5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
The 5x5 Antimicrobial Audit
Challenging Cases:
A tutorial for 5x5 Auditors
START
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Introduction
To complete the Challenging Cases Tutorial you should have access to
Youfollowing
will
also documents
require: has
progressing
The Challenging
the
Cases
Tutorial
from
been
the 5x5While
Antimicrobial
Auditthrough
package:this interactive
PowerPoint presentation, auditors will be
included in the 5x5
Antimicrobial
Audit
A pen
•• Audit
User Guide, including the appendices
required to undertake data collection on a
Package as a supplement resource for
Copies of Asked
the Data
Collection
Form,ofavailable
in patients.
Appendix B of
•• and
Frequently
Questions
series
5 sample
auditor education
engagement.
the Audit User Guide
• Community Acquired Pneumonia Cheat Sheet
In eachAntibiotic
case, the auditor will be able to
• Access tothat
Therapeutic
Guidelines:
It is important to understand
this
(NOTE:
If need to aaccess the
eTGs,
press
ALT + TAB
to toggle
between
review
limited
but
relevant
information in
It isdoes
STONGLY
RECOMMENDED
that
you
become
familiar
with
these
training module
not represent
windows without losing your slide
theposition)
chart,
and electronic medical
prior to completing
thenotes
tutorial.
complete induction to thedocuments
5x5
record. They will also be able to make a
Antimicrobial Audit, but simply allows
to
contact the doctor or declare the
I and
have
everything
I need
auditors to navigate theIprocesses
have read
through
thedecision
above
documents
patient ineligible for the audit.
challenges of data collection using mockedup clinical scenarios that are representative
of real patients.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Some things to remember…
Therapeutic Guidelines: Antibiotic Vs. Locally endorsed guidelines
For the purpose of this training module, please only refer to the Therapeutic
Guidelines: Antibiotic. (In a real audit situation, you should refer to locally
endorsed guidelines from your facility, or if they are not available, use
Therapeutic Guidelines: Antibiotic.)
You are auditing the choice of antimicrobial agent only
This audit does not require you to look at the dose, route, frequency etc. You
are only considering which antimicrobial agent(s) has been prescribed.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Some things to remember…
Guideline Concordance Vs. Appropriateness
Occasionally you may find a patient receiving therapy that is not concordant with
guidelines, but you believe the therapy is still appropriate. In these scenarios, you
need to list the therapy as non-concordant (question 3), and check whether the
reason for this non-concordance has been documented (question 4).
Please do not be tempted to record what you perceive as ‘appropriate’
therapy as concordant when it doesn’t match the guidelines.
Keep in mind that concordance with guidelines AND non-concordance with a
documented reason are BOTH considered positive outcomes for this audit.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 1
You have randomly selected a patient on your
Based on the information available, is
general medical ward. Your bed list tells you it
sure?
is an 82yo male admitted this morning. Are youthis
patient eligible for inclusion in the
audit? eligibility criteria, based
This
patient
appears
to
fulfil
the
audit’s
Correct!
patient appears to be eligible for the audit.
Please click the icons
belowThis
to review
on the information available. You should continue with the audit
relevant information in the chart, notes
on the next slide.
and electronic medical record.
OK
YES
NO
OK
Please Note: The User Guide contains an Eligibility
Flowchart (Appendix C) that you may find helpful.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 1
If at any time you believe the patient is not
Use the Data Collection Form to record
eligible
for the audit, click the ‘Patient Not
your answers to the 5 auditContact
questions.
doctor to clarify
indication
Eligible’
icon.
Are
you
sure?
The icons are still Is
available
formade
you
review
has should
been
quite
clear
in the
notes
that
patient has
You
not to
need
to
contact
the
doctor
tothis
recommend
information from the chart, guideline
notes andconcordant
‘severe cellulitis’.
therapy in this case.
This patient appears to fulfil the
audit’s eligibility criteria, based
OR
electronic medical record.
on need
the
information
available.
You should
not
to contact
the
doctor
in this you
case.
Perhaps
you should
review
your answers
to questions
3 &are
4? ready to go
Click
NEXT
when
doctor
guideline
If you need to contact the Contact
doctor for
eitherto recommend
through the answers.
OK
question 2 or question 5, please click concordant
the
OKtherapy
‘Contact Doctor’ icon.
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 1 - Answers
Q1. Yes
Q2. N/A
Q3. No
Q4. Yes
Q5. N/A
The entry in the progress notes states that the
patient
has
previously
had LFTwithout
derangement
with
For
severe
cellulitis
in a patient
a penicillin
flucloxacillin.
allergy,
Therapeutic
Guidelines:
Antibiotic
Thethe
indication
severe
cellulitis has
been
recommend
flucloxacillin.
clearly documented
in asks
the progress
Remember,
this question
whethernotes.
or not a
reason has been provided. It is unrelated to
This patient is receiving cephazolin, therefore the
whether or not you believe
OK the reason is ‘good
therapy is considered non-concordant.
enough’ to divert from guidelines, (however feel
free to record this sort of information in the
comments section). OK
OK
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 2
You have randomly selected a bed in your
Based on the information available, is
general medical ward. The bed list tells
sure?
patient eligible for inclusion in the
you the patient is a 68yo F, and displaysAre youthis
their reason for This
admission
“chesttoinf”.
patientas
appears
fulfil theaudit?
audit’s eligibility criteria, based
Correct! This patient appears to be eligible for the audit.
on the information available. You should continue with the audit
Please click the icons below to reviewon the next slide.
NO
YES
relevant information in the chart, notes OK
and electronic medical record.
OK
Please Note: The User Guide contains an Eligibility
Flowchart (Appendix C) that you may find helpful.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
ED Review
Verified E. Anders 12/03/14 16:22
Modified E. Anders 12/03/14 16:44
PC: Referral by GP - worsening SOB, fatigue, mild fevers, has had 4/7 po abx.
Sputum Culture **ERROR
Post 13/03/14 07:35
RR 29 and O2 saturation 88% on RA, BP 95/70
Sputum culture could not be performed. (Microscopy showed sample
Patient oriented T,P,P. States just “very tired” and SOB
provided is saliva.)
Hx: HTN, anaemia, R TKR (2009)
Plan: Supplemental O2 to keep >90%, Meds as charted, CXR, Resp consult,
likely admit MAU
___________________
E. Anders
Addit: Resp will attend, sputum culture and IV Abx as per team
Click on relevant results to reveal more information.
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 2
Well Done!
would
a good ideaForm
to contact
the prescriber
intent
recommend
a change
If with
at any
timetoyou
believe the
patienttois not
Use Itthe
DatabeCollection
to
record
It
is
written
on
the
chart
that
this
patient
is
receiving
antibiotics
for
therapy for moderate CAP. You may wish to do this
by making
in the Not
eligible
for (CAP).
thea recommendation
audit, click the ‘Patient
Contact
doctor
your answers to the 5 audit
questions.
Community
Acquired
Pneumonia
Are to
youclarify
sure?indication
notes or speaking to the medical team in person.
Eligible’ icon.
The icons are still available for you to review
This
patient
appears
the
eligibility
criteria,
Although
the
severity
ofnotes
this
has
notaudit’s
been explicitly
stated,
youbased
are provided
information
from
the
chart,
andto fulfil
The
following
excerpt
from
the diagnosis
Therapeutic
Guidelines:
Antibiotic
may
be
used
to support
OR
with
enough
cues
to
determine
severity
and
thus
should
not
need
to
contact
the
on
the
information
available.
You
should
continue
with
the
audit
your recommendation:
electronic
medical record.
doctor
this case.
on theinnext
slide.
Click
NEXT when you are ready to go
‘Since penicillin-resistant
S. pneumoniae
and H.
isolates areguideline
currently uncommon causes of CAP in
Contact
doctor
toinfluenzae
recommend
Australia,
the routine
ofuse
ceftriaxone
or cefotaxime
forthrough
moderate
(nonsevere)
CAPthese
is not recommended
If you need
to
contact
theuse
doctor
forCAP
either
the
answers.
(You
may
wish
to
the
Cheat Sheet
to assist
you
with
cases.) as it
concordant
therapy
provides no additional benefit over the penicillins. There is evidence associating overuse of cephalosporins in
question 2hospitals
or question
5, please
click the
with increases
in multiresistant
organisms and Clostridium difficile.’
OK
‘Contact
Doctor’ icon.
Community-acquired pneumonia in adults: rationale for antibioticOK
choice [revised 2010 Jun]. In: eTG complete [Internet]. Melbourne:
Therapeutic Guidelines Limited; 2013 Nov.
DONE
OK
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
ED Review
Verified E. Anders 12/03/14 16:22
Modified E. Anders 12/03/14 16:44
PC: Referral by GP - worsening SOB, fatigue, mild fevers, has had 2/7 po abx.
Sputum Culture **ERROR
Post 13/03/14 07:35
RR 29 and O2 saturation 88% on RA, BP 95/70
Sputum culture could not be performed. (Microscopy showed sample
Patient oriented T,P,P. States just “very tired” and SOB
provided is saliva.)
Hx: HTN, anaemia, R TKR (2009)
Plan: Supplemental O2 to keep >90%, Meds as charted, CXR, Resp consult,
likely admit MAU
___________________
E. Anders
Addit: Resp will attend, sputum culture and IV Abx as per team
Click on relevant results to reveal more information.
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 2 - Answers
Q1. Yes
Q2. N/A
Q3. No
It would
be aisgood
idea
to contact theofprescriber
with intent to
There
a clear
documentation
community-acquired
recommend
a change
toon
therapy
for moderate
Youwere
mayavailable,
do this by
pneumonia
(CAP)
the chart.
If only theCAP.
notes
making
a recommendation
in the
or speaking
the medical team
“pneumonia”
would not
be notes
considered
a clearto
enough
in person.
indication
asreceiving
we need ceftriaxone
to know which
type of pneumonia
This
patient is
+ azithromycin.
When
There is no reason documented to justify
(Community-Acquired,
Hospital-Acquired,
Aspiration
etc.)your
in
reviewing
thisfrom
regimen
against
the
Therapeutic
Guidelines:
The following
excerpt
the Therapeutic
Guidelines
may be
used
to support
guideline
non-concordance
thisnot
case.
order tofor
match
the patient’s
therapy
to a in
treatment
guideline.
recommendation:
Antibiotic
moderate
CAP, this
treatment
does
Q4. No
Sinceappear
penicillin-resistant
S. pneumoniae and H. influenzae isolates are currently
to be guideline-concordant.
You causes
may have
noticed
that the
theroutine
severity
not explicitly
uncommon
of CAP
in Australia,
usewas
of ceftriaxone
or cefotaxime for
moderate
(nonsevere) CAP
is not recommended
as it provides
no additional
benefit
documented.
In these
cases the auditor
must use
the available
over the
penicillins.
There is evidence
associating
of cephalosporins
cues
to determine
the severity
of theoveruse
condition
at the timeinofhospitals
with increases
in multiresistant
and the
Clostridium
difficile.
prescribing.
(You mayorganisms
wish to use
CAP Cheat
Sheet to help
Q5. Yes*
*If you choose
not to contact the doctor when prompted by the audit
Using the CORB score, this patient appears to have
OK
OK
you.)
tool, you should record your reasoning
the comments section.
moderateinCAP.
OK
OK
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 3
Your randomly selected patient has comeAre
to you sure?
your geriatrics ward overnight. She is a 78yo
Based on the information available, is
Although
partial
culture
results
have
now been posted, these were
F who was sent into hospital from a nursing
this
patient eligible for inclusion in the
not available at the time of prescribing and current therapy is still
home.
audit?
considered
empirically
Correct! This
patient appears
to beprescribed.
eligible for the audit.
Please click the icons below to review
It is still within the audit rules to continue, but keep in mind whether
relevant information in the chart, notes
OK
or not the current culture results
should prompt
NO
YESa change in therapy
and electronic medical record.
for this patient.
OKPlease Note: The User Guide contains an Eligibility
Flowchart (Appendix C) that you may find helpful.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Triage Review
Verified J. Wilkinson 30/05/14 09:16
78 year old female BIBA from NH
Urine Culture
Blood Culture
BP 95/70, tachycardic 130bpm, O2 sats 99%
LoggedLogged
30/05/14
30/05/14
09:50 10:27
Bolus fluids given on route
Posted 31/05/14 10:03
Temp 39.0 C, last paracetamol 8am
Pending.
Heavy growth of likely coliform bacteria.
Pt drowsy but rousable, not oriented to TPP
Identification and susceptibilities report to follow.
Noted penicillin allergy
?Sepsis pathway
TRIAGE CAT 3
J Wilkinson
Click on relevant results to reveal more information.
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 3
Are patient
you
sure?
The progress
for need
this
anthis
indication
of the patient is not
If provide
at any
time
you
believe
Use the Data Collection
to record
AreForm
you notes
sure
you
to proceed
with
step?
eligible
for
the
audit,
clickwere
the
likely
urosepsis.
appears
to be
receiving
guideline
concordant
therapy
for‘Patient Not
your answersThis
to patient
the 5 audit
questions.
Contact
doctor
tohave
clarify
Although
partial
culture
results
nowindication
been
posted,
these
Eligible’
icon.Guidelines:
severe
sepsis
with
a urinary
(Therapeutic
The icons are
still
foratyou
to
review
notavailable
available
the
time
ofsource.
prescribing
and current
therapy Antibiotic
is still
You
have
been
provided
with enough
to match the indication
suggests
treatment
as forinformation
severe
pyelonephritis).
information
from
the
chart,
notes
and
considered
empirically
prescribed.
OR
antimicrobial
electronic for
medical
record. therapy to a specific guideline, thus you should not need
In
cases like
you
shouldthe
continue
with
the
audit
but keepand
in mind
to
contact
doctor
in this
case.
Perhaps
youthis,
should
review
which
guidelines
you
were
Click
NEXT
whenusing
you are the
ready to go
Contact
doctor
to
recommend
guideline
whether or not
the current
culture
results
should
prompt
a
change
in
status? the answers.
If you need to contact the doctor forpatient’s
either allergythrough
therapy
for this
patient.
concordant
question 2 or question 5, please click the
OK therapy
‘Contact Doctor’ icon.
OK
OK
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Triage Review
Verified J. Wilkinson 30/05/14 09:16
78 year old female BIBA from NH
Urine Culture
Blood Culture
BP 95/70, tachycardic 130bpm, O2 sats 99%
LoggedLogged
30/05/14
30/05/14
09:50 10:27
Bolus fluids given on route
Posted 31/05/14 10:03
Temp 39.0 C, last paracetamol 8am
Pending.
Heavy growth of likely coliform bacteria.
Pt drowsy but rousable, not oriented to TPP
Identification and susceptibilities report to follow.
Noted penicillin allergy
?Sepsis pathway
TRIAGE CAT 3
J Wilkinson
Click on relevant results to reveal more information.
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 3 - Answers
Q1. Yes
Q2. N/A
Q3. Yes
Q4. N/A
Q5. N/A
Therapeutic Guidelines: Antibiotic states that severe sepsis of a likely
urinary source should be treated as per the guidelines for severe
The
progress
that the
patient
has case the
pyelonephritis.
This
patientnotes
has astate
penicillin
allergy,
in which
sepsis,recommendations
probably from a UTI.
guidelines provide
for gentamicin alone. This therapy
therefore appears to be guideline concordant.
Based on the available cues (hypotension, fever,
tachycardia,
delirium), youor
would
expect thisalternate
If the guidelines
had not acknowledged
recommended
condition
be treated
as severe sepsis
from
a be
therapy for this
patient’stoallergy,
the prescribed
therapy
would
urinary source,In
assuch
opposed
to being treated
as may be
considered non-concordant.
circumstances,
the allergy
the direct reason
guidelines
for UTI (acute cystitis).
recorded as aper
documented
for non-concordance
(question 4).
Had the medical team had any concerns that gentamicin alone was not
sufficient, they would be expected to consult an infectious diseases or
microbiology expert, or the AMS team.
OK
OK
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 4
You have randomly selected a patient on
Based on the information available, is
your general medical ward. This 54yo F is
patient eligible for inclusion in the
Are youthis
sure?
documented as having ‘abdo pain’.
audit?
This patient
appears
fulfil the
audit’s
Correct!
This to
patient
appears
to eligibility
be eligiblecriteria,
for thebased
audit.on the
Please click the
icons below
to review
information
available
at this time. You should continue with the audit
relevant information in the chart, notes
on the next slide.
and electronic medical record.
OK
OK
YES
NO
Please Note: The User Guide contains an Eligibility
Flowchart (Appendix C) that you may find helpful.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
ED Review
Verified P. Melling 16/03/14 21:40
Modified P. Melling 16/03/14 21:54
54yo female presented with fever and RUQ pain developing over prev 6hrs.
Exam: Strong guarding response (upper abdo) with obvious tenderness in RUQ.
Positive
Murphy’s sign. ??mass
Blood Culture
PtPending.
states pain
wasdue
8/10,
constant.
Now 5/10 30min post endone
Report
1400
17/3/14.
Hx: Breast Ca (remission since 2005), Generalised anxiety disorder, Gallstones
P/call to AH Gen Surg reg (Moroney Team)
Pt needs RUQ US
Triple abx Amp/Gent/Flagyl
r/v US results with senior - If not immed surgical, admit pt to Gen Med 2. Team
will r/v mane.
___________________
Addit: Pt has strong penicillin allergy – change abx to Gent + Clinda
DONE
Click on relevant results to reveal more information.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 4
Well Done!
If atpatient
any time
youeligible
believefor
the patient is not
Use the Data Collection
to record
You have Form
correctly
identified that this
is not
eligible
for the audit, click the ‘Patient Not
your answers to the 5 auditContact
questions.
doctor toinclarify
indication
inclusion
the
audit.
Are you sure you need to proceed
Eligible’ with
icon. this step?
The icons are still available for you to review
When
reviewing
thisand
treatment against the Therapeutic Guidelines:
information from
the
chart,
notes
Given
the
patient’s
and
allergy
status,
the guidelines
‘seek
ORbefore
Antibiotic
fordiagnosis
acute cholangitis
, this
patient’s
immediate
therecord.
patient
was
diagnosed
in ED
she
came
under oursay
team.
electronic “Oh…
medical
expert
advice’. The Frequently
Asked
Questions
document provides
some
hypersensitivity
to
leads
toClick
a recommendation
toare
‘seek
Shepenicillin
has acute
cholecystitis.”
NEXT
when
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ready
to go
advice
on
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scenario.
Contact
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guideline
expertthe
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explained
4 of thethe
Frequently
If you need to contact
doctorAsfor
either on page
through
answers.Asked
concordant
therapy
Questions5,document,
the
patient is no longer eligible for
question 2 or question
please clickthis
themeans
OK
the audit and all data
OKshould be discarded.
‘Contact Doctor’ icon.
Discard data and proceed to next patient
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
ED Review
Verified P. Melling 16/03/14 21:40
Modified P. Melling 16/03/14 21:54
54yo female presented with fever and RUQ pain developing over prev 6hrs.
Exam: Strong guarding response (upper abdo) with obvious tenderness in RUQ.
Positive
Murphy’s sign. ??mass
Blood Culture
PtPending.
states pain
wasdue
8/10,
constant.
Now 5/10 30min post endone
Report
1400
17/3/14.
Hx: Breast Ca (remission since 2005), Generalised anxiety disorder, Gallstones
P/call to AH Gen Surg reg (Moroney Team)
Pt needs RUQ US
Triple abx Amp/Gent/Flagyl
r/v US results with senior - If not immed surgical, admit pt to Gen Med 2. Team
will r/v mane.
___________________
Addit: Pt has strong penicillin allergy – change abx to Gent + Clinda
DONE
Click on relevant results to reveal more information.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 4 - Answers
When reviewing this treatment against the Therapeutic
Guidelines: Antibiotic for acute cholangitis, this patient’s
immediate hypersensitivity to penicillin leads to a
recommendation to ‘seek expert advice’.
The Frequently Asked Questions document provides the following
information on page 4:
“If the guidelines refer to ‘expert advice’, the indication or patient
scenario is likely to be complex and as such no set guidelines have
been constructed. In cases where no recommended therapy (in
either locally endorsed guidelines or the Therapeutic Guidelines:
Antibiotic) is listed, the patient is considered outside the audit
scope and their data should be discarded.”
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 5
The next patient has been on your endocrine
Based on the information available, is
Are you sure?
ward for 5 days. He is a 36yo male who was
originally admitted for DKA and has been
this patient eligible for inclusion in the
This patient appears to fulfil the audit’s eligibility criteria, based
recovering well.
audit?
on Correct!
the information
available.
You should
continue
the audit
This patient
appears
to be eligible
forwith
the audit.
on the next slide.
Please click the icons below to review
relevant information in the chart, notes
and electronic medical record.
OK
OK
YES
NO
Please Note: The User Guide contains an Eligibility
Flowchart (Appendix C) that you may find helpful.
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
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Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Nursing Note
Verified H. O’Day 22/07/14 17:19
Pt activated call button – stated ‘feeling dizzy and slight headache’.
Noted pale, clammy. Still sitting up in bed.
CultureBlood
(Other)
Culture
LoggedLogged
22/07/14
22/07/14
18:10 18:10
Manual BP 90/60
Posted 24/07/14 08:05
Temp 39.5
Pending.
HR 105 – prev obs usually around 60
Culture (Other): IVC line tip
BSL attended = 8.9
Nil growth at 36hrs.
Pt requiring clinical review
Nil response from team – contacted AH RMO
Report to follow if growth occurs.
Bolus fluids given by ph order
Pt r/v by RMO within 20 minutes
H O.Day RN (with R. Swallei, EN)
Click on relevant results to reveal more information.
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 5
Are you sure you need to proceed with this step?
This patient appears to have been prescribed antimicrobial therapy for
Use the Data
Collection
Form
toinfection).
record
If atindicate
any
time
believe
the patient is not
sepsis
site
The notes
there
also have
You
may(?cannula
have found
the
current antimicrobial
therapy
toyou
bemay
non-concordant
your answerswith
to the
audit
questions.
eligible
the
clickclinical
the ‘Patient Not
Contact
doctor
clarify
been
some
concern
about
the indication
riskfor
ofofMRSA.
the5guidelines,
however
theto
documentation
theaudit,
patient’s
Are you effectively
sure?
The icons are improvement
still available and
for you
to review
Eligible’ icon.
imminent
discharge
provides a reason for the
Please note that although the antimicrobial therapy has recently changed,
information from
thethis
chart,
notes
andbe difficult
early
de-escalation
of therapy
to oral
antibiotics.
patient
may
to prescribed
assess,
they
the audit’s
itWhile
is clear
from
the notes
that this is OR
still
forstill
thefulfil
indication
that
electronic medical record.
eligibility
criteria
and
should
included
in the
audit.
wasaudit
originally
identified
and
isto
not
for abe
different
diagnosis
or
condition.
The
will only
prompt
you
recommend
guideline
concordant
therapy
Click NEXT when you are ready to go
Contact
doctor to recommend
guideline
where
reason
for non-concordance
has not been
documented.
Keep in
If you need toYou
contact
the doctor
forwith
either
haveabeen
provided
enough information
to
match
the indication
through
the
answers.
concordant
therapy
OK
mind
that you
cantherapy
always
contact
the
doctor
for thus
otheryou
concerns
the
antimicrobial
a specific
guideline,
should outside
not need
question 2 orfor
question
5, please
clickto
the
scope of data collection,
especially
if you
the patient is at risk.
to contact
the doctor
in believe
this case.
‘Contact Doctor’ icon.
OK
OK
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Nursing Note
Verified H. O’Day 30/05/14 17:19
Pt activated call button – ‘bit dizzy and slight headache’.
Noted pt clammy but still sitting up in bed.
CultureBlood
(Other)
Culture
LoggedLogged
22/07/14
22/07/14
18:10 18:10
Manual BP 90/60
Posted 24/07/14 08:05
Temp 38.5
Pending.
HR 105 – prev obs usually around 60
Culture (Other): IVC line tip
BSL attended = 8.9
Nil growth at 36hrs.
Pt requiring clinical review
Nil response from team – contacted AH RMO
Report to follow if growth occurs.
Panadol, bolus fluids given by ph order
Pt r/v by RMO within 20 minutes
H O.Day RN (with R. Swallei, EN)
Click on relevant results to reveal more information.
DONE
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
Case Study 5 - Answers
Q1. Yes
Q2. N/A
Q3. No
Q4. Yes
Q5. N/A
This patient has been prescribed antimicrobial therapy for suspected sepsis,
secondary Guidelines:
to a cannulaAntibiotic
site infection.
At the time
of diagnosis,
the altered
Therapeutic
recommend
gentamicin
+ vancomycin
for
Documentation
in
the
notes
suggests
that
the
patient
had
shown
significant
clinical
parameters
classify
this
patient’s
condition
as
‘severe’
and
the
notes
severe sepsis from an IVC source (with suspicion of MRSA).
clinical improvement,
also
thatathe
medical
were nowphysician.
unsure if
indicate
that MRSA mayand
have
been
concern
for team
the reviewing
this waswe
a case
of ‘true’
sepsis.
Thisdid
canreceive
be interpreted
as atherapy
reason for
the
Although
can see
that this
patient
concordant
initially,
patient’s
current
(oral
clindamycin)
not
the guidelines
Please
remember
that theonly
audit
does
not ask
you
to determine
you
are required
totherapy
review
what
is current.
Asmatching
clindamycin
is the
not extent
listedfor
in
sepsis
secondary
to
an
intravascular
device
infection,
as
the
therapy
has
to
which
a
documented
diagnosis
is
correct
or
incorrect,
or
whether
current
the guidelines, technically it should be recorded as non-concordant. There is
been
de-escalated
upon
reviewing
the
patient’syou
current
condition.
therapy
appropriate reason
or
warranted.
an auditor
are asked
to focus
however,
aisdocumented
(clinicalAs
improvement
leading
to
de-escalation
what the medical team believes they are treating and whether they have
ofontherapy).
Had the medical
notes via
simply
‘change to
oral therapy’ without
prescribed
the stated
corresponding
guidelines.
making
thatyou
the may
patient
had significantly
may be
Although
as itanclear
auditor
sometimes
feel that improved,
step-downthis
therapy
is (or
If,
for
example,
you
believed
the
patient
in
front
of
you
only
had
mild
interpreted
as not
providing
a clear
as there
isn’t)
‘appropriate’,
you
must must
still reason
follow the
rulesisofno
theclinical
audit.rationale
thrombophlebitis
that
has
largely
resolved,
you
are
encouraged
to discuss
with
reference to
change in therapy.
Remember thatprovided
guideline
concordance
ORthe
documentation
of a reason
for nonthese
concerns
with
the
doctor
.
Your
personal
assessment
should
not
concordance are both considered positive outcomes and will count towards
however,
alter your response to the audit questions.
the same indicator
result.
OK
OK
OK
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
You’ve Finished!
Congratulations on completing the
Challenging Cases Tutorial.
Kate Callaghan
As an auditor, you should now have a better
idea of how to proceed with some of the
more complex patients you encounter.
kate.callaghan@cec.health.nsw.gov.au
PH: (02) 9269 5618
If you have any questions or concerns about
the answers provided in this tutorial, or
general queries regarding the 5x5
Antimicrobial Audit, please feel free to get in
touch with us.
Project Officer, Antimicrobial Stewardship
Clinical Excellence Commission
Evette Buono
Program Lead, Antimicrobial Stewardship
Clinical Excellence Commission
evette.buono@cec.health.nsw.gov.au
PH: (02) 9269 5581
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013
5x5 Antimicrobial Audit: CHALLENGING CASES TUTORIAL
You’ve Finished!
Congratulations on completing the
Challenging Cases Tutorial.
Kate Callaghan
As an auditor, you should now have a better
idea of how to proceed with some of the
more complex patients you encounter.
kate.callaghan@cec.health.nsw.gov.au
PH: (02) 9269 5618
If you have any questions or concerns about
the answers provided in this tutorial, or
general queries regarding the 5x5
Antimicrobial Audit, please feel free to get in
touch with us.
Project Officer, Antimicrobial Stewardship
Clinical Excellence Commission
Evette Buono
Program Lead, Antimicrobial Stewardship
Clinical Excellence Commission
evette.buono@cec.health.nsw.gov.au
PH: (02) 9269 5581
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Challenging Cases Tutorial (Released March 2014) © Clinical Excellence Commission 2013