation as is commonplace in acute Trusts; there was no AMS pharmacist, no AMS strategy or formal programme and our baseline NICE assessment score was 63% in 2016.
Following a previous successful bid for Patient Safety Federation funding to improve antimicrobial prescribing, Pharmacy kept up the momentum following national recommendations to improve AMS (through the publication of NICE guidelines) and reduce resistance, and developed an AMS programme and strategy and outlined the key areas for development to ensure prudent AMS throughout the Trust.
Project work in several areas across the Trust resulted in improvements in the following areas:
– Formal Trust approval of its first AMS programme and strategy at executive level.
– Collaboration and engagement with key senior Trust staff to approve and set up an AMS Group as a formal working group, through which the strategy and action plan could be delivered (with direct reporting lines to both DTC and Infection Prevention & Control Strategy Group).
– As a non-acute NHS Trust with no pathology laboratory, we ensured engagement and collaboration with a local acute trust to arrange a service level agreement for microbiologist support for our Trust. This was approved and this consultant microbiologist is a core member of our Trust AMS Group.
– Raised awareness of good AMS across the Trust and provided support and guidance for audit to be carried out in inpatient services, 2 walk-in centres in both parts of the county, out-of–hours GP service and rapid-response teams.
– Face to face education and training sessions to promote good AMS to ward, community service settings and GPs. This allowed engagement in inpatient and community settings to improve the implementation of both Start Smart Then Focus and TARGET toolkit recommendations.
– Development of a job description and successful recruitment into our first AMS Pharmacist position.
– Evidencing how engagement of staff in the AMS work has made significant improvement in NICE AMS compliance
The AMS programme is tabulated and is RAG rated to enable closer monitoring of compliance, where RED is no progress; YELLOW is Partial progress however further work is required; and GREEN is delivering against this standard.
List any supporting partners or organisations worked with: Engagement with all seven local county-wide CCGs, community nursing teams, dentists, out of hours GP service, Public Health England representation lead for Berkshire, 2 acute hospital Trusts (Royal Berkshire and Frimley Health NHS Trusts), acute hospital microbiologist and infection control leads from our Trust, local acute Trust and Berkshire wide CCGs.
We also improved our county-wide engagement by setting up a county-wide AMS Network with all the above staff representatives who meet on a quarterly basis.
We engaged with the out of hours GP service medical director who is now our AMS Group chairman.
Region-wide engagement with South Central Antimicrobial Network – who meet quarterly.
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category?: The internal strategy highlighted the need for permanent funding for an AMS pharmacist. This pharmacist is now in post and links with all departments across the Trust who prescribe AM drugs.
The AMS Group is a formal sub-group of the DTC and Infection Prevention & Control Strategy Group and as such provides a more secure mechanism to support good AMS in the Trust.
Our baseline AMS NICE guidelines compliance assessment score was 63%. The Trusts target compliance is 80%. The above work of the AMS group and Pharmacists has led to a significant improvement in meeting this national guidance target and exceeded it (currently at 83%).
Governance of IV antimicrobials used by the Trusts Rapid Response and Treatment Team (RRaT) – this is a new Trust initiative which is nurse led to prevent patients in care homes and under the care of their GP, from being admitted into hospital if they become unwell and are safe to remain at their care home. As a primary care initiative any prescribed drugs are funded through the CCG/primary care via an FP10, however the RRaT nurses working on the project are employed by the Trust. The AMS Pharmacist has linked with the RRaT nurses to resolve Issues around quick access to IV AB, since access to IVs from community pharmacies is too slow. The AMS pharmacist in consultation with senior colleagues have agreed to authorise a store of IV antibiotics to be available for RRaT usage and cross charged to the CCG. Whilst this store has been necessary to allow the RRaT to work, it has required careful monitoring as issues around AB formulary requirements and prescription screening have started to be ignored as the service has grown. Currently the RRaT service has tripled in size and the AMS Group is working with them to support good AMS within this service.
The AMS Group has provided a network for sharing of ideas and work around Near Patient Testing (NPT) which is currently used by OOH GPs. This work has been shared with our community hospital senior practitioners via the quarterly AMSG meetings. Pilot work with NPT, will now be trialled at the community hospitals to see if quick access to CRP and Strep A testing may reinforce the decision to treat (or not) with ABs.
Cite 3 examples within the project which highlight promotion of the protection of antibiotics?: 1. Funding of a designated AMS pharmacist has enabled more time to be dedicated to implementing the AMS strategy.
2. The increased usage of Antibiotics by the RRaT as detailed above, has required intervention to control issues around Governance and good AMS. The AMS Group and AMS Pharmacist are working with the RRaT to try and resolve these problems. Without the development of the programme and the supporting AMS Group and dedicated AMS pharmacist it would be very hard to manage potential risks that this RRaT service has exposed.
3. As the Trust also has community services such as walk-in centres, the Group has provided guidance and support for these services to give community patients nationally approved and recommended (PHE) produced literature about good AMS – patient information leaflets to reduce antibiotic demand and use them properly. The TARGET Toolkit has been implemented at the walk-in centres, AB usage audited last year and recommendations made.
Key outcomes of project?: 1. Development and approval of the Trust’s first AMS Strategy and programme
2. Evidence to support the funding of a designated AMS pharmacist – post created and successfully recruited into
3. Setting up of Trust’s first AMS Group with direct lines of reporting into both the Trust medicines and the trust infection control groups. This has allowed key senior Trust staff to come together and plan the delivery of trust strategy
4. Setting up of a county-wide AMS Network to improve engagement and expert advice and support around AMS
5. AM audits in inpatient, community and GP out of hours services.
6. Significant improvement in NICE guidelines compliance for AMS during 2016 – now our compliance is over the Trust target range of 80%, at 83% (previous to any of the above, our NICE compliance was 63%).
How is the project to be developed in the future?: 1. Greater awareness and visibility of AMS through the AMS Group, pharmacist and networks.
2. Better, more relevant audit data to inform where improvements are required.
3. As the Trust grows in size and more patients are managed in the community it will be essential for pharmacy to be involved in new initiatives to treat patients in the community from the start of project planning, rather than having to react to an established framework. The new AMSP gives weight to the importance of MDT collaboration from an early stage and will need to be continually developed and adapted to accommodate Trust growth.
Name: Laura Whitney
Provide a brief overview of your project?:
The majority of education and training on antimicrobial prescribing and stewardship is focused on junior doctors, which contrasts with our local knowledge that most antibiotic prescribing decisions are driven by consultants, who are a particularly hard group to target with educational strategies in a large teaching hospital with 300 consultants.
Our stewardship programme is well developed within the Trust, but is challenged by lack of engagement from some specialities. This is associated with pockets of poor prescribing, difficulties in creating collaborative guidelines, poor submission rates the doctors antibiotic audit and difficulties in disseminating key stewardship messages within the organisation.
We had Consultant representation on the Antimicrobial Stewardship Committee, but this was often limited to infection specialists.
The aim of our project was to nominate an antimicrobial stewardship lead in each of the 35 care groups. We hoped this would lead to improved communication, an increase in antibiotic audit submissions from the medical team; promote development of and adherence to guidelines; Increase the proportion of patients with a day 3 clinical review of therapy and reduce antibiotic consumption by working with each care group to identify areas of antibiotic overuse. This in turn will assist in our achievement of the 2016-17 AMR CQUIN
We began by engaging with the Trust board to gain support for the need for champions. This was followed up by attendance at the 4 divisional governance boards to discuss antimicrobial resistance and stewardship and gain practical support for the champion programme. Support from our Associate Medical Director who sits on the antimicrobial stewardship committee was crucial.
Champions were then identified, sent a welcome letter and given a stewardship information pack (developed with Pfizer) and invited to the antibiotic stewardship committee as part of EAAD 2016.
List any supporting partners or organisations worked with: Pfizer healthy living partnership
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category?: Champions have been appointed in all clinical areas.
Attendance at the Antimicrobial Stewardship Committee increased from an average of 5 consultants to 11.
We have expanded the number of speciality guidelines ensuring all surgical specialities have prophylaxis guidelines, and completing guidelines for treatment of ENT infections, obstetric sepsis and infective endocarditis.
25 care groups submitted audit data for the most recent antibiotic audit compared to 18 submissions prior to the champions programme.
Cite 3 examples within the project which highlight promotion of the protection of antibiotics?: Improvement in clinical review of antibiotics – review within 3 days has risen from 82% to 91%.
Reduction in antibiotic consumption compared to 2013/14 levels – Total antibiotic consumption reduced by 7%, Carbapenem consumption reduced by 22% and Tazocin consumption reduced by 2% compared to 2013/14 usage
Adherence to guidelines or microbiology advice is above 90%
Key outcomes of project?: Stewardship has been raised up the Trust agenda and is now seen as a priority. It is also seen as a clinical activity for all staff rather than just the responsibility of the AMS team.
How is the project to be developed in the future?: The Trust Stewardship leads will meet with all care group champions to further promote the role and develop bespoke plans for stewardship within each specialty. E-mail newsletters for champions are being prepared for regular dissemination. We are also working with the Trust communications team to highlight the success of the stewardship programme both internally and externally.
The pack created for the stewardship champion programme will be made available to other NHS organisations through the Pfizer healthy living partnership programme.
We look forward to continuing to work with the champions to improve stewardship in 2017/18 and beyond.
Name: Sarah Thomson, Pharmacy Technician
Provide a brief overview of your project?: • It was identified that there is no antimicrobial stewardship education tailored specifically to pharmacy technicians. Pharmacy technicians recently became regulated by a professional body and their roles and responsibilities are constantly evolving.
• In 2015 the Healthcare Associated Infection (HAI) standards were published by Healthcare Improvement Scotland. These standards apply to all healthcare providers and practitioners and aim to aid the prevention and control of infection. Each Health Board in Scotland must meet these standards, with regular announced and unannounced inspections being carried out by the Healthcare Environment Inspectorate. Within this document, standard 5 covers antimicrobial stewardship and there are a number of statements relating to the knowledge that is expected of healthcare workers including;
“The antimicrobial management team has a planned programme of education on antimicrobial stewardship for all healthcare teams involved in the prescribing, supply and administering of antimicrobials.”
“…staff demonstrate knowledge of local and national policies and guidance regarding antimicrobial prescribing that is relevant to their responsibilities and duties…”
• Although there is education provided to the pharmacy team within NHS Tayside, these sessions have historically not been attended by pharmacy technicians.
• Other AMTs throughout Scotland were contacted and a question posted on the UKCPA Infection Management Group discussion form, however there was no response to suggest other areas currently provide education tailored to pharmacy technicians.
• Therefore, an education session was developed to be delivered to pharmacy technicians. The content was agreed with AMT colleagues plus gaps in the knowledge of pharmacy technicians were confirmed with an electronic questionnaire.
• The session format is a presentation with discussion and questions encouraged throughout, as well as a brief practical element.
• A “5 Golden Rules” quick reference guide was developed to be used predominantly by ward based clinical pharmacy technicians.
• Paper copies of the “5 Golden Rules” and other relevant guides plus links to more in depth education resources were supplied during the education session.
• The session was delivered to groups of pharmacy technicians throughout NHS Tayside.
List any supporting partners or organisations worked with: • Local Antimicrobial Management Team provided expert advice around the content and delivery of proposed education for pharmacy technicians
• Service Improvement Manager within the NHS Tayside learning hub provided guidance and quality assurance for the development of an electronic questionnaire
• Head of Leadership & Management for NHS Tayside provided assurance that all materials used with the session had been referenced appropriately and permissions given where required
• Antibiotic Guardian committee provided agreement to use Antibiotic Guardian logo
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category?: • During 2016 approximately two thirds of pharmacy technicians working within the hospital setting attended a training session.
• Feedback following attendance was collected and was extremely positive with comments including the session being interesting and relevant to their role, having better knowledge, awareness and confidence, understanding the impact of antibiotic resistance globally etc . Specific areas of improvement were;
o changed behaviours and an interest in further learning.
• An electronic questionnaire was completed before and after the session by attendees. 100% of respondents felt their confidence with antimicrobials had improved after attending the session. The majority of respondents pre-session claimed their knowledge of antimicrobials was “POOR”. Post-session all respondents felt their knowledge was “GOOD”, “VERY GOOD”, or “EXCELLENT”
Cite 3 examples within the project which highlight promotion of the protection of antibiotics?: • A presentation which includes an overview of antimicrobial resistance and its global impact.
• An education session which promotes further learning materials as well as links to websites of interest.
• An education session which aims to raise awareness of the work undertaken by the local AMT as well as highlighting antimicrobial prescribing policies and when to use them.
Key outcomes of project?: • Develop, deliver and evaluate an education session on antimicrobial stewardship for pharmacy technicians working within hospital, locality and primary care within NHS Tayside.
• Increased awareness amongst pharmacy technicians of the AMT and work undertaken.
• Ensure this profession meets the national standards on antimicrobial stewardship as set out in Healthcare Associated Infection (HAI) standard 5.
How is the project to be developed in the future?: • Encourage all pharmacy technicians in NHS Tayside to attend this session.
Abertawe Bro Morgannwg University Health Board
Name: Avril Tucker
Provide a brief overview of your project?: To improve the quality of antibiotic prescribing in the North Cluster of Bridgend through targeted antimicrobial stewardship and thereby minimise the risks of increased antibiotic resistance. The North Cluster of Bridgend shows significant variation in antibiotic usage between the lowest and highest prescribing practices, providing an opportunity to understand the drivers for variation and address them appropriately. An antimicrobial pharmacist went into all 8 GP practices within the North Cluster. GPs within those practices were engaged and an antibiotic champion appointed. An audit was conducted to analyse where impact could be seen in terms of antimicrobial prescribing. Amoxicillin use in urinary tract infections (UTI), all co-amoxiclav prescribing, phenoxymethylpenicillin (penV) length of course in tonsillitis and the incidence of trimethoprim treatment failure in UTIs were audited. All prescriptions generated for these categories, in each of the 8 surgeries, during the months of September, October & November 2015, were analysed and the results formed the basis of a surgery-specific action plan. The results were also plotted in a series of graphs benchmarking where the practice sat in relation to their cluster peers. This information was then presented back to the practice in order to promote engagement.
List any supporting partners or organisations worked with: Data analysis support provided by 1000 lives, a subsidiary of Public Health Wales.
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category?: Of all the prescriptions issued for amoxicillin, 206 (9.4%) were for UTI. Of the 206, 6 were in line with current ABMU antimicrobial guidelines, i.e. after a susceptible culture result. That equates to 3.2%. UTI in pregnancy was the biggest driver for the sub-optimal use.
58% of the prescriptions for co-amoxiclav were in line with ABMU antimicrobial guidelines. There are currently 8 indications for co-amoxicilav use in the ABMU antimicrobial guidelines. However, in addition to these, particular note was also taken to what was written in the ‘free text’ in the patient’s medical records. If there was justification annotated then this, too, was included as appropriate use. Although guidelines are evidence based and should underpin the majority of prescribing, the clinicians experience and diagnostic discretion should also be taken into account. The proportion of co-amoxiclav use attributed to pyelonephritis in each surgery, an appropriate indication for its use, varied from 9.1% to 38.5%. From review of patient notes, the threshold for a pyelonephritis diagnosis varied considerably between surgeries, rather than individual GPs, suggesting a prescribing culture within the practice.
A 10 day course of penV is recommended in tonsillitis. 45.5% were in line with this recommendation, 44% were issued for a 7 day course. The GP computer software was identified as being the biggest driver for this as it pre-populates a quantity of 56 tablets resulting in a 7day course. A manual over-ride was required to give a 10 day course. This has since been corrected.
One practice was responsible for prescribing 26% of the total cluster volume of trimethoprim (229 prescriptions). They also had the highest rate of treatment failure with 31% returning within 28days with similar symptoms, 2.3times that of a similar size neighbouring surgery. 29 of the 71 patients who returned had a mid-stream urine analysis and trimethoprim resistance was responsible for 52% of the treatment failures. This surgery managed their UTI consultations differently to the other surgeries in the cluster, they used a symptom questionnaire. This system was introduced in October 2015 and, within a month, their prescribing rate of trimethoprim had increased by 40%. They did, however, save in terms of appointments.
As a result of the audit, prescribing cultures were exposed, gaps in knowledge were identified and closed, IT solutions were implemented and benchmarking with peers was established
CIte 3 examples within the project which highlight promotion of the protection of antibiotics?: Reducing resistance: The use of sub-optimal antibiotics promotes further resistance. The majority of UTIs are caused by E.coli. 60% of coliforms (including E.coli) are resistant to amoxicillin. Therefore, the use of amoxicillin to empirically treat UTI infections is not evidence-based or appropriate. This is particularly problematic in pregnant women due to the risks of complications from prolonged infections. Through identifying this gap in knowledge in relation to resistance data, and through reinforcing the current ABMU antimicrobial guidelines for the management and treatment of UTI in pregnancy, this educational issue was closed. In addition, the overuse of antibiotics (trimethoprim) speeds up the rate at which resistant isolates occur and resistance results in treatment failure. Treatment failure will require a GP appointment, a mid-stream urine sample culture and a subsequent course of antibiotics, increasing the population exposure to ‘second-line’ antibiotics. The short-term benefit of reduced GP appointment pressure has to weighed up against the long term cost of increased resistance, which will result in more of the very thing that was trying to be saved in the first place.
Broad spectrum to narrow spectrum: The use of broad spectrum antibiotics, like co-amoxiclav, should be used only when indicated as they kill vast amounts of the gut flora in addition to the target bacteria. This is problematic in terms of colonisation and further infection, e.g. C.diff. By identifying sub-optimal use, potentially through addressing lower diagnostic thresholds, improvement can be seen in terms of antibiotic choice. The surgery who attributed 38.5% of their total co-amoxiclav use to pyelonephritis were diagnosing it on the basis of a UTI with the presence of blood. Blood is not a diagnostic indicator for pyelonephritis. This educational need was identified and closed.
Engagement with GPs: Having a collaborative approach rather than becoming the ‘antibiotic police’ allowed for closer working relationships. Identifying specific areas for improvement and collaboratively helping GPs to develop their own surgery specific action plans built ownership and engagement far more effectively than the top-down direction.
Key outcomes of project?: In addition to the quality of prescribing in relation to compliance with the current ABMU antimicrobial guidelines, this project has contributed to a cluster reduction of ↓6.91% in items per 1000PUs in Quarter 4 (Jan – March 2016), compared to the same period from the previous year. The ABMU heath board average was ↓2.75% and the Welsh national average was ↓4.17%, over the same time period.
Effective benchmarking was not comparing the highest antibiotic prescribing practice to that of the lowest, but involved working out the relationships within the cluster. There was far more buy-in and engagement when comparisons were made to ‘buddy’ surgeries or those seen to have a largely similar patient profile, this lead to a ‘competitive improvement’ culture within the cluster. There was also much more engagement with the supportive approach to improvement where change was decided upon collaboratively, i.e. identifying the issues and then coming up with a plan to close them.
How is the project to be developed in the future?: The next phase of this project has been to work with local patient groups and Primary Schools to raise awareness of the issues around antimicrobial resistance and the need for prudent antibiotic use, from a patient perspective.
The initial measures are being re-audited, over the same time period this year, to show sustained improvement. This is on-going.
A data-extraction tool, which can capture all information from the patient medical record pertaining to a consultation where an antibiotic was prescribed, is being developed in collaboration with 1000 lives. This will make clinical audit more time efficient and effective.