Action Plan for Antimicrobial Stewardship February 2014 Background The ‘Code of Practice on the prevention and control of infections and related guidance’ which applies to all providers of healthcare and adult social care under The Health and Social Care Act 2008 states that procedures should be in place to ensure prudent prescribing and antimicrobial stewardship. In addition The Department of Health issued guidance in November 2011 ‘Antimicrobial Stewardship: Start Smart – Then Focus’ providing an evidence based framework for antimicrobial stewardship in the secondary care setting. This guidance states that an Antimicrobial Stewardship Programme is a key component in reduction in healthcare associated infections, improving patient outcomes contributes to the slowing of the development of antimicrobial resistance. The ‘Start Smart – Then Focus’ guidance outlines the elements of a successful Antimicrobial Stewardship Programme: Element: RWT achievements in this area Assessment of the Trust’s Antimicrobial Stewardship Activities using the evidencebased antimicrobial self-assessment toolkit (ASAT) for acute hospitals A score of 109 achieved in March 2013 at the end the 2012-2013 CQUIN assessment; the payment threshold for this was a score of 90. This audit will be repeated on an annual basis. We have an expanding multi-disciplinary Antimicrobial Stewardship Committee with representation from Pharmacy, Medicine, Surgery, A&E, ICCU, Anaesthetics, Obstetrics and Gynaecology, Paediatrics, Infection Prevention and Clinical Governance. The committee has been place since March 2012. Prior to this this there was no Antimicrobial Stewardship programme within the Trust. We have not yet established an Antimicrobial Stewardship ward round; currently insufficient staffing to support this. An Antimicrobial Stewardship Management Team/Committee A ward-focused antimicrobial team is recommended in addition to the management team/committee. It is suggested that organisations develop an Antimicrobial Stewardship ward focused team (Antimicrobial pharmacist and/or consultant microbiologist/infectious diseases specialist) that report to the Management Team/Committee and are available to review prescriptions at ward level. Evidence-based antimicrobial prescribing guidelines Evidence-based antimicrobial prescribing guidelines are in place and reviewed annually. They are now available in a web based format on the Trust intranet site. They are also available in a concise format on a pocket Quality Assurance Measures/Audits: Procedures should be in place to ensure prudent antibiotic prescribing and antimicrobial stewardship. There should be an ongoing programme of audit, revision and update monitored by the Antimicrobial Stewardship Committee/Management Team. Regular (at least annual) feedback of adherence to prescribing standards should be provided to the Trust Board (as part of the annual infection control committee (or equivalent) report), prescribers, lead clinicians and microbiologists, nurses, pharmacists and the DIPC. sized guide. Dr Ashcroft also advises on the Primary Care Antimicrobial Prescribing Guidelines. We now have an established Antimicrobial Stewardship Audit Programme in place as outlined in the new Antimicrobial Policy. This comprises of quarterly KPIs which are fed back to the clinicians, matrons, pharmacists and IPCG and a larger annual audit examining adherence to Trust guidelines and adherence to the Trust Antimicrobial Policy in more detail. In addition to the achievements outlined above the committee also oversaw the successful completion of the Antimicrobial Stewardship CQUINS 2012-13. Since the initiation of the committee no funding has been provided to support this important Trust wide initiative with the exception of additional pharmacy support for the CQUIN audits; this support was withdrawn upon completion of the CQUIN. The Chair of the committee is Dr Ashcroft, a part time Consultant Microbiologist who is supported by Pam Kang a part time antimicrobial pharmacist; recent pharmacy staffing benchmarking has shown that RWT is still below the national average for Pharmacy staffing and has less Antimicrobial pharmacy time than most equivalent acute Trusts. In 2013 the Chief Medical Officer of England stated that global action was needed to tackle the catastrophic threat of antimicrobial resistance and called for antimicrobial resistance to be put on the national risk register. This was followed in September 2013 by the ‘UK Five Year Antimicrobial Resistance Strategy: 2013 to 2018. It states that there are few public health issues of greater importance than antimicrobial resistance in terms of impact on society. It concerns the entire world and requires action at local, national and global level. Of greatest concern is the rapid development of bacterial resistance to antibiotics, if the number of hard-to-treat infections continues to grow then it will become increasingly difficult to control infection in a range of routine medical care settings. The overarching goal of the Strategy is to slow the development and spread of antimicrobial resistance. It focuses activities around three strategic aims: Improve the knowledge and understanding of antimicrobial resistance Conserve and steward the effectiveness of existing treatments o Of particular importance is: Optimising prescribing practice through implementation of antimicrobial stewardship programmes that promote rational prescribing Improving professional education, training and public engagement Providing clinical leadership and improved collaborative working, between senior management and infection prevention and control teams, by prioritising antimicrobial stewardship and adherence to best practice in infection prevention and control, in both active and preventative treatment regimes Stimulate the development of new antibiotics, diagnostics and novel therapies The Chief Medical Officer acknowledges that ensuring that antibiotics are used responsibly and less often will not happen overnight and that it will require the full commitment and engagement of a range of experts, professionals and the public. Similarly at RWT good Antimicrobial Stewardship practices require full commitment and engagement of all medical and nursing staff. The Trust Development Authority has acknowledged the importance of Antimicrobial Stewardship in the Integrated Planning Checklist 2014/15: Quality. Within this document it states that there should be ‘An established antimicrobial stewardship programme that meets all of the recommendations in the national Department of Health guidance’ and also the Trust should have a ‘Development plan to implement the recommendations of the 5-year strategy for antimicrobial resistance’. Clearly there are many incentives for and benefits of a robust antimicrobial stewardship programme within the Trust, however as with Infection Prevention the power for success does not lie solely with the Antimicrobial Stewardship Committee but is the responsibility of all staff involved with antibiotic prescribing or administration. The key to success is greater clinical engagement and wider education. Whilst the Antimicrobial Stewardship Committee agree that improvements are needed across the Trust we believe that this issue needs Trust wide engagement and embedding good antimicrobial stewardship into the culture of the organisation. As such we believe it cannot remain unfunded and additional Consultant Microbiologist and pharmacist support is needed to deliver the action plan: for improvement in Antimicrobial Stewardship practices and ultimately and more importantly improved patient safety and patient outcome. Action Plan: Action Staffing Timeline Potential benefits Successful business case for and appointment of a full time Consultant Microbiologist to replace Dr Ashcroft with funded sessions for Antimicrobial Stewardship work Successful business case for and appointment of additional Antimicrobial Pharmacist August 2014 Expand on work to date with regular ward visits, regular AS ward rounds, both by Microbiologist and Antimicrobial Pharmacist. More in-depth real time review of prescribing data and habits to allow proactive interventions. In addition to the clinical goals of an effective antimicrobial stewardship programme and the financial saving to be made from the prevention of HCAI and reduction in emergence of resistant organisms there are other potential savings to be made from regular ward visits. These can result from relatively simple interventions such as iv to oral switch, de-escalation in antibiotic therapy to narrow therapeutic options and reduction in overall antimicrobial use by ensuring antibiotics are stopped when no longer necessary. Other indirect anticipated savings stem from decreased length of stay with an increase in iv to oral conversion and optimised treatment regimes. September 2014 Expansion of current educational programme with interactive sessions Expansion of current Antimicrobial Prescribing Guidelines and Antibiotic Web site. Development of Antimicrobial Apps for smart phones. Extension of the Antimicrobial Stewardship programme into Primary Care with enhanced engagement with primary care prescribers. Successful business case for administrative support for the Antimicrobial Stewardship team. Antimicrobial Stewardship ward rounds. Both by pharmacists and microbiologists September 2014 Upon appointment of additional personnel Development of new antimicrobial initiatives to enable improved patient care and financial saving e.g. fosfomycin business case to reduce use of IV ertapenem for UTIs caused by ESBL organisms Support the Consultant Microbiologist and Antimicrobial Pharmacist. See above Antimicrobial Stewardship Committee members to become ‘champions’ in their individual areas. Education Incorporation of the Department of Health Antimicrobial prescribing and stewardship competencies into the RWT mandatory Antimicrobial training. This will specifically target all medical and non-medical prescribers. Antimicrobial Stewardship basic principles to be covered in IP level 2 mandatory training. This will target all clinical staff however will not be as in depth as the mandatory Antimicrobial training. Antimicrobial Stewardship basic principles to be covered in ‘Sepsis’ training educational material Resources Trial in AMU and SAU of stapling Antimicrobial stickers to admission treatment sheets Provide Antimicrobial stickers in additional A4 sheets as requested by various wards. Concise pocket guide: combine surviving sepsis and good AS principles (one side each) Other: Refinement of KPI data collection. To ensure that data collected relates to the ward where the antibiotic was started and not the ward where the notes were audited. On-going Engagement with clinical colleagues; in a position to affect change. February 2014 To ensure that all relevant staff receive appropriate and comprehensive training. April 2014 To ensure that all clinical staff are aware of the basic principles of good antimicrobial stewardship. To empower all clinical staff to challenge poor antimicrobial stewardship. April 2014 See above April 2014 To serve as a reminder to all staff clerking new admissions April 2014 To facilitate ease of use to fit in with individual ward practices To explore this idea further with colleagues April 2014 To ensure that wards received robust data and are not penalised for other poorly performing areas. Of all the measures outlined above I feel the key to improved Antimicrobial Stewardship practices within the Trust is wider clinical engagement resulting in individual ownership and accountability, with Consultants leading by example. The Trust approach for Infection Prevention has been that it is everyone’s responsibility; this is the same for Antimicrobial Stewardship. We need Trust wide engagement to embed Antimicrobial Stewardship into the culture of the organisation. This can be achieved if the Antimicrobial Stewardship team is adequately resourced and staffed. References: The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections. ‘Antimicrobial Stewardship: Start Smart – Then Focus. Guidance for antimicrobial stewardship in hospitals.’ Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection. November 2011 ‘Antimicrobial prescribing and stewardship competencies’ Public Health England September 2013 ‘UK Five Year Antimicrobial Resistance Strategy 2013 – 2018 September 2013 Trust Development Authority – Integrated Planning Checklist 2014/15: Quality ‘Supporting Safe Services’ December 2013 Dr Mary Ashcroft Chair Antimicrobial Stewardship Committee 13th February 2014