Antimicrobial Audit. Philip Howard Consultant Antimicrobial Pharmacist. Medicines Management & Pharmacy Services
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1 Antimicrobial Audit Philip Howard Consultant Antimicrobial Pharmacist
2 Leeds Teaching Hospitals NHS Trust (North of England) Serves population 900k plus 2.5m for tertiary services ~ 2300 inpatient beds 2 teaching hospitals: LGI & SJUH 3 peripheral sites 93m drug budget ( 17m AB) 430 staff incl ~125 pharmacists, 8 Microbiologists & 3 Infectious disease consultants
3 LTH Antimicrobial Consultant Pharmacist worst acute teaching hospital in UK for MRSA and C difficile Cases CDI Acute Teaching Trusts Best Rate Admissions 140 MRSA Acute Teaching Cases Trusts Best Rate Admissions DoH: undertake regular audit until you are assured that guidelines are embedded into practice
4 Audit & feedback as an element of Antimicrobial Stewardship Developed on-line antimicrobial resource Each speciality to undertake one antimicrobial related audit each quarter Guidelines, TDM antibiotics, MRSA screening, etc Develop a plan and enter onto Clinical Audit database in advance. Enter results when completed NOT a repeat the ward pharmacist audit Ward pharmacists to do a monthly pseudo point-prevalence audit Audit tools available on-line
5 Posters: How to prescribe antimicrobials Regular Medicines Month & year:oct 07 Date: 1/ 10 2/ 10 3/ 10 4/ 10 5/ 10 6/ 10 7/ 10 8/ 10 9/ 10 Drug (1) TRIMETHOPRIM Route PO Additional Instructions Dose Uncomplicated UTI 3 day course Sign (NAME & Bleep) A Doctor (DOCTOR)1234 Pharm 200mg Date 1/10/07 Supply DAY ADocctor (DOCTOR1/10/07 Indication lets everyone know the reason why. Easy to check if correct. An Indication Duration or Review Date Regular Medicines Month & year:oct 07 Date: 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 Drug (1) FLUCLOXACILLIN Route IV Additional Instructions Sign (NAME & Bleep) A Doctor (DOCTOR)1234 Cellulitis Review 48 hrs Pharm Dose 2g Date 2/10/07 Supply DAY R/V Review at 48 hours. C&S results Stop / step down to oral or narrow spectrum agent Less AB resistance
6 Over 65 years? Decrease C. difficile risk Avoid if possible: clindamycin cefuroxime ceftazidime ciprofloxacin
7 Prescribe antimicrobials correctly Print name and contact number
8 Beware of disguised penicillins! Don t give penicillin allergic patients: Tazocin Piperacillin-tazobactam CoAmoxiclav (Augmentin) Amoxicillin-clavulanic acid CoFluampicil (Magnapen) Ampicillin-flucloxacillin
9 Education sessions for junior doctors
10 All in-patient wards audited on any one single day each month by the ward pharmacist Results entered onto a spreadsheet by secretary She chases up any late audits = 100% for last 9 months Entered onto Trust dashboard with other HII Report to Trust, Divisional, Specialty or Ward level.
11 HCAI monitor snapshot On home page of hospital website link to KPIs
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13 CQUIN target: 100k / qtr (>90% in Q4) keys to success initially part of the board report for HCAI. What s so difficult about writing. part of medicines management CQUIN
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15 Peer review for duration (blue line) & indication (red dots) on prescriptions? 100% 1 90% % % % % % % % % * = electronic 0% Confidential sharing of data (30 Trusts) place us 3rd behind one with electronic prescribing and a previously poorly performing Trust. Only 3 trusts would publicly share data
16 Antimicrobial Medicines Code Audit Division league table Trust Take 5 Feb Medicine Medicine Oncology-Surgery WCHN&D Specialist Surgery Speciality Derm & Rheumatology Cardiology Cystic fibrosis Respiratory Elderly Diabetes & Endo Infectious disease Renal Urgent care Acute medicine Pts on Abs/no of ABs Indication on chart Review date or duration on chart Prescriber ID clear 450/627 42/71 174/ /157 82/131 92% (+1%) 90% (-4%) 95% (+4%) 92% (no change) 88% (+1%) 91% (+1%) 89% (-4%) 95% (no change) 91% (-8%) 89% (+3%) 88% (-6%) 82% (-8%) 90% (-2%) 90% (+7%) 85% (no change) 72/91 86% (+9%) 81% (-9%) 81% (-6%) Pts on Abs/no of ABs Indication on chart Review date or duration Prescriber ID clear 3/3 8/10 11/40 43/60 59/70 14/15 10/14 17/25 5/6 7/8 100% (no change) 100% (+44%) 98% (-2%) 98% (no change) 97% (+3%) 93% (+1%) 100% (+8%) 88% (+7%) 83% (+16%) 63% (-22%) 100% (no change) 100% (+22%) 98% (-2%) 98% (no change) 97% (+6%) 93% (+1%) 93% (+5%) 92% (+11%) 83% (+16%) 50% (-35%) 100% (no change) 100% (+22%) 100% (no change) 90% (-1%) 84% (+12%) 93% (-7%) 100% (+8%) 84% (+7%) 100% (no change) 75% (-25%) Achieved Local CQUIN target of >90% worth 100k per quarter (just) Management & Pharmacy Medicines ward level data and trends on LHPServices Antimicrobials performance pages
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19 Antimicrobial Usage Last yr vs prev Total broad spectrum LTH Div A&E Acute Diab Older Renal Derma GU Med Endo peopl tology Med e 8% 10 82% 78% -15% 6% % ID Cardiolo gy 4% 0% 23% 5% -65% 1st gen ceph(cdi) -36% -58% -28% -54% -11% -60% -31% 44% -31% -26% -84% 2nd gen ceph(cdi) -28% -3% 12% -3% 79% -81% -5% -100% n/a 154% -35% 3rd gen ceph(cdi>mrsa) Ciprofloxacin (MRSA>CDI) Clindamycin (CDI) Co-amoxiclav (CDI) Meropenem (MRSA) Piperacillintazobactam (MRSA) 11% 17% 33% 67% -27% 136% 21% -36% 5% 199% -17% 11% 10% 73% 234% -44% 8% 6% -4% 12% -12% 65% 82% 91% 588% 310% -58% 38% 30% 62% 54% 28% 5% 3% -23% 21% 20% 109% 22% 41% 0% 80% -26% -22% 45% 383% n/a 742% -100% -8% -3% 236% -43% 83% -86% 15% 12% 12% -5% 22% n/a 11% 31% 27% 51% 61%
20 Antimicrobial Audits 1 per quarter audit of common guidelines used in specialty, MRSA screening & decolonisation or high risk drugs e.g. gentamicin, vancomycin (not Take 5 or rpt of Pharmacist audit) enter a plan onto LTH Clinical Audit Database for the year, and update results when complete. Specialty Q1 results Q2 results Q3 results Q4 plan/results 55% 82% 73% 45% GU Med UTI Pharyngeal gonnorhoea Epididymitis Chlamydia Cardiology Cannulae Cannulae Cannulae Peritonitis in PD PD exit site infections AB Med Code & Cannulae MRSA screening in HD UTI* Vancomycin Rx/ Qual of AB Rxing* Pulm CF Exac Home vs IP Abs Neb Abs Self-med of Abs* AB Rx stds VIP NICE TB* Levofloxacin in CAP Notes & Rx (no AB) Sepsis Micro liaison Cipro in OP CAP* Div Audit rate Renal Infectious disease Cystic fibrosis Respiratory Dermatology Urgent care Elderly Acute medicine Diab & endo Medicines Services * New entriesmanagement this month =& 4Pharmacy #=no results Cannulae pack availability CDI#
21 Antimicrobial Audits 1 per quarter Audit of common guidelines used in specialty, MRSA screening & decolonisation; SSI prophylaxis; commonly used AB treatment guidelines, high risk drugs e.g. gentamicin, vancomycin. Enter a plan onto LTH Clinical Audit Database for the year, and update results when complete. 1 new audit last quarter by Ortho (MRSA screening & decolonisation = 100%). Specialty Critical care Q1 results AB Med Code Q2 results MRSA screen x2 T&O None recorded MRSA proph Rheumatology Plastics Neurosurgery None recorded None recorded None recorded Q3 plan / results MRSA proph MRSA screen CAH (+2 Q4 plan None planned unfinished in # s Chronic periprosthetic inf OP AB Rxing AB guidelines SSI proph x 2 MRSA screen Cellulitis SSI proph x 2 None planned Skin prep OT None planned Cardiac surgery None recorded None recorded AB Med Code None planned Theatres & DC None recorded None recorded AB proph N/S None planned Neurology None recorded None recorded PEG proph (plan, but no results) None planned
22 Key lessons learnt Antibiotic prophylaxis wasn t being given incision (vascular) in >50%. Introduced WHO Safer Surgery checklist early. CDI severity not being assessed so difficult to identify if correct agent being used Patients at high risk of MRSA not routinely receiving correct teicoplanin based prophylaxis Restricted antimicrobial code durations supplied by trainees are longer than consultants.
23 Primary Care Audits in Leeds Quality Outcomes Framework (QoF) Antimicrobials not included Medicines Management points allow for audit Quinolone Asked all GP practices to audit their prescribing against their guidelines Cephalosporins New guidelines Audit against guidelines Stop reporting cephalosporin sensitivities to urines unless only one other option
24 Leeds PCT Quinolone Audit Results Appropiate prescribing for quinolones (Avg 59.9%) 120 % of appropriate prescriptions practices % Appropiate prescribing Average
25 Quinolone changes Figure 10 - Yorkshire & The Humber PCTs: Weighted Quinolone prescribing; April 2007 to September Barnsley Item s/1000 Antibacterial (CHI) STAR-PU 14 Bradford & Airedale Calderdale Doncaster East Riding of Yorkshire 12 Hull Teaching Kirklees Leeds North East Lincolnshire Care Trust Plus 10 North Lincolnshire North Yorkshire & York Rotherham 8 Sheffield Wakefield District Yorkshire & The Humber North of England 6 England Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4 1011Q1 1011Q2
26 Cephalosporins over time Figure 6b - Yorkshire & The Humber PCTs: Weighted Cephalosporin prescribing; April 2007 to September Barnsley Bradford & Airedale Items/1000 Antibacterial (CHI) STAR-PU 46 Calderdale Doncaster 41 East Riding of Yorkshire Hull Teaching 36 Kirklees Leeds 31 North East Lincolnshire Care Trust Plus North Lincolnshire North Yorkshire & York 26 Rotherham Sheffield 21 Wakefield District Yorkshire & The Humber 16 North of England England Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4 1011Q1 1011Q2
27 Summary Reporting monthly to Trust board as part of HCAI report forces change League tables encourage competition and improves performance Specialties with more HCAI engage better in their own audit GPs can improve performance where paid to audit own practice Doctors will audit prescribing against guidelines each month with new HII Antimicrobial Prescribing
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