1. 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

2. 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

4. 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

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

6. The critical period ……

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

9. The beginning….

10. 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

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

12. 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

13. 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 / discharge – Run Charts & other analysis
Proportion of babies discharged who never received antibiotics
% of antibiotics stopped appropriately at hours
Other outcomes
Parent awareness – % aware of antibiotic use and intended duration
Any evidence of harm reported
** excluded prophylactic anti fungal, trimethoprim and antivirals

14. 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

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

16. 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)

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

18. Progress so far………

19. 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 hours -
32.5%
Proportion of admitted patients who never received antibiotics
21.9%

21. New Rotational staff
Graph 2:

23. 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

24. Graph 5:

25. 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

26. 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 hours -
32.5%
91%
Proportion of discharged patients who never received antibiotics
21.9%
41.2%

27. 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

28. 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