1. Prescriber Led Antibiotic Audits and Ward Rounds
Charlotte Makanga
Antimicrobial Pharmacist
BCUHB
16/09/2018

2. Background
Betsi Cadwaladr University Health Board - the largest health organisation in Wales.
Clostridium difficle outbreak in 2012/13
Professor Duerden independent report 2012 into outbreak
Outbreak independent report commissioned to support change
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3. Duerden Recommendations
Clinicians:
leadership of an audit programme for antimicrobial prescribing that should involve the ward pharmacists and, particularly, the medical staff on the wards who are prescribing the antibiotics.
3 reports this if from Repeated in 2014 and more recently March 2016
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4. Start Smart then Focus
It is recommended that a multi-disciplinary quality improvement/audit programme for antimicrobial stewardship should be developed and sustained in every Acute Trust.
DoH recommendation as well as more local Duerden report
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5. Start Smart then Focus
Improving antimicrobial prescribing and stewardship dependant on strong clinical leadership.
Medical teams, in particular consultants should take leadership role for antimicrobial quality improvement specialist areas.
Done in collaboration with consultant microbiologist/infectious diseases specialist and antimicrobial pharmacist.
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6. Ward based Audit Every ward Every month 5 Patients Junior doctors
Registered audit
Inputted by Ward Managers onto Fundamentals of Care (Care Metrics)
Incentive or junior dr’s - part of portfolio
Registered with clinical
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7. 10 Key Standards
Displayed in prominent place on ward for all to see staff, patients and visitors
Completed monthly
Red of Green
Point 9 is antibiotic audit
Must meet 95% on each question to gain green on chart
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8. Ward based Audit Poor uptake By December 2015 - 28%
East 21%, Central 38%, West 21%
Some wards no returns at all since start of audit
Unable to analyse data, scrutinise prescribing, provide any analysis for change
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9. Duerden 2016
2013 critical about the lack of audits of antimicrobial prescribing
2014 pleased to find that audits being done by clinical staff, including junior medical staff.
Audit data put Ward Metrics by the nursing staff
Breaks the chain of ownership
In 2013 I was critical about the lack of audits of antimicrobial prescribing and I was pleased in 2014 to find that audits were being done on a regular basis by the clinical staff, including junior medical staff. These audit data feed into the Ward Metrics but the entry has to be done, currently, by the nursing staff who are given the data by the junior doctors who have done the audits. This immediately breaks the chain of ownership and the effectiveness of the feedback to those who have done the audits. I am concerned that the system is not working effectively and the chair of ASG endorsed this view. We agreed that two aspects could be addressed to improve the process:
Change the data entry system so that the junior doctors who have done the audits enter the data into a system linked to the Ward Metrics but not necessarily fully embedded so that the feedback comes to those who have done the audits and made the entries.
Simplify the audit tool so that it is more readily understandable to those using it. It was reported to me that the audit questions currently used were complex and did not always require a direct yes/no answer and therefore could lead to a subjective or even confused response. I understand that a simplified audit tool is being implemented and I strongly support this approach. This revised tool should also be used by the antimicrobial pharmacists for their external validation audits of the ward staff’s own results.
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10. Duerden 2016 Two changes discussed with medical director
Change the data entry system
2. Simplify the audit tool
Now in place having discussed with the medical director
Also revalidation by antimicrobial pharmacist using same tool
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11. Re-launched May 2016 Still same data collection
Junior doctor, 5 patients each ward per month
Office of Medical Director involvement
Completed forms sent directly to OMD
Data input and analysis
Report back to Antibiotic Steering Group (ASG)
Antibiotic walk rounds
Each 3 sites done, one named member of OMD does this
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12. This is the current form
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13. 16/09/2018

14. Compliance Antibiotic Audit
Data to August 2016
Individual
West community hospitals as high at 89%
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15. Audit data Reported and scrutinised at ASG
Antibiotic Walk rounds to teams for direct feedback
Reported to Ward managers for 10 key standards
Also sent to:
Clinical directors, nursing and medical directors on each site
Medicine and surgery medical directors
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16. Antibiotic Walk Rounds
Hospital Medical Director
Consultant Microbiologist
Consultant Gastroenterologist
Antimicrobial Pharmacist
Matron Infection Prevention
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17. Antibiotic Walk Rounds
Weekly/Daily
 Antibiotic prescribing
10 key standards
 Antibiotic resources
 Antibiotic Stewardship
Stop/review, IV/PO, barriers to prescribing
 Any ideas for improvement
Tend to do one or two wards max as we may spend up to half hour with the staff
Abx prescribing audit with us to start discussions – not least because our process of feeding back via dept governance meetings is quite established yet
10 key standards – not least because it is easy
Microguide
current global concern re stewardship and impact
PPI’s – raise awareness
Prescribing hurdles – particularly if they are being asked to prescribe off guidance (many are – by their consultants)
if they are empowered to review to step down / stop
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18. Any Questions?
This is from YG from world sepsis day 13th September, the message is spreading!
16/09/2018