Development of Antimicrobial Prescribing Care Bundles

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Development of Antimicrobial Prescribing Care
Bundles

• to Monitor Quality of
• Antimicrobial Management
• Liz Fleet
• Senior Antibiotic Pharmacist
• The Lewisham Hospital NHS Trust
• July 2009

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Monitoring of Antimicrobial Management at
University Hospital Lewisham

• 2004 - Chest Infection Audit (adults)
• Key finding Junior doctors require increased
  input around differential diagnoses
• 2005 Trust-wide Point Prevalence Study
• Key finding Need to review indication for
  intravenous (IV) therapy in first instance as
  well as IV to oral switch
• 2006 - Repeat Point Prevalence Study
• Key finding Is possible for an antimicrobial
  prescription to be in accordance with local
  guideline choice but clinically inappropriate if
  diagnosis not confirmed
• 2007 - Annual Point Prevalence Study
• Notes checked for evidence of infection and that
  dosage regimen prescribed appropriate for
  individual patient

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What is a Care Bundle?

• Quality Improvement Tool that is simple to apply
  
• Consists of 4-6 key elements
• Evidence based (best) practice
• All or nothing approach
• All elements crucial if one element left out
  process likely to fail
• Elements must be rigorous with straightforward
  Yes/No answers
• All measurable in one time and space

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Success of Care Bundles in Healthcare Environment

• Institute of Healthcare Improvement 100K Lives
  Campaign in USA has now become the 5 Million
  Lives Campaign
• Care Bundles demonstrated to be highly
  effective
• Central Line Bundle has reduced bloodstream
  infections
• Ventilator Bundle has reduced ventilator
  associated pneumonia
• Care Bundles to prevent HCAI are advocated High
  Impact Interventions in the Department of Health
  Saving Lives delivery programme
• Seven Care Bundles published to date
• Most for insertion/care of indwelling
  catheters/devices
• Care Bundle for prevention of spread of
  Clostridium Difficile includes an element for
  prudent antibiotic prescribing

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The missing care bundle
antibiotic prescribing in hospitalsCooke FJ,
Holmes A. Int J Antimicrob Agents 2007 3025-29

• Proposed antimicrobial care bundle comprises of
  six elements
• On initiation of prescription
• 1. Clinical rationale for initiation
• 2. Appropriate specimens sent for microbiology
  culture and sensitivity
• 3. Adherence to local prescribing guidelines
• 4. Additional clinical interventions to manage
  infection (e.g. remove indwelling device,
  surgical procedure)
• On continuation of prescription
• 5. Daily review based on clinical response and
  laboratory results regards
• De-escalation of treatment
• Intravenous ? Oral switch
• Stopping antimicrobials
• 6. Correct performance of therapeutic drug
  monitoring

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Off the Peg Care Bundle ExperienceConclusions
and Recommendations

• A care bundle is a useful tool to measure total
  quality of antimicrobial management
• A baseline was established giving quantifiable
  targets for quality improvement
• The care bundle tested was found to be too
  complex and to require further definition
• We frequently had to record not applicable
• We have proposed two separate Lewisham Empirical
  Antimicrobial Prescribing (LEAP) Care
  Bundles One to be applied on initiation of
  treatment and the other 48 hours afterwards when
  reviewing treatment

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References

• Department of Health
• Antimicrobial Prescribing A summary of best
  practice. www.dh.gov.uk/en/Publichealth/Healthprot
  ection/Healthcareacquiredinfection/Healthcareacqui
  redgeneralinformation/Thedeliveryprogrammetoreduce
  healthcareassociatedinfectionsHCAIincludingMRSA/in
  dex.htm (accessed 16 Jul 2009)
• Dellit TH, Owens RC, Mc Gowan JL et al.
• Infectious Diseases Society of America and
  Society for Healthcare Epidemiology of America
  guidelines for developing an institutional
  programme to enhance antibiotic stewardship.
• Clin Infect Dis 2007 44 159-177
• Rubin HR, Pronovost P, Diette GB
• From a process of care to a measure the
  development and testing of a quality indicator.
• Int J Qual Health Care 2001 13 489-496

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References (continued)

• Schouten JA, Hulscher MEJL, Wollersheim H et al.
  Quality of Antibiotic Use for Lower Respiratory
  Tract Infections at Hospital (How) Can We
  Measure It? Clin Infect Dis 2005 41 541-640
• Barlow G, Nathwani D and Davey P
• The CURB65 pneumonia severity score
  outperforms generic sepsis and early warning
  scores in predicting mortality in
  community-acquired pneumonia.
• Thorax 2007 62 253-259
• Pulcini C, Defres S, Aggarwal I et al.
• Design of a day 3 bundle to improve the
  reassessment of inpatient empirical antibiotic
  prescriptions.
• J Antimicrob Chemother 2008 61 1384-1388

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LEAP Initiation Care Bundle

• Two relevant clinical signs of infection
  documented in medical notes
• Working diagnosis including severity of infection
  documented Must include CURB-65 score for CAP
  
• Appropriate clinical specimens sent for
  microscopy, culture and sensitivity before
  starting antimicrobials / appropriate blood
  samples requested including
  Therapeutic Drug Monitoring (TDM)
• Antimicrobial prescription in accordance with
  local guidelines and appropriate for individual
  patient If patient is said to be
  allergic to an antimicrobial, the type of
  reaction must be recorded
• First dose antimicrobial administered within four
  hours of prescription
  one hour if Severe Sepsis or
  Neutropenic Sepsis

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LEAP 48hr Review Care Bundle

• Diagnosis confirmed by Consultant/Registrar
  and clinical indication for antimicrobial
  recorded on drug chart
• Microbiology results checked and initial choice
  of antimicrobials reviewed regards possible
  de-escalation or stopping of therapy
• Route of administration reviewed regards possible
  Intravenous ? Oral switch
  Need for IV therapy must be reviewed
  every 24 hours
• Dose and frequency reviewed in relation to
  clinical progress and laboratory findings
  including renal function and TDM results
• Duration of treatment or next review date
  recorded on drug chart and documentation of
  planned end point in medical notes

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Lewisham Antimicrobial Prophylaxis Prescribing
(LAPP) Care Bundle
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LEAP Care Bundle Compliance all in-patients UHL
March 09
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Application of LEAP Initiation Care Bundle all
in-patients UHL March 2009
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Collection of Clinical Specimens including Blood
Samples for TDM
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Application of LEAP 48hr Review Care Bundle all
in-patients UHL 2009
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What are the current antimicrobial management
challenges at UHL?

• Add up CURB-65 Scores from documented parameters
• Ensure specimens/blood samples requested are
  taken and sent to pathology
• Better attempt at allergy substantiation
• Re-launch IV to oral switch policy
• Promote antibiotic TDM guidelines with aim to
  Get it right first time
• Develop antimicrobial management plan template
  for medical notes

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LEAP Initiation Care Bundle Compliance Medical
Admissions Unit UHL Dec 08 Feb
09Acknowledgment Ozlem Dogus Kingston University
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LEAP Initiation 48hr Review Care Bundle
Compliance for UTIs Care of Elderly Wards UHL
Dec 08Feb 09Acknowledgment Khairul Chowdhury
Kingston University
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In Summary

• Application of Lewisham Empirical Antimicrobial
  Prescribing Care Bundles is providing a simple,
  reproducible measure of quality of antibiotic
  management
• These bundles have been included in the
  Principles of Antibiotic Management in the new
  edition of Trust Antibiotic Handbook
• Next step is to promote the bundles to junior
  doctors as means of self-audit
• Pharmacy and Microbiology will continue use and
  develop the bundles

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Thank you

• Questions will be taken after the next
  presentation