Messina. A, Van den Bergh. D, Gokool. V, Vieira. L, Jenkinson. I, Singh. N, Jacobs. T

7 November 2015

Pharmacist intervention improves the

early administration of antimicrobials

across 33 private hospitals.

RESULTS

32,985 patients assessed for ‘hang time’ compliance of first doses of new antibiotic orders over 60 weeks

21,069 patients compliant.

Change in compliance improved from 41.2% pre-intervention week 1 (164/398) to 78.4% post

intervention week 60 (480/612) p<0.0001.

3

CARE • DIGNITY • TRUTH • PARTICIPATION • PASSION

Understanding systems

Paul B. Batalden, MD, Professor of Pediatrics, of Community and Family Medicine

The Dartmouth Institute for Health Policy and Clinical Practice at The Dartmouth Medical School

“Every system is perfectly designed

to achieve exactly the results it gets”

Paul Batalden

“All improvement

needs a change

Not all change is

an improvement”

4

CARE • DIGNITY • TRUTH • PARTICIPATION • PASSION

Quality defects

Time

40

20

0

Quality

improvement

Original zone of

quality control/ practice

New zone of

quality

control/practice

LESSONS LEARNED

Ddo

Sstudy

Pplan

Aact

Juran Trilogy:

RATIONALE FOR THE INTERVENTION

• Ensuring the timely administration of antimicrobials is critical in the management of patients with

infections.

• Mortality increases by 7.6% for every hour of delay in the administration of antimicrobial therapy in

patients with sepsis1.

• The time elapsed from the written antibiotic order to actual intravenous administration or ‘hang-time’

can often be several hours due to logistics within the hospital.

• Our purpose is to evaluate the change in compliance of administering antimicrobials within an hour of

prescription after implementation of a national antibiotic stewardship pharmacist-driven ‘hang-time’

process improvement protocol.

Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical

determinant of survival in human septic shock. Crit Care Med. 2006; 34:1589-96.

COMMON BARRIERS

• The following barriers are common reasons for the delay of antibiotic administration in South African

hospital settings:

o use of paper charts,

o delays in delivery of the prescription order to the pharmacy,

o delays in prescription chart assessment,

o processing time in pharmacy,

o delivery delays in the transportation of medication from the pharmacy to the wards and,

o routine fixed medicine dosing schedules

o reconstitution of IV antibiotics by nursing staff at the patient bed side.

• ‘Hang time’, referred to as the “golden hour” of antibiotic administration, is a fundamental process which

relies extensively on the involvement, collaboration and participation of all healthcare team members

including: doctors, pharmacists, nursing staff and hospital management.

• As a result, it provides a multi-disciplinary platform to augment the awareness required when initiating

and driving an antibiotic stewardship program in a hospital.

0%

20%

40%

60%

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100%

%

week

HOSPITAL 1HANGTIME % COMPLIANCE (< 1 hour)

Start Date 2 April 2012

% compliance Median % Compliance

Early Adopters

Ddo

Sstudy

Pplan

Aact

Learning

session 2

Learning

session 1

PDSA

cycles

PDSA

cycles

Learning

session 3

intensive support

Breakthrough Series : QI methods – accelerating spread and impact

• Learn from each other so we can make a bigger impact faster

• Input of skills, tools and reflective learning

• Identify common challenges and opportunities that we can work on

together

• Motivate and support each other to succeed.

• Stretch the boundaries of what is possible

Accelerating change “together”:

Creating a learning network of hospitals

Best available

clinical evidence

and experience

plus local

relevance

Antibiotic ‘hang-time’ implementation tool kit for 33 hospitals

Building the

collaborative

0

4 Week Baseline

for each hospital

1

Implementing

and driving the

change

2

Continued data

collection

3

Collation of data

of all 33 hospitals

4

• Nursing and

pharmacy

management

• Evidence and

rationale

• Standardised

measurement tool

• Launch date

• Allocated time to

collect hang-time

baseline

• Captured into

template

• Reviewed at each

hospital

• Submitted to

project leader

• Continued data

collection on

template

• Collated weekly at

hospitals and

feedback provided

to unit managers

• Submitted monthly

to project leader

• Project leader

collated all the

data from 33

hospitals

• Excluded some

data

• Small group

educational

sessions by

pharmacists

• Doctor

engagement

• Poster as reminder

• Time of prescribing

• Sharing solutions

Tracking using Multiple Graphs – Hang Time

Antimicrobial Stewardship with Pharmacist Intervention

Improves Timeliness of Antimicrobials

Across Thirty-three Hospitals in South Africa

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% o

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Netcare Group Weekly Run Chart: Percentage of patients compliant to Hang Time <1 Hr (n=33)

% Compliance to Hang Time <1 Hr Median: % Compliance to Hang Time <1Hr

There are no prizes for predicting the rain

Only for building an Ark

CONCLUSION

• Timely administration of antimicrobials should be

considered a low-hanging fruit component of AMS.

• Pharmacy led inter-disciplinary engagement between

doctors and nurses to strengthen the importance of

early administration of antimicrobials to improve patient

care.

• Structure and rigor of data allows real time feedback of

data to front line staff is a key strategy to get sustained

buy-in.

• Sharing knowledge and value of collective learning.

Dispel myth of low resource

• Making a greater impact together

• Extending our work to record and publish for others to

adapt or adopt

ACKNOWLEDGEMENTS

• Netcare clinical pharmacists, pharmacy managers, nursing staff and nursing

management, hospital management

• Doctors

• Prof Debbie Goff