The Hospital Pharmacy Initiative for promoting prudent use of antibiotics in hospitals

1
The Hospital Pharmacy Initiativefor promoting
prudent use of antibiotics in hospitals

• Dr. Hayley Wickens
• St. Marys Hospital, London W2

2
In this session

• Role of the hospital pharmacist
• Strategic drivers for pharmacy services
• The Hospital Pharmacy Initiative
• Hows the money being spent?
• Working together practical examples
• Challenges ahead

3
Current roles of the hospital pharmacist

• Admission
• Drug history
• ADR assessment
• Interception of drug errors
• Supply function
• Pre-admission clinics
• Discharge
• Writing discharge Rx
• Dispensing for discharge
• Pharmaceutical care

• Inpatient stay
• Risk reduction clarification of Rx, dosage,
  identifying managing interactions
• Encouraging high-quality rational prescribing
  presence on ward rounds
• Monitoring efficacy
• Promoting cost-effectiveness
• Production advocacy of evidence-based formulary
  / guidelines / policy

4
Efficacy of clinical pharmacy services

• Improved patient care
• More appropriate, cost-effective use of medicines

applied to anti-infectives?
Schumock et al (2003) Pharmacotherapy 23113-132
NAO (2001) A Spoonful of Sugar
5
SMAC report (1998)The path of least resistance

• A realistic expectation would be that more
  appropriate prescribing would prevent the
  situation deteriorating further
• Pharmacists, particularly in hospitals, have an
  important role in controlling prescribing and
  identifying inappropriate prescribing

6
WHO Global Strategy for the Containment of
Antimicrobial Resistance (2001)

• The most effective infection control team
  consists of a physician, a microbiologist,
  infection control nurses, pharmacist(s) and
  hospital management representatives

7
The hospital pharmacy mandate for Micro/ID

• Health Service Circular 1999/049
• Policies/guidelines annual review
• Support CPD for all professional groups
• Reduce inappropriate prescribing
• Clinical governance
• Medicines management framework
• Standard 16 Lead pharmacist for antimicrobial
  prescribing

8
Star ratings for NHS Trusts implementing
Winning Ways (2003)

• Does the Trust have an up-to-date policy on
  antimicrobial prescribing?
• Is this audited?
• Is support for prudent prescribing provided by
  clinical pharmacists, medical microbiologists and
  ID clinicians?

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The Hospital Pharmacy Initiative for promoting
prudent use of antibiotics in hospitals

• CMO/CPhO letter June 2003
• 12m over 3 years to hospital pharmacists in
  England to monitor and control more carefully the
  use of antibiotics
• Allocated via PCT
• SHA to monitor use of funds - ?mechanism
• Outcome measures not defined
• Non-cost! e.g. ivpo, EBM guidelines, prophx,
  IC, paeds
• Follow up SACAR

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Micro/ID Pharmacists in the UK

• In 2000 85 UK Trusts contacted
• 60 hospitals had no ID pharmacist
• 25 hospitals had an ID pharmacist
• 20 with ID and HIV duties
• 5 with sole ID duties
• many new posts since then

• UKCPA network national Infection Management
  practice interest group (2001)
• E-mail newsgroup, meetings and workshops
• Local groups, collaborative research

Lawson et al (2000). J Infect 40A31.
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Infection Management Group membership June 2004

• 110 members
• 84 in England
• 46 specialising in abx/ID

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How is the money being spent?

• UKCPA e-mail newsgroup Sept/Oct 2004
• How is your Trust using the DoH money allocated
  last June?  Quick answers (e.g. 'staff' 'books'
  'software' 'education' 'what money?' etc.) would
  be just fine

• 33 responses
• All respondents had employed new staff or
  expanded current staff role

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Increased pharmacy staffing

• 4 hospitals already had ID/abx Ph
• 1 ? upgrade
• 1 ? tech
• 2 ? new junior Ph posts
• Most new jobs part-time

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What does a micro/ID pharmacist do?
Education clinicians, nurses, pts, Phs
Clinical role member of ID/micro team
Monitoring abx use and expenditure financial
control
Infection Control integrating abx control into
IC
Audit Feedback adherence to guidelines etc
Knox et al (2003) JHI 5385-90 Weller Jamieson
(2004) JAC 54295-298
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Micro/pharmacy collaboration at St. Marys

• Microbiology Pharmacist post (since 1998)
• Split 0.6 Micro/ID, 0.4 Pharmacy
• Aim To facilitate best practice in use of
  antimicrobials within the Trust safe,
  rational, effective and economic
• Education and training, publicity!
• Advice on drug choice and monitoring
• Liaison between Pharmacy and Micro/ID/IC
• Antibiotic Review Group
• Policies, protocols and audit

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St Marys WAR

• Weekly antibiotic rounds (WAR)
• Patients identified by ward pharmacists
• Inappropriate dose/route/duration
• Non-policy abx choice

• Microbiologist and/or Microbiology Pharmacist
  review all queries follow up with clinicians
• Complex or repeated events - pts and docs seen on
  WAR, plan written in notes

Wickens Jepson (2003) Pharm J 271744-745
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3 month query log

• 242 queries
• Choice of drug (73), duration (29),
  dose reductions (21), monitoring (17) etc.
• 46 different drugs
• Most common vancomycin
• 19 required a literature search or written answer
• Approx 20 ? WAR

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Query log outcomes

• Of 242 queries received
• 47 required no change in therapy
• Monitoring e.g. timing of gentamicin levels,
  outcome of sensitivity testing, repeat cultures
  sent
• Information provided e.g. predicted serum
  concentrations vs MICs, availability of
  unlicensed products
• 195 required a change in therapy
• Fed back via ward pharmacist or directly to team
• 2 (1) declined advice
• 21 (11) outcome not documented
• 172 (88) advice followed

19
Hammersmith Hospitals

• Two ID pharmacists, integrated with IC/ID teams
• Antibiotic Steering Group, meets 6 weekly
• Reports to DTC, feed in from Clinical Guidelines
  Committee and New Drugs Panel
• Rolling programme of reviewing guidelines,
  restriction policies, prescribing errors
• Audits of drug monitoring, prophylaxis etc
• Regular point prevalence studies
• Data guides subsequent activities
• Collaborative Research

Dean et al (2002) Int J Pharm Prac 10 121-125
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Southampton SUHT

• Directorate antibiotic teams
• Consultant microbiologist, SpR, senior
  directorate pharmacist
• Patients identified by ward pharmacist, clinical
  teams and microbiology
• Ward based weekly patient review

• 56K reduction in medical directorate drug costs
  (2001)
• 18 of reviews abx stopped, further 20 modified
• 70 of modifications IV ? oral

Wylie et al (2003) JHI 54246
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Ipswich Hospital NHST

• Weekly Micro-Pharm Review ward round
• made possible by DH money new post
• Referrals taken from ward pharmacists
• 3 months 51 patients reviewed
• 25 on unnecessary abx
• 30 on inappropriate abx
• 5 required iv?po switch
• Training needs identified MRSA/LRTI

Cheesman, M (2004) personal communication
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Challenges ahead

• Building an evidence base?
• Outcome measures
• Cost easiest measure, but may be misleading
• Usage DDDs, national hospital data?
• Microbiological long-term, confounding factors
• Clinical difficult, labour-intensive
• Formal descriptive study of funding use and
  outcomes in progress
• Recurrent fundingthe search is on!

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Summary the specialist microbiology pharmacist

• A point of contact between pharmacy/micro/ID/IC
• Identifying where input required
• Efficient engagement with clinical teams
• Can help to rationalise antibiotic use
• ? direct/indirect costs, ?limit spread of
  resistance
• addressing clinical governance in abx prescribing
• Hospital Pharmacy Initiative funding
• Increasing numbers of specialists
• Outcomes awaited

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Acknowledgements

• Dr. Alison Holmes
• Dr. Kieran Hand
• UKCPA - IMG
• Dr. Annette Jepson
• the Micro/ID/IC team at St. Marys