Hospital antimicrobial stewardship: network to identify improvements
Antimicrobial stewardship can be defined as co-ordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy and route of administration.1
NHS trusts have realised many of the benefits of antimicrobial stewardship, yet more can be done to improve communication between organisations to promote best practice.
In England in 2011, the Department of Health’s advisory committee on antimicrobial resistance and healthcare-associated infection issued best practice guidance for antimicrobial stewardship.2 The aim of this and similar guidance is to provide an evidence-based outline for antimicrobial stewardship practice in hospitals.
Although such guidance has been essential for improving antimicrobial use within individual NHS trusts, the lack of a standard, defined methodology prevents benchmarking between organisations. Consequently, there is no formal means for putting antibiotic consumption data into context.
This article describes how an antimicrobial network was set up across Hertfordshire and Bedfordshire to improve antimicrobial stewardship and share best practice locally. Examples of the collaborative work of the network are provided to illustrate the benefits of this type of approach.
Owing to the location of four NHS trusts in the Hertfordshire and Bedfordshire regions, the antimicrobial pharmacists in those organisations, like many, would communicate with each other by email and telephone on an ad hoc basis. Although this form of contact can be useful it lacks the structure, actions and direction that could be achieved by holding formal regular meetings.
We sought to formalise the development of a clinical network for these pharmacists. The ultimate aim of the network was twofold:
- To compare antimicrobial consumption through the auditing of antimicrobial usage on an ongoing basis
- To support open comparison and sharing of information to allow continuous improvement and development of service provision
In April 2010 the first meeting was organised and the terms of reference for the antimicrobial network were defined. The overarching theme was to define the scope of the collaborative work and be realistic about what might be achieved. Although it was noted that other antimicrobial networks existed in the UK at that time, it was thought there was a need to address the requirements of the population and resource challenges locally. It was agreed the network would meet for three hours every quarter.
The reason for benchmarking antimicrobial prescribing data is to understand the relationship between the use of antimicrobial drugs with emerging bacterial resistance and healthcare-associated infections.
As a network we standardised the method for data collection and applied it to the anatomical therapeutic chemical (ATC) classification system (see Box 1). This provides a consistent means of monitoring antibiotic consumption within and between organisations, thereby allowing accurate analysis of antimicrobial consumption between trusts. These data were then used to identify areas for discussion within the group and, where appropriate, to support changes in prescribing practice.
Sharing best practice
The standardised prescribing data are used by the network to benchmark the use of antibacterial medicines such as fluoroquinolones, cephalosporins, clindamycin and co-amoxiclav — which are known to increase patients’ risk of Clostridium difficile infection. Figure 1 (p58) provides an example of the application of the data. It shows the consumption of co-amoxiclav over 20 months at the four NHS trusts.
In this example, the sharing of these data identified relatively high consumption of co-amoxiclav in one trust (trust 2). In response to this, prescribing guidelines were changed in November 2010. In 2011 a second trust (trust 3) introduced similar policy changes to reduce co-amoxiclav use. We believe that this collaborative approach aided the identification of high co-amoxiclav consumption as an issue and the solutions and experiences of implementing change could also be shared.
Point prevalence audit
Point prevalence audits provide a snapshot of antimicrobial use at a particular point in time. They are used within individual trusts to monitor the effectiveness of antibiotic policies and to provide data on patterns of antibiotic use. We wanted to expand on this to make comparisons between organisations.
As with collection of antimicrobial consumption data, the absence of a defined methodology for point prevalence audits nationally makes comparison between one trust and another difficult. The antimicrobial network undertook a piece of work to standardise the methodology for audit data collection thereby facilitating accurate benchmarking between trusts.
Comparing point prevalence data between trusts provides further context to the findings. For example, there is no published definition of what constitutes a "high" level of intravenous antimicrobial prescribing (relative to oral). One trust with 64% of antibiotics prescribed via the IV route relaunched its IV-to-oral switch policy as a result of benchmarked point prevalence data. The effect of this initiative can be assessed during the next annual point prevalence audit.
Pharmacists in the network identified the need to improve the information and learning provided for colleagues within their own organisation. To address this there was an agreement to develop a competency-based programme for junior pharmacists within each trust — the focus being the management of the most common infections encountered in hospital.
Rather than duplicating effort, each of the four antimicrobial network pharmacists devised competencies based on two common infections, and so the network members could make use of competencies around eight infections for pharmacists in their own organisation. This collaborative approach ensured that resources could be pooled and a consistent standard applied across different organisations.
A gap analysis using a recognised hospital antimicrobial self-assessment toolkit3 identified learning needs among the network members themselves.
In January 2012 the network organised its first antimicrobial pharmacist educational meeting. Over 60 UK pharmacists attended the free-of-charge, industry-sponsored meeting. Based on positive feedback from the meeting, the network held a second event in January 2013 and intends to do so annually hereafter.
Until now the work accomplished by the network has been largely intuitive and based on the needs of the members’ trusts. We believe that working in this way has allowed resources to be pooled and common problems discussed and, where possible, resolved.
By standardising methodology for data collection, antimicrobial data have been benchmarked between trusts — in this way we have identified areas for improvement which otherwise would have been hard to identify.
We believe that our work has brought about tangible benefits and we wish to subject it to further study and peer review. We are now looking at how changes made through this collaborative process have affected antimicrobial stewardship and, more importantly, impacted on clinical care.
We would also like to draw upon the expertise of other networks to harness ideas and integrate them into our practice locally.
Figure 1: Benchmarking data for 20 months of co-amoxiclav use at the four NHS trusts within the antimicrobial network (expressed as defined daily dose per 1,000 bed days per month)
Thanks to the other members of the network:
Tejal Vaghela at West Hertfordshire Hospitals NHS Trust; Imran Khan at Luton and Dunstable NHS Foundation Trust; and Naomi Currie at Bedford Hospital NHS Trust.
1 Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship. Infection Control and Hospital Epidemiology 2012;33:322–7.
2 Department of Health advisory committee on antimicrobial resistance and healthcare associated infection. Antimicrobial stewardship: "Start smart — then focus". November 2011. www.dh.gov.uk (accessed 24 June 2012).
3 Cook J, Alexander K, Charani E, et al. Antimicrobial stewardship: An evidence-based, antimicrobial self-assessment toolkit for acute hospitals. Journal of Antimicrobial Chemotherapy 2010;65:2669–73.
David Ladenheim is antimicrobial pharmacist at East and North Hertfordshire NHS Trust.
Box 1: Comparing antibiotic consumption
The anatomical therapeutic chemical classification system uses a technical unit of measurement, the defined daily dose (DDD), to facilitate the comparison of consumption information. The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults.
To determine antibiotic use in a hospital, the total number of grams of each antibiotic used (dispensed) are summed during the period of interest and divided by the World Health Organization-assigned DDD (grams/day) — yielding an estimate of the number of days of antibiotic therapy.
One of the problems with DDD usage data alone is that unless the comparator hospitals are of a similar size it is difficult to draw meaningful conclusions. Standard practice in hospitals is therefore to correct for workload variations and express the number of DDDs as a proportion of occupied bed-days.
At present there is no national or regional co-ordination of this data collection in England. By standardising the methodology comparison can be made between trusts.
Citation: Clinical Pharmacist URI: 11117619
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