philip howard consultant antimicrobial pharmacist programme for... · antimicrobial audit philip...

Medicines Management & Pharmacy Services

Antimicrobial Audit

Philip Howard

Consultant Antimicrobial Pharmacist


Leeds Teaching Hospitals NHSTrust (North of England)

• Serves population 900k plus 2.5mfor tertiary services

• ~ 2300 inpatient beds

• 2 teaching hospitals: LGI & SJUH

• 3 peripheral sites

• £93m drug budget (£17m AB)

• 430 staff incl ~125 pharmacists, 8Microbiologists & 3 Infectiousdisease consultants


LTH Antimicrobial Consultant Pharmacist

• 2008 - worstacute teachinghospital in UK forMRSA and Cdifficile

CDI Acute Teaching

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Cases

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Best Rate

MRSA Acute Teaching

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Best Rate • DoH: undertakeregular audit until youare assured thatguidelines areembedded into practice


Audit & feedback as an element ofAntimicrobial Stewardship

• Developed on-line antimicrobial resource

• Each speciality to undertake oneantimicrobial related audit each quarter• Guidelines, TDM antibiotics, MRSA screening, etc

• Develop a plan and enter onto Clinical Audit databasein advance. Enter results when completed

• NOT a repeat the ward pharmacist audit

• Ward pharmacists to do a monthly pseudopoint-prevalence audit

• Audit tools available on-line


Posters: How to prescribe antimicrobialsRegularMedicines

Month& year:Oct ‘07

Date:1/10

2/10

3/10

4/10

5/10

6/10

7/10

8/10

9/10

DAY 1 2 3 ┬ Drug (1)

TRIMETHOPRIM

Dose

200mg8-9 │

│Route

PO

Additional Instructions

Uncomplicated UTI

3 day course

Date

1/10/0713-14 │

17-18 │ AD

occt

or

(DO

CT

OR

1/1

0/07

Sign (NAME & Bleep)

A Doctor

(DOCTOR)1234

Pharm Supply

21-22 ┴

RegularMedicines

Month& year:Oct ‘07

Date:1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10

DAYDrug (1)

FLUCLOXACILLIN

Dose

2g8-9

R/VRoute

IV

Additional Instructions

Cellulitis

Review 48 hrs

Date

2/10/07

13-14

17-18Sign (NAME & Bleep)

A Doctor

(DOCTOR)1234

Pharm Supply

21-22

An Indication Duration or Review Date

Indication letseveryone know thereason why. Easy tocheck if correct.

Review at 48 hours.C&S resultsStop / step down tooral or narrowspectrum agentLess AB resistance


Over 65 years?

Decrease C. difficile risk

Avoid if possible:

clindamycin

cefuroxime

ceftazidime

ciprofloxacin


Prescribe antimicrobials correctly

Print name and contact number


Beware of disguised penicillins!

Don’t give penicillin allergic patients:

Tazocin

Piperacillin-tazobactam

CoAmoxiclav (Augmentin)

Amoxicillin-clavulanic acid

CoFluampicil (Magnapen)

Ampicillin-flucloxacillin


Education sessions for junior doctors


All in-patient wards audited onany one single day each monthby the ward pharmacist

Results entered onto aspreadsheet by secretary

She chases up any late audits =100% for last 9 months

Entered onto Trust dashboardwith other HII

Report to Trust, Divisional,Specialty or Ward level.


HCAI monitor snapshot

On home page of hospitalwebsite – link to KPIs


CQUIN target: £100k / qtr (>90% in Q4)

keys to success• initially part of the board report for HCAI. “What’s so difficult about writing….• part of medicines management CQUIN


Peer review for duration (blue line) &indication (red dots) on prescriptions?

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* = electronic

Confidential sharing of data (30 Trusts) place us 3rd behind onewith electronic prescribing and a previously poorly performingTrust. Only 3 trusts would publicly share data


Antimicrobial Medicines Code Audit

• Achieved Local CQUIN target of >90% worth £100k per quarter (just)• ward level data and trends on LHP Antimicrobials performance pages

Division league table Pts on Abs/no of

ABs

Indication on chart Review date or

duration on chart

Prescriber ID clear

Trust 450/627 92% (+1%) 91% (+1%) 88% (-6%)

Take 5 Feb Medicine 42/71 90% (-4%) 89% (-4%) 82% (-8%)Medicine 174/248 95% (+4%) 95% (no change) 90% (-2%)

Oncology-Surgery 122/157 92% (no change) 91% (-8%) 90% (+7%)WCHN&D 82/131 88% (+1%) 89% (+3%) 85% (no change)

Specialist Surgery 72/91 86% (+9%) 81% (-9%) 81% (-6%)

Speciality Pts on Abs/no of ABs Indication on chart Review date or

duration

Prescriber ID clear

Derm & Rheumatology 3/3 100% (no change) 100% (no change) 100% (no change)

Cardiology 8/10 100% (+44%) 100% (+22%) 100% (+22%)

Cystic fibrosis 11/40 98% (-2%) 98% (-2%) 100% (no change)

Respiratory 43/60 98% (no change) 98% (no change) 90% (-1%)

Elderly 59/70 97% (+3%) 97% (+6%) 84% (+12%)

Diabetes & Endo 14/15 93% (+1%) 93% (+1%) 93% (-7%)

Infectious disease 10/14 100% (+8%) 93% (+5%) 100% (+8%)

Renal 17/25 88% (+7%) 92% (+11%) 84% (+7%)

Urgent care 5/6 83% (+16%) 83% (+16%) 100% (no change)

Acute medicine 7/8 63% (-22%) 50% (-35%) 75% (-25%)


Antimicrobial Usage

Last yr vs prev LTH Div A&E AcuteMed

DiabEndo

Olderpeopl

e

Renal Dermatology

GUMed

ID Cardiology

Total broadspectrum

8% 10%

82% 78% -15% 6% 4% 0% 23% 5% -65%

1st gen ceph(CDI) -36% -58% -28% -54% -11% -60% -31% 44% -31% -26% -84%

2nd gen ceph(CDI) -28% -3% 12% -3% 79% -81% -5% -100% n/a 154% -35%

3rd genceph(CDI>MRSA)

11% 17% 33% 67% -27% 136% 21% -36% 5% 199% -17%

Ciprofloxacin(MRSA>CDI)

11% 10% 73% 234% -44% 8% 6% -4% 12% -12% 65%

Clindamycin (CDI) 82% 91% 588% 310% -58% 109% 0% -22% n/a -8% -43%Co-amoxiclav (CDI) 38% 30% 62% 54% 28% 22% 80% 45% 742% -3% 83%Meropenem(MRSA)

5% 3% -23% 21% 20% 41% -26% 383% -100% 236% -86%

Piperacillin-tazobactam(MRSA)

15% 12% 27% 51% 61% 12% -5% 22% n/a 11% 31%


Antimicrobial Audits – 1 per quarter• audit of common guidelines used in specialty, MRSA screening & decolonisation orhigh risk drugs e.g. gentamicin, vancomycin (not Take 5 or rpt of Pharmacist audit)• enter a plan onto LTH Clinical Audit Database for the year, and update resultswhen complete.

Specialty Q1 results Q2 results Q3 results Q4 plan/results

Div Audit rate 55% 82% 73% 45%

GU Med UTI Pharyngeal gonnorhoea Epididymitis Chlamydia

Cardiology Cannulae CannulaeAB Med Code &

CannulaeCannulae

Renal Peritonitis in PD PD exit site infections MRSA screening in HD CDI#

Infectious disease UTI* Vancomycin Rx/ Qual of AB

Rxing*None listed None listed

Cystic fibrosis Pulm CF Exac Home vs IP Abs Neb Abs Self-med of Abs*

Respiratory AB Rx stds Levofloxacin in CAP VIP NICE TB*

Dermatology None listed Notes & Rx (no AB) None listed None listed

Urgent care None listed Sepsis Cipro in OP None listed

Elderly None listed Micro liaison Cannulae packavailability

None listed

Acute medicine None listed None listed CAP* None listed

Diab & endo None listed None listed None listed None listed

* New entries this month = 4 #=no results


Antimicrobial Audits – 1 per quarter• Audit of common guidelines used in specialty, MRSA screening &decolonisation; SSI prophylaxis; commonly used AB treatment guidelines, highrisk drugs e.g. gentamicin, vancomycin.• Enter a plan onto LTH Clinical Audit Database for the year, and update resultswhen complete.• 1 new audit last quarter by Ortho (MRSA screening & decolonisation =100%).

Specialty Q1 results Q2 results Q3 plan / results Q4 plan

Critical care AB Med Code MRSA screen x2 MRSA proph None planned

T&O None recorded MRSA prophMRSA screen CAH (+2

unfinished in #’s

Chronic

periprosthetic inf

Rheumatology None recorded OP AB Rxing MRSA screen None planned

Plastics None recorded AB guidelines Cellulitis Skin prep OT

Neurosurgery None recorded SSI proph x 2 SSI proph x 2 None planned

Cardiac surgery None recorded None recorded AB Med Code None planned

Theatres & DC None recorded None recorded AB proph N/S None planned

Neurology None recorded None recordedPEG proph (plan, but no

results)None planned


Key lessons learnt

• Antibiotic prophylaxis wasn’t being given incision(vascular) in >50%. Introduced WHO SaferSurgery checklist early.

• CDI severity not being assessed so difficult toidentify if correct agent being used

• Patients at high risk of MRSA not routinelyreceiving correct teicoplanin based prophylaxis

• Restricted antimicrobial code durations suppliedby trainees are longer than consultants.


Primary Care Audits in Leeds

• Quality Outcomes Framework (QoF)

• Antimicrobials not included

• Medicines Management points allow for audit

• Quinolone

• Asked all GP practices to audit their prescribingagainst their guidelines

• Cephalosporins

• New guidelines

• Audit against guidelines

• Stop reporting cephalosporin sensitivities to urinesunless only one other option


Leeds PCT Quinolone Audit ResultsAppropiate prescribing for quinolones (Avg 59.9%)

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Quinolone changes

Figure 10 - Yorkshire & The Humber PCTs: Weighted Quinolone prescribing; April 2007 to September

2010

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0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4 1011Q1 1011Q2

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Barnsley

Bradford & Airedale

Calderdale

Doncaster

East Riding of Yorkshire

Hull Teaching

Kirklees

Leeds

North East Lincolnshire Care Trust Plus

North Lincolnshire

North Yorkshire & York

Rotherham

Sheffield

Wakefield District

Yorkshire & The Humber

North of England

England


Cephalosporins over timeFigure 6b - Yorkshire & The Humber PCTs: Weighted Cephalosporin prescribing; April 2007 to

September 2010

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0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4 1011Q1 1011Q2

Ite

ms

/10

00

An

tib

ac

teri

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(CH

I)S

TA

R-P

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Barnsley

Bradford & Airedale

Calderdale

Doncaster

East Riding of Yorkshire

Hull Teaching

Kirklees

Leeds

North East Lincolnshire Care Trust Plus

North Lincolnshire

North Yorkshire & York

Rotherham

Sheffield

Wakefield District

Yorkshire & The Humber

North of England

England


Summary• Reporting monthly to Trust board as part of HCAI

report forces change

• League tables encourage competition andimproves performance

• Specialties with more HCAI engage better intheir own audit

• GPs can improve performance where “paid” toaudit own practice

• Doctors will audit prescribing against guidelineseach month with new HII AntimicrobialPrescribing

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