Tasmanian Infection Prevention and

Control Unit

Antimicrobial Utilisation

Surveillance Protocol

Version 1.0

(April 2010)

Department of Heal th & Human Services

Editors:

• Catherine Drake, Drug Utilisation & Evaluation Pharmacist, RHH (behalf of TIPCU)

• Duncan McKenzie, ID Pharmacist, RHH (behalf of TIPCU)

• Dr Alistair McGregor, Specialist Medical Advisor, TIPCU, DHHS

• Amber Roberts, State-wide Medication Co-ordinator, DHHS

• Mr Brett Mitchell, Director, TIPCU, DHHS

3

Contents

FOREWORD 5

BACKGROUND 6

INCLUSION CRITERIA 7

EXCLUSION CRITERIA 11

DENOMINATOR DATA 11

SPECIFICS & DEFINITIONS 12

PROCESS OF SURVEILLANCE 13

DATA COLLATION 14

REPORTS 14

QUALITY IMPROVEMENT 14

REFERENCES 15

5

FOREWORD

Health care associated infections (HAIs) can have a significant impact on the functioning of a health

service and more importantly, have an impact on patients and the quality of health care we provide for

the population.

Within the health care system and related environment, we strive to prevent infections. The patient

must be at the centre of what we do with the desired outcome of care being to minimise and reduce

the risk of infection. The prevention and control of infection must be the responsibility of many

disciplines, involve all members of the health care team, and not simply be the role of a professional

trying to manage this solo.

The Department of Health & Human Services has taken a proactive step in the prevention and control

of health care associated infections by establishing the Tasmanian Infection Prevention & Control Unit.

One of the functions of Unit is to co-ordinate and implement surveillance programs for health care

associated infections in Tasmania. Surveillance of health care associated infections is crucial in

understanding the current infection control issues in Tasmania and provides a means by which

performance can be monitored. It also prepares Tasmania for any future changes in the epidemiology

of health care associated infections.

Patterns of antimicrobial usage within healthcare facilities have an important impact on HAIs. The

inappropriate and over use of antibiotics results in increased rates of antimicrobial resistant micro-

organisms, which in turn are responsible for an increasing and difficult to manage proportion of HAIs.

The monitoring and evaluation of patterns of antimicrobial use is an important aspect of addressing this

problem.

Surveillance is just one of many aspects needed for the successful prevention and control of infections

and we welcome, support and fully endorse the surveillance program outlined in this document.

Dr Roscoe Taylor Dr Craig White

Director of Public Health Chief Health Officer

BACKGROUND

During 2008, the Australian Commission on Safety & Quality in Healthcare recommended monitoring

and analysis of antibiotic usage. This surveillance protocol supports this recommendation.

It is widely understood that the inappropriate and overuse of antimicrobials is a major driver of

increased rates of antimicrobial resistance amongst bacteria, particularly in hospital settings. Many of

these resistant bacteria (such as Methicillin resistant Staphylococcus aureus, Vancomycin resistant

Enterococci and Clostridium difficile) are important and increasingly reported causes of HAIs.

Institutions and countries that have successfully minimised the inappropriate and excessive use of

antimicrobials have seen reductions in the rates of resistant bacteria and infections caused by these.

An essential first step in this process is the accurate monitoring and analysis of antimicrobial usage, as

detailed in the following protocol.

The methodology used is consistent with that used in the Australian National Antimicrobial Usage

Surveillance Program (NAUSP) which currently collates data from approximately 50% of Australia’s

principal referral hospitals.

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INCLUSION CRITERIA

• Surveillance is restricted to Tasmanian acute hospitals, with the following inclusions:

Clinical areas to be included in monthly datasets

• Acute adult in-patient antibiotic use only (to include imprest and individual patient supply) • Exclude outpatient and discharge drug issues • Includes Emergency Department use (i.e. imprest and inpatient use, not outpatient dispensing)

o Any overnight bed-stay figures allocated to Emergency Departments are included in the bed-stay figure for the hospital

• Exclude paediatric/neonatal use (where possible - it may not always be possible to exclude all paediatric use if not with specialist wards or units)

• Exclude use by psychiatric units • Exclude use by rehabilitation units • Exclude Hospital-in-the Home use • Exclude same-day procedure areas • Exclude palliative care inpatients if they can be separated (e.g. such as off-site ward associated with

RHH) • Separate datasets for ICU and 'non-ICU' (i.e. other wards, theatres etc) where possible.

o If pharmacy data cannot be supplied separately for ICU, a single 'total hospital ' dataset. o Note: In general ‘ICU’ should not include use by high dependency, CCU or similar units. If these

categories can not be excluded from the usage reported from the ICU imprest, then a ‘total hospital’ dataset should be submitted.

RHH wards included in the dataset

• Last reported to the national surveillance group as equalling 261 beds. • RHH has contributed “total hospital” antimicrobial usage data to the NAUSP since mid 2004. • Separate reporting of ICU usage figures can be undertaken for RHH, as patient acuity in the unit fits

required definition (i.e. minimal numbers of CCU/HDU patients). o Separate ICU reporting has not occurred to date, but is planned to occur with the new reporting

system to be in place in 2010. o “Total hospital” usage data for the RHH will continue to be reported to allow for historical

comparison.

Table 1: RHH wards currently included in iPharmacy national antibiotic surveillance report

Site iPharmacy ward

code (cost_cntr_xid)

iPharmacy ward description

(cost_cntr_desc)

Number

of beds

RHH RHH1BN 1BN Medical Ward 27

RHH RHH1BS 1BS Oncology Inpatient Ward 20

RHH RHH2BS 2B Medical Ward 38

RHH RHH2DC 2DC Cardiology Ward 12

RHH CARD_UNIT Cardiac Unit 4

RHH RHH2DS 2DS Cardio Thoracic Surgery Ward 17

RHH RHHDEMR ED - Emergency Department n/a

RHH RHH6A GSU - General Surgical/ Gynae Ward 6A 26

RHH RHHDCCM ICU Intensive Care Unit 14

RHH RHH3D Maternity Ward 3D 26

RHH RHH1H NSU - Neurosurgery Ward 24

RHH OPER_TH Operating Theatre n/a

RHH RHH2A Orthopaedics (ORU) Ward 2A 25

RHH RHH5A SSU - Specialist Surgery Ward 5A 18

RHH RHHESSU ESSU - Emergency Short Stay Unit 10

(Note – the RHH wards and descriptors will be reviewed in light of changes that will occur with the

implementation of the iPM patient administration system at the RHH in med 2010).

LGH wards included in the dataset

• Number of beds included in the LGH dataset – 195 beds • Separate reporting of ICU usage figures cannot be undertaken for LGH, as usage includes CCU/HDU

patients

Table 2: LGH wards currently included in iPharmacy national antibiotic surveillance report

Site

iPharmacy

ward code

(cost_cntr_xid)

iPharmacy ward

description

(cost_cntr_desc)

Additional

description

Current

ward?

Number

of beds

LGH LGHED Accident & Emergency Dept Yes n/a

LGH LGHICU Intensive Care Unit Yes 11

LGH LGHW4B Ward 4B Birthing Suite Yes 6

LGH LGHW4D Ward 4D Renal/Med Yes 28

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LGH LGHW4O Ward 4O Obstetrics Yes 26

LGH LGHW5A Ward 5A Surgical Yes 28

LGH LGHW5B Ward 5B Surgical Yes 32

LGH LGHW5D Ward 5D Oncology/Med Yes 32

LGH LGHW6D Ward 6D Stroke/Med Yes 32

LGH OPE Operating Theatre Suite Yes n/a

LGH AEIP Accident & Emergency Dept

Stock Issues No

LGH AEOP Accident & Emergency Script

Dispensing No

NWRH Burnie wards included in the dataset

• Number of beds included in the NWRH dataset – 84 beds • Separate reporting of ICU usage figures cannot be undertaken for NWRH, as usage includes

CCU/HDU patients

Table 3: NWRH Burnie wards currently included in iPharmacy national antibiotic surveillance report

Site

iPharmacy

ward code

(cost_cntr_xid)

iPharmacy ward description

(cost_cntr_desc)

Current

ward?

Number

of beds

NWRH NWRHDEM ACCIDENT-EMERGENCY NWRH Yes n/a

NWRH NWRHICU INTENSIVE CARE NWRH Yes 8

NWRH NWRHME MEDICAL WARD NWRH Yes 34

NWRH BOT OPERATING THEATRE BURNIE Yes n/a

NWRH NWRHSC SURGICAL CENTRAL NWRH Yes 26

NWRH NWRHSW SURGICAL WEST NWRH Yes 16

NWRH BAE ACCIDENT & EMERGENCY BURNIE No

NWRH BICU BURNIE INTENSIVE CARE UNIT No

NWRH BMED BURNIE MEDICAL WARD No

NWRH BSC BURNIE SURGICAL CENTRAL WARD

(B) No

NWRH BSW BURNIE SURGICAL WEST WARD (A) No

MCH wards included in the dataset

• Number of beds included in the MCH dataset – 101beds • Separate reporting of ICU usage figures cannot be undertaken for MCH, (HDU only).

Table 4: MCH wards currently included in iPharmacy national antibiotic surveillance report

Site

iPharmacy

ward code

(cost_cntr_xid)

iPharmacy ward description

(cost_cntr_desc)

Current

ward?

Number

of beds

MERSEY MCH1A SURGICAL WARD 1A MCH Yes 19

MERSEY MCH1B SURGICAL WARD 1B MCH Yes 19

MERSEY MCH3A MEDICAL WARD 3A MCH Yes 17

MERSEY MCH3B MEDICAL WARD 3B MCH Yes 17

MERSEY MCHBIRTH MATERNITY/GYNAECOLOGICAL 2B

MCH Yes 12

MERSEY MCHWCHC MATERNITY/GYNAECOLOGICAL 2A

MCH Yes 13

MERSEY MCHDEM ACCIDENT - EMERGENCY MCH Yes n/a

MERSEY MCHHDU HIGH DEPENDENCY MCH Yes 4

MERSEY MOT OPERATING THEATRE MCH Yes n/a

MERSEY M1A SURGICAL WARD MCH 1A No

MERSEY M1B SURGICAL WARD MCH 1B No

MERSEY M3A MEDICAL WARD MCH 3A No

MERSEY M3B MEDICAL WARD MCH 3B No

MERSEY M2A MATERNITY/GYNAECOLOGY MCH 2A No

MERSEY M2B MATERNITY/GYNAECOLOGY MCH 2B No

MERSEY MAE ACCIDENT & EMERGENCY MCH No

MERSEY MHDU HIGH DEPENDENCY UNIT MCH No

• Imprest medications for MCH wards are supplied by NWRH Burnie. Due to this - the following MCH wards in the NWRH iPharmacy site need to be included in the antibiotic surveillance report for MCH.

Table 5: MCH wards attached to the NWRH iPharmacy site to be included in iPharmacy national antibiotic

surveillance report

Site

iPharmacy

ward code

(cost_cntr_xid)

iPharmacy ward description

(cost_cntr_desc)

Current

ward?

NWRH MCH1A SURGICAL WARD 1A MCH Yes

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NWRH MCH1B SURGICAL WARD 1B MCH Yes

NWRH MCH3A MEDICAL WARD 3A MCH Yes

NWRH MCH3B MEDICAL WARD 3B MCH Yes

NWRH MCHBIRTH MATERNITY/GYNAECOLOGICAL 2B MCH Yes

NWRH MCHWCHC MATERNITY/GYNAECOLOGICAL 2A MCH Yes

NWRH MCHDEM ACCIDENT-EMERGENCY MCH Yes

NWRH MCHHDU HIGH DEPENDENCY MCH Yes

NWRH HOT OPERATING THEATRE MCH Yes

NWRH HSA SURGICAL WARD MCH 1A No

NWRH HSB SURGICAL WARD MCH 1B No

NWRH HMA MEDICAL WARD MCH 3A No

NWRH HMB MEDICAL WARD MCH 3B No

NWRH HMAT MATERNITY/GYNAECOLOGY MCH 2A No

NWRH HOBS MATERNITY/GYNAECOLOGY MCH 2B No

NWRH HAE ACCIDENT & EMERGENCY MCH No

NWRH HICU HIGH DEPENDENCY UNIT MCH No

NWRH MCHWCHU 2A MCH No

EXCLUSION CRITERIA

The exclusion is implicit from the inclusion criteria.

DENOMINATOR DATA

Denominator data will be provided to the NAUSP by the TIPCU and will be consistent with the definitions

applied nationally. Examples of such include:

Bed stay data

• Matching monthly overnight stay occupied bed days are also required for both 'total hospital' and ICU - this will exclude day patients.

• Bed stay data needs to match the wards the antibiotic usage report has been limited to (i.e. the same subset of wards should be used for the bed stay data).

• If ICU and total hospital use are being reported on separately, then separate overnight bed day data needs to be submitted for ICU and the whole of hospital (including ICU).

• Overnight stay occupied bed days for the specified month can be accessed for all sites via the DHHS FYI Executive Information System.

SPECIFICS & DEFINITIONS

National data requirements requested for drug usage report confirm with the following:

• Datasets should be forwarded in Excel or .csv format each month. • The only specific requirements are 'drug description' and 'quantity'.

• Data should be aggregated to provide one line per item if possible to minimise problems associated with negative amounts from credited items.

• There is no requirement to select particular antimicrobials for inclusion or exclusion. o Provision of data for total 'anti-infectives' or 'antibacterials and antifungals' is preferred. o Antivirals, anthelmintics and other groups may also be included (not currently analysed). o Any particular agents or dosage forms not required will be discarded automatically during

processing (antibacterials are currently the only subset that is analysed by the national reporting group).

Drug usage data supplied by Tasmanian hospitals to surveillance program

• Supplied in Excel format. • Monthly report of drug product name and quantity of vials/tablets used in specified month. • Includes inpatient and imprest use only. Outpatient and discharge supplies are excluded. • Includes all anti-infectives (i.e. antibacterials, antifungals, antivirals and antihelmintics). • Includes all dose forms (intravenous, oral, topical etc).

Functionality of current iPharmacy Report

• Report used for the national antibiotic surveillance is titled ‘Monthly - National Antibiotic Reporting incl ICU_TAS’.

• This report can be run centrally by any iPharmacy user with appropriate privileges.

• The report returns the aggregate quantity used of each anti-infective product during the specified timer period. If there has been no use of a product in the time period it will not be listed.

• The report limits data to: o Inpatient dispensing and imprest and requisition supplies. o Requisitions or inpatient dispensings that are cancelled or returned to pharmacy for credit are

taken into account, (if they have been credited against the patient or ward). o All drugs which are coded as anti-infectives are included (in iPharmacy this correlates to

products with SHPA Codes 4200000 to 4700000 and 4955000 to 4957000). o Wards that have been flagged to be included in the report (by adding the flag ‘abx’ into the

‘Account4’ field in the cost centre maintenance screen of iPharmacy).

• Flagging wards for inclusion in the report. o Wards to be included in the RHH, LGH and NWRH usage reports are flagged by adding the

text ‘abx’ into the ‘Account4’ field in the cost centre maintenance screen of iPharmacy. o Because in iPharmacy the MCH wards exist at both the MCH and NWRH sites, the MCH

wards to be included are flagged at both sites by adding the text ‘mch’ into the ‘Account4’ field in the cost centre maintenance screen of iPharmacy.

• New wards or new products o If new wards are created in iPharmacy or new descriptors are created for existing wards – for

these wards to be included in the report, the ‘abx’ flag (or for MCH wards the ‘mch’ flag) needs to be present in the correct field (as outlined above).

o Both ‘current’ and ‘non-current’ (old) wards are included in the report to allow retrospective reporting.

o If new products are added to iPharmacy they will be automatically added to the report if they have been assigned an SHPA code in the specified range. New drugs that do not have an appropriate SHPA code available in the system will need one to be created.

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PROCESS OF SURVEILLANCE

A monthly report will be run for each participating hospital at one location (Royal Hobart Hospital),

using iPharmacy. The report will be sent to the TIPCU who will include the necessary bed day data.

The TIPCU will forward to the NAUSP. The NAUSP will undertake the data analysis and forward

reports back to each hospital directly and to the TIPCU.

The process is summarised by the following diagram.

Report run for all

hospitals

Data sent to TIPCU

Bed day data added

TIPCU forwards to NAUSP

NAUSP undertakes analysis /

develops reports

NAUSP sends reports

to hospitals & the

TIPCU

DATA COLLATION

Data will be analysed by the NAUSP, according to national definitions and processes.

ADDITIONAL REPORTS

Additional reports may be produced upon request on a limited basis.

DATA HANDLING

All information held by the TIPCU will be done in accordance with the information privacy principles as

set out in the Privacy Act (Cth) 1988 and the personal information protection principles as set out in the

Personal Information Protection Act 2004.

REPORTS

It is vital that hospitals can compare rates in order to comply with quality improvement and clinical

governance frameworks.

Key Principles of Reports/Data Presentation:

Reports will be sent to the each hospital (nominated person) and

• may be available on the TIPCU internet site with the above principles applied.

• results from this particular piece of surveillance may also be included in the TIPCU annual report

• reports will be developed in a manner as directed from DHHS

QUALITY IMPROVEMENT

For issues of governance and quality improvement, where results from a participating organisation

cause concern, the Chief Executive Officer of that area will be informed in line with the TIPCU

operational policy. Issues raised from surveillance are to be used within the participating organisation’s

own quality improvement frameworks and participation in the program assumes this will occur.

The HAI Steering Committee will also review and discuss results and reports pertaining to any work

undertaken by the TIPCU in respect to the DHHS.

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REFERENCES

Australian Commission on Safety and Quality in Healthcare (2008) Reducing Harm to Patients from Health Care Associated Infection: The role of Surveillance. Commonwealth of Australia.

TASMANIAN INFECTION

PREVENTION & CONTROL UNIT

Division of Population Health

Department of Health and

Human Services

Editors: Brett Mitchell, Dr

Alistair McGregor & Saffron

Brown

GPO Box 125, Hobart 7001

Ph: 6222 7779

Fax: 6233 0553

Email: tipcu@dhhs.tas.gov.au