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Verroken A, Favresse J, Anantharajah A, Rodriguez-Villalobos H, Wittebole X, Laterre PF. Optimized Antibiotic Management of Critically Ill Patients with Severe Pneumonia Following Multiplex Polymerase Chain Reaction Testing: A Prospective Clinical Exploratory Trial. Antibiotics (Basel) 2024; 13:67. [PMID: 38247626 PMCID: PMC10812711 DOI: 10.3390/antibiotics13010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Molecular diagnostic testing is assumed to enable fast respiratory pathogen identification and contribute to improved pneumonia management. We set up a prospective clinical trial at a tertiary hospital intensive care unit including adult patients suspected of severe pneumonia from whom a lower respiratory tract sample could be obtained. During control periods (CPs), routine testing was performed, and during intervention periods (IPs), this testing was completed with the FilmArray Pneumonia Panel plus test (FA-PNEU) executed 24/7. The main objective was to measure the impact of FA-PNEU results in terms of reduced time to targeted antimicrobial treatment administration. Over a 10-month period, analysis was performed on 35 CP and 50 IP patients. The median time to targeted antimicrobial treatment administration was reduced to 4.3 h in IPs compared to 26.4 h in CPs, with 54% of IP patients having FA-PNEU results that led to a treatment modification, of which all but one were targeted. Modifications included 10 (37%) de-escalations, 7 (25.9%) escalations, 3 (11.1%) regimen switches, and 7 (25.9%) complete antimicrobial discontinuations. FA-PNEU results were available with a 42.3 h gain compared to routine identification. This prospective study confirmed retrospective data demonstrating the benefit of FA-PNEU testing in severe pneumonia management of critically ill patients through improved antimicrobial use.
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Affiliation(s)
- Alexia Verroken
- Department of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Julien Favresse
- Department of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Ahalieyah Anantharajah
- Department of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Hector Rodriguez-Villalobos
- Department of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Xavier Wittebole
- Department of Critical Care Medecine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium;
| | - Pierre-François Laterre
- Department of Critical Care Medecine, Centres Hospitaliers Universitaires HELORA, 1200 Brussels, Belgium
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Miranda-Novales MG, Flores-Moreno K, Rodríguez-Álvarez M, López-Vidal Y, Soto-Hernández JL, Solórzano Santos F, Ponce-de-León-Rosales S. The Real Practice Prescribing Antibiotics in Outpatients: A Failed Control Case Assessed through the Simulated Patient Method. Antibiotics (Basel) 2023; 12:antibiotics12050915. [PMID: 37237818 DOI: 10.3390/antibiotics12050915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
The first level of medical care provides the largest number of consultations for the most frequent diseases at the community level, including acute pharyngitis (AP), acute diarrhoea (AD) and uncomplicated acute urinary tract infections (UAUTIs). The inappropriate use of antibiotics in these diseases represents a high risk for the generation of antimicrobial resistance (AMR) in bacteria causing community infections. To evaluate the patterns of medical prescription for these diseases in medical offices adjacent to pharmacies, we used an adult simulated patient (SP) method representing the three diseases, AP, AD and UAUTI. Each person played a role in one of the three diseases, with the signs and symptoms described in the national clinical practice guidelines (CPGs). Diagnostic accuracy and therapeutic management were assessed. Information from 280 consultations in the Mexico City area was obtained. For the 101 AP consultations, in 90 cases (89.1%), one or more antibiotics or antivirals were prescribed; for the 127 AD, in 104 cases (81.8%), one or more antiparasitic drugs or intestinal antiseptics were prescribed; for the scenarios involving UAUTIs in adult women, in 51 of 52 cases (98.1%) one antibiotic was prescribed. The antibiotic group with the highest prescription pattern for AP, AD and UAUTIs was aminopenicillins and benzylpenicillins [27/90 (30%)], co-trimoxazole [35/104 (27.6%)] and quinolones [38/51 (73.1%)], respectively. Our findings reveal the highly inappropriate use of antibiotics for AP and AD in a sector of the first level of health care, which could be a widespread phenomenon at the regional and national level and highlights the urgent need to update antibiotic prescriptions for UAUTIs according to local resistance patterns. Supervision of adherence to the CPGs is needed, as well as raising awareness about the rational use of antibiotics and the threat posed by AMR at the first level of care.
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Affiliation(s)
- María Guadalupe Miranda-Novales
- Unidad de Investigación en Análisis y Síntesis de la Evidencia, Instituto Mexicano del Seguro Social, Centro Médico Nacional Siglo XXI, Mexico City 06720, Mexico
| | - Karen Flores-Moreno
- Laboratorio de Microbioma, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Mauricio Rodríguez-Álvarez
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Yolanda López-Vidal
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - José Luis Soto-Hernández
- Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City 14269, Mexico
| | - Fortino Solórzano Santos
- Unidad de Investigación en Enfermedades Infecciosas, Hospital Infantil de México Federico Gómez, Secretaría de Salud, Mexico City 06720, Mexico
| | - Samuel Ponce-de-León-Rosales
- Programa Universitario de Investigación Sobre Riesgos Epidemiológicos y Emergentes, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
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Saust LT, Siersma VD, Bjerrum L, Hansen MP. Development of quality indicators for the diagnosis and treatment of urinary tract infections in general practice: a RAND appropriateness method. BMJ Open Qual 2023; 12:bmjoq-2022-002156. [PMID: 37230738 DOI: 10.1136/bmjoq-2022-002156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 05/07/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To develop a set of quality indicators for the diagnosis and antibiotic treatment of adult patients with suspected urinary tract infections in general practice. DESIGN A Research and Development/University of California Los Angeles appropriateness method was used. SETTING Danish general practice. SUBJECTS A panel of nine experts, mainly general practitioners, was asked to rate the relevance of 27 preliminary quality indicators. The set of indicators was based on the most recent Danish guidelines for the management of patients with suspected urinary tract infection. An online meeting was held to resolve misinterpretations and achieve consensus. MAIN OUTCOME MEASURES The experts were asked to rate the indicators on a nine-point Likert scale. Consensus of appropriateness was reached if the overall panel median rating was 7-9 with agreement. Agreement was defined as: no more than one expert rated the indicator outside the three-point region (1-3, 4-6 and 7-9) containing the median. RESULTS A total of 23 of the 27 proposed quality indicators attained consensus. One additional indicator was proposed by the panel of experts, leading to a final set of 24 quality indicators. All indicators focusing on the diagnostic process achieved consensus of appropriateness, while the experts agreed on three quarters of the proposed quality indicators concerning either the treatment decision or the choice of antibiotics. CONCLUSION This set of quality indicators may be used to strengthen general practice's focus on the management of patients with a possible urinary tract infection and to identify potential quality problems.
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Affiliation(s)
- Laura Trolle Saust
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Center for General Practice, Aalborg University, Aalborg, Denmark
| | - Volkert Dirk Siersma
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Department of Clinical Medicine, Center for General Practice, Aalborg University, Aalborg, Denmark
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Van Staa T, Li Y, Gold N, Chadborn T, Welfare W, Palin V, Ashcroft DM, Bircher J. Comparing antibiotic prescribing between clinicians in UK primary care: an analysis in a cohort study of eight different measures of antibiotic prescribing. BMJ Qual Saf 2022; 31:831-838. [PMID: 35241573 PMCID: PMC9606525 DOI: 10.1136/bmjqs-2020-012108] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a need to reduce antimicrobial uses in humans. Previous studies have found variations in antibiotic (AB) prescribing between practices in primary care. This study assessed variability of AB prescribing between clinicians. METHODS Clinical Practice Research Datalink, which collects electronic health records in primary care, was used to select anonymised clinicians providing 500+ consultations during 2012-2017. Eight measures of AB prescribing were assessed, such as overall and incidental AB prescribing, repeat AB courses and extent of risk-based prescribing. Poisson regression models with random effect for clinicians were fitted. RESULTS 6111 clinicians from 466 general practices were included. Considerable variability between individual clinicians was found for most AB measures. For example, the rate of AB prescribing varied between 77.4 and 350.3 per 1000 consultations; percentage of repeat AB courses within 30 days ranged from 13.1% to 34.3%; predicted patient risk of hospital admission for infection-related complications in those prescribed AB ranged from 0.03% to 0.32% (5th and 95th percentiles). The adjusted relative rate between clinicians in rates of AB prescribing was 5.23. Weak correlation coefficients (<0.5) were found between most AB measures. There was considerable variability in case mix seen by clinicians. The largest potential impact to reduce AB prescribing could be around encouraging risk-based prescribing and addressing repeat issues of ABs. Reduction of repeat AB courses to prescribing habit of median clinician would save 21 813 AB prescriptions per 1000 clinicians per year. CONCLUSIONS The wide variation seen in all measures of AB prescribing and weak correlation between them suggests that a single AB measure, such as prescribing rate, is not sufficient to underpin the optimisation of AB prescribing.
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Affiliation(s)
- Tjeerd Van Staa
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Yan Li
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Natalie Gold
- Behavioural Insights and Evaluation, Public Health England, London, UK
- Centre for Philosophy of Natural and Social Science, London School of Economics and Political Science, London, England
- Behavioural Practice, Kantar Public, London, England
| | - Tim Chadborn
- Behavioural Insights and Evaluation, Public Health England, London, UK
| | - William Welfare
- North West Health Protection Team, Public Health England North West, Manchester, UK
| | - Victoria Palin
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety and NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
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Sales A. Reporting on implementation trials with null findings: the need for concurrent process evaluation reporting. BMJ Qual Saf 2022; 31:779-781. [PMID: 35701169 DOI: 10.1136/bmjqs-2022-014693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Anne Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Saini S, Leung V, Si E, Ho C, Cheung A, Dalton D, Daneman N, Grindrod K, Ha R, McIsaac W, Oberai A, Schwartz K, Shiamptanis A, Langford BJ. Documenting the indication for antimicrobial prescribing: a scoping review. BMJ Qual Saf 2022; 31:787-799. [PMID: 35552253 DOI: 10.1136/bmjqs-2021-014582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/05/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice. OBJECTIVES We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations. ELIGIBILITY CRITERIA Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing. SOURCES OF EVIDENCE A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature. CHARTING AND ANALYSIS Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively. RESULTS We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice. CONCLUSION There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.
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Affiliation(s)
- Sharon Saini
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Elizabeth Si
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Certina Ho
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Safe Medication Practices, Toronto, Ontario, Canada
| | - Anne Cheung
- West Park Healthcare Centre, Toronto, Ontario, Canada
| | | | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Rita Ha
- North York Family Health Team, Toronto, Ontario, Canada
| | - Warren McIsaac
- Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anjali Oberai
- Wawa Family Health Team, Wawa, Ontario, Canada
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Kevin Schwartz
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Bradley J Langford
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, Ontario, Canada
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Liang M, Fan Y, Zhang D, Yang L, Wang X, Wang S, Xu J, Zhang J. Metagenomic next-generation sequencing for accurate diagnosis and management of lower respiratory tract infections. Int J Infect Dis 2022; 122:921-929. [PMID: 35908723 DOI: 10.1016/j.ijid.2022.07.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/07/2022] [Accepted: 07/23/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate the clinical value of metagenomic next-generation sequencing (mNGS) in patients with suspected lower respiratory tract infections (LRTIs). METHODS This retrospective study reviewed patients with suspected LRTIs in Wuhan Union Hospital. Data including demographic, laboratory, and radiological profiles; treatment; and outcomes were recorded and analyzed. RESULTS mNGS identified pathogenic microbes in 100/140 (71.4%) patients, although 135 (96.4%) had received empiric antibiotic treatment before the mNGS tests. Single bacterial infection (35/100, 35%) was the most common type of infection in patients with positive mNGS results, followed by single fungal infection (14/100, 14%), bacterial-viral co-infection (14/100, 14%), single viral infection (12/100, 12%), bacterial-fungal co-infection (9/100, 9%), fungal-viral co-infection (9/100, 9%), and bacterial-fungal-viral co-infection (7/100, 7%). Moreover, compared with culture test, mNGS showed higher sensitivity (63/85, 74.1% vs. 22/85, 25.9% P=0.001) and lower processing time (24 h vs 48 h). Antibiotic treatment was adjusted or confirmed based on the mNGS results in 123 (87.9%) patients, including 5 (3.6%), 33 (23.6%) and 85 (60.7%) patients in whom treatment was downgraded, upgraded and unchanged, respectively, and almost all patients, regardless of escalation, de-escalation, or no change in treatment, showed significant improvement in clinical symptoms and inflammatory indicators. Additionally, 17 (12.1%) patients were referred to Wuhan Pulmonary Hospital for further treatment because of confirmed or suspected tuberculosis. CONCLUSIONS mNGS could be a promising technique for microbiological diagnosis and antibiotic management, potentially improving outcomes of patients.
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Affiliation(s)
- Mengyuan Liang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, China
| | - Yamin Fan
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, China
| | - Dongmei Zhang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, China
| | - Lian Yang
- Department of Radiology, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, China
| | - Xiaorong Wang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, China
| | - Sufei Wang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, China
| | - Juanjuan Xu
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, China.
| | - Jianchu Zhang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, China.
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Bleuse A, Roy H, Lebel D, Ovetchkine P, Blackburn J, Bussières JF. Exploration de l’association possible entre la consommation d’antibiotiques et l’émergence de résistance dans un centre hospitalier universitaire mère-enfant. Can J Hosp Pharm 2022; 75:201-209. [PMID: 35847460 PMCID: PMC9245413 DOI: 10.4212/cjhp.3183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background The emergence of antibiotic resistance has contributed to the development of multidrug-resistant bacteria, which is a major concern. Objectives The primary objective was to explore the possible association between antibiotic use and the emergence of resistance in a mother-child university hospital. Method This retrospective study was conducted in a university hospital centre. Antibiotic-bacteria pairs were established, taking into account the number of isolates, actual antibiotic use, and clinical relevance. For each pair, a comparison of 2 variables (antibiotic utilization and rate of resistance) was quantified with the Pearson coefficient. Three analyses were conducted: no lag between utilization and resistance, 1-year lag, and 2-year lag. Results Thirty antibiotic-bacteria pairs were selected from hematology-oncology and 18 from neonatology. In hematology-oncology, 6 pairs had a positive correlation (Pearson coefficient > 0.7): 2 pairs involving meropenem, 2 involving ceftazidime, and 2 involving piperacillin-tazobactam. In 3 of these cases, there was no lag between consumption of antibiotics and presence of resistance. In neonatology, 3 antibiotic-bacteria pairs had a positive correlation, 1 each involving vancomycin, cloxacillin, and meropenem. Conclusions It is possible to explore the potential association between consumption of antibiotics and emergence of resistance in a particular centre. Our exploratory approach was based on manual data processing. It would be interesting to consider a continuous systematic approach, allowing automatic generation of correlations.
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Puri M, Nain S, Gautam A, Chaudhary V, Jaiswal N, Gs T, Meena D, Singh M, Chopra K, Sharma P, Chhillar E, Verma H, Mahato R. Rational use of antibiotics for major elective gynaecological and obstetrical surgical procedures: quality improvement journey from a tertiary care public facility. BMJ Open Qual 2022; 11:e001438. [PMID: 35545270 PMCID: PMC9092174 DOI: 10.1136/bmjoq-2021-001438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 08/19/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antibiotic resistance is a global problem. Irrational use of antibiotics is rampant. Guidelines recommend administration of single dose of antibiotic for surgical antimicrobial prophylaxis (SSAP) for elective obstetrical and gynaecological surgeries. However, it is not usually adhered to in practice. Majority of women undergoing elective major gynaecological surgeries and caesarean sections in the department of obstetrics and gynaecology of our tertiary level heavy case load public health facility were receiving therapeutic antibiotics (for 7-10 days) instead of recommended SSAP. Our aim was to increase the SSAP in our setting from a baseline 2.1% to more than 60% within 6 months. METHODS After root cause analysis, we formulated the departmental antimicrobial policy, spread awareness and sensitised doctors and nursing officers regarding antimicrobial resistance and asepsis through lectures, group discussions and workshops. We initiated SSAP policy for elective major surgeries and formed an antimicrobial stewardship team to ensure adherence to policy and follow processes and outcomes. The point of care quality improvement (QI) methodology was used. Percentage of patients receiving SSAP out of all low-risk women undergoing elective surgery was the process indicator and percentage of patients developing surgical site infection (SSI) of all patients receiving SSAP was the outcome indicator. The impact of various interventions on these indicators was followed over time with run charts. RESULTS SSAP increased from a baseline 2.1%-67.7% within 6 months of initiation of this QI initiative and has since been sustained at 80%-90% for more than 2 years without any increase in SSI rate. CONCLUSION QI methods can rapidly improve the acceptance and adherence to evidence-based guidelines in a busy public healthcare setting to prevent injudicious use of antibiotics.
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Affiliation(s)
- Manju Puri
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Shilpi Nain
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Akriti Gautam
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Vidhi Chaudhary
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Nishtha Jaiswal
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Triveni Gs
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Deepika Meena
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Meenakshi Singh
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Kanika Chopra
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Poornima Sharma
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Ekta Chhillar
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Harpreet Verma
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
| | - Richa Mahato
- Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
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Guo C, Shi Y. Editorial: Intestinal Microbiota in the Pathogenesis and Management of Necrotizing Enterocolitis in Preterm Infants. Front Pediatr 2022; 10:837925. [PMID: 35252069 PMCID: PMC8892253 DOI: 10.3389/fped.2022.837925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Chunbao Guo
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Shi
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Neonatology, Chongqing Medical University, Chongqing, China
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Luong HX, Ngan HD, Thi Phuong HB, Quoc TN, Tung TT. Multiple roles of ribosomal antimicrobial peptides in tackling global antimicrobial resistance. R Soc Open Sci 2022; 9:211583. [PMID: 35116161 PMCID: PMC8790363 DOI: 10.1098/rsos.211583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/20/2021] [Indexed: 05/03/2023]
Abstract
In the last century, conventional antibiotics have played a significant role in global healthcare. Antibiotics support the body in controlling bacterial infection and simultaneously increase the tendency of drug resistance. Consequently, there is a severe concern regarding the regression of the antibiotic era. Despite the use of antibiotics, host defence systems are vital in fighting infectious diseases. In fact, the expression of ribosomal antimicrobial peptides (AMPs) has been crucial in the evolution of innate host defences and has been irreplaceable to date. Therefore, this valuable source is considered to have great potential in tackling the antimicrobial resistance (AMR) crisis. Furthermore, the possibility of bacterial resistance to AMPs has been intensively investigated. Here, we summarize all aspects related to the multiple applications of ribosomal AMPs and their derivatives in combating AMR.
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Affiliation(s)
- Huy Xuan Luong
- Faculty of Pharmacy, PHENIKAA University, Hanoi 12116, Vietnam
- PHENIKAA Institute for Advanced Study (PIAS), PHENIKAA University, Hanoi 12116, Vietnam
| | | | | | - Thang Nguyen Quoc
- Nuclear Medicine Unit, Vinmec Healthcare System, Hanoi 10000, Vietnam
| | - Truong Thanh Tung
- Faculty of Pharmacy, PHENIKAA University, Hanoi 12116, Vietnam
- PHENIKAA Institute for Advanced Study (PIAS), PHENIKAA University, Hanoi 12116, Vietnam
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12
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Rochon P, Borhani P, Akerman J, Mishra A. Physician variation in opioid prescribing: the importance of sex and gender. BMJ Qual Saf 2021; 31:331-333. [PMID: 34725229 DOI: 10.1136/bmjqs-2021-013697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Paula Rochon
- Women's Age Lab and Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada .,Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,RTOERO Chair, Geriatric Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Parya Borhani
- Women's Age Lab and Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Akerman
- Women's Age Lab and Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalhousie University, Halifax, Nova Scotia, Canada
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Konda KC, Singh H, Madireddy A, Poodari MMR. Quality improvement initiative approach to decrease the unindicated usage of antibiotics in a neonatal intensive care unit of a tertiary care teaching hospital in Hyderabad, India. BMJ Open Qual 2021; 10:bmjoq-2021-001474. [PMID: 34344742 PMCID: PMC8336182 DOI: 10.1136/bmjoq-2021-001474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/29/2021] [Indexed: 11/21/2022] Open
Abstract
Antimicrobial resistance is an emerging global problem concerned with patient safety. It is even more challenging in developing countries like India. Antibiotic stewardship initiative is the best arrow in the quiver to prevent and control this antimicrobial resistance. We observed 61% of the neonates admitted to neonatal intensive care unit of Niloufer hospital, Hyderabad, India were receiving improper antibiotics with respect to choice of drug or dosage or duration. Subsequently, an antibiotic stewardship team was formed to address the antibiotic misuse. Team consisted of neonatology faculty, residents, staff nurses, infection control nurses and microbiologist. We identified problems related to staff awareness, policy issues like lack of display of the antibiotic policy and lack of antibiotic lock, process issues like low rate of documentation of indication for initiation or escalation of antibiotic and a lack of dynamic review plan regarding continuation or de-escalation. We used the Plan-Do-Study-Act cycles to test and adapt solutions to these problems. Within 10 weeks of starting our quality improvement (QI) project, the proportion of unindicated antibiotic usage decreased from 61% to 27%. Timely de-escalation of antibiotic is a neglected intervention in neonates, and yielded the maximum result in our study. We conclude that QI projects are simple, doable yet powerful effective tools to address the burning problems like antibiotic misuse. This result was very satisfying and encouraging boosting our team’s faith in the effectiveness of QI approach.
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Affiliation(s)
| | - Himabindu Singh
- Department of Neonatology, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, India
| | - Alimelu Madireddy
- Department of Neonatology, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, India
| | - Megha Mala Rao Poodari
- Department of Neonatology, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, India
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14
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Agarwal S, Patodia J, Mittal J, Singh Y, Agnihotri V, Sharma V. Antibiotic stewardship in a tertiary care NICU of northern India: a quality improvement initiative. BMJ Open Qual 2021; 10:bmjoq-2021-001470. [PMID: 34344741 PMCID: PMC8336190 DOI: 10.1136/bmjoq-2021-001470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background The overuse of antibiotics in newborns leads to increased mortality and morbidities. Implementation of a successful antibiotic stewardship programme (ASP) is necessary to decrease inappropriate use of antibiotics and its adverse effects. Problem Our neonatal intensive care unit (NICU) is a tertiary referral centre of north India, consisting of all outborn babies mostly with sepsis caused by high rate of multidrug-resistant organisms (MDROs). So antibiotics are not only life-saving but also used excessively with a high antibiotic usage rate (AUR) of 574 per 1000 patient days. Method A quality improvement (QI) study was conducted using the Plan–Do–Study–Act (PDSA) approach to reduce AUR by at least 20% from January 2019 to December 2020. Various strategies were made : such as making a unit protocol, education and awareness of NICU nurses and doctors, making check points for both starting and early stoppage of antibiotics, making specific protocol to start vancomycin, and reviewing yearly antibiotic policy as per antibiogram. Results The total AUR, AUR (culture negative) and AUR (vancomycin) was reduced by 32%, 20% and 29%, respectively, (p<0.01). The proportion of newborns who never received antibiotics increased from 22% to 37% (p<0.045) and the proportion of culture-negative/screen-negative newborns where antibiotics were stopped within 48 hours increased from 16% to 54% (p<0.001). The compliance with the unit protocol in starting and upgrading antibiotic was 75% and 82%, respectively. In early 2020, there was a sudden upsurge in AUR due to central line-related bloodstream infection breakout. However, we were able to control it, and all the PDSA cycles were reinforced. Finally, we could reattain our goals, and also able to sustain it until next 1 year. There was no significant difference in overall necrotising enterocolitis and mortality rates. Conclusion In a centre such as ours, where sepsis is a leading cause of neonatal deaths, restricting antibiotic use is a huge challenge. However, we have demonstrated implementation of an efficient ASP with the help of a dedicated team and effective PDSA cycles. Also, we have emphasised the importance of sustainability in success of any QI study.
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Affiliation(s)
- Sunita Agarwal
- Department of Microbiology, SMS Medical College, Jaipur, Rajasthan, India
| | - Jyoti Patodia
- Deparment of Neonatology, Neoclinic, Jaipur, Rajasthan, India
| | | | - Yatish Singh
- Deparment of Neonatology, Neoclinic, Jaipur, Rajasthan, India
| | | | - Varun Sharma
- Deparment of Neonatology, Neoclinic, Jaipur, Rajasthan, India
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15
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Jain M, Bang A, Meshram P, Gawande P, Kawhale K, Kamble P, Deotale V, Datta V, Dhanireddy R. Institution of an antibiotic stewardship programme for rationalising antibiotic usage: a quality improvement project in the NICU of a public teaching hospital in rural central India. BMJ Open Qual 2021; 10:bmjoq-2021-001456. [PMID: 34344740 PMCID: PMC8336129 DOI: 10.1136/bmjoq-2021-001456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/14/2021] [Indexed: 11/03/2022] Open
Abstract
Antibiotic misuse is the most common cause of antimicrobial resistance-a globally declared emergency. This necessitates the introduction of rational antibiotic usage management policy. The paediatrics department of a public teaching hospital with around 500 neonatal intensive care unit (NICU) admissions annually revealed 75% of NICU admission exposure to any antibiotics. The aim was to institute antibiotic stewardship programme (ASP) to optimise antibiotic usage from existing 75% to 40% in a 6-month period through a quality improvement (QI) project.A root cause analysis using fishbone diagram was performed to identify the possible reasons for the high antibiotic usage. Six Plan-Do-Study-Act cycles were conducted to implement the protocols for usage of antibiotics for well-defined indications; active laboratory engagement to decrease the turnaround time for blood culture results; a hard stop to all antibiotic orders after 72 hours; streamlining of antibiotic usage; strengthening universal aseptic practices; and confidence building of staff. The outcomes monitored were antibiotic exposure rates, average number of antibiotic days in all NICU admissions, sepsis rates and mortality.Institution of ASP had significantly reduced antibiotic exposure in NICU admissions, that is, from 75% in March to 41% in August 2018. Median (IQR) antibiotic days per infant in NICU went down from 3 to 0 (0-6). The per cent of NICU admission with culture-positive sepsis and all-cause mortality rate in NICU declined from 18% to 11.56% and 25% to 16%, respectively, over these 6 months.Thus, ASP for rationalising antibiotic usage was successfully instituted in NICU of a rural medical college in central India through QI, without any adverse effect on sepsis and mortality.
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Affiliation(s)
- Manish Jain
- Paediatrics, Mahatma Gandhi Institute of Medical Sciences,Sewagram, Wardha, Maharashtra, India
| | - Akash Bang
- Pediatrics, All India Institute of Medical Sciences-Nagpur, Nagpur, Maharashtra, India
| | - Payal Meshram
- Paediatrics, Mahatma Gandhi Institute of Medical Sciences,Sewagram, Wardha, Maharashtra, India
| | - Prachi Gawande
- Paediatrics, Mahatma Gandhi Institute of Medical Sciences,Sewagram, Wardha, Maharashtra, India
| | - Karuna Kawhale
- Paediatrics, Mahatma Gandhi Institute of Medical Sciences,Sewagram, Wardha, Maharashtra, India
| | - Pushpanjali Kamble
- Paediatrics, Mahatma Gandhi Institute of Medical Sciences,Sewagram, Wardha, Maharashtra, India
| | - Vijayshri Deotale
- Microbiology, Mahatma GandhinInstitute of Medical Sciences,Sewagram, Wardha, Maharashtra, India
| | - Vikram Datta
- Neonatology, Lady Hardinge Medical College, New Delhi, Delhi, India
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16
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Ray S, Sundaram V, Dutta S, Kumar P. Ensuring administration of first dose of antibiotics within the golden hour of management in neonates with sepsis. BMJ Open Qual 2021; 10:bmjoq-2021-001365. [PMID: 34344748 PMCID: PMC8336151 DOI: 10.1136/bmjoq-2021-001365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/15/2021] [Indexed: 12/29/2022] Open
Abstract
Administration of first dose of antibiotics within the golden hour in infants with sepsis is critical. Delays can increase mortality. During our observations as part of antibiotic stewardship programme in inborn neonatal unit, we found a significant delay in the administration of first dose of antibiotics from the decision time. We set up a quality improvement team to improve the proportion of neonates with sepsis, who received first dose of antibiotics within 1 hour of decision, from 0% to 80% over 2 months.We included inborn neonates requiring initiation or upgradation of antibiotics for a diagnosis of sepsis, from 1 May to 30 November 2018. We assessed the root causes behind delayed administration and found the lack of immediate availability of blood culture bottles, lack of awareness and busy clinical area as the major contributors to the delays in first dose. Various change ideas like ensuring prior availability of blood culture bottles, sensitising nursing staff and resident doctors, utilisation of hospital attendants and sharing responsibility of drawing culture between team members were tested through plan-do-study-act (PDSA) cycles.The proportion of neonates receiving first dose of antibiotics within 1 hour increased from 0% to 91% over the study period and was sustained at 92% after 6 months. There was a significant reduction in median (IQR) time interval between decision and first dose from 120 (100-290) to 45 (30-60) min (p<0.001) and after 6 months, it further decreased to 30 (30-45) min. We achieved significant improvement in administration of first dose of antibiotics within 1 hour of decision, by using system analysis and testing change ideas in sequential PDSA cycles.
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Affiliation(s)
- Somosri Ray
- Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Venkataseshan Sundaram
- Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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17
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Affiliation(s)
- Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Eva M Krockow
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
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18
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Johnson MC, Hulgan T, Cooke RG, Kleinpell R, Roumie C, Callaway-Lane C, Mitchell LD, Hathaway J, Dittus R, Staub M. Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis. BMJ Open Qual 2021; 10:bmjoq-2020-001275. [PMID: 34210668 PMCID: PMC8252871 DOI: 10.1136/bmjoq-2020-001275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 06/06/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Antibiotics are not recommended for treatment of acute uncomplicated bronchitis (AUB), but are often prescribed (85% of AUB visits within the Veterans Affairs nationally). This quality improvement project aimed to decrease antibiotic prescribing for AUB in community-based outpatient centres from 65% to <32% by April 2020. METHODS From January to December 2018, community-based outpatient clinics' 6 months' average of prescribed antibiotics for AUB and upper respiratory infections was 63% (667 of 1054) and 64.6% (314 of 486) when reviewing the last 6 months. Seven plan-do-study-act (PDSA) cycles were implemented by an interprofessional antimicrobial stewardship team between January 2019 and March 2020. Balancing measures were a return patient phone call or visit within 4 weeks for the same complaint. Χ2 tests and statistical process control charts using Western Electric rules were used to analyse intervention data. RESULTS The AUB antibiotic prescribing rate decreased from 64.6% (314 of 486) in the 6 months prior to the intervention to 36.8% (154 of 418) in the final 6 months of the intervention. No change was seen in balancing measures. The largest reduction in antibiotic prescribing was seen after implementation of PDSA 6 in which 14 high prescribers were identified and targeted for individualised reviews of encounters of patients with AUB with an antimicrobial steward. CONCLUSIONS Operational implementation of successful stewardship interventions is challenging and differs from the traditional implementation study environment. As a nascent outpatient stewardship programme with limited resources and no additional intervention funding, we successfully reduced antibiotic prescribing from 64.6% to 36.8%, a reduction of 43% from baseline. The most success was seen with targeted education of high prescribers.
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Affiliation(s)
- Morgan Clouse Johnson
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Todd Hulgan
- Infectious Diseases, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robin G Cooke
- Pharmacy, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Ruth Kleinpell
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Christianne Roumie
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carol Callaway-Lane
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Lauren D Mitchell
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Jacob Hathaway
- Primary Care, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Robert Dittus
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Milner Staub
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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19
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败血症风险计算器指导下疑诊早发型败血症新生儿的抗生素管理. Zhongguo Dang Dai Er Ke Za Zhi 2021; 23. [PMID: 34130779 DOI: 10.7499/j.issn.1008-8830.2101167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate the efficacy of sepsis risk calculator (SRC) in guiding antibiotic use in neonates with suspected early-onset sepsis (EOS). METHODS A total of 284 neonates with a gestational age of ≥ 35 weeks were enrolled as the control group, who were hospitalized in the Children's Hospital of Chongqing Medical University from March to July, 2019 and were suspected of EOS. Their clinical data were retrospectively collected and the use of antibiotics was analyzed based on SRC. A total of 170 neonates with a gestational age of ≥ 35 weeks were enrolled as the study group, who were admitted to the hospital from July to November, 2020 and were suspected of EOS. SRC was used prospectively for risk scoring to assist the decision making of clinical antibiotic management. The two groups were compared in terms of the rate of use of antibiotics, blood culture test rate, clinical outcome, and adherence to the use of SRC. RESULTS Compared with the control group, the study group had a significantly higher SRC score at birth and on admission (P < 0.05). The rate of use of antibiotics in the study group was significantly lower than that in the control group[84.7% (144/170) vs 91.5% (260/284), 6.8% decrease; P < 0.05]. The blood culture test rate in the study group was also significantly lower than that in the control group (85.3% vs 91.9%, P < 0.05). There was no significant difference between the two groups in the incidence rate of adverse outcomes and the final diagnosis of EOS (P > 0.05). CONCLUSIONS The use of SRC reduces the rate of empirical use of antibiotics in neonates with suspected EOS and does not increase the risk of adverse outcomes, and therefore, it holds promise for clinical application.
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20
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Pandolfo AM, Horne R, Jani Y, Reader TW, Bidad N, Brealey D, Enne VI, Livermore DM, Gant V, Brett SJ. Understanding decisions about antibiotic prescribing in ICU: an application of the Necessity Concerns Framework. BMJ Qual Saf 2021; 31:199-210. [PMID: 34099497 PMCID: PMC8899486 DOI: 10.1136/bmjqs-2020-012479] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/25/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotics are extensively prescribed in intensive care units (ICUs), yet little is known about how antibiotic-related decisions are made in this setting. We explored how beliefs, perceptions and contextual factors influenced ICU clinicians' antibiotic prescribing. METHODS We conducted 4 focus groups and 34 semistructured interviews with clinicians involved in antibiotic prescribing in four English ICUs. Focus groups explored factors influencing prescribing, whereas interviews examined decision-making processes using two clinical vignettes. Data were analysed using thematic analysis, applying the Necessity Concerns Framework. RESULTS Clinicians' antibiotic decisions were influenced by their judgement of the necessity for prescribing/not prescribing, relative to their concerns about potential adverse consequences. Antibiotic necessity perceptions were strongly influenced by beliefs that antibiotics would protect patients from deterioration and themselves from the ethical and legal consequences of undertreatment. Clinicians also reported concerns about prescribing antibiotics. These generally centred on antimicrobial resistance; however, protecting the individual patient was prioritised over these societal concerns. Few participants identified antibiotic toxicity concerns as a key influencer. Clinical uncertainty often complicated balancing antibiotic necessity against concerns. Decisions to start or continue antibiotics often represented 'erring on the side of caution' as a protective response in uncertainty. This approach was reinforced by previous experiences of negative consequences ('being burnt') which motivated prescribing 'just in case' of an infection. Prescribing decisions were also context-dependent, exemplified by a lower perceived threshold to prescribe antibiotics out-of-hours, input from external team members and local prescribing norms. CONCLUSION Efforts to improve antibiotic stewardship should consider clinicians' desire to protect with a prescription. Rapid molecular microbiology, with appropriate communication, may diminish clinicians' fears of not prescribing or of using narrower-spectrum antibiotics.
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Affiliation(s)
- Alyssa M Pandolfo
- Centre for Behavioural Medicine, University College London, London, UK
| | - Robert Horne
- Centre for Behavioural Medicine, University College London, London, UK
| | - Yogini Jani
- UCLH-UCL Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tom W Reader
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, UK
| | - Natalie Bidad
- Centre for Behavioural Medicine, University College London, London, UK
| | - David Brealey
- Division of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Virve I Enne
- Division of Infection and Immunity, University College London, London, UK
| | | | - Vanya Gant
- Department of Medical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
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21
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Sun T, Wu X, Cai Y, Zhai T, Huang L, Zhang Y, Zhan Q. Metagenomic Next-Generation Sequencing for Pathogenic Diagnosis and Antibiotic Management of Severe Community-Acquired Pneumonia in Immunocompromised Adults. Front Cell Infect Microbiol 2021; 11:661589. [PMID: 34141628 PMCID: PMC8204719 DOI: 10.3389/fcimb.2021.661589] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background Metagenomic next-generation sequencing (mNGS) is a promising technique for pathogens diagnosis. However, application of mNGS in immunocompromised adults with severe community-acquired pneumonia (SCAP) is relatively limited. Methods We retrospectively reviewed 23 immunocompromised and 21 immunocompetent SCAP patients with mNGS detection from April 2019 to December 2019. The performances of pathogenic diagnosis and subsequently antibiotic adjustment in immunocompromised SCAP patients were compared to immunocompetent SCAP patients. The defined by days of therapy (DOT) method was used for estimate daily antibiotic use. Results There was a significant difference in the diagnostic positivity rate between mNGS and conventional test in both groups (P<0.001). Compared to immunocompetent patients, more mixed pathogens in immunocompromised patients were found (P=0.023). Before the availability of mNGS, the DOTs in immunocompromise patients were higher than immunocompetent patients (3.0 [3.0, 4.0] vs. 3.0 [2.0, 3.0], P=0.013). Compared to immunocompetent patients, immunocompromised patients had fewer full pathogen covered empirical antibiotic therapy (14.7% vs. 57.1%, P=0.022), more adjustments of antibiotic treatment (87.0%) vs. 57.1%, P=0.027). More than a half (13 of 23) SCAP patients in immunosuppressed group had reduced or downgraded antibiotic adjustments based on the results. Conclusions mNGS may be a useful technique for detecting mixed pathogens and personalized antibiotic treatment in immunocompromised SCAP patients.
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Affiliation(s)
- Ting Sun
- Capital Medical University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaojing Wu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Ying Cai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Tianshu Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Linna Huang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Yi Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Qingyuan Zhan
- Capital Medical University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
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22
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Chambers A, Chen C, Brown KA, Daneman N, Langford B, Leung V, Adomako K, Schwartz KL, Moore JE, Quirk J, MacFarlane S, Cronsberry T, Garber GE. Virtual learning collaboratives to improve urine culturing and antibiotic prescribing in long-term care: controlled before-and-after study. BMJ Qual Saf 2021; 31:94-104. [PMID: 33853868 PMCID: PMC8785008 DOI: 10.1136/bmjqs-2020-012226] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/16/2021] [Accepted: 04/05/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Urine culturing practices are highly variable in long-term care and contribute to overprescribing of antibiotics for presumed urinary tract infections. The purpose of this study was to evaluate the use of virtual learning collaboratives to support long-term care homes in implementing a quality improvement programme focused on reducing unnecessary urine culturing and antibiotic overprescribing. METHODS Over a 4-month period (May 2018-August 2018), 45 long-term care homes were self-selected from five regions to participate in virtual learning collaborative sessions, which provided an orientation to a quality improvement programme and guidance for implementation. A process evaluation complemented the use of a controlled before-and-after study with a propensity score matched control group (n=127) and a difference-in-difference analysis. Primary outcomes included rates of urine cultures performed and urinary antibiotic prescriptions. Secondary outcomes included rates of emergency department visits, hospital admission and mortality. An 18-month baseline period was compared with a 16-month postimplementation period with the use of administrative data sources. RESULTS Rates of urine culturing and urinary antibiotic prescriptions per 1000 resident days decreased significantly more among long-term care homes that participated in learning collaboratives compared with matched controls (differential reductions of 19% and 13%, respectively, p<0.0001). There was no statistically significant changes to rates of emergency department visits, hospital admissions or mortality. These outcomes were observed with moderate adherence to the programme model. CONCLUSIONS Rates of urine culturing and urinary antibiotic prescriptions declined among long-term care homes that participated in a virtual learning collaborative to support implementation of a quality improvement programme. The results of this study have refined a model to scale this programme in long-term care.
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Affiliation(s)
| | - Cynthia Chen
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Kevin Antoine Brown
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | | | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Gary E Garber
- Public Health Ontario, Toronto, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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McMullan BJ, Mahony M, Java L, Mostaghim M, Plaister M, Wu C, White S, Al Yazidi L, Martin E, Bryant P, Thursky KA, Buono E. Improving intravenous-to-oral antibiotic switch in children: a team-based audit and implementation approach. BMJ Open Qual 2021; 10:bmjoq-2020-001120. [PMID: 33731484 PMCID: PMC7978100 DOI: 10.1136/bmjoq-2020-001120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 02/14/2021] [Accepted: 02/28/2021] [Indexed: 11/27/2022] Open
Abstract
Children in hospital are frequently prescribed intravenous antibiotics for longer than needed. Programmes to optimise timely intravenous-to-oral antibiotic switch may limit excessive in-hospital antibiotic use, minimise complications of intravenous therapy and allow children to go home faster. Here, we describe a quality improvement approach to implement a guideline, with team-based education, audit and feedback, for timely, safe switch from intravenous-to-oral antibiotics in hospitalised children. Eligibility for switch was based on evidence-based guidelines and supported by education and feedback. The project was conducted over 12 months in a tertiary paediatric hospital. Primary outcomes assessed were the proportion of eligible children admitted under paediatric and surgical teams switched within 24 hours, and switch timing prior to and after guideline launch. Secondary outcomes were hospital length of stay, recommencement of intravenous therapy or readmission. The percentage of children switched within 24 hours of eligibility significantly increased from 32/50 (64%) at baseline to 203/249 (82%) post-implementation (p=0.006). The median time to switch fell from 15 hours 42 min to 4 hours 20 min (p=0.0006). In addition, there was a 14-hour median reduction in hospital length of stay (p=0.008). Readmission to hospital and recommencement of intravenous therapy did not significantly change postimplementation. This education, audit and feedback approach improved timely intravenous-to-oral switch in children and also allowed for more timely discharge from hospital. The study demonstrates proof of concept for this implementation with a methodology that can be readily adapted to other paediatric inpatient settings.
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Affiliation(s)
- Brendan Joseph McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia .,NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michelle Mahony
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia
| | - Lolita Java
- Medication Safety, Clinical Excellence Commission, Sydney, New South Wales, Australia
| | - Mona Mostaghim
- Pharmacy Department, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia
| | - Michael Plaister
- Department of General Paediatrics, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia
| | - Camille Wu
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Paediatric Surgery, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia
| | - Sophie White
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia
| | - Laila Al Yazidi
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia.,Child Health Department, Sultan Qaboos University, Muscat, Oman
| | - Erica Martin
- Department of Nursing, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia
| | - Penelope Bryant
- Infectious Diseases and Hospital in the Home Departments, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Paediatrics, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Karin A Thursky
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.,National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Evette Buono
- Medication Safety, Clinical Excellence Commission, Sydney, New South Wales, Australia
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Bonaconsa C, Mbamalu O, Mendelson M, Boutall A, Warden C, Rayamajhi S, Pennel T, Hampton M, Joubert I, Tarrant C, Holmes A, Charani E. Visual mapping of team dynamics and communication patterns on surgical ward rounds: an ethnographic study. BMJ Qual Saf 2021; 30:812-824. [PMID: 33563790 DOI: 10.1136/bmjqs-2020-012372] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/03/2020] [Accepted: 01/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effect of team dynamics on infection management and antimicrobial stewardship (AMS) behaviours is not well understood. Using innovative visual mapping, alongside traditional qualitative methods, we studied how surgical team dynamics and communication patterns influence infection-related decision making. MATERIALS/METHODS Between May and November 2019, data were gathered through direct observations of ward rounds and face-to-face interviews with ward round participants in three high infection risk surgical specialties at a tertiary hospital in South Africa. Sociograms, a visual mapping method, mapped content and flow of communication and the social links between participants. Data were analysed using a grounded theory approach. RESULTS Data were gathered from 70 hours of ward round observations, including 1024 individual patient discussions, 60 sociograms and face-to-face interviews with 61 healthcare professionals. AMS and infection-related discussions on ward rounds vary across specialties and are affected by the content and structure of the clinical update provided, consultant leadership styles and competing priorities at the bedside. Registrars and consultants dominate the discussions, limiting the input of other team members with recognised roles in AMS and infection management. Team hierarchies also manifest where staff position themselves, and this influences their contribution to active participation in patient care. Leadership styles affect ward-round dynamics, determining whether nurses and patients are actively engaged in discussions on infection management and antibiotic therapy and whether actions are assigned to identified persons. CONCLUSIONS The surgical bedside ward round remains a medium of communication between registrars and consultants, with little interaction with the patient or other healthcare professionals. A team-focused and inclusive approach could result in more effective decision making about infection management and AMS.
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Affiliation(s)
- Candice Bonaconsa
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Oluchi Mbamalu
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Adam Boutall
- Division of General Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Claire Warden
- Division of General Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Shreya Rayamajhi
- Division of General Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Tim Pennel
- Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Mark Hampton
- Dr. Matley & Partners Surgical Practice, Cape Town, South Africa
| | - Ivan Joubert
- Division of Critical Care, Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alison Holmes
- NIHR Health Protection Research Unit in Healthcare Associated infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
| | - Esmita Charani
- NIHR Health Protection Research Unit in Healthcare Associated infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
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Laur C, Sribaskaran T, Simeoni M, Desveaux L, Daneman N, Mulhall C, Lam J, Ivers NM. Improving antibiotic initiation and duration prescribing among nursing home physicians using an audit and feedback intervention: a theory-informed qualitative analysis. BMJ Open Qual 2021; 10:e001088. [PMID: 33547157 PMCID: PMC7871236 DOI: 10.1136/bmjoq-2020-001088] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/25/2020] [Accepted: 01/13/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In nursing homes, 25%-75% of antibiotic days of treatment are inappropriate or unnecessary and are often continued for longer durations than necessary. In Ontario, physicians can receive a provincial audit and feedback report that provides individualised, confidential, data about their antibiotic prescribing. Objectives of this study were to explore antibiotic prescribing of nursing home physicians and the influence of the report. METHODS All physicians who received a personalised MyPractice: Long-Term Care report from Ontario Health (Quality) (OH(Q)) in January 2019 (n=361) were eligible to participate in semistructured telephone interviews that were recorded then transcribed verbatim. Recruitment emails were sent from OH(Q) until saturation of ideas. Analysis was conducted by two team members inductively, then deductively using the theoretical domains framework, a comprehensive, theory-informed framework to classify determinants of specific behaviours. RESULTS Interviews were conducted with n=18 physicians; 78% (n=14) were men, practising for an average of 27 years, with 18 years of experience working in nursing homes. Physicians worked in a median of 2 facilities (range 1-6), with 72% (n=13) in an urban setting. 56% (n=10) were medical directors for at least one home. Professional role and identity impacted all aspects of antibiotic prescribing. Key roles included being an 'Appropriate prescriber', an 'Educator' and a 'Change driver'. For antibiotic initiation, these roles interacted with Knowledge, Skills, Beliefs about consequence, Beliefs about capabilities, and Social influence to determine the resulting prescribing behaviour. When considering the impact of interacting with the report, participants' perceived roles interacted with Reinforcement, Social influence, and Intention. Environmental context and resources was an overarching domain. CONCLUSION This theory-informed approach is being used to inform upcoming versions of existing audit and feedback initiatives. Appealing to the role that prescribers see themselves offers a unique opportunity to encourage desired changes, such as providing tools for physicians to be Educators and facilitating, particularly medical directors, to be Change drivers.
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Affiliation(s)
- Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Thivja Sribaskaran
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Michelle Simeoni
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Laura Desveaux
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Nick Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | - Noah Michael Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Dresser L, Stephen MS, McIntyre M, Jorgoni L, Jorgensen SCJ, Nelson S, Bell C, Morris AM. Evaluating the effect of nurse-initiated discussion of infection management during ICU bedside rounds. BMJ Open Qual 2020; 9:e001037. [PMID: 33139296 PMCID: PMC7607598 DOI: 10.1136/bmjoq-2020-001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/20/2020] [Accepted: 10/14/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Linda Dresser
- Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | | | - Mark McIntyre
- Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Linda Jorgoni
- Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
| | - Sarah C J Jorgensen
- Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
- Department of Pharmacy, Sinai Health, Toronto, Ontario, Canada
| | - Sandra Nelson
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Chaim Bell
- Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
- Division of Internal Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew M Morris
- Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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27
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Mantzourani E, Evans A, Cannings-John R, Ahmed H, Hood K, Reid N, Howe R, Williams E, Way C. Impact of a pilot NHS-funded sore throat test and treat service in community pharmacies on provision and quality of patient care. BMJ Open Qual 2020; 9:bmjoq-2019-000833. [PMID: 32111608 PMCID: PMC7047494 DOI: 10.1136/bmjoq-2019-000833] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/08/2020] [Accepted: 02/11/2020] [Indexed: 11/23/2022] Open
Abstract
Objective A National Health Service (NHS)-funded sore throat test and treat (STTT) service was introduced in selected pharmacies in two local health boards in Wales, as an extension to the national pharmacy common ailment scheme. The aim of this study was to evaluate the impact of STTT on provision and quality of patient care, namely antibiotic use, patient safety and general practitioner (GP) consultation rates. Methods Secondary analyses of STTT consultation data to describe service outcomes, and routine data to explore changes in antibiotic prescribing and the prevalence of complications. Data were also collected from one GP practice to explore the feasibility of measuring changes in sore throat consultation rates in general practice. Results Less than 20% of 1725 consultations resulted in antibiotic supply. The availability of STTT was associated with greater reductions in prescriptions for phenoxymethylpenicillin than in areas where STTT was not available (−3.8% and −3.4%, difference 0.4%). When pharmacy supplies were included, the reductions in the supply of the antibiotic were similar. No increase in the monthly number of incidents of quinsy was detected, and patients were appropriately referred to other healthcare professionals during pharmacy consultations. GP consultation rates since introduction of STTT were found to be lower than the equivalent monthly average since 2014. Conclusions Data from the first 5 months of the STTT service suggest that it may have a role in safely rebalancing uncomplicated sore throat management from general practice to community pharmacies while continuing to promote antibiotic stewardship.
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Affiliation(s)
- Efi Mantzourani
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK .,Primary Care, Information and Communications Technology, NHS Wales Informatics Service, Cardiff, UK
| | - Andrew Evans
- Health and Social Services Group, Welsh Government, Cardiff, UK
| | | | - Haroon Ahmed
- Division of Population Medicine, Cardiff University, Cardiff, South Glamorgan, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, South Glamorgan, UK
| | - Nicholas Reid
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK.,Health Protection Division, Public Health Wales, Cardiff, UK
| | - Robin Howe
- Microbiology, Public Health Wales, Cardiff, UK
| | - Emma Williams
- Primary Care, Information and Communications Technology, NHS Wales Informatics Service, Cardiff, UK
| | - Cheryl Way
- Clinical Informatics, NHS Wales Informatics Service, Cardiff, UK
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28
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Downen J, Jaeger C. Quality improvement of intravenous to oral medication conversion using Lean Six Sigma methodologies. BMJ Open Qual 2020; 9:bmjoq-2019-000804. [PMID: 31986120 PMCID: PMC7011893 DOI: 10.1136/bmjoq-2019-000804] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/19/2019] [Accepted: 12/30/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction Lack of medication conversion from intravenous to oral contributes to increased risk of infection, delayed discharges and higher medication costs. At our institution, intravenous to oral medication conversion rate was 76% with missed opportunity for conversion of 37%. The goal of the project was to reduce the percent of missed opportunities for intravenous to oral conversion for applicable medications. Methods A pharmacy-driven intravenous to oral policy and procedure was implemented. To identify potential opportunities, a patient worklist of applicable intravenous to oral medications was created for pharmacy review in real time. An intravenous to oral conversion order was implemented in the computerised provider order entry. ‘Convert to oral’ was added as an option in the electronic medication request and highlighted reminders were added to the electronic medication administration record for eligible medications. Results After improvements, the missed opportunity rate for intravenous to oral conversion decreased from 37% (19/51) to 21% (24/113) (p=0.04, two-proportion test), a 43% improvement. The trend in intravenous to oral conversion rate increased from 76% (39/51) to 85% (171/201) and severity adjusted length of stay was reduced from 8.1 days to 6.4 days post improvements (p<0.001, t-test).
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Affiliation(s)
- Julie Downen
- Pharmacy, Memorial Medical Center, Springfield, Illinois, USA
| | - Cassie Jaeger
- Operations Improvement, Memorial Medical Center, Springfield, Illinois, USA
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29
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Cruz AT, Lane RD, Balamuth F, Aronson PL, Ashby DW, Neuman MI, Souganidis ES, Alpern ER, Schlapbach LJ. Updates on pediatric sepsis. J Am Coll Emerg Physicians Open 2020; 1:981-993. [PMID: 33145549 PMCID: PMC7593454 DOI: 10.1002/emp2.12173] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
Sepsis, defined as an infection with dysregulated host response leading to life-threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.
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Affiliation(s)
- Andrea T. Cruz
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Roni D. Lane
- Division of Pediatric Emergency Medicinethe University of Utah Primary Children's HospitalSalt Lake CityUtahUSA
| | - Fran Balamuth
- Division of Emergency MedicineDepartment of PediatricsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Paul L. Aronson
- Section of Pediatric Emergency MedicineDepartments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - David W. Ashby
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Mark I. Neuman
- Division of Emergency MedicineDepartment of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Ellie S. Souganidis
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Elizabeth R. Alpern
- Division of Emergency MedicineDepartment of PediatricsAnn & Robert H. Lurie Children's HospitalFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Luregn J. Schlapbach
- Department of Intensive Care Medicine and Neonatologyand Children's Research CenterUniversity Children's Hospital of ZurichUniversity of ZurichZurichSwitzerland
- Paediatric Critical Care Research GroupThe University of Queensland and Queensland Children's HospitalBrisbaneQueenslandAustralia
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30
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Affiliation(s)
- Scott G Weiner
- Department of Quality and Safety and Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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31
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Blogg SG. NPS MedicineWise evaluation finds changes in general practitioners' prescribing of proton pump inhibitors following education programmes. BMJ Qual Saf 2020; 30:68-69. [PMID: 32928912 DOI: 10.1136/bmjqs-2020-012111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 11/04/2022]
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Haney V, Maman S, Prozesky J, Bezinover D, Karamchandani K. Improving intraoperative administration of surgical antimicrobial prophylaxis: a quality improvement report. BMJ Open Qual 2020; 9:e001042. [PMID: 32958474 PMCID: PMC7507890 DOI: 10.1136/bmjoq-2020-001042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/12/2020] [Accepted: 09/08/2020] [Indexed: 11/17/2022] Open
Abstract
Despite widespread adoption of the Surgical Care Improvement Programme, the incidence of surgical site infections (SSIs) remains high. It is possible that lapses in appropriate administration of antimicrobial prophylaxis may play a role. We noted significant discordance with national guidelines with regards to intraoperative antibiotic administration at our institution, leading to implementation of a quality improvement initiative using multidisciplinary education and reminder-based interventions to improve prescribing practices and increase compliance with national guidelines. We observed a significant improvement in adherence to all aspects of antibiotic administration guidelines as a result of such interventions. Targeted multidisciplinary interventions may help improve prescribing practices of surgical antimicrobial prophylaxis and provide an opportunity to potentially decrease the burden of SSI and the related morbidity and mortality.
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Affiliation(s)
- Victoria Haney
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Stephan Maman
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jansie Prozesky
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dmitri Bezinover
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kunal Karamchandani
- Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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Jewell MJ, Leyenaar J, Shieh MS, Pekow PS, Stefan M, Lindenauer PK. Unnecessary antibiotic prescribing in children hospitalised for asthma exacerbation: a retrospective national cohort study. BMJ Qual Saf 2020; 30:292-299. [PMID: 32423905 DOI: 10.1136/bmjqs-2019-010792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antibiotic resistance represents a worldwide public health threat. Characterising prescribing patterns for conditions for which antibiotics have no role can inform antimicrobial stewardship efforts. Asthma is among the most common non-infectious diseases in children and results in 100 000 hospitalisations annually in the USA. We sought to identify the rate of antibiotic prescribing in children hospitalised for asthma exacerbations, and to characterise patient and hospital factors associated with receipt of antibiotics. METHODS Children and adolescents aged 2-17 years admitted to hospital between 1 October 2015 and 30 June 2018 with an asthma exacerbation were identified from the Premier Alliance Database. After excluding hospitalisations for which antibiotics appeared to have been justified, we assessed receipt and duration of antibiotic treatments during the hospital stay. We developed a hierarchical logistic regression model to identify patient and hospital factors associated with antibiotic treatment. For each hospital with at least 10 asthma cases we computed the percentage of cases receiving antibiotic treatment. RESULTS 23 129 hospital stays met inclusion criteria; in 3329 (14%) of these, antibiotics were prescribed without clear indication. Hospital prescribing rates varied widely (range 0%-95%), with 25% of hospitals prescribing antibiotics at a rate of 27.5% or more. Patient factors most strongly associated with receipt of antibiotics included the presence of a complex chronic condition (OR: 2.4, 95% CI 2.1 to 2.9; p<0.0001) and admission to the intensive care unit compared with a general medical-surgical bed (OR: 1.6, 95% CI 1.5 to 1.9; p<0.0001). Hospitalisation at general hospitals with minimum paediatric specialty support conferred a nearly threefold higher odds of antibiotic treatment (OR: 2.9, 95% CI 1.5 to 5.6; p<0.0001). CONCLUSIONS These findings illustrate an opportunity to reduce unnecessary exposure to antibiotics in children hospitalised with asthma, particularly in general hospitals where three-quarters of children in the USA receive their hospital-based care.
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Affiliation(s)
- Marcella J Jewell
- Institute of Healthcare Delivery and Population Science, Baystate Medical Center, Springfield, Massachusetts, USA
| | - JoAnna Leyenaar
- Department of Pediatrics and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Meng-Shiou Shieh
- Institute of Healthcare Delivery and Population Science, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Penelope S Pekow
- Institute of Healthcare Delivery and Population Science, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Mihaela Stefan
- Institute of Healthcare Delivery and Population Science, Baystate Medical Center, Springfield, Massachusetts, USA.,Division of Hospital Medicine, Baystate Medical Center, Springfield, Massachusetts, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
| | - Peter K Lindenauer
- Institute of Healthcare Delivery and Population Science, Baystate Medical Center, Springfield, Massachusetts, USA.,Division of Hospital Medicine, Baystate Medical Center, Springfield, Massachusetts, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
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34
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Sahota RS, Rajan KK, Comont JMS, Lee HH, Johnston N, James M, Patel R, Nariculam J. Increasing the documentation of 48-hour antimicrobial reviews. BMJ Open Qual 2020; 9:bmjoq-2019-000805. [PMID: 32034009 PMCID: PMC7011884 DOI: 10.1136/bmjoq-2019-000805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/08/2019] [Accepted: 12/20/2019] [Indexed: 11/15/2022] Open
Abstract
Antimicrobial resistance is a growing problem worldwide. Encouraging antimicrobial stewardship can help to reduce the negative consequences of inappropriate antibiotic use. This quality improvement project targets to do this by aiming to improve the proportion of 48-hour antimicrobial reviews completed and documented on two surgical wards at Darent Valley Hospital with a goal of 100% compliance. This project used four PDSA (plan, do, study, act) cycles to achieve our aim: a trust-wide email; education sessions with junior doctors; sticker reminders in patient notes; presenting our study to surgical consultants and displaying posters on the wards. The proportion of antimicrobial reviews completed at 48 hours in the patient notes increased from 18% to 77% over 19 weeks from 10 October 2018 to 20 February 2019. The most successful intervention was providing a presentation for consultants at an audit meeting in conjunction with displaying posters on the wards. The most successful interventions (education sessions with junior doctors and presentation to surgical consultants alongside displaying posters on the wards) were found to be those that required minimal further input after their initial rollout. This project was carried out by medical students and is highly transferrable to other hospitals, and highlighted that a successful quality improvement project can be undertaken by any member of the healthcare team.
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Affiliation(s)
| | | | | | | | | | - Mary James
- Department of Surgery, Darent Valley Hospital, Dartford, Kent, UK
| | - Rakhee Patel
- Department of Surgery, Darent Valley Hospital, Dartford, Kent, UK
| | - Joseph Nariculam
- Department of Surgery, Darent Valley Hospital, Dartford, Kent, UK
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Hota SS, Doll M, Bearman G. Preventing Clostridioides difficile infection in hospitals: what is the endgame? BMJ Qual Saf 2019; 29:157-160. [PMID: 31582570 DOI: 10.1136/bmjqs-2019-009953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/11/2019] [Accepted: 09/20/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Susy S Hota
- Infection Prevention and Control Department, University Health Network, Toronto, Ontario, Canada .,Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Doll
- Department of Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Gonzalo Bearman
- Department of Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA
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Cunney R, Kirrane-Scott M, Rafferty A, Stapleton P, Okafor I, McNamara R. 'Start smart': using front-line ownership to improve the quality of empiric antibiotic prescribing in a paediatric hospital. BMJ Open Qual 2019; 8:e000445. [PMID: 31523725 PMCID: PMC6711488 DOI: 10.1136/bmjoq-2018-000445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/06/2018] [Accepted: 06/19/2019] [Indexed: 11/16/2022] Open
Abstract
Infection is the most frequent indication for non-scheduled admission to paediatric hospitals, leading to high levels of empiric antibiotic prescribing. Antibiotic prescribing in line with local guidelines, improves patient outcomes, reduces adverse drug events and helps to reduce the emergence of antimicrobial resistance. We undertook an improvement project at Temple Street Children’s University Hospital targeting documentation of indication and compliance with empiric antibiotic prescribing guidelines among medical admissions via the emergency department (ED). Results of weekly audits of empiric antibiotic prescribing were fed back to prescribers. Front-line ownership techniques were used to empower prescribers to generate ideas for change, such as regular discussion of antibiotic prescribing issues at weekly clinical meetings, antibiotic ‘spot quiz’, updates to prescribing guidelines, improved access and promotion of a prescribing app, laminated guideline summary cards, and reminders and guideline summaries at a point of prescribing in ED. Documentation of indication and guideline compliance increased from a median of 30% in December 2014 to 100% in March 2015, and was sustained at 100% to September 2016, then 90% to December 2017. The intervention was associated with improvements in non-targeted indicators of prescribing quality, an overall reduction in antimicrobial consumption in the hospital, and a €105 000 reduction in annual antimicrobial acquisition costs. We found that a simple, paper-based, data collection system was effective, provided opportunities for a point-of-care interaction with prescribers, and facilitated weekly data feedback. We also found that using a pre-existing weekly clinical meeting to foster prescriber ownership of the data, allowing prescribers to identify possible tests of change, and exploiting the competitive nature of doctors, led to a rapid and sustained improvement in prescribing quality. Awareness of local prescribing processes and culture are essential to delivering improvements in antimicrobial stewardship.
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Affiliation(s)
- Robert Cunney
- Microbiology, Temple Street Children's University Hospital, Dublin, Ireland
| | | | - Aisling Rafferty
- Pharmacy, Temple Street Children's University Hospital, Dublin, Ireland
| | - Patrick Stapleton
- Microbiology, Temple Street Children's University Hospital, Dublin, Ireland
| | - Ikechukwu Okafor
- Emergency Medicine, Temple Street Children's University Hospital, Dublin, Ireland
| | - Roisin McNamara
- Emergency Medicine, Temple Street Children's University Hospital, Dublin, Ireland
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Kyaw BM, Tudor Car L, van Galen LS, van Agtmael MA, Costelloe CE, Ajuebor O, Campbell J, Car J. Health Professions Digital Education on Antibiotic Management: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. J Med Internet Res 2019; 21:e14984. [PMID: 31516125 PMCID: PMC6746065 DOI: 10.2196/14984] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/07/2019] [Accepted: 08/17/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescription is one of the key contributors to antibiotic resistance, which is managed with a range of interventions including education. OBJECTIVE We aimed to summarize evidence on the effectiveness of digital education of antibiotic management compared to traditional education for improving health care professionals' knowledge, skills, attitudes, and clinical practice. METHODS Seven electronic databases and two trial registries were searched for randomized controlled trials (RCTs) and cluster RCTs published between January 1, 1990, and September 20, 2018. There were no language restrictions. We also searched the International Clinical Trials Registry Platform Search Portal and metaRegister of Controlled Trials to identify unpublished trials and checked the reference lists of included studies and relevant systematic reviews for study eligibility. We followed Cochrane methods to select studies, extract data, and appraise and synthesize eligible studies. We used random-effect models for the pooled analysis and assessed statistical heterogeneity by visual inspection of a forest plot and calculation of the I2 statistic. RESULTS Six cluster RCTs and two RCTs with 655 primary care practices, 1392 primary care physicians, and 485,632 patients were included. The interventions included personal digital assistants; short text messages; online digital education including emails and websites; and online blended education, which used a combination of online digital education and traditional education materials. The control groups received traditional education. Six studies assessed postintervention change in clinical practice. The majority of the studies (4/6) reported greater reduction in antibiotic prescription or dispensing rate with digital education than with traditional education. Two studies showed significant differences in postintervention knowledge scores in favor of mobile education over traditional education (standardized mean difference=1.09, 95% CI 0.90-1.28; I2=0%; large effect size; 491 participants [2 studies]). The findings for health care professionals' attitudes and patient-related outcomes were mixed or inconclusive. Three studies found digital education to be more cost-effective than traditional education. None of the included studies reported on skills, satisfaction, or potential adverse effects. CONCLUSIONS Findings from studies deploying mobile or online modalities of digital education on antibiotic management were complementary and found to be more cost-effective than traditional education in improving clinical practice and postintervention knowledge, particularly in postregistration settings. There is a lack of evidence on the effectiveness of other digital education modalities such as virtual reality or serious games. Future studies should also include health care professionals working in settings other than primary care and low- and middle-income countries. CLINICAL TRIAL PROSPERO CRD42018109742; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=109742.
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Affiliation(s)
- Bhone Myint Kyaw
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Lorainne Tudor Car
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Louise Sandra van Galen
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Research & Expertise Center In Pharmacotherapy Education, Amsterdam, Netherlands
| | - Céire E Costelloe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Onyema Ajuebor
- Health Workforce Department, World Health Organization, Geneva, Switzerland
| | - James Campbell
- Health Workforce Department, World Health Organization, Geneva, Switzerland
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
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Lean K, Nawaz RF, Jawad S, Vincent C. Reducing urinary tract infections in care homes by improving hydration. BMJ Open Qual 2019; 8:e000563. [PMID: 31363503 PMCID: PMC6629391 DOI: 10.1136/bmjoq-2018-000563] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 05/21/2019] [Accepted: 06/24/2019] [Indexed: 11/07/2022] Open
Abstract
Dehydration may increase the risk of urinary tract infections (UTIs), which can lead to confusion, falls, acute kidney injury and hospital admission. We aimed to reduce the number of UTIs in care home residents which require admission to hospital. The principal intervention was the introduction of seven structured drink rounds every day accompanied by staff training and raising awareness. UTIs requiring antibiotics reduced by 58% and UTIs requiring hospital admissions reduced by 36%, when averaged across the four care homes. Care home residents benefited from greater fluid intake, which in turn may have reduced infection. Structured drink rounds were a low-cost intervention for preventing UTIs and implemented easily by care staff.
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Affiliation(s)
- Katie Lean
- Patient Safety, Oxford Patient Safety Collaborative, Oxford, UK
| | - Rasanat Fatima Nawaz
- Patient Safety, Oxford Patient Safety Collaborative, Oxford, UK.,Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Sundus Jawad
- Medicines Optimisation Team, NHS East Berkshire Clinical Commissioning Group, Windsor, UK
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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Fitzpatrick F, Tarrant C, Hamilton V, Kiernan FM, Jenkins D, Krockow EM. Sepsis and antimicrobial stewardship: two sides of the same coin. BMJ Qual Saf 2019; 28:758-761. [PMID: 31018985 PMCID: PMC6860726 DOI: 10.1136/bmjqs-2019-009445] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/31/2019] [Accepted: 04/08/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Fidelma Fitzpatrick
- Clinical Microbiology, RCSI, Dublin, Ireland.,Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Vida Hamilton
- Department of Anaesthesia & Intensive Care, University College Hospital, Waterford, Waterford, Ireland
| | - Fiona M Kiernan
- Department of Anaesthesia and Intensive Care Medicine, RCSI, Dublin, Ireland
| | - David Jenkins
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Eva M Krockow
- Department of Health Sciences, University of Leicester, Leicester, UK
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40
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Pedersen PU, Tracey A, Sindby JE, Bjerrum M. Preoperative oral hygiene recommendation before open-heart surgery: patients' adherence and reduction of infections: a quality improvement study. BMJ Open Qual 2019; 8:e000512. [PMID: 31206058 PMCID: PMC6542424 DOI: 10.1136/bmjoq-2018-000512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 03/06/2019] [Accepted: 03/08/2019] [Indexed: 01/08/2023] Open
Abstract
Aim To implement recommendations for oral hygiene before elective open-heart surgery in a thoracic surgery ward and to evaluate whether the number of patients who needed to be treated with antibiotics postoperatively was reduced. Background Healthcare systems are challenged to implement initiatives that reduce the development of nosocomial infections, to offer patients a safe and cost-efficient treatment and to reduce the use of antibiotics. Previous interventions have focused on staff behaviour in reducing postoperative infections. In this study, patients were recommended to carry out oral hygiene as recommended in a clinical guideline. Methods A quasiexperimental design with a control and an intervention group was used. Information on adherence to the recommendation was collected at admission. All medical information and prescriptions of antibiotics were obtained from patients’ medical records. Data were reported as intention to treat. Results Altogether 972 patients (506 controls and 466 interventions) were included in the study. Of the intervention patients, 405 (86.9%, 95% CI 83.3 to 89.8) reported that they had adhered to the oral hygiene recommendation. 64 (12.6%) control patients and 36 (7.7%) in the intervention group (p=0.015) were treated with antibiotics postoperatively. Conclusions It was feasible to involve patients in a programme for oral hygiene and thereby reduce the number of patients needing antibiotics after open-heart surgery and this might contribute to reducing costs.
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Affiliation(s)
- Preben Ulrich Pedersen
- Aalborg University, Department of Clinical Medicine, Centre of Clinical Guidelines and Clinical Research Unit, Aalbirg University Hospital, Aalborg University, Aalborg, Denmark
| | - Anita Tracey
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Jesper Eske Sindby
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Merete Bjerrum
- Section of Nursing Research, Aarhus Universitet, Aarhus, Denmark
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41
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Milani RV, Wilt JK, Entwisle J, Hand J, Cazabon P, Bohan JG. Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports. BMJ Open Qual 2019; 8:e000351. [PMID: 30997411 PMCID: PMC6440589 DOI: 10.1136/bmjoq-2018-000351] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 12/28/2022] Open
Abstract
Importance Antibiotic resistance is a global health issue. Up to 50% of antibiotics are inappropriately prescribed, the majority of which are for acute respiratory tract infections (ARTI). Objective To evaluate the impact of unblinded normative comparison on rates of inappropriate antibiotic prescribing for ARTI. Design Non-randomised, controlled interventional trial over 1 year followed by an open intervention in the second year. Setting Primary care providers in a large regional healthcare system. Participants The test group consisted of 30 primary care providers in one geographical region; controls consisted of 162 primary care providers located in four other geographical regions. Intervention The intervention consisted of provider and patient education and provider feedback via biweekly, unblinded normative comparison highlighting inappropriate antibiotic prescribing for ARTI. The intervention was applied to both groups during the second year. Main outcomes and measures Rate of inappropriate antibiotic prescription for ARTI. Results Baseline inappropriate antibiotic prescribing for ARTI was 60%. After 1 year, the test group rate of inappropriate antibiotic prescribing decreased 40%, from 51.9% to 31.0% (p<0.0001), whereas controls decreased 7% (61.3% to 57.0%, p<0.0001). In year 2, the test group decreased an additional 47% to an overall prescribing rate of 16.3%, and the control group decreased 40% to a prescribing rate of 34.5% after implementation of the same intervention. Conclusions and relevance Provider and patient education followed by regular feedback to provider via normative comparison to their local peers through unblinded provider reports, lead to reductions in the rate of inappropriate antibiotic prescribing for ARTI and overall antibiotic prescribing rates.
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Affiliation(s)
- Richard V Milani
- Center for Healthcare Innovation, Ochsner Health System, New Orleans, Louisiana, USA
| | - Jonathan K Wilt
- Center for Healthcare Innovation, Ochsner Health System, New Orleans, Louisiana, USA
| | - Jonathan Entwisle
- Center for Healthcare Innovation, Ochsner Health System, New Orleans, Louisiana, USA
| | - Jonathan Hand
- Center for Healthcare Innovation, Ochsner Health System, New Orleans, Louisiana, USA
| | - Pedro Cazabon
- Center for Healthcare Innovation, Ochsner Health System, New Orleans, Louisiana, USA
| | - Jefferson G Bohan
- Center for Healthcare Innovation, Ochsner Health System, New Orleans, Louisiana, USA
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42
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Jones TRE, Nurse K. Electronic prescribing: introducing a stat optional dose to improve time to antibiotic on the acute medical unit. BMJ Open Qual 2018; 7:e000292. [PMID: 30623110 PMCID: PMC6307570 DOI: 10.1136/bmjoq-2017-000292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 11/17/2018] [Indexed: 12/29/2022] Open
Abstract
Darlington Memorial Hospital is a district general hospital in the North East of England. The acute medical unit (AMU) takes referrals from the emergency department and also direct from general practitioners (GPs) in the region. Research shows that early recognition and management of sepsis is key to improving outcomes and significantly decreases mortality. Having observed several cases of delayed sepsis management in patients referred from their GP, we aimed to improve time to antibiotic therapy in patients identified as having sepsis as per the National Institute for Health and Care Excellence 2016 NG51 sepsis guidelines. We analysed the time from admission to antibiotic administrations for patients referred to AMU via their GP with suspected sepsis. We found there was a significant delay between antibiotic prescribing and administration. Baseline data showed that only 36% of patients received a stat dose of antibiotic on admission. Results showed that those patients with a stat dose prescribed had a median time of 36 min from prescription to antibiotic compared with 98 min for those without. We introduced a stat antibiotic option with all antibiotic prescriptions on the electronic prescribing system, encouraging prescribers to administer a stat dose. Through focusing on antibiotic prescribing systems and practices over two PDSA cycles, we were able to improve the time from prescription to administration of antibiotics for patients with sepsis. We reduced the delay in antibiotic administration in patients with sepsis from 49 to 34 min, an improvement of 31% (15/49). The percentage of patients receiving a stat dose of antibiotics increased from 36% to 63%. While we acknowledge that there remains room for improvement with regards to antibiotic prescribing and sepsis management, we have made sustainable interventions with important improvements. E-prescribing systems must be evaluated and modified accordingly on a regular basis to ensure that they positively contribute to quality patient care and clinical practice.
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Affiliation(s)
| | - Kim Nurse
- Acute Medical Unit, County Durham and Darlington Foundation Trust, England, UK
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43
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Hamilton D, Bugg I. Improving antimicrobial stewardship in the outpatient department of a district general hospital in Sierra Leone. BMJ Open Qual 2018; 7:e000495. [PMID: 30623113 PMCID: PMC6307603 DOI: 10.1136/bmjoq-2018-000495] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/12/2018] [Accepted: 11/17/2018] [Indexed: 11/30/2022] Open
Abstract
There is global concern over increasing antibiotic resistance rates due to poor antimicrobial stewardship, particularly in low-income and middle-income countries where there are limited diagnostic facilities, fewer doctors per capita and inadequate control over the production and sale of antibiotics. This quality improvement project was designed to improve the antimicrobial prescriptions practices of paramedical staff in the outpatient department of a rural district general hospital in Masanga, Sierra Leone, West Africa. At baseline, 57 of 66 (86%) of patients were prescribed at least one antimicrobial. On further review of 243 prescriptions for 128 patients, only 161 (66%) antimicrobials were deemed appropriate for the named diagnosis when compared with international guidelines or senior medical opinion, and 86 (35%) prescriptions had the correct drug, dose and course-length. A full, empirical antimicrobial guideline was written and introduced to local staff via a number of different methods, including: one-to-one feedback, announcements in general meetings and printed copies placed in each outpatient room. After the first cycle, the choice of appropriate antimicrobial had improved to 85% and the correct drug, dose and course-length to 53%. Unfortunately, 2 months after the second cycle, coinciding with the departure of the international internal medical physician, the rates had degraded to 65% and 43%, respectively. This study shows that implementing an empirical antimicrobial guideline can be effective at improving appropriate antibiotic prescription but that other measures are required for sustainable change. It is suggested that projects designed to change practice in low-resource countries should include national staff from the outset to improve longer term sustainability.
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Affiliation(s)
- David Hamilton
- Critical Care, Northern Care Alliance, Manchester, UK
- Masanga Medical Research Unit, Masanga Hospital, Tonkolili District, Sierra Leone
| | - Ian Bugg
- Humanitarian Studies Department, Liverpool School of Tropical Medicine, Liverpool, UK
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44
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Dehn Lunn A. Reducing inappropriate antibiotic prescribing in upper respiratory tract infection in a primary care setting in Kolkata, India. BMJ Open Qual 2018; 7:e000217. [PMID: 30555928 PMCID: PMC6267302 DOI: 10.1136/bmjoq-2017-000217] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 07/19/2018] [Accepted: 07/21/2018] [Indexed: 12/30/2022] Open
Abstract
Inappropriate antibiotic use is a key factor in the emergence of antibiotic resistance. The majority of antibiotics are prescribed in primary care, where upper respiratory tract infection (URTI) is a common presentation. Inappropriate antibiotic prescribing in URTI is common globally and has increased markedly in developing and transitional countries. Antibiotic stewardship is crucial to prevent the emergence and spread of resistant microbes. This project aimed to reduce inappropriate antibiotic prescribing in URTI in a non-governmental organisation’s primary care outreach clinics in Kolkata, India, from 62.6% to 30% over 4 months. A multifaceted intervention to reduce inappropriate antibiotic use in non-specific URTI was implemented. This consisted of a repeated process of audit and feedback, interactive training sessions, one-to-one case-based discussion, antibiotic guideline development and coding updates. The primary outcome measure was antibiotic prescribing rates. A baseline audit of all patients presenting with non-specific URTI over 8 weeks in November and December 2016 (n=222) found that 62.6% were prescribed antibiotics. Postintervention audit over 4 weeks in April 2017 (n=69) showed a marked reduction in antibiotic prescribing to 7.2%. An increase in documentation of examination findings was also observed, from 52.7% to 95.6%. This multifaceted intervention was successful at reducing inappropriate antibiotic prescribing, with sustained reductions demonstrated over the 4 months of the project. This suggests that approaches previously used in Europe can successfully be applied to different settings.
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45
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Ward C. Point-of-care C-reactive protein testing to optimise antibiotic use in a primary care urgent care centre setting. BMJ Open Qual 2018; 7:e000391. [PMID: 30397661 PMCID: PMC6203029 DOI: 10.1136/bmjoq-2018-000391] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/26/2018] [Accepted: 08/21/2018] [Indexed: 12/04/2022] Open
Affiliation(s)
- Caroline Ward
- Swindon Clinical Commissioning Group, The Pierre Simonet Building, North Latham Road, Swindon, UK.,West of England Academic Health Science Network, South Plaza, Marlborough Street, Bristol, UK
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46
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Thursky K, Lingaratnam S, Jayarajan J, Haeusler GM, Teh B, Tew M, Venn G, Hiong A, Brown C, Leung V, Worth LJ, Dalziel K, Slavin MA. Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs. BMJ Open Qual 2018; 7:e000355. [PMID: 30019016 PMCID: PMC6045757 DOI: 10.1136/bmjoq-2018-000355] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/09/2018] [Accepted: 06/02/2018] [Indexed: 01/14/2023] Open
Abstract
Infection and sepsis are common problems in cancer management affecting up to 45% of patients and are associated with significant morbidity, mortality and healthcare utilisation. Objective To develop and implement a whole of hospital clinical pathway for the management of sepsis (SP) in a specialised cancer hospital and to measure the impact on patient outcomes and healthcare utilisation. Methods A multidisciplinary sepsis working party was established. Process mapping of practices for recognition and management of sepsis was undertaken across all clinical areas. A clinical pathway document that supported nurse-initiated sepsis care, prompt antibiotic and fluid resuscitation was implemented. Process and outcome measures for patients with sepsis were collected preimplementation (April-December 2012), postimplementation cohorts (April-December 2013), and from January to December 2014. Results 323 patients were evaluated (111 preimplementation, 212 postimplementation). More patients with sepsis had lactate measured (75.0% vs 17.2%) and appropriate first dose antibiotic (90.1% vs 76.1%) (all p<0.05). Time to antibiotics was halved (55 vs 110 min, p<0.05). Patients with sepsis had lower rates of intensive care unit admission (17.1% vs 35.5%), postsepsis length of stay (7.5 vs 9.9 days), and sepsis-related mortality (5.0% vs 16.2%) (all p<0.05). Mean total hospital admission costs were lower in the SP cohort, with a significant difference in admission costs between historical and SP non-surgical groups of $A8363 (95% CI 81.02 to 16645.32, p=0.048) per patient on the pathway. A second cohort of 449 patients with sepsis from January to December 2014 demonstrated sustained improvement. Conclusions The SP was associated with significant improvement in patient outcomes and reduced costs. The SP has been sustained since 2013, and has been successfully implemented in another hospital with further implementations underway in Victoria.
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Affiliation(s)
- Karin Thursky
- National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.,National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Senthil Lingaratnam
- Department of Pharmacy, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Jasveer Jayarajan
- Department of General Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Gabrielle M Haeusler
- National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Benjamin Teh
- National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Michelle Tew
- National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.,Center for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,University of Melbourne, Center for Health Policy, Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Georgina Venn
- Department of Infectious Diseases, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Alison Hiong
- Department of Infectious Diseases, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Christine Brown
- Department of Infectious Diseases, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Vivian Leung
- Department of Infectious Diseases, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Leon J Worth
- National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Kim Dalziel
- Center for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,University of Melbourne, Center for Health Policy, Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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47
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Makri V, Davies G, Cannell S, Willson K, Winterson L, Webb J, Kandhari A, Mansour M, Thomas J, Morris G, Matthes J, Banerjee S. Managing antibiotics wisely: a quality improvement programme in a tertiary neonatal unit in the UK. BMJ Open Qual 2018; 7:e000285. [PMID: 29756072 PMCID: PMC5942449 DOI: 10.1136/bmjoq-2017-000285] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/22/2018] [Accepted: 04/18/2018] [Indexed: 12/22/2022] Open
Abstract
Microbial resistance to antibiotics is a serious global health problem compounded by antibiotic overuse and limited investment in new antibiotic research. Inappropriate perinatal antibiotic exposure is increasingly linked to lifelong adverse outcomes through its impact on the developing microbiome. Antibiotic stewardship may be the only effective preventative strategy currently available. As the first tertiary neonatal unit in the UK to collaborate in an international quality improvement programme (QIP) with Vermont Oxford Network (VON), we present the results of our antibiotic stewardship initiative. The QIP was officially launched in January 2016 and aimed to reduce antibiotic usage rate (AUR) by 20% of baseline by 31st December 2016 without compromising patient safety. A multidisciplinary team of professionals and parent representatives shared good practices and improvement strategies through international webinars and local meetings, devised uniform data collection methodology and implemented a number of carefully selected ‘Plan–Do–Study–Act’ cycles. Run charts were used to present data and, where appropriate, statistical analysis undertaken to compare outcomes. The QIP resulted in a sustained reduction in AUR from a baseline median of 347 to 198 per 1000 patient-days (a reduction of 43%). The proportion of culture-negative sepsis screens where antibiotics were stopped within 36–48 hours increased consistently from a baseline of 32.5% to 91%. The antibiotic days per patient at discharge reduced from a median of 3 to 2 days, and there was a reduction in practice variation. Our annual mortality and necrotising enterocolitis rates for the VON cohort (<30 weeks or <1500 g) were the best ever recorded, 5.5% and 1.4%, respectively. Audits confirmed a high level of staff and family awareness of the QIP. The QIP achieved a sustained reduction in antibiotic use without compromising patient safety. Our challenge is to sustain this improvement safely.
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Affiliation(s)
- Vasiliki Makri
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Gemma Davies
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Stephanie Cannell
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Katherine Willson
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Lucy Winterson
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Joanna Webb
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Amit Kandhari
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Maha Mansour
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Joanne Thomas
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Geraint Morris
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Jean Matthes
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Sujoy Banerjee
- Neonatal Unit, Abertawe Bro Morgannwg University Health Board, Swansea, UK
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Abstract
The handover of large numbers of medical patients, during on call periods when staffing levels are reduced, is a challenge for all acute medical services. At the Royal Cornwall Hospital, a large district general hospital, we identified that foundation doctors were reviewing medical inpatients during weekend on call periods with limited written handover information. We chose to address this problem by developing an intervention, a weekend handover sticker, and piloting it. We used the review of documentation to measure improvement and feedback from users to assess the processes involved. Use of the weekend handover form improved the written communication between weekday and weekend teams. The number of weekend plans documented in the notes increased from 15% to 84% and the provision of a patient summary within the last 7 days increased from 26% to 94%. The feedback from users confirmed it was a useful intervention and 100% (15/15) of doctors and nurses responded positively to the question "Do you think the weekend sticker should be introduced and used at the weekend for all medical patients?" The feedback also identified concerns regarding additional workload for weekday ward staff and this has led to ongoing work to try and ensure that the weekend handover form continues to be used effectively to maintain an improved level of written handover information for on call staff. While we have not included a direct measure of patient care, we hope that by improving the quality of written handover information we are acting to ensure patient information is shared effectively, with likely positive impact on patient care.
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Affiliation(s)
- Rhys Martin
- Post Graduate Education, Royal Cornwall Hospital, Cornwall, UK
| | - Melanie Huddart
- Post Graduate Education, Royal Cornwall Hospital, Cornwall, UK
| | - Cara Garbett
- Post Graduate Education, Royal Cornwall Hospital, Cornwall, UK
| | - Wendell Storr
- Post Graduate Education, Royal Cornwall Hospital, Cornwall, UK
| | - Olivia Watts
- Post Graduate Education, Royal Cornwall Hospital, Cornwall, UK
| | - Sanjeev Gupta
- Post Graduate Education, Royal Cornwall Hospital, Cornwall, UK
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49
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Haque A, Hussain K, Ibrahim R, Abbas Q, Ahmed SA, Jurair H, Ali SA. Impact of pharmacist-led antibiotic stewardship program in a PICU of low/middle-income country. BMJ Open Qual 2018; 7:e000180. [PMID: 29333498 PMCID: PMC5759741 DOI: 10.1136/bmjoq-2017-000180] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/27/2017] [Accepted: 12/08/2017] [Indexed: 11/04/2022] Open
Affiliation(s)
- Anwarul Haque
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Kashif Hussain
- Department of Pharmacy, Aga Khan University Hospital, Karachi, Pakistan
| | - Romesa Ibrahim
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Shah Ali Ahmed
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Humaira Jurair
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
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50
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DiDiodato G, McAthur L. Transition from a dedicated to a non-dedicated, ward-based pharmacist antimicrobial stewardship programme model in a non-academic hospital and its impact on length of stay of patients admitted with pneumonia: a prospective observational study. BMJ Open Qual 2017; 6:e000060. [PMID: 29435502 PMCID: PMC5728275 DOI: 10.1136/bmjoq-2017-000060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/29/2017] [Accepted: 09/24/2017] [Indexed: 01/01/2023] Open
Abstract
Pharmacists play an integral role in antimicrobial stewardship (AS). Some AS programmes employ dedicated pharmacists, sometimes with infectious diseases (ID) training, while others employ ward-based pharmacists. The role and impact of both are under investigation. This study compares the length of stay (LOS) of patients admitted to hospital with community-acquired pneumonia (CAP) after the implementation of an AS programme initially led by a dedicated ID-trained pharmacist, and then transitioned to a ward-based pharmacist. Starting 1 April 2013, all adult patients admitted with CAP were prospectively reviewed by the AS programme. The control period (phase 0) lasted 3 months. Thereafter, AS was implemented in each of four medicine wards at 2-month intervals in a staggered fashion. During this period (phase 1), an ID-trained pharmacist and physician performed daily prospective audit and feedback. After 24 months, ward-based pharmacists assumed this AS role (phase 2). Over the 36-month study period, 1125 patients with CAP were entered into the AS database, with 518 and 247 patients receiving an AS audit and feedback in phases 1 and 2, respectively. The acceptance rate for AS recommendations was similar for phases 1 and 2, each exceeding 82%. After accounting for secular trends, the overall reduction in LOS was 19.4% (95% CI 1.4% to 40.5%). There was no difference in LOS between phases 1 and 2. This study demonstrated that an AS audit and feedback intervention reduced the median LOS in patients with CAP by approximately 0.5 days regardless of pharmacist model. However, fewer patients were exposed to the AS intervention in phase 2, suggesting dedicated AS pharmacists may be necessary to realise the full benefits of AS.
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Affiliation(s)
- Giulio DiDiodato
- Department of Critical Care Medicine, Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | - Leslie McAthur
- Department of Pharmacy, Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
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