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