WA.CA
COMMITTEE FOR ANTIMICROBIALS
Western Australian Committee for Antimicrobials
Symposium 2014
‘ANTIMICROBIAL STEWARDSHIP AND STANDARDS THE ROAD TO IMPLEMENTATION’
Program
16th June 2014
Bruce Hunt Lecture Theatre
Royal Perth Hospital
Perth, Western Australia
Welcome
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Program
8:00
8:25
Registration
Welcome
Dr John Dyer
Chair of WACA and Director Infectious Diseases Department, Fremantle Hospital and
Health Service
Professor Gary Geehoed,
Chief Medical Officer, Department of Health, Western Australia.
8:30
"Resisting Antimicrobial Resistance (AMR) - Antimicrobial Stewardship in
Australia."
Debbie Carter, Australian Commission on Safety and Quality in Health Care.
8:55
“A Vitamin T Overdose? : An audit of piperacillin/ tazobactam use at Royal Perth
Hospital.”
Amelia Davis and Matthew Hanson (Abstract 1). Royal Perth Hospital
9:10
“What’s New in Hospital AMS?”
Associate Professor Karin Thursky, Department of Infectious Diseases, Peter MacCallum
Cancer Centre.
9:35
“Improving Antimicrobial documentation with the use of an Antimicrobial Plan
sticker.”
Evonne Fong, Armadale Health Service (Abstract 2).
9:50
“WACHS Antimicrobial stewardship.”
Dr Helen Van Gessel, Western Australian Country Health Service-Great Southern.
10:15 Morning tea
10:45 "Antimicrobial Stewardship and the pharmacist."
Matthew Rawlins Royal Perth Hospital.
11:15 ‘Tablet application central to hospital antimicrobial stewardship program.’
Chris Shenton, Joondalup Health Campus (Abstract 3).
11.30 “Super bugs, wonder drugs and flesh-eating furphies.”
Tom Snelling and Jonathan Carapetis.
12:30 Lunch break
1:15
“Private hospitals and health funds – the challenge of AMS.”
Dr Duncan McLellan, Western Diagnostic Pathology
1:45
“Implementation of a Hospital Paediatric Antimicrobial Stewardship Program.”
Mona Mostaghim AMS pharmacist at Sydney Children’s Hospital, Randwick and Tom
Snelling, Sydney Children’s Hospital (Abstract 4).
“Antimicrobial stewardship in the community.”
Shirley Harrison, NPS MedicineWise
“These children get sicker, quicker.”
Dr David Gaskell, Western Australian Country Health Service –Kimberley (Abstract 5).
“Development of Antimicrobial Stewardship at Swan Districts Hospital- A work in
progress.”
Dr Marilyn Hassell, PathWest.
“Antimicrobial stewardship in a mental health setting.”
Sandra Mazarakis, The Marian Centre (Abstract 6).
Closing remarks
2:00
2:25
2:40
3:05
3:20
Neil Keen, Chief Pharmacist, Department of Health, Western Australia.
3:30
Close
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Western Australian Committee for Antimicrobials
Dr John Dyer (Chairman)
Director, Infectious Disease Department
Fremantle Hospital and Health Service
Dr Duncan McLellan
Dr Ronan Murray
Clinical Microbiologist and Infectious Disease
Physician
PathWest
Head of Department of Microbiology
Microbiologist and Infectious Disease
Physician
Western Diagnostic Pathology
Dr Helen Van Gessel
Dr Tom Snelling
Director of Medical Services
Infectious Disease Physician
Western Australian Country Health ServicesSouth West.
Princess Margaret Hospital
Dr Michelle Porter
Dr Owen Robinson
Microbiologist and Infectious Disease Physician
Infectious Disease Consultant
Princess Margaret Hospital
Royal Perth Hospital
Matt Rawlins
Dr Paul Ingram
Infectious Disease Pharmacist
Microbiologist and Infectious diseases
Physician
Royal Perth Hospital
Royal Perth Hospital
Anna Allman
Rebecca McCann
Senior Pharmacist
Program Manager
Fremantle Hospital and Health Service
Healthcare Associated Infection Unit
Public Health Division
Kerry Fitzsimons
Medication Safety Pharmacist,
Fremantle Hospital and Health Service
Pharmacy Advisor
Quality Improvement and Change
Management Unit, Dept of Health.
Kathy Irwin
Project Coordinator
Western Australian Committee for Antimicrobials
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Invited speakers
Debbie Carter
Australian Commission on Safety and Quality in Health Care
Debbie leads the antimicrobial stewardship program at the Australian Commission on Safety and
Quality in Health Care. Prior to this Debbie worked as a Team Leader at NPS MedicineWise, where
she was involved in the development and implementation of behavioural change activities for health
professionals and consumers as part of NPS’s national educational visiting programs. She has a
pharmacist by background with over 12 years clinical experience specialising in haematology, bone
marrow transplantation, and palliative care.
Matthew Rawlins
Infectious Disease Pharmacist, Royal Perth Hospital
Matt is a Curtin University pharmacy graduate. He was the first antibiotic pharmacist at St Mary's
Hospital London, UK and has been the infectious diseases pharmacist at RPH since 2004. He has
been a key member of their long-running antimicrobial stewardship program since its inception.
Helen Van Gessel
Western Australian Country Health Service-Great Southern.
Helen has been the director of medical services for the Great Southern region, WA Country Health
Service since 2011. Prior to that she worked in Perth as an infectious diseases physician at RPH,
was the inaugural chair of the RPH antimicrobial stewardship committee, a clinical advisor to the
WA Office of Safety and Quality in Health care and a member of the Australian Commission on
Quality and Safety HAI advisory group.
Associate Professor Karin Thursky
Department of Infectious Diseases
Associate Professor Karin Thursky is an infectious diseases physician with appointments at Royal
Melbourne Hospital and Peter MacCallum Cancer Centre and is an honorary fellow with the
University of Melbourne medical school. She is actively involved in the area of quality and safety
and has a national profile in antimicrobial stewardship, and development and implementation of
consensus guidelines for the prevention and treatment of infections in the cancer patient. Her
research area is broad with interests such as clinical epidemiology of infections in the
immunocompromised host, health economics, and computerised decision support for stewardship,
natural language processing and surveillance.
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Dr Duncan McLellan
Head of Department of Microbiology at Western Diagnostic Pathology
Duncan is a consulting infectious diseases physician at Fremantle Hospital, St John of God Murdoch, Mount Hospital and Joondalup Health Campus.
Shirley Harrison
NPS MedicineWise educational visiting pharmacist
Shirley graduated from the Victorian College of Pharmacy, is a Fellow of the Australian College of
Pharmacy Practice and is a previous community pharmacy proprietor. She has experience in
hospital pharmacy, research in hospital ward pharmacy, community pharmacy and is currently an
HMR accredited pharmacist and NPS Educational Visiting Pharmacist.
Marilyn Hassell
PathWest.
Marilyn completed her medical degree at UWA in 1994 and underwent advanced physician training
in infectious diseases in Perth, Cairns and Darwin, a significant proportion of which involved
management of patients in and from remote communities. She previously worked as an infectious
diseases physician at Royal Perth and SCGH, and has a particular interest in home IV antibiotic
therapy. She has been involved in antimicrobial stewardship at Swan Districts Hospital since 2010.
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08:30
"Resisting Antimicrobial Resistance (AMR) - Antimicrobial Stewardship in
Australia"
Presenter
Debbie Carter, Australian Commission on Safety and Quality in Health Care
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8:55
A Vitamin T Overdose? : An audit of piperacillin/ tazobactam use at Royal Perth
Hospital’
Authors
M. Hanson, A. Davis, S. Benson, O. Robinson and M. Rawlins.
Presenters Amelia Davis and Matthew Hanson.
A cross sectional study was undertaken on 571 inpatients at Royal Perth Hospital to
quantify and analyze the use of piperacillin/ tazobactam. Of the 571 inpatients, 256
were prescribed antimicrobials and, of these, 79 (30.86%) were prescribed
piperacillin/ tazobactam.
Inpatient progress notes and Antimicrobial Prescribing Survey (2013) data, were
reviewed to establish the clinical scenario leading to the prescription of piperacillin/
tazobactam. Prescriptions were reviewed on a case-by-case basis and were deemed
concurrent with guidelines, if piperacillin/ tazobactam was recommended by the
Antibiotic Therapeutic Guidelines. In cases where the prescription was not concurrent
with guidelines, two infectious disease physicians undertook further review to assess
the appropriateness of the prescription.
Of those prescribed piperacillin/ tazobactam, 39 (49.4%) of prescriptions were
deemed not concurrent with guidelines, and 5.1% were prescribed at an incorrect
dose or frequency. Diagnoses most associated with non-concurrent prescriptions
were: community acquired pneumonia, sepsis, urinary tract infection, post- surgical
prophylaxis and abscess.
An in depth analysis may be required to highlight hospital-specific causative factors
responsible for the “over prescription” of piperacillin/ tazobactam in order to guide
future intervention and improve prescribing habits.
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9:10
What’s New in Hospital AMS
Presenter
Associate Professor Karin Thursky, Department of Infectious Diseases, Peter
MacCallum Cancer Centre.
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9:35
“Improving Antimicrobial documentation with the use of an Antimicrobial
Plan sticker”
Author
E. Fong.
Presenter
Evonne Fong, Armadale Health Service.
Objective or Purpose:
The Australian Commission on Safety and Quality in Health Care has drafted a
Clinical Care Standard for antimicrobial stewardship. This standard includes a
number of quality statements describing the clinical care a patient should be
offered for a specific clinical condition.
Quality Statement 6 in this standard centres on documentation, and recommends
that when a patient is prescribed antibiotics, the clinical reason, drug name, dose,
route of administration, intended duration and review plan is documented in their
medical record.
The aim of this project was to improve documentation of antibiotic treatment and
effective communication between clinicians. Health Services should ensure there is
a system in place to support this documentation.
Methodology:
A baseline audit in November 2013 took a one day “snap shot” of inpatients
prescribed antimicrobials. On the day of the audit, 57 inpatients were prescribed
antimicrobials, with 85 current antimicrobial orders.
The percentage of total antimicrobial prescriptions where an indication was
documented was 67.1%. For best practice, this should ideally be greater than 95%.
To improve documentation, AHS is piloting the use of a sticker in ICU, for inclusion
in a patient’s integrated progress notes when an antimicrobial is newly charted (see
Figure 1).
Figure 1. Antimicrobial Plan
Medical staff have been educated about using this sticker for documentation, which
is to be launched in May. Results and reauditing are planned for June.
Implications and relevance to other services:
Compliance with using this sticker means that patients will have the details of their
antibiotic treatment documented in their medical record. It also helps to ensure
good communication between clinicians and complies with Quality Statement 6 in
the Commission’s Clinical Care Standards as well as NSQHS standard 3 and
standard 4 for accreditation.
Biography
Evonne is a clinical pharmacist working at Armadale Health Service in the
Emergency Department and Intensive Care Unit
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More note space available at end of booklet
9:50
WACHS Antimicrobial stewardship
Presenter
Dr Helen Van Gessel, Western Australian Country Health Service-Great Southern.
10:45
"Antimicrobial Stewardship and the pharmacist"
Presenter
Matthew Rawlins, Royal Perth Hospital.
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11:15
Tablet Application Central to Hospital Antimicrobial Stewardship Program
Authors
Giannasi S and Shenton C.
Presenters
Chris Shenton and Sarah Giannasi, Joondalup Health Campus.
Background: Joondalup Health Campus is a private/ public hospital of 650 beds in
Perth’s northern suburbs. Joondalup Health Campus has grown quickly from 60
beds in 1995 to the current size. The emergency department is one of Perth’s
busiest, with over 90,000 patients treated per year.
This paper describes the setup of an AMS service and the central tablet based IT
infrastructure that connects the team and collates the data.
Methods: All clinical pharmacists at JHC have a role in the AMS program. AMS is
an integral part of every pharmacist’s clinical round. The pharmacy IT team have
developed an extension to the clinical pharmacy application, Clinical Workhorse, to
manage AMS. The tablet displays data such as pathology, medication history and
ward movements. One pharmacist collates the data and shares with the ID
physicians.
Results: The clinical pharmacists notate individual patient profiles with drug choice
and indication. The ID physician will then review and provide advice on therapy.
Ward pharmacists then review and record prescriber compliance and patient
outcomes.
Conclusions: This method of implementation involves all pharmacists in the AMS
program. The outcomes of patients are recorded live and shared amongst all
members of the team. Patients benefit from a widespread application of the AMS
principles and pharmacists benefit from the growing knowledge of antimicrobials.
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11:30
“Super bugs, wonder drugs and flesh-eating furphies”
Presenters
Tom Snelling and Jonathan Carapetis.
1:15
Private hospitals and health funds – the challenge of AMS
Presenter
Dr Duncan McLellan,
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1:45
Implementation of a Hospital Paediatric Antimicrobial Stewardship Program
Authors
M.Mostaghim, T.Snelling, B. McMullan & P.Palasanthiran.
Presenters
Mona Mostaghim or Tom Snelling.
Background: Antimicrobial Stewardship (AMS) programs based on Therapeutic
Guidelines® recommendations are established in many adult hospitals and have
been included in the National Safety and Quality Health Service (NSQHS)
Standards.
Implementing AMS programs in paediatric hospitals is complicated by limited
evidence-based or consensus paediatric guidelines and frequent “off label”
prescribing, particularly in complex settings such as transplantation and
chemotherapy. With half of paediatric inpatients on average prescribed antibiotics
AMS resources are required at the point of care to ensure timely access to
antimicrobials.
Aims:
1. Optimise antimicrobial use within a tertiary paediatric hospital by implementing
an AMS program aided by an electronic approval and decision support system.
2. Achieve accreditation under NSQHS criteria 3.14 Antimicrobial Stewardship.
Methods: Comprehensive review of best practice guidelines and literature on
antimicrobial use in paediatric medical, surgical and high-risk patients, stratification
of antimicrobials based on risk and site specific resistance data was undertaken
and a multisite, multidisciplinary working party was formed.
An electronic approval and decision support system was programmed comprising
evidence- and consensus derived recommendations on optimal antimicrobial use,
indication specific dose, route, duration, management and monitoring
requirements. Guidance on IV to oral switch, escalation and de-escalation of
therapy and access to endorsed guidelines were integrated into the approval
process. Governance and evaluation structures are based on systematic collation
of real-time and long term feedback, and auditing addressing cost, safety, quality,
prescribing practices, system adherence and uptake of AMS team
recommendations.
Results: Biannual hospital-wide point prevalence audits identified 10% and 22%
improvements in appropriate antimicrobial prescribing (6 and 12 months
respectively) after implementation, with a trend towards reduced third generation
cephalosporin, gentamicin and carbapenem use. NSQHS accreditation was
achieved with merit for all elements of criteria 3.14.
Conclusion: A comprehensive multidisciplinary paediatric AMS program was
successfully implemented, performing routine evaluation and optimisation of
antimicrobial use.
Biography
Mona Mostaghim is the Quality Use of Medicine, Medication Safety and
Antimicrobial Stewardship pharmacist at Sydney Children’s Hospital Randwick,
one of three tertiary centres for child health in New South Wales.
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2:00
Antimicrobial Stewardship in the Community
Presenter
Shirley Harrison, NPS MedicineWise.
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2:25
“These children get sicker, quicker”: Using AMS governance to develop
consensus for assessment and early management of the unwell Aboriginal
child in the Kimberley (Abstract 5)
Authors
Anti-Microbial Stewardship Committee ,Febrile Child Protocol Working Group.
Presenter
Dr David Gaskell , Western Australian Country Health Service – Kimberley.
AntiMicrobial Stewardship Committee Febrile Child Protocol Working Group –
WACHS – Kimberley
In November 2011, a WACHS-K Febrile Child Protocol was produced to reduce
mortality and morbidity from bacterial sepsis among Aboriginal children in the
Kimberley. Unpublished clinical audit data corroborated subsequent positive impact
across the region. When the WACHS-K Antimicrobial Stewardship (AMS)
Committee convened in late 2013, one of its priorities was to collaborate with
clinicians from diverse organisations to review this Protocol. Factors prompting this
review included a need to better target the clinical content of the Protocol, feedback
about its length and limited accessibility to clinicians outside WACHS-K and
changing patterns of antibiotic resistance in the Kimberley. As Aboriginal babies
and children in the Kimberley get ‘sicker, quicker’, it was important to focus on
community-based management in very remote settings. The AMS Committee
established a Working Group with representatives of key stakeholder services in
the Kimberley which obtained inputs from a broad disciplinary range including
primary health care, paediatrics, nursing and microbiology. Recognition of the
diversity of service providers in the Kimberley has seen the creation of a common
‘Kimberley template’ which ensures that guidelines can be endorsed through the
Kimberley Aboriginal Health Planning Forum (KAHPF) upon recommendation by an
expert Standing Committee for universal use in the region. Using this common
‘Kimberley template’, the Working Group finalized a two-page flowchart in February
2014 for clinicians dealing with septic presentations due to infections of unknown
origin in Aboriginal infants and children. This presentation will cover key revisions
to the Protocol and their rationale including triage and risk assessment, advice for
clinical decision-making and antibiotic choices. AMS achieved consensus across
Kimberley service providers. Implementation of the final version of Assessment
and Early Management of the Unwell Child will also be discussed.
Biography
Dr David Gaskell joined WACHS-Kimberley as Regional Medical Director in 2013
and brings diverse experiences in health systems design and delivery in both
developed and developing countries. He is a member of the Regional Executive
Team and maintains an active clinical role in general practice in Broome where he
is currently based. As Chair, David has reinvigorated the Anti-Microbial
Stewardship Committee by ensuring a wide disciplinary mix and an agenda
responsive to the challenges of the Kimberley.
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2:40
‘Development of Antimicrobial Stewardship at Swan Districts Hospital- A
work in progress’
Presenter
Dr Marilyn Hassell, PathWest.
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3:05
Antimicrobial Stewardship in a mental health setting
Author
Sandra Mazarakis.
Presenter
Sandra Mazarakis, Accreditation Coordinator, The Marian Centre.
Objectives: Identification of gaps and requirements in meeting Antimicrobial
Stewardship criterion 3.14 of National Standard 3: Preventing and Controlling
Healthcare Associated Infections. Implementation of effective and robust
Antimicrobial Stewardship Team and governance structure for monitoring,
development of formularies for use by practitioners, educating and facilitating
correct antimicrobial prescribing as would be applicable to a mental health setting
with more common infection presentations seen at our service.
Methodology: Data collected for an annual period September 2012 – September
2013 to obtain a baseline of more common infections seen at our hospital.
Antimicrobials prescribed to patients over reported period obtained from pharmacy
supplying antimicrobials to the hospitals. Data collected retrospectively as a
baseline for organisation to determine infection rates, community and healthcare
associated infections. Data correlated with report from pharmacy on antimicrobials
prescribed. Point prevalence study undertaken and results reported.
Conclusion: Identification of requirement for imprest system of three common
antimicrobials to treat common presentations noted at our hospital. Development of
a formulary system for ease of reference for our Accredited Psychiatrists and
Clinical Staff. Plan to perfect our current process over next 12 months and then
focus on identification of more common infection patient presentations and focus
on targeted point prevalence studies specific to more common presentations.
Biography
Sandra Mazarakis is an accreditation coordinator and registered nurse. She has
worked in a variety of clinical settings since 1991 – acute, general, transplant, aged
care, telephone triage, quality and risk management and accreditation. She is
currently working in mental health setting with a role that involves accreditation.
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