ABMU Antibiotic Audits An Update Siân Price Antimicrobial Pharmacist

The Background Cardiff and Vale stickers introduced Care bundle introduced and monthly care bundle audits started Feb July Sept April 2011 2012

The ABMU Antimicrobial Care Bundle Applies to all antimicrobials prescribed on the regular side of the medication chart: Documentation of allergy status on medication chart Clear indication for antimicrobial(s) on medication chart Documentation of a stop or review date on medication chart Consistency with Health Board guidelines Use of antimicrobial sticker(s)

The Background Smaller stickers introduced Infection Prevention Board established First monthly audit report Feb July Sept April 2011 2012

Issues with original audit format Labour intensive for ward pharmacists and AM pharmacists Focus on documentation rather than clinical appropriateness Relied on assessment of appropriateness by ward pharmacist – results consistently (falsely?) high Lack of familiarity with guidelines? Lack of confidence in clinically checking antimicrobial prescriptions?

Issues with original audit format No patient/antibiotic details recorded No quality check by AM pharmacist No intervention into patient care

So…… Progress came to a standstill without achieving the targets and…… ….there was a need to move forward and audit more clinical and relevant aspects of antimicrobial prescribing…… ….and further engage with prescribers

Jan 2015 – new format audits Frequency reduced to two monthly Data still collected by clinical pharmacists All patients prescribed systemic antibiotics All acute areas audited Every audit quality checked by AM Pharmacist Coding used to enable automation

Patient details Day of therapy Indication Antibiotic Route

Data Reported Care bundle data: Clear indication for antimicrobial(s) on medication chart Documentation of a stop or review date on medication chart Use of antimicrobial sticker(s) Documentation of allergy status no longer audited (duplication of All Wales patient safety thermometer data)

4 Key Prescribing Indicators Percentage of antimicrobial prescriptions assessed as appropriate in terms of choice of antimicrobial Percentage of antimicrobial prescriptions over 7 days (excluding deep seated and high risk infections) Percentage of prescriptions for surgical prophylaxis over 24 hours Percentage of IV antimicrobial prescriptions over 72 hours (excluding deep seated and high risk infections)

Trigger Points Prescribing Indicator Trigger Point Rationale for Trigger Point Percentage of antibiotic prescriptions assessed as appropriate in terms of choice of antimicrobial ≤ 95% Current target Percentage of antibiotic prescriptions over 7 days (excluding deep seated and high risk infections) ≥ 20% All Wales average = 19% Percentage of antibiotic prescriptions for surgical prophylaxis over 24 hours All Wales average = 30%, which also requires improvement Percentage of IV antibiotic prescriptions over 72 hours (excluding deep seated and high risk infections) ≥ 30% All Wales average = 48% (does not include deep seated and high risk infections) Directorates reaching these trigger points highlighted to the C. difficile Improvement Group and asked to investigate further

Exclusions > 7 days IV > 72 hours Liver abscess Osteomyelitis Septic arthritis Empyema Cavitating pneumonia S. aureus bacteraemia Severe necrotising soft tissue infections Infected implants/prostheses Meningitis Encephalitis Intracranial abscess Mediastinitis Endocarditis Exacerbation bronchiectasis/CF Medical prophylaxis Neutropenic sepsis Liver abscess Osteomyelitis Septic arthritis Empyema Cavitating pneumonia S. aureus bacteraemia Severe necrotising soft tissue infections Infected implants/prostheses Meningitis Encephalitis Intracranial abscess Mediastinitis Endocarditis Exacerbation bronchiectasis/CF Hospital-acquired pneumonia

Benefits of new format Information more relevant to prescribers Identify poorly performing areas Identify gaps in pharmacists’ knowledge Intervene in individual cases to improve patient care Reported to Clostridium difficile group for directorates to investigate Enables directed, in-depth audits by clinicians (minimum 2 audits per year)

Feedback received from directorates – mostly positive/constructive The First Report Directorate Feedback received from directorates – mostly positive/constructive

Teething Problems…. Approximately 20% prescriptions excluded from assessment of appropriateness as indication not featured in guidelines Low numbers of surgical prophylaxis audited Needed to change some exclusions e.g. HAP (IV>72 hours) More codes/code changes needed Help from PHW to simplify and ensure only necessary data collected More education of pharmacists needed Some prescribing indicators may not be applicable to some specialities

The Future Interactive data (Tableau) down to speciality level via Public Health Wales Care bundle data to be inputted automatically into FOC database Continue to adapt based on feedback and amend/add to guidelines Trend data ? Audit by consultant (anonymously)

Summary Major changes to ABMU audit format introduced Jan 2015 Modifications made after Jan and March data collections Data appears to be more meaningful Still a work in progress……

Thank you for listening Any Questions?