Managing Antibiotics Wisely A Quality Improvement Programme Gemma Davies, Vanessa Makri, Stephanie Cannell, Sujoy Banerjee on behalf of all staff on the neonatal unit at Singleton Hospital

Why this initiative? Antibiotic resistance is increasing Bugs are becoming really clever! Inappropriate use of antibiotics There are very few new antibiotics in the pipeline! Arch Dis Child Fetal Neonatal Ed 2012;97:F141-F146

NICU - Antibiotic use Wide variation in antibiotic use No difference in Proven sepsis NEC Death Surgical case volume Differ only in rates of suspected infection !! Schulman J et al. Pediatrics 2015; 135(5):826-33

Challenges of antibiotic stewardship Highly emotive set up Vulnerable population Defensive custom and practice Need for evidence of benefit to the specific population

The critical period ……

The evidence…………. Kupalla VS et al. J Pediatr.2011;159:720-5

The beginning….

The groundwork….. Group participation in a series of webinars to identify and share good practices and tool kits Out of hours!! – majority of consultants, senior nurses, lead pharmacist, CEO, one or two motivated parents!! Multiple debates - dedicated meetings - agree a common way forward that is…. Realistic and achievable Take into account resources – staff, time Measurable Sustainable Entails an amount of risk that is acceptable and is manageable

Set an overarching SMART aim Reduce antibiotic usage rates by 20% of baseline by 31st December 2016 without compromising patient safety

Establish a culture of antibiotic Stewardship MDT Team Data handling Senior leaders Reduce duration of antibiotics Agree guideline Introduce PDSA Measure change SMART Aim Reduction of AUR by 20% Agree intervention PDSA Measure change Reduce initiation of antibiotics Involve parents Posters, leaflets Newsletters Audit awareness Family & staff involvement

Outcome definitions AUR ( Antibiotic Usage Rates) – primary outcome No. of days on antibiotics /1000 patient days stratified by class Analysed every 15 days – disseminated every month Secondary outcomes Days of antibiotics / patient @ discharge – Run Charts & other analysis Proportion of babies discharged who never received antibiotics % of antibiotics stopped appropriately at 36 -48hours Other outcomes Parent awareness – % aware of antibiotic use and intended duration Any evidence of harm reported ** excluded prophylactic anti fungal, trimethoprim and antivirals

Data collection A written, uniform and pragmatic methodology Baseline data – November 2015 – January 2016 Triangulation of data reliability Prescription chart audit - Pharmacist Clinical notes audit – Team of ANNP, medical and nursing staff Badgernet outputs Badgernet daily entries- standardised for all analysis Rotating teams - avoid fatigue and monotony

Initiation Establish baseline data VON spot day audit – Feb 2016 – 50-75th © Parent awareness campaign – high awareness Introduction of PDSA cycles

Examples of PDSA cycles PDSA 2: review and stop antibiotics at 36 hours Introduction of antibiotic stickers Culture of challenge – pharmacist, nurses, Grand round, parents Measure and review PDSA 1 Raise Staff and Parent Awareness Webinars Posters Leaflets Audits PDSA 3: Reduce initiating antibiotics in low –risk well babies >30 weeks Incidence and days of antibiotics saved Analysis of harm PDSA 4: Stop antibiotics early if baby well, cultures –ve (5 days or CRP<10 whichever earlier)

Informing and engaging Newsletters keep team informed of progress Maintain enthusiasm highlight areas for improvement Posters & leaflets Parent awareness audits

Progress so far………

All patients admitted to NNU All patients with negative blood culture Baseline data Parameter All patients admitted to NNU All patients with negative blood culture AUR (median ) (No. days on antibiotics /1000 patient days) 347 268 AUR (mean ) 322 276 No. of days on antibiotics at discharge (days/patient) (mean) 5.5 4.9 (days/patient) (median) 3 Proportion of culture negative patients where antibiotics were stopped by 36-48 hours - 32.5% Proportion of admitted patients who never received antibiotics 21.9%

New Rotational staff Graph 2:

Aware of QIP Agree QIP VON Web 1 VON Day Audit VON Web 2 PDSA 1 PDSA 2 PDSA 3 VON Web 3 VON Web 4 PDSA 4 PDSA 5 VON Web 5

Graph 5:

Mortality and morbidities ( <30 wks, ,1500 gms) Years Mortality NEC Culture positive sepsis 2014 14% 7.6% 16.9% 2015 12.3% 4.9% 14.3% 2016* 5.5% 1.4% 19.4% Source VON * 10 babies still to be entered

All patients admitted to NNU (Baseline) All patients admitted to NNU Table 2: Manging Antibiotics Wisely - Comparative results – End of programme report Parameter All patients admitted to NNU (Baseline) All patients admitted to NNU (End of Programme) All patients with –ve blood culture (Baseline) (End of programme) AUR (median ) (No. days on antibiotics /1000 patient days) 347 198 (↓43%) 268 153 (↓43%) AUR (mean ) 322 198 (↓38.5%) 276 (↓44.6%) No. of days on antibiotics at discharge (days/ patient) (mean) 5.5 2.3 (↓58.2%) 4.9 1.7 (↓65.3%) (days/patient) (median) 3 2 (↓33.3%) 2 (↓33.3%) Proportion of culture negative patients where antibiotics were stopped by 36-48 hours - 32.5% 91% Proportion of discharged patients who never received antibiotics 21.9% 41.2%

Our journey….. Strengths Challenges Severe staff shortages Rotational staff Defensive mindset Variation in practice Changes not always evident in short term – ‘The lag’ Long lengths of stay Changes too small Well motivated team Strong leadership Data monitoring tools Good communication Excellent early results No adverse events so far

Conclusions Challenging and a worthwhile activity Embraced by a wide multidisciplinary team Demonstrated strong clinical leadership; change in culture is palpable and evident in all data set Remarkable drop in AUR ( ~43%) – sustained No compromise in patient safety Challenge -sustain improvement over a longer period