SMC Antibiotic Prescribing Policy

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Scottish Model Antibiotic Policy and
Prescribing (APPP)
Dilip Nathwani
Ninewells Hospital Medical School March 2003
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Background

• Antibiotics in hospitals
• 30 of hospitals pharmacy budget,
• 65 of inpatients are treated inappropriately
• Antibiotic policies
• 62 of UK hospitals have a policy for antibiotic
  therapy
• Few have information system for easy assessment
  of practice

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Our study indicates a high level of confidence
amongst respondents that current control measures
are succeeding, and yet the usage patterns found
in this study indicate poor performances of these
same control measures
BSAC Working Party 1994 Hospital antibiotic
control
4
...to ensure efficacy of control measures
and improved prescribing we need to include
the organisation features and implementation proce
dures of policies and formularies, the science
and psychology of prescribing, the design of
proper programmes for monitoring and evaluation
of therapy and prophylaxis and, most importantly,
the instigation of therapy and prophylaxis
BSAC Working Party 1994 Hospital antibiotic
control
5
The Issues in Scotland

• In Scotland there are a number of challenges
  related to antimicrobial prescribing facing
  hospitals.
• Evidence of wide variation in antimicrobial
  prescribing policy and practice
• Concern about insufficient regular liaison
  between microbiologists, clinicians and
  pharmacists
• Concern about inadequate supervision of
  prescribing and inappropriate choice, duration
  and records of administration by junior doctors
• Need to work particularly on standardisation of
  approaches to acute hospital prescribing of
  antimicrobials
• Evidence of suboptimal linkage between
  prescribing and infection expertise
• Need for hospital wide multidisciplinary
  approaches to antimicrobial prescribing including
  role and limitations of medicines, knowledge of
  local susceptibility patterns, use of IV and oral
  routes, duration of treatment and prophylaxis,
  monitoring of levels and routine collection of
  data in relation to outcomes, streamlining/rationa
  lisation and use of laboratory results

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SCOTTISH ACTION PLAN ON ANTIMICROBIAL RESISTANCE
AND HAI MINISTERIAL TASK FORCE

• Prudent Antimicrobial Prescribing is at the core
  of the Scottish Action Plan on Antimicrobial
  Resistance, alongside surveillance of resistance
  and control of healthcare associated infection.
• Prudent Antimicrobial Prescribing requires
  multidisciplinary collaboration with a rigorous
  approach to combining the best available research
  evidence with detailed knowledge of local
  clinical needs and antimicrobial resistance.

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Antimicrobial prescribing policy and practice in
Scotland recommendations for good antimicrobial
practice in acute hospitals

• JAC 2006 57 1186-1196
• http//www.Scotland.gov.uk/publications/2005/09/02
  132609/26114

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SMC and SEHD HAI TASK FORCE working party

• Bryson S
• Charlwood R
• Dancer S
• Davey P
• Gould I
• Gray R
• Haughney J

• McIver L
• Maxwell S
• Nathwani D
• Power A
• Seaton A

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APPP KEY DOMAINS FOR RECOMMENDATIONS
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1. Establish standard structures and lines of
responsibility and accountability in NHS Scotland
across Boards

• Chief Executives of Boards and Single Delivery
  Units take overall responsibility for APPP
  within acute hospitals
• HAI and prescribing should be on NHS boards Local
  Delivery Plan which has replaced the Local Health
  Plan and PAF.

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2. Define structures and responsibility for
multi-disciplinary and generic undergraduate and
post-graduate training related to antimicrobial
prescribing

• Undergraduate
• to roll the programme out to all UK medical
  schools
• Postgraduate
• To roll out and develop programmes for
  non-medical prescribers (nurses, pharmacists,
  dentists etc)
• Based around clinical vignettes and link to
  competencies around antibiotic prescribing

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2. Define structures and responsibility for
multi-disciplinary and generic undergraduate and
post-graduate training related to antimicrobial
prescribing

• Undergraduate
• Appropriate Antibiotic Prescribing for Tomorrows
  Doctor (APT) Project Funded by SEHD and BSAC
  http//www.dundee.ac.uk/facmedden/APT/index.htm.
  Web-based learning tool.
• Postgraduate
• Scottish National Antibiotic Prescribing
  Project (SNAPP) is funded by National Education
  Scotland and the HAI SEHD Taskforce. E-learning
  tool.
• Aimed at on line training for doctors in training
  at foundation level link between DOTS
  (https//www.nhsdots.org/nhsdots/dotsx/login.asp)
  and NES HAI portal ( http//www.elib.scot.nhs.uk/
  portal//hai/Pages/index.aspx)

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Recommendation 3 Hospital Structures

• Multi-disciplinary anti-microbial management
  team main remit implementation of the APPP
  document
• Replaces current antibiotic subcommittee
  (formulary, guidelines/protocols, new drugs,
  audit etc)
• Lead Pharmacist and Lead Clinician for
  Prescribing of Anti-microbials
• Anti-microbial quality coordinator
• Communication of information (prescribing
  quantity and quality), ensuring action
  (implementation) and bridge between each of the
  clinical groups and AMT

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Establish standard structures and lines of
responsibility and accountability in NHS Scotland
across Boards

• Antimicrobial Management Team (AMT) should be
  formed to implement APPP. This should include a
  microbiologist and/or id physician, a senior
  management representative (e.g senior infection
  control manager) and Lead Doctor and Lead
  Pharmacist. Liase with DTC ICT.
• Lead Doctor and Pharmacist should have prime
  responsibility in ensuring the delivery of the
  APPP objectives and is directly accountable to
  the CE.

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Antibiotic Prescribing Policy Practice in Acute
Hospitals
Medical Director
Chief Executive
Infection Control Manager
Drugs Therapeutics Committee
Risk Management Committee
Antimicrobial Management Team (AMT)
Clinical Governance Committee
Dissemination feedback
Infection Control Committee
Speciality-based Pharmacy leads for APPP with
responsibility for antimicrobial prescribing
Microbiologist / Infectious Diseases Physician
Prescribing support / feedback
Ward Based Clinical Pharmacists
PRESCRIBER
http//www.scotland.gov.uk
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NHS TAYSIDE VISION

• In Tayside proposed Infection Control Managed
  Network directly accountable to NHS Board
• Strategic Function with lead Infection Control
  Doctor, Lead Infection Control Nurse /Consultant,
  Public Health, Infection Control Manager, Lead
  Pharmacist and Lead Doctor for Prescribing and
  Antibiotic Quality Co-ordinator. ? Risk
  Management Lead
• Operational Function Infection control team,
  public health, risk management and AMT.

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The Clinical Effectiveness Cycle
Health intervention
New Research Systematic Reviews
Guideline development
Guideline implementation
Compliance measurement
Standard setting
Minimum data set Clinical audit criteria
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5. Define key areas for acute hospital policy and
recommendations for audit

• National collection of consumption data to
  evaluate use trends
• Facilitate audit of quantity and quality of
  antimicrobial consumption by use of point
  prevalence snapshot survey
• STRAMA
• GAAT
• ESAC

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European Surveillance of Antimicrobial
Consumption ESAC
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ESAC II (2004-2007)

• Main objectives
• To consolidate the continuous collection of
  comprehensive antibiotic consumption data in all
  European countries, for ambulatory care and
  hospitals
• To disseminate our knowledge in the field of
  antibiotic consumption by the development of an
  interactive ESAC website
• To develop health indicators of antibiotic use
  based on consumption data, to validate these
  indicators and to use a set of core indicators
  to give feedback of the antibiotic consumption in
  the participating countries

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ESAC II

• Additional objective
• To deepen the knowledge of antibiotic consumption
  
• For hospital care (HC), data for individual
  hospitals/wards
• In ambulatory care (AC), data for specific
  prescriber groups, specific age and sex
  categories, specific high consumers groups and
  for specific indications
• Additionally (HC AC), a pharmaco-economic
  evaluation

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Define the minimum dataset requirements and
standard procedures for collecting information
related to antimicrobial consumption and quality
of prescribing at an organisational level and/or
ward specific level.

• A national agency should collate and report
  antimicrobial utilization trends across Scotland.
  It is intended that these data would be collected
  centrally by an organisation such as the
  Medicines Utilisation Unit within NHS National
  Services Scotland.
• All acute hospitals should analyse and report
  antimicrobial use using the WHO DDDs
  (http//www.escmid.org/Seviware/Script/SvFiles.asp
  ?Ref404 ) as the numerator and occupied bed days
  as the denominator.
• Responsibility for setting standards and
  reporting hospital antimicrobial use should be
  clearly identified and implemented within all
  acute hospitals.
• In order to facilitate audits of antimicrobial
  prescribing there should be national
  co-ordination of minimum datasets for clinical
  records to support prescribing for common
  infections.

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6 PERFORMANCE INDICATORS FOR ANTIMIROBIAL
PRESCRIBING

• Systems should be in place to measure
• qantimicrobial consumption by defined daily dose
  (DDD) /1000 bed days for key antimicrobials.
  Once such systems are developed and their
  interpretation refined they should be considered
  for assessment as an additional Board Performance
  Indicator.
• q the number of courses of antimicrobial therapy
  exceeding 24 hours, expressed as a percentage of
  the total number of courses in patients having
  clean surgery.
• q the number of antibiotic courses prescribed in
  line with hospital policy for community acquired
  pneumonia (CAP), expressed as a percentage of all
  antibiotic courses prescribed for CAP

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Alert Antibiotics Ansari et al, JAC 52
(5)842-848, 2003.

• First implemented August 2001
• By 2004 clear evidence that use was going back up
• Re-launched February 2006 with quarterly feedback
  via clinical groups
• Pharmacy initiated consults to support early
  switch from April 2006

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Controlled Before After, 2 Hospitals
Barlow et al 2006
Before
After
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36
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Intervention
Winter 2002
Winter 2003
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APPP Future

• Needs active implementation-early signs of action
  by some boards
• National co-ordination of consumption data
  collection and feedback
• Identify appropriate audit tool but link this to
  quality improvement e,g at specific ward levels
  or problem areas
• Extend education and training particularly to non
  specialist prescribers