1. ANTIBIOTIC PRESCRIBING AUDIT IN PALLIATIVE SETTING
11th Annual All Wales Palliative Care Conference
Thursday 3rd November 2011
Matthew Angilley
Slide 1
Undertook Yr 3 Student Selected Component in palliative medicine, spending most of my time down in the Marie Curie Hospice in Penarth.
Undertook an audit looking at the antibiotic prescribing practice of the medics and it is the results of this audit that I am going to share with you today.

2. Background HAI’s a significant problem
An infection that an inpatient acquires, whilst being treated in hospital for a reason other than the infection in question (WHO)
9% prevalence (BMA 2009)
COSTLY
a bit about why this is an important and relevant topic to clinical practice.
hospital acquired infections/healthcare associated infections are a significant problem facing today’s healthcare providers.
A study by the British Medical Association found a 9% prevalence of HAIs in 2009 and this is similar to the worldwide estimation of 8.7%
Costly to both the patient and the healthcare providers. While the patient has avoidable and potentially life-threatening symptoms and complications, providers incur loss most through the number of increased bed days, which on average is found to be an additional 6.5 days.
Further interventions, additional investigations along with isolation and barrier nursing costs contribute to this further.
So this is clearly a significant issue, to which there are a number of contributing factors. *

3. HAIs on the rise Therapeutic interventions Facilities
Patient susceptibility
Environmental factors
Behaviour of HCPs
RISE in HAIs
Focus on 3 that I feel are particularly relevant to palliative medicine*
These factors that contribute to the rise in HAI prevalence include:
1 The ageing population and also the increasing treatment of patients who are seriously ill has lead to an increase in patient susceptibility
2 The use of medical devices that breach the natural barriers are another factor.
3 The behaviour of HCPs, in terms of infection control measures
4 Cleanliness of our hospitals
5 Extensive movement of patients within our systems and a high bed-occupancy rate
6Facilities available, with not enough single use rooms and shared bathrooms
7 AMR leading to multi-resistance organisms.
Organisational factors
AMR
BMA 2006

4. In Palliative medicine
Facilities
Therapeutic interventions
Patient susceptibility
Environmental factors
Behaviour of HCPs
RISE in HAIs
In palliative medicine, all the general factors identified are relevant but I have highlighted these as being particularly contributing in this field.
The degree of underlying illness in patients has been identified as one of the two strongest risk factors and clearly in PM the patients often have a complex and sometimes long standing underlying illness. Furthermore they are rendered further susceptible by the treatments they receive.
The delivery of these treatments and also the history of their illness often mean they have lines, for treatment, feeding and so on.
And the nature of the complexity of their illnesses means the patients move between departments, and from hospital to hospice, NHs etc.
One of the most easily addressed factors in terms of practical terms is to try and reduce antimicrobial resistance*
Organisational factors
AMR

5. Antimicrobial resistance is a consequence of the inappropriate use of medicines
WHO
Which is occuring as a direct consequence of the inappropriate medicines we prescribe in healthcare everyday. Most documents adressing HAI reduction therefore, emphasise that the use of antimicrobials should be governed strictly and appropriateness, quite a simple concept, should be more readily governed and this was emphasised by the WHO*

6. *who chose as their topic for World Health Day in 2011, AMR, a direct consequence of the inappropriate use of medicines.
Recognising the importance of this issue, they have made several recommendations to improve the situation and promote antimicrobial stewardship.
On to audit…

7. Audit Aims Assess the practice of antibiotic prescription by doctors
Improve the maintenance of effectiveness of antibiotic therapy
Ensure a minimised contribution to resistance and HAIs development
Reducing associated costs
The aims of this audit were as follows:
Overall, to assess the prescribing practice of antibiotic prescription by the doctors, confirming or otherwise compliance with policy.
Through improvement in practice as a result of audit findings and recommendations, the aim is to improve the maintenance of these therapies and in doing so, ensure a reduced contribution to the development of HAIS and AMR.
This will then reduce costs to the Hospice associated with the development of HAIs.

8. Audit Retrospective review (reduce bias)
All patients admitted in March 2011, regardless of discharge date or outcome.
Hospice uses policy from the Velindre Trust
The audit was carried out in the 30-bedded inpatient unit and the inclusion criteria was all patients admitted as an inpatient during March 2011, regardless of their discharge outcome. This was a retrospective case note and drug chart review. This method was chosen in order to eliminate any bias that may result from knowledge that the audit is occuring.
The 1000 lives campaign along with DofH and WHO recommend that all healthcare providing services have a policy or guidelines for Antimicrobial use and the Hospice uses the Policy developed by the local Velindre NHS trust. I audited against the guidelines that were in use during March 2011 but I know that since then a knew version has been released.
The standards for audit were all taken from this policy*

9. Standards 1
The clinical indication for any prescribed antibiotic should be clearly stated upon initiation in the medical notes
100% 2
The clinical indication for any prescribed antibiotic should be clearly stated upon initiation in the special instructions box on the treatment chart 3
Appropriate samples should be sent for microbiological analysis whenever possible before treatment initiation 4
Treatment duration should be specified for all prescribed antibiotics 5
Treatment start date should be annotated on all re-written charts 6
Treatment should be reviewed upon receipt of results when available 7
Parenteral treatment should be switched to oral when there is evidence of clinical improvement, whenever possible* 8
Choice of treatment should be made according to up to date prescribing guidelines 9
Previous antibiotic treatment should be a factor when considering choice of therapy
It was felt that each of these should be achieved in 100% of cases where they are applicable and so the wording took this into account.
Standard 1-4 and 8-9 were assessed as achieved or not achieved, while 5 and 7 were assessed if applicable. 6 was only assessed if 3 was achieved.
The standard relating to choice of antibiotic was based on the guidance issued within the Velindre policy, although when further guidance was required the C&V guidelines were consulted.

10. 51 admissions during March 2011, identified from palcare database
Antibiotics prescribed on drug chart?
YES =
18 patients
Standards 1, 2, 3, 4, 8 and 9 assessed as yes (achieved) or no (not achieved)
Standards 5 and 7 only assessed if applicable to the case
Standard 6 assessed only if standard 3 was achieved
NO=
33 patients
This shows how the patients were identified and how the standards were assessed.
Looked at all antibiotics prescribed onto the inpatient drug chart

11. 1
The clinical indication for any prescribed antibiotic should be clearly stated upon initiation in the medical notes
83% 2
The clinical indication for any prescribed antibiotic should be clearly stated upon initiation in the special instructions box on the treatment chart
19% 3
Appropriate samples should be sent for microbiological analysis whenever possible before treatment initiation
56% 4
Treatment duration should be specified for all prescribed antibiotics
44% 5
Treatment start date should be annotated on all re-written charts
67% 6
Treatment should be reviewed upon receipt of results when available
70% 7
Parenteral treatment should be switched to oral when there is evidence of clinical improvement, whenever possible
100% 8
Choice of treatment should be made according to up to date prescribing guidelines 9
Previous antibiotic treatment should be a factor when considering choice of therapy
16%
Results

12. Results Percent (%) Standard
This displays the results graphically. The first red line demonstrates where we should be aiming for, in terms of 100% achieving status for all standards.
The red line is set at 50% to show which standards are poorly achieved ie less than 50% achievement at time of audit.
Results

13. Analysis 3 cases indication not documented at all
? Documentation issue
100% was achieved in IV to oral switch, however the rest of the standards fell short of this expected level so there is scope for improvement.
Documentation of indication in notes, treatment start date on rewritten charts and review on receipt of results was done in more than 2/3 of cases, along with choice being made according to the guidelines.
Not achieved so well: documentation on drug chart
samples being sent
treatment duration specified
use of previous therapy to guide choice – may be due to this being carried out in a hospice with limited access to medical records and previous treatment knowledge.
Limited by the fact that this was retrospective so these may be embedded in the practitioners thought process but not getting written down, so is this a documentation problem?
Of note: In 3 cases the indication was not noted anywhere.

14. Recommendations
Reintroduce the policy into the hospice, in order to increase awareness of the policy and its contents, and promote safe prescribing.
Policy should be made easily available on each of the wards and a copy should be given to each prescribing practitioner for easy reference.
The summary page from the policy should be displayed at a point of visibility, for example in the treatment room on each ward.
Education of the prescribing practitioners is important and all doctors should be made aware of the expectations of prescribing practice and the contents of the policy when they start their jobs at the hospice.
The stock of antibiotics kept at the hospice should be based around those that are recommended in the policy to enable the use of these as recommended treatments.
Recommendation reiterate those of WHO in their campaign, who recognise that poor education was a key factor as well as a lack of guidelines/poor compliance to existing guidelines
Therefore: centres should have in place guidelines, provide ongoing education, monitoring and review (audit etc)

15. Improve documentation:
Legally documentation is essential
Doctors working out of hours need to have a clear picture of why the patient has been on the drug – have often not met the patient
Particularly important when doctors rotate jobs – it was noted that documentation was particularly poor during this time window
Use of this sticker used by the UHB may aid this
Cardiff and Vale University Health Board

16. Thank you

17. ANTIBIOTIC PRESCRIBING AUDIT IN PALLIATIVE SETTING
11th Annual All Wales Palliative Care Conference
Thursday 3rd November 2011
Matthew Angilley