An Audit to measure compliance of trust guidelines

An Audit to measure compliance of trust guidelines when prescribing antibiotics in obstetrics Margaret Holmes Clinical Pharmacist, Heart of England NHS Foundation Trust. Project supervisors Rashmeet Bhogal, Shahzad Razaq, Dr Das Pillay, Dr Abid Hussain Introduction Method Antibiotic resistance cannot be eradicated completely, but a multi – disciplinary action approach locally, nationally and globally can limit the risk and minimise its impact for health, now and in the future. Using Start Smart and Focus criteria enabling the right drug, dose and duration within healthcare settings. Study Population All adult patients who were prescribed antibiotics on inpatient drug charts on obstetric wards within Heart of England NHS Trust, Heartlands hospital site, Birmingham. Obstetric wards covered were Aspen, Cedar and Maple wards on days when I was allocated Microbiology time usually 1 day each Month until I reached a goal of 50 patients. Details collected on data collection form A data collection form was designed and the following data was collected on the form • Patient Details(initial, hospital number, date of birth, age, weight and allergy status • Consultant and ward • Past medical history • Indication documented in notes • Choice of antibiotic • Start date of antibiotic • Stop/review date? • Bloods • Microbiology • Observations Data collection process Data collection was performed prospectively for a period of six months from 28 th November 2016 to 26 th May 2017. Patients prescribed antibiotics were identified by searching through the drug chart folders kept on Aspen, Cedar and Maple ward, each folder holds all drug charts for patients that are currently inpatients on those wards. Neonates are exposed to antibiotics before and after birth, there is increasing evidence that the use of antibiotics in pregnancy may cause resistance and also alter the microbiome in the foetus possibly causing long term adverse effects. Many antibiotics in obstetrics are prescribed empirically or as prophylaxis and a majority of prescriptions are broad spectrum antibiotics. Aim To determine the compliance to the trusts obstetric antimicrobial guidelines when prescribing antibiotics. The audit will focus on the choice of antimicrobial prescribed, the appropriateness and course duration. This Audit will also focus whether a stop/review date has been documented on the drug chart. Key Objectives • Identify patients that have been prescribed antibiotics on obstetric wards within the trust. • Identify patient’s indication for antibiotics and appropriateness of choice. • Identify appropriate duration of course of antibiotic for each patient ensuring correct stop/review dates are in place. Standards • 100% of antibiotic prescriptions have an indication documented in the patients notes at the point of prescribing • 100% of antibiotic prescriptions comply with trust obstetric antimicrobial guidelines / micro advice / ID advice • 100% of antibiotic prescriptions have a review at 72 hours for possible: IV to PO switch, de-escalation or escalation of antibiotics (you will need to check if appropriate samples are sent for patients where applicable. • 80% of prescriptions have an appropriate stop/review date (as per trust policy) RESULTS A total of 50 patients were identified and all patients were used in the audit to determine compliance with standards set above . The types of infections that antibiotics were prescribed for are set out in the chart below : Breaking the data down further to compare areas that are weaker in others at achieving determined standards are laid out in the table below: Indication Compliant Indication Stop Date 72 hr Review Documented rd th 3 /4 Degree 80% (4) 100% (5) 60% (3) 100% (5) Sepsis (16) 94% (14) 100% (16) 44% (7) 100% (16) GBS +ve (5) 100% (5) 60% (3) 100% (5) UTI (3) 100% (3) 67% (2) 100% (3) LRTI (3 ) 100% (3 ) 67% (2) 67% (2 ) 100% (3) 80% (8) 100% (10) 60% (6) 100% (10) 33% (1) 100% (3) 100% (2) 50% (1) 100% (2) 100% (3) 67% (2) 100% (3) Tear (5) SROM (10) Placental Complica tions (3) Wound Infection (2) • • Other Infection Placental complications included, Manual removal of placenta, Acreta placenta, and Retained placenta Sepsis included, Postpartum sepsis, Sepsis during labour and Sepsis in pregnancy UTI included, simple UTI and Pyelonephritis Other Infections included, Rectus sheath Haematoma, choriomnionitis and muscle balloon insertion in theatre (3) When data was analysed against standards set out, the results for all patients prescriptions were as detailed in chart below An Audit to measure compliance with Trust guidelines when prescribing antibiotics in Obstetrics 120 100 80 % 60 40 100 98 72 Hour Review Indication Documented 84 54 20 0 Compliance of Trust Guidelines Stop Dates Standards The Audit displayed that 100% of all patients’ prescriptions had a 72 hour review which met antibiotic prescribing standards. Measures as to whether the indication was documented in the notes were 98% falling short of the 100% standard. Compliance with trust antimicrobial guidelines resulted in 88% of the trust target of 100%. Documentation of a stop/review date fell very short at 54% out of an 80% target. Discussion Looking at the data collected and the results that were obtained, the trust was very good at reviewing the antibiotics after a period of 72 hours and met trust standards. This demonstrates that practitioners are aware of the importance of antibiotic review. Although this may be due to the fact that most patients that come into Obstetrics have a short period of stay and many prescriptions are reviewed on discharge, or for example with the GBS +ve patients antibiotics are only given until delivery. Indications documented in notes fell short of 2% of the Trust standards, with only one patients prescription out of 50 where the indication had not been formerly documented, this demonstrates awareness of good documentation and rationale of choice of antibiotics generally. The one prescription that was not documented still had all evidence, including examination, observations and pathology documented which indicated the patient had a chest infection and although there was no stop date, the antibiotics were reviewed within 72 hours and were compliant with trust guidelines based on choice of antibiotic. Compliance with trust antimicrobial guidelines fell below target, particular areas which included 3 rd and 4 th degree tears where I. V co-amoxiclav should be given as a stat dose along with I. V metronidazole and oral metronidazole to continued alone co-amoxiclav oral being continued, also with placenta removal instead of Stat doses of I. V antibiotics the patient was prescribed a course of oral antibiotics with no clear explanation in the notes. Prophylaxis treatment for SROM as per guidelines should be erythromycin but patient prescribed co-amoxiclav again with no indication in notes of any allergy or reason for deviance. There may have been rationale for these additions but nothing documented in notes to suggest reasoning. Stop dates in these areas were also poor but documentation of indication and 72 hour reviews were excellent. Stop dates resulted in only just over 50% compliant, although all antibiotics were reviewed at 72 hours. Conclusion Overall antimicrobial stewardship is good. However this audit has highlighted that performance with stop dates is poor and similar to wards with electronic prescribing. A behavioual change in prescribing needs to be managed across the Trust to ensure that healthcare professionals are aware of their responsibilities for antimicrobial stewardship. A review / stop date must be added at the point of prescribing and prescribers should be challenged when a review / stop date is not complete. From this audit it has been highlighted that several areas can be improved upon with only 72 hour reviews hitting the expected target. Re – training sessions for practitioners with regards to the importance of correct documentation in notes, how to access antimicrobial guidelines and interpretation of guidelines. It has also highlighted the need for antimicrobial stewardship on the wards and the need for a pharmacist at least to regularly review drug charts. Emails or access to links on the intranet, to highlight signposting if needed in case the prescriber is unsure of choice of antibiotic or duration needed. REFERENCES 1. 2. 3. 4. UK Five Year Antimicrobial Resistance Strategy, 2013 to 2018 https: //www. gov. uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy. pdf Accessed 15 th December 2016 Antimicrobial prescribing and stewardship competencies From: Department of Health and Public Health England Part of: Antibiotic awareness resources: 2016 and Antimicrobial Resistance (AMR) Published: 29 October 2013 Applies to: England https: //www. gov. uk/government/publications/antimicrobial-prescribing-and-stewardship-competencies Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE guideline [NG 15] Published date: August 2015 https: //www. nice. org. uk/guidance/ng 15/resources/antimicrobial-stewardship-systems-and-processes-for-effective-antimicrobial-medicine-use-1837273110469 Start Smart - Then Focus Antimicrobial Stewardship Toolkit for English Hospitals Updated, March 2015 https: //www. gov. uk/government/uploads/system/uploads/attachment_data/file/215308/dh_131181. pdf