Oslo 2013 Antibiotic Stewardship Organisations, Systems and Teams. Alison Holmes

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1 Oslo 2013 Antibiotic Stewardship Organisations, Systems and Teams Alison Holmes

2 Integration of AS and IPC

3 Report on Point Prevalence Survey of Antimicrobial Prescribing in European Hospitals 2009 ESAC-3: 30% of inpatients were treated with antibiotics The proportion for treating HAI was 35%

4 The Chennai Declaration The declaration also has a much broader scope stretching beyond antibiotic stewardship to improve patient care and patient safety, as it promotes the important role of the infection control committee and team by mandating that there must be one in every hospital. The roadmap states that it will be these infection control committees that should deliver the hospitals antibiotic stewardship agenda, and this integration of infection control and antimicrobial stewardship is a critical component of the action plan. A lack of infection prevention and control activity and committees in Indian hospitals has been recognized as a cause for concern. A. H. Holmes and M. Sharland. The Chennai Declaration: India's landmark national commitment to antibiotic stewardship demonstrates that truth alone triumphs J. Antimicrob. Chemother. March 18, 2013

5 UK CMO Report 2013

6 UK CMO Report 2013 Acute trusts and their boards will need to learn a new language and consider how to strengthen infection prevention and control practice using new methods of organisational and behavioural change to reinforce policy implementation.

7 AS in Acute Care A marriage of infection control and antibiotic management However % of patients do not receive care according to evidence 1/3 of patients in acute care receive antibiotics Significant proportion of antibiotic prescribing in acute setting is sub-optimal Hand hygiene compliance sub-optimal Staff adherence to best practice needs to be improved

8 Policies and guidelines are not enough. J Carthey et al BMJ 2011; 343

9 How can we do better? What could be done differently? Consider: Organisation, Systems Teams

10 Organisational Approach required 1. A belief in a shared purpose 2. Reinforcement systems 3. Skills required for change 4. Consistent role models E. Lawson, C. Price McKinsey Quarterly 2003: The Psychology of Change Management e.g. Internal Reinforcement Reporting structures: Management and operational processes Measurement procedures: Setting targets and measuring performance Granting rewards All must be consistent with behaviour to be embraced i.e. must reflect commitment to IPC and AS

11 Organisational Approach required Addresses: Much expertise, not used effectively Small teams in huge hospitals (fire-fighting, without major strategic input) Expertise not closely linked to management framework Systems based approach for sustainability Making it a core part of corporate governance and patient safety Changing culture and behaviour of whole organisation Creating organisational learning Institutional and cultural barriers Ensuring organisational leadership

12 Organisational Approach required Addressing AS as an organisational change issue need to consider : Issues and agendas: Political science concept of a crowded decision making agenda; Power and influence: Specialists and generalists, Who owns antibiotic stewardship? Coalition building needs? Governance framework Roles and relationships: difficult move from a narrow technical role to a broader strategic role, coalition of supporters Organisational culture and learning Supporting Knowledge bases E Ferlie.et al 2003 British Journal of Management, 14, S1: S1-14.

13 Organisational Approach required Increasing recognition in last five years that an organisational approach is required, along with appropriate technical expertise

14 Organisational Approach required Increasing recognition in last five years that an organisational approach is required, along with appropriate technical expertise

15 Charani et al JAC 2010 Whole Systems Approach Decision architecture. Necessary to understand the factors that influence prescribing behaviour and decisions Address human factors Supporting choice architecture Making some small changes to existing systems Adopt a whole-system approach to support optimal prescribing choices.

16 Reinforcing AS Structures and Systems 1) Structures, lines of responsibility and high-level notification to the Board. 2) Operational delivery of an antimicrobial strategy- with operational standards of good antimicrobial stewardship. 3) Risk assessments of antimicrobial treatments 4) Clinical governance assurance 5) Education and training 6) Antimicrobial pharmacist -with systems in place for ensuring optimum use. 7) Patients, Carers and the Public-addressing information needs 8) 9)

17 Understanding what Interventions work

18

19 Prescribing is a behaviour Antibiotic prescribing is complex A social process Under influence of many determinants Collateral impact not tangible at prescriber/patient level Expertise required but not universally used Principles need reinforcing/sharing Recognising the unwritten rules of prescribing Social sciences and qualitative perspective also needed

20 Greater Understanding Antimicrobial Prescribing Behaviours Interventions to optimize antimicrobial prescribing behaviour are of poor quality and are not based on robust theoretical science. Behaviour and social science research is underutilized in the development of antimicrobial prescribing interventions. Qualitative evidence highlights the influence of social norms, attitudes, and beliefs on antimicrobial prescribing behaviour When designing and evaluating interventions in antimicrobial prescribing, these influences on prescribing are generally not considered. Charani E et al Behavior Change Strategies to Influence Antibiotic Prescribing in Acute Care: A Systematic Review. CID, October 2011;53(7):

21 Successful interventions based on.. Social process The sense of community Bottom up approach Importance of systems with network and teams

22 Greater Understanding Antimicrobial Prescribing Behaviours

23 Multidisciplinary approach has primarily included: Infectious Disease Physicians Clinical Microbiologists Clinical or Infectious Disease Pharmacists Epidemiologist At times, infection prevention and control teams Can nurses contribute to antimicrobial stewardship?

24 How can Nurses Contribute? Duration of Treatment Route of antimicrobial administration Timing of antimicrobial administration Therapeutic drug monitoring Outpatient Antibiotic Therapy (OPAT) Relatively stable work force/organisational memory Edwards et al The potential for greater multi-disciplinary involvement needs to be considered, particularly to address: prescribing principles patient safety sustained quality improvement in clinical care

25

26

27 Enhancing the nurses role in AS Nurses ability to discuss or challenge decisions associated with constructs of knowledge and power Role as knowledge brokers Major workforce resource Edwards, R, et al. (2011) J. Infection Prevention 12: 6-10 EU Antibiotic Awareness day18 th November, 2010 CIPM launched the first Conference on Nurses Role in Antimicrobial Stewardship Challenges Time and Resources Knowledge Motivation Skills

28 Enhancing the nurses role in AS Nurses ability to discuss or challenge decisions associated with constructs of knowledge and power Role as knowledge brokers Challenges Time and Resources Knowledge Motivation Skills EU Antibiotic Awareness day18 th November, 2010 CIPM launched the first Conference on Nurses Role in Antimicrobial Stewardship Has run in Nov 2011 and Nov Gaining momentum. Collaborations formed

29 Enhancing the nurses role in AS Nurses ability to discuss or challenge decisions associated with constructs of knowledge and power Role as knowledge brokers Challenges Time and Resources Knowledge Motivation Skills EU Antibiotic Awareness day18 th November, 2010 CIPM launched the first Conference on Nurses Role in Antimicrobial Stewardship Has run in Nov 2011 and Nov Gaining momentum. Collaborations formed

30 Also

31 Also Integration or embedding within Patient safety

32 Also Integration or embedding within Patient safety Engaging the Public?

33 Also Involving Vets? Integration or embedding within Patient safety Engaging the Public?

34 Learning through collaboration and supportive networks

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