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Medicines Management & Pharmacy Services
Antimicrobial Audit
Philip Howard
Consultant Antimicrobial Pharmacist
Medicines Management & Pharmacy Services
Leeds Teaching Hospitals NHSTrust (North of England)
• Serves population 900k plus 2.5mfor tertiary services
• ~ 2300 inpatient beds
• 2 teaching hospitals: LGI & SJUH
• 3 peripheral sites
• £93m drug budget (£17m AB)
• 430 staff incl ~125 pharmacists, 8Microbiologists & 3 Infectiousdisease consultants
Medicines Management & Pharmacy Services
LTH Antimicrobial Consultant Pharmacist
• 2008 - worstacute teachinghospital in UK forMRSA and Cdifficile
CDI Acute Teaching
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Best Rate
MRSA Acute Teaching
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Best Rate • DoH: undertakeregular audit until youare assured thatguidelines areembedded into practice
Medicines Management & Pharmacy Services
Audit & feedback as an element ofAntimicrobial Stewardship
• Developed on-line antimicrobial resource
• Each speciality to undertake oneantimicrobial related audit each quarter• Guidelines, TDM antibiotics, MRSA screening, etc
• Develop a plan and enter onto Clinical Audit databasein advance. Enter results when completed
• NOT a repeat the ward pharmacist audit
• Ward pharmacists to do a monthly pseudopoint-prevalence audit
• Audit tools available on-line
Medicines Management & Pharmacy Services
Posters: How to prescribe antimicrobialsRegularMedicines
Month& year:Oct ‘07
Date:1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
DAY 1 2 3 ┬ Drug (1)
TRIMETHOPRIM
Dose
200mg8-9 │
│Route
PO
Additional Instructions
Uncomplicated UTI
3 day course
Date
1/10/0713-14 │
17-18 │ AD
occt
or
(DO
CT
OR
1/1
0/07
Sign (NAME & Bleep)
A Doctor
(DOCTOR)1234
Pharm Supply
21-22 ┴
RegularMedicines
Month& year:Oct ‘07
Date:1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10
DAYDrug (1)
FLUCLOXACILLIN
Dose
2g8-9
R/VRoute
IV
Additional Instructions
Cellulitis
Review 48 hrs
Date
2/10/07
13-14
17-18Sign (NAME & Bleep)
A Doctor
(DOCTOR)1234
Pharm Supply
21-22
An Indication Duration or Review Date
Indication letseveryone know thereason why. Easy tocheck if correct.
Review at 48 hours.C&S resultsStop / step down tooral or narrowspectrum agentLess AB resistance
Medicines Management & Pharmacy Services
Over 65 years?
Decrease C. difficile risk
Avoid if possible:
clindamycin
cefuroxime
ceftazidime
ciprofloxacin
Medicines Management & Pharmacy Services
Prescribe antimicrobials correctly
Print name and contact number
Medicines Management & Pharmacy Services
Beware of disguised penicillins!
Don’t give penicillin allergic patients:
Tazocin
Piperacillin-tazobactam
CoAmoxiclav (Augmentin)
Amoxicillin-clavulanic acid
CoFluampicil (Magnapen)
Ampicillin-flucloxacillin
Medicines Management & Pharmacy Services
All in-patient wards audited onany one single day each monthby the ward pharmacist
Results entered onto aspreadsheet by secretary
She chases up any late audits =100% for last 9 months
Entered onto Trust dashboardwith other HII
Report to Trust, Divisional,Specialty or Ward level.
Medicines Management & Pharmacy Services
HCAI monitor snapshot
On home page of hospitalwebsite – link to KPIs
Medicines Management & Pharmacy Services
CQUIN target: £100k / qtr (>90% in Q4)
keys to success• initially part of the board report for HCAI. “What’s so difficult about writing….• part of medicines management CQUIN
Medicines Management & Pharmacy Services
Peer review for duration (blue line) &indication (red dots) on prescriptions?
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0%
10%
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30%
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50%
60%
70%
80%
90%
100%
* = electronic
Confidential sharing of data (30 Trusts) place us 3rd behind onewith electronic prescribing and a previously poorly performingTrust. Only 3 trusts would publicly share data
Medicines Management & Pharmacy Services
Antimicrobial Medicines Code Audit
• Achieved Local CQUIN target of >90% worth £100k per quarter (just)• ward level data and trends on LHP Antimicrobials performance pages
Division league table Pts on Abs/no of
ABs
Indication on chart Review date or
duration on chart
Prescriber ID clear
Trust 450/627 92% (+1%) 91% (+1%) 88% (-6%)
Take 5 Feb Medicine 42/71 90% (-4%) 89% (-4%) 82% (-8%)Medicine 174/248 95% (+4%) 95% (no change) 90% (-2%)
Oncology-Surgery 122/157 92% (no change) 91% (-8%) 90% (+7%)WCHN&D 82/131 88% (+1%) 89% (+3%) 85% (no change)
Specialist Surgery 72/91 86% (+9%) 81% (-9%) 81% (-6%)
Speciality Pts on Abs/no of ABs Indication on chart Review date or
duration
Prescriber ID clear
Derm & Rheumatology 3/3 100% (no change) 100% (no change) 100% (no change)
Cardiology 8/10 100% (+44%) 100% (+22%) 100% (+22%)
Cystic fibrosis 11/40 98% (-2%) 98% (-2%) 100% (no change)
Respiratory 43/60 98% (no change) 98% (no change) 90% (-1%)
Elderly 59/70 97% (+3%) 97% (+6%) 84% (+12%)
Diabetes & Endo 14/15 93% (+1%) 93% (+1%) 93% (-7%)
Infectious disease 10/14 100% (+8%) 93% (+5%) 100% (+8%)
Renal 17/25 88% (+7%) 92% (+11%) 84% (+7%)
Urgent care 5/6 83% (+16%) 83% (+16%) 100% (no change)
Acute medicine 7/8 63% (-22%) 50% (-35%) 75% (-25%)
Medicines Management & Pharmacy Services
Antimicrobial Usage
Last yr vs prev LTH Div A&E AcuteMed
DiabEndo
Olderpeopl
e
Renal Dermatology
GUMed
ID Cardiology
Total broadspectrum
8% 10%
82% 78% -15% 6% 4% 0% 23% 5% -65%
1st gen ceph(CDI) -36% -58% -28% -54% -11% -60% -31% 44% -31% -26% -84%
2nd gen ceph(CDI) -28% -3% 12% -3% 79% -81% -5% -100% n/a 154% -35%
3rd genceph(CDI>MRSA)
11% 17% 33% 67% -27% 136% 21% -36% 5% 199% -17%
Ciprofloxacin(MRSA>CDI)
11% 10% 73% 234% -44% 8% 6% -4% 12% -12% 65%
Clindamycin (CDI) 82% 91% 588% 310% -58% 109% 0% -22% n/a -8% -43%Co-amoxiclav (CDI) 38% 30% 62% 54% 28% 22% 80% 45% 742% -3% 83%Meropenem(MRSA)
5% 3% -23% 21% 20% 41% -26% 383% -100% 236% -86%
Piperacillin-tazobactam(MRSA)
15% 12% 27% 51% 61% 12% -5% 22% n/a 11% 31%
Medicines Management & Pharmacy Services
Antimicrobial Audits – 1 per quarter• audit of common guidelines used in specialty, MRSA screening & decolonisation orhigh risk drugs e.g. gentamicin, vancomycin (not Take 5 or rpt of Pharmacist audit)• enter a plan onto LTH Clinical Audit Database for the year, and update resultswhen complete.
Specialty Q1 results Q2 results Q3 results Q4 plan/results
Div Audit rate 55% 82% 73% 45%
GU Med UTI Pharyngeal gonnorhoea Epididymitis Chlamydia
Cardiology Cannulae CannulaeAB Med Code &
CannulaeCannulae
Renal Peritonitis in PD PD exit site infections MRSA screening in HD CDI#
Infectious disease UTI* Vancomycin Rx/ Qual of AB
Rxing*None listed None listed
Cystic fibrosis Pulm CF Exac Home vs IP Abs Neb Abs Self-med of Abs*
Respiratory AB Rx stds Levofloxacin in CAP VIP NICE TB*
Dermatology None listed Notes & Rx (no AB) None listed None listed
Urgent care None listed Sepsis Cipro in OP None listed
Elderly None listed Micro liaison Cannulae packavailability
None listed
Acute medicine None listed None listed CAP* None listed
Diab & endo None listed None listed None listed None listed
* New entries this month = 4 #=no results
Medicines Management & Pharmacy Services
Antimicrobial Audits – 1 per quarter• Audit of common guidelines used in specialty, MRSA screening &decolonisation; SSI prophylaxis; commonly used AB treatment guidelines, highrisk drugs e.g. gentamicin, vancomycin.• Enter a plan onto LTH Clinical Audit Database for the year, and update resultswhen complete.• 1 new audit last quarter by Ortho (MRSA screening & decolonisation =100%).
Specialty Q1 results Q2 results Q3 plan / results Q4 plan
Critical care AB Med Code MRSA screen x2 MRSA proph None planned
T&O None recorded MRSA prophMRSA screen CAH (+2
unfinished in #’s
Chronic
periprosthetic inf
Rheumatology None recorded OP AB Rxing MRSA screen None planned
Plastics None recorded AB guidelines Cellulitis Skin prep OT
Neurosurgery None recorded SSI proph x 2 SSI proph x 2 None planned
Cardiac surgery None recorded None recorded AB Med Code None planned
Theatres & DC None recorded None recorded AB proph N/S None planned
Neurology None recorded None recordedPEG proph (plan, but no
results)None planned
Medicines Management & Pharmacy Services
Key lessons learnt
• Antibiotic prophylaxis wasn’t being given incision(vascular) in >50%. Introduced WHO SaferSurgery checklist early.
• CDI severity not being assessed so difficult toidentify if correct agent being used
• Patients at high risk of MRSA not routinelyreceiving correct teicoplanin based prophylaxis
• Restricted antimicrobial code durations suppliedby trainees are longer than consultants.
Medicines Management & Pharmacy Services
Primary Care Audits in Leeds
• Quality Outcomes Framework (QoF)
• Antimicrobials not included
• Medicines Management points allow for audit
• Quinolone
• Asked all GP practices to audit their prescribingagainst their guidelines
• Cephalosporins
• New guidelines
• Audit against guidelines
• Stop reporting cephalosporin sensitivities to urinesunless only one other option
Medicines Management & Pharmacy Services
Leeds PCT Quinolone Audit ResultsAppropiate prescribing for quinolones (Avg 59.9%)
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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75
practices
%o
fap
pro
pri
ate
pre
scri
pti
on
s
% Appropiate prescribing Average
Medicines Management & Pharmacy Services
Quinolone changes
Figure 10 - Yorkshire & The Humber PCTs: Weighted Quinolone prescribing; April 2007 to September
2010
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0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4 1011Q1 1011Q2
Ite
ms
/10
00
An
tib
ac
teri
al
(CH
I)S
TA
R-P
U
Barnsley
Bradford & Airedale
Calderdale
Doncaster
East Riding of Yorkshire
Hull Teaching
Kirklees
Leeds
North East Lincolnshire Care Trust Plus
North Lincolnshire
North Yorkshire & York
Rotherham
Sheffield
Wakefield District
Yorkshire & The Humber
North of England
England
Medicines Management & Pharmacy Services
Cephalosporins over timeFigure 6b - Yorkshire & The Humber PCTs: Weighted Cephalosporin prescribing; April 2007 to
September 2010
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11
16
21
26
31
36
41
46
51
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0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4 1011Q1 1011Q2
Ite
ms
/10
00
An
tib
ac
teri
al
(CH
I)S
TA
R-P
U
Barnsley
Bradford & Airedale
Calderdale
Doncaster
East Riding of Yorkshire
Hull Teaching
Kirklees
Leeds
North East Lincolnshire Care Trust Plus
North Lincolnshire
North Yorkshire & York
Rotherham
Sheffield
Wakefield District
Yorkshire & The Humber
North of England
England
Medicines Management & Pharmacy Services
Summary• Reporting monthly to Trust board as part of HCAI
report forces change
• League tables encourage competition andimproves performance
• Specialties with more HCAI engage better intheir own audit
• GPs can improve performance where “paid” toaudit own practice
• Doctors will audit prescribing against guidelineseach month with new HII AntimicrobialPrescribing
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