monthly webinar · cap lrti aecopd non-pneumonic lrti remember ‘lrti’ is an umbrella term - you...
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Monthly WebinarTuesday 14th December 2017, 16:00
“CURB Your Enthusiasm”
Event number: 847 953 303
Audio dial-in (phone): 01 526 0058
“CURB Your Enthusiasm”:Improving the Antibiotic
Prescribing for CommunityAcquired Pneumonia
Connolly Hospital BlanchardstownDr Eoghan O’Neill/Ms Bernie Love
November 2017
Quality Improvement (QI) project• In Feb 2016, "Start Smart" Antibiotic Stewardship
Quality Improvement Collaborative wasestablished by the RCPI/HSE HCAI and AMRClinical Programme
• Involved project teams from interested hospitalsattend 4-5 meetings (QI training) over 12 months,to share learning from local projects and identifyinterventions to test and feed back to subsequentmeetings
QI training undertaken by projectteams
Why did we choose CA-LRTIs?• Majority of antimicrobial use (min 30%) in CHB is
used to treat CA-LRTIs, consistent with otheracute hospitals nationally.
• Baseline data over a number years• Increasing recognition of incorrect classification
of patients admitted with CA-LRTIs…… leading toincorrect antimicrobial prescriptions….. e.g.inappropriate dual therapy, not using CURB scorefor CAP, using broader agents (e.g. Piperacillin-Tazobactam)
• Focused on initial prescription…. “Start smart….”
CHB 2017 PPS data
0 10 20 30 40 50
Bacteraemia
CNS
Lower UTI
Neutropenic sepsis
Skin/Soft tissue (surgery related)
Bone/Joint
Medical Prophylaxis
Clinical sepsis (unconfirmed)
GI infection
Bone/Joint related to surgery
Surgical propylaxis
Bronchitis
Intra-abdominal
Pyelonephritis/Upper UTI
Skin/Soft tissue
Pneumonia
Number of infections
Indication for antimicrobial therapy
Baseline audit (2012):– 74% of patients admitted with CA-LRTI were prescribed dual
therapy Co-amoxiclav + Clarithromycin (17% compliance)– >45% classified as ‘LRTI’
• Treatment algorithm devised to encompass all CA-LRTIsto aide classification & treatment choices
• Some improvement but remained sub-optimal
Baseline audit (n=47) Post introduction ofclinical pathway (n=47)
2014 (n=17) 2015 (n=20)
Guideline-adherenttherapy
17% 34% 41.2% 41.6%
CURB-65 23% 35% 10% 33.3%
Classification 46.8% 46.8% 35.2% 58.3%
Aim 1 Driver 2 Driver Change idea
Ensure ≥85% ofadults admitted toCHB with a CA-LRTIhave their diagnosis
appropriatelyclassified and
antibioticsprescribed in line
with local guidelines
Assess barriers toadherence to guidelines
Survey/Interview withprescribers
Ideas for change
Guidelines
Revise/Simplifyguideline algorithm +/-
app tool
Give assurance toprescribers re.
effectiveness; measureneed for escalation
Education
Get peer involvement
Weekly assessment ofcompliance with run
charts & feedback
Attendance at morninghandover/ED/NCHD
teaching
Design prescriber interview
Audit 20 patients to assess currentstatus of compliance & interviewprescribers where non-compliancesidentified to assess barriers
•37.5% lack of knowledge•62.5% lack of confidence inguideline•37.5% influence ofpeers/senior colleagues
Make guideline more accessible(more hardcopies)
Increase confidence/assurance fromC&S that amoxicillin will work-analyse C&S data & report
Teaching sessions
Increase awareness/inform people
Visual aides/ Laminatedcards/Checklist/Posters
Real-time reporting – run charts;assurance with Consultants present.Convincing data will influencebehaviour more positively thancritique
Driver Diagram: How do we improve compliance?
Prescriber interview to assess barriersS I R Total
numberspecimens
Streptococcus pneumoniae
PEN 56.6% 30.2% 13.2%
53ERY 62.3% 37.7%
TE 71.7% 1.9% 26.4%
Haemophilus influenzae
AMP 70.7% 29.2%
198
ERY 2.5% 91.9% 5.6%
TE 98% 0.5% 1.5%
AMC 82.3% 17.7%
• Lack of confidence inAmoxicillin noted
• C&S data for respiratorypathogens extracted for2014/2015
• Feedback to prescribersas part of educationsessions
Re-designed algorithm- Launched within CHB- Updated on app- Laminates in ED
New toy…………..
0
10
20
30
40
50
60
70
80
90
100
Perc
enta
ge co
mpl
ianc
e
Run chart for compliance with CA-LRTI guidelines
Choice
CURB-65
Classification
Target
Weekly assessment of compliance with runcharts & feedback at morning handover
Key messages from weekly audits
CAP
LRTI
AECOPD
Non-pneumonicLRTI
Remember ‘LRTI’ is an umbrella term - you need to define which type of ‘LRTI’ it isbefore appropriate antibiotic therapy can be determined
•New focal consolidation on CXR = community-acquired pneumonia•CXR clear but hx COPD = AECOPD•CXR clear, no hx COPD = Non-pneumonic LRTI
1
Key messages from weekly audits
Remember CURB-65 score should be calculated for all CAP & used to guide antibiotictherapy
•CURB-65 score 0-1: Amoxicillin OR Clarithromycin OR Doxycycline•CURB-65 score 2: Amoxicillin plus Clarithromycin•CURB-65 score ≥3: Co-amoxiclav plus Clarithromycin
2
Key messages from weekly audits
Remember CURB-65 score is only validated for CAP therefore is not relevant for:•AECOPD•Non-pneumonic LRTI•HAP
3
Challenges
• Sustainability of intensive QI approach
• Ongoing support of consultant/seniorcolleagues vitals (including those outside ofthe specialty….. e.g. general medicalconsultants on-call)
• Clinical/Prescriber change over every 6-12months – starting again!
Some suggestions……• National template for CA-LRTI
• Re-inforce at undergraduate/postgraduateteaching level
• Use of algorithm and implementation at hospitalgroup/national level……
e.g. a focus for hospital group stewardship teams
• Adopt audit tool for local KPIs etc.
Thank you!