improving antibiotic prescribing for surgical · pdf filescope of the problem • surgical...

Improving antibiotic prescribing for surgical prophylaxis

Lolita Tu Antimicrobial Stewardship Project Officer

Clinical Excellence Commission

Fiona Doukas Antimicrobial Stewardship Pharmacist

Concord Hospital

Antibiotic Awareness Week

November 2017

Scope of the problem

• Surgical prophylaxis has been the top indication for prescribing antimicrobials in hospitals for 3 consecutive years (2013-2015)

• 40.5% inappropriateness (2015) – Incorrect duration 29.9% – Incorrect dose 27.6% – Does not require antibiotics 22%

• 27.4% of prescriptions prescribed longer than 24 hours (2015)

National Centre for Antimicrobial Stewardship (NCAS). NAPS Report 2015 Melbourne: NCAS, 2015 Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2017: second Australian report on antimicrobial use and resistance in human health – summary report. Sydney: ACSQHC, 2017

Presenter

Presentation Notes

In 2015, SAP accounted for 15.5% Most inappropriately prescribed indication for antibiotics

Priority Area 2.3 Develop resources that support appropriate antibiotic use for surgical prophylaxis and consistency with national guidelines.

Actions • Australian Commission on Safety and Quality

in Health Care (ACSQHC) will investigate opportunities to improve prescribing in collaboration with – Royal Australasian College of Surgeons (RACS) – State and Territory health authorities

• Accreditation advisory requiring inclusion of surgical prophylaxis as a part of an AMS program

Presenter

Presentation Notes

Focus on: prolonged duration of therapy, incorrect dosing and the high rates of inappropriate prescribing of cefalexin Accreditation advisory developed in consultation with RACS, Australian and New Zealand College of Anaesthetists and state and territory health authorities Provide guidance and direction on the interpretation and/or assessment of the National Safety and Quality Health Service Standards to accrediting agencies

https://www.safetyandquality.gov.au/wp-content/uploads/2014/11/Antimicrobial-Stewardship-Clinical-Care-Standard-web.pdf

Tools for data collection • NSW TAG QUM indicators • Hospital NAPS • SNAPS Required data sources • Medical notes, medication charts and intra-

operative medication administration records (anaesthetic chart) – SNAPS also requires microbiology and radiology

reports

http://www.ciap.health.nsw.gov.au/nswtag/pages/indicators-set-2.html

Presenter

Presentation Notes

Accessible via CIAP

Process Measures • Percentage of patients who received an appropriate

antimicrobial timely prior to incision • Percentage of patients who received an antibiotic for the

correct duration

Presenter

Presentation Notes

Specified surgical procedures refers to the procedure types identified in the latest version of the Therapeutic Guidelines: Antibiotic as requiring antibiotic prophylaxis. Correct antibiotic choice: includes correct medication choice, route of administration and dosing schedule Correct timing: generally the antibiotic should be administered up to 60 minutes prior to skin incision and as a single dose. A second dose may be necessary: if there is a delay in starting the operation; if a short acting antibiotic is used (e.g. cephalothin, cephazolin, dicloxacillin or flucloxacillin) and the operation is prolonged (longer than 3 hours); or in other circumstances specified in guidelines Correct duration: Antibiotic prophylaxis is ceased within 24 hours of completion of surgery except where postoperative use is specifically recommended (e.g. cardiac and vascular surgery or amputation of an ischaemic lower limb). A limitation of this tool is that is does not examine situations where antibiotics were given unnecessarily in procedures that typically do not require antibiotic prophylaxis

• Hospital NAPS audit tool - https://www.naps.org.au

Presenter

Presentation Notes

As stated in the Advisory, Hospital NAPS is an option for monitoring to inform if surgical antibiotic prophylaxis is a risk requiring action in your hospital Surgical prophylaxis greater than 24 hours is an indicator in Hospital NAPS – but it does not capture timing of administration with respect to incision, or re-dosing in relation to procedure duration Limitation of NAPS – performed on a single day and may not be accurately representative of the norm (eg. OT closures, low surgical activity periods) Point prevalence methodology possible making SAP appear worse than actually is Conversely it could also make it appear better

• Surgical NAPS (SNAPS) specifically designed for surgical (and non-surgical) procedures

• Longitudinal survey – Recommended to be done over a minimum of

one week or 30 consecutive procedures

• Retrospective or prospective • Benchmarking period for 2017: 1 February

2017-30 November 2017

Presenter

Presentation Notes

Surgical NAPS (SNAPS) specifically designed for surgical (and non-surgical) procedures [Non surgical procedures = colonoscopies, radiological procedures ] Captures more comprehensive data on the quantity and quality of antimicrobial prescribing in this setting. Longitudinal survey Recommended to be done over a minimum of one week or 30 consecutive procedures Retrospective or prospective – retrospective audit is recommended because you can capture all the patient data, including 30 day outcome. Alternatively you can do directed auditing – looking at a particular procedure or specialty Closing date for data entry is 30 November 2017

• Surgical NAPS audit tool - https://www.naps.org.au

Presenter

Presentation Notes

Data can be collected using this form and then entered into the data entry portal Fields in grey are optional Definitions for each question are available from the SNAPS user guide American Society of Anaesthesiologists (ASA) score is a preoperative risk score based on the present of comorbidities at the time of surgery 1 = normal healthy patient, ASA 3 = severe systemic diseases, 6= declared brain dead Risk factors affecting antibiotic prophylaxis or risk of surgical site infection eg. smoking increases risk of SSI, diabetics may requires SAP for biliary surgery or dentoalveolar surgery, MRSA colonisation will determine the choice of surgical antibiotic prophylaxis

Other options • Form your own data collection tool

– Focus on a specific problem in your facility

Presenter

Presentation Notes

Specific problem – choice of agent or duration, may want to focus on that so it easier to measure and sustainable

A case for change • Strong evidence to support the use of

appropriate surgical antibiotic prophylaxis to prevent postoperative infection

• Inappropriate use increases both cost and the selective pressure favouring the emergence of resistant bacteria

• Continuing antibiotic prophylaxis does not improve efficacy and increases toxicity and cost

Bratzler D, Dellinger P, Olsen K et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst

Pharm 2013; 70: 195-283.

Presenter

Presentation Notes

Standardise practice according to best evidence Reduce unwarranted clinical variation

To improve patient care by

increasing appropriate

surgical antibiotic prophylaxis to

above 95% within 18 months

Improve knowledge & confidence in antibiotic prophylaxis prescribing

Improve communication before and after surgery

between staff

Standardise the process of prescribing antibiotic

prophylaxis

Improve accuracy of attitudes & beliefs about

appropriate antibiotic prophylaxis

Increase access to ID/Micro/other experts in antibiotic use

Provide guidance on appropriate antibiotic use

Increase education on appropriate antibiotic use

Improve the identification of those who require antibiotic prophylaxis

Increase the rate of appropriate antibiotic choice for the specific procedure

Increase the rate of appropriate antibiotic administration time, dosing & duration

Improve documentation of antibiotic choice, dose & duration

Improve review process of antibiotic order

Change entrenched habits of previous suboptimal practice

Promote & support a culture of appropriate antibiotic use

Deconstruct myths that antibiotics are harmless medicines

In-services by AMS team on appropriate antibiotic use to surgeons and anaesthesists

Poster campaign to promote principles of good prescribing

Academic detailing with surgeons anaesthesists and by AMS team

AMS-surgical rounds

Develop evidence based guidelines in consultation with surgeons/anaesthetists

Display guidelines in theatres - poster

Establish antibiotic order set for specific surgical procedures in eMM

Stock operating theatre with antibiotics only recommended by guidelines

Monitor adherence with guidelines and provide feedback – compare specialty’s performance to

others and report to relevant committees

Incorporate prompts for antibiotic stop within the operating report

Post operative checklist with documented plan that includes antibiotic review

Feedback of 30 day morbidity and mortality results to treating teams

Clinical champions supportive of AMS

Gain support of hospital Exec

Regular forum to support peer to peer accountability

Primary Drivers

Secondary Drivers Change ideas

Improve adherence to evidence-based antibiotic prophylaxis guidelines

Increase awareness of existing guidelines

Increase agreement with guidelines to promote relevance to practice

Increase transparency of reasons for non-concordant orders

Aim

Presenter

Presentation Notes

Driver diagram is a tool that can help translate your goal into actionable ideas to achieve it Operational definition of ‘appropriate surgical antibiotic prophylaxis’ is correct agent, dose, route and duration according to Therapeutic Guidelines Primary Drivers - these are key areas that we need to address in order to reach our goal. Secondary Drivers - these are the actions we can take to successfully implement primary drivers. Change Ideas- these are specific changes that can help us implement secondary drivers

Thank you Questions? Comments?

Lolita Tu Antimicrobial Stewardship Project Officer

Clinical Excellence Commission [email protected] www.cec.health.nsw.gov.au

Presenter

Presentation Notes

We are looking to identify strategies and develop resources to support hospitals with improvement of surgical antibiotic prophylaxis, if you have had success with this in your facility I would be very interested to hear from you. Pilot sites to test these resources and essentially partner for a QI project – 2018

Prepared by Fiona Doukas BPharm MPH BCGP

Senior Pharmacist (Antimicrobial Stewardship)

Concord Repatriation General Hospital

November 2017

Surgical Antibiotic

Prophylaxis

Aims

• Describe strategies that were implemented to support compliance with surgical antibiotic prophylaxis guidelines

Background and evidence • One-third to one-half of all hospital antibiotic

use

• Inappropriate antibiotic use ranges from 30% to 90%, especially with respect to timing and duration of antibiotic therapy

• A national report recently released indicates that NSW hospital have one of the lowest rates of compliance with surgical antibiotic prophylaxis guidelines

Strategies

Governance & leadership

Engage key stakeholder (enablers & barriers)

Peri-operative Anaesthetics,

Surgeons, Theatre nurses

Post-operative Ward nurses, CNCs, pharmacists, JMOs

Monitor performance

Hospital/ward/unit level

Education & training

Support & tools including guidelines

Monitor performance

• Local Audit

– Retrospective

– Prospective

• NSW TAG QUM indicator 2.1

Percentage of patients undergoing specified surgical procedures that

receive an appropriate prophylactic antibiotic regimen

• Surgical National Antimicrobial Prescribing Survey (sNAPS)

Monitor performance

Doukas FF, Fox JA, Gottlieb T, McLaws ML , McLachlan AM. Surgical Antibiotic Prophylaxis in a University teaching hospital: A retrospective

study investigating prescribing according to national guidelines. Poster presented at Medicines Management 2015; SHPA


• AMS Committee

• Division of Surgery

– Heads of Surgical departments

– Surgical superintendent

• Anaesthetists

• Clinical Nurse Consultants

• Executives

• Consumers

Engage key stakeholders

• Provide feedback from the national report / local audit

• Determine enablers and barriers to compliance with surgical antibiotic prophylaxis guidelines

• Consensus on best evidence-based practice

• Engagement with guideline development & dissemination – Letter co-signed by Division of Surgery & AMS

• Agenda on M&M meetings


Peri-operative

• Anaesthetists

• Surgeons

• Theatre Nurses

Post Operative

• JMOs

• Pharmacists

• Nurses: CNCs & RNs


• Guidelines

Education & Training

• Presentations targeted at key stakeholders – Surgical Grand Rounds

– One-on-ones with Surgeons & Anaesthetists

– JMO & Pharmacy teaching

– Mandatory Nurse education sessions

• Local guidelines in line with Therapeutic Guidelines: Antibiotic

• Contact for feedback

• Surgical AMS rounds


Timing info

Monitor performance

• Next steps

– Completing the post-intervention data analysis (looks positive)

– Prospective audit data analysis

– No post-op doses

• Electronic prescribing surveillance

– Direct intervention

– Collate data for feedback

Strategies


Engage key stakeholder (enablers & barriers)

Peri-operative Anaesthetics,

Surgeons, Theatre nurses

Post-operative Ward nurses, CNCs, pharmacists, JMOs

Monitor performance

Hospital/ward/unit level

Education & training

Support & tools including guidelines

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