A Multicentre Drug Use Evaluation in Hospitals:
The CAPTION Project
Community-acquired pneumonia: Towards improving
outcomes nationally.
Final Report to the National Prescribing Service
Project Report
September 2005
NSW TAG Project Team:
Karen Kaye
David Maxwell
(Project Manager)
(Project Officer)
NSW TAG CAPTION Final Report
Contents
Executive summary ................................................................................................ 3
Recommendations ................................................................................................. 7
Introduction .......................................................................................................... 10
Background ...................................................................................................... 10
Aims ................................................................................................................. 12
Methods ............................................................................................................... 13
Project set up ................................................................................................... 13
Hospital recruitment .......................................................................................... 13
Patient identification ......................................................................................... 13
Baseline data collection tool and pilot study ...................................................... 14
Intervention tools .............................................................................................. 14
Intervention plan ............................................................................................... 15
Data management ............................................................................................ 15
Evaluation......................................................................................................... 16
Communication processes ............................................................................... 17
Results ................................................................................................................. 18
Discussion............................................................................................................ 20
Conclusion ........................................................................................................... 23
Tables .................................................................................................................. 24
Table 1: CAPTION exclusion criteria ................................................................ 24
Table 2. Summary of patient demographics according to audit cycle ................ 25
Table 3. Empiric CAP antibiotic therapy prescribed in EDs ............................... 26
Table 4. Antibiotic monotherapy according to calculated disease severity ....... 27
Table 5. Process indicator results compared to baseline (1st audit) .................. 28
Table 6. Summary of 1st intervention phase activity - Group sessions............... 29
Table 7. Summary of 1st intervention phase activity - Academic detailing ........ 30
Table 8. Summary of 2nd intervention phase activity - Group sessions .............. 31
Table 9. Summary of 2nd intervention phase activity - Academic detailing ........ 32
Acknowledgements .............................................................................................. 33
References........................................................................................................... 34
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Executive Summary
Introduction
There is evidence that knowledge of and adherence to the community-acquired
pneumonia (CAP) guidelines within the Therapeutic Guidelines: Antibiotic,
Version 12, 2003 (Guidelines) is suboptimal. The National Prescribing Service
(NPS) has funded and supported a 2-year multicentre drug use evaluation (DUE)
project, CAPTION (Community-acquired pneumonia: Towards improving
outcomes nationally), to improve patient outcomes through the implementation of
national Guidelines for the management of CAP.
The project engaged the expertise of state DUE groups from Victoria, New South
Wales (NSW), Tasmania, South Australia and Queensland as well as the
experience and skill of the NPS in social marketing techniques to influence
prescribing.
Aim
To implement the CAP recommendations of the Guidelines in NSW and the
Australian Capital Territory (ACT) hospital emergency departments (ED).
To train health professionals in the use of social marketing techniques to
influence and improve prescribing practice, as part of a suite of interventions.
Methods
NSW and ACT hospitals were recruited to participate on a voluntary basis.
Invitations were sent to all NSW TAG and TAG Net members in December 2003.
Each hospital expressing an interest to participate was then required to obtain
endorsement and support of the project from local authority figures (Chief
Executive Officer, Director of Emergency and Director of Pharmacy). Because
this was a quality improvement project, endorsement of the project by the local
Human Research and Ethics Committee was also required. Participating
hospitals formed a local project team to coordinate CAPTION activities at an
institutional level and identified a hospital coordinator responsible for liaising and
reporting to NSW TAG.
Key messages (see box below) of the CAP recommendations in the Guidelines
were identified at a national level through the consensus of expert opinion and
were endorsed by members of the state-based project steering committees. The
key messages were incorporated into a suite of intervention tools that were
distributed to participating hospitals. Education in the principles and practice of
academic detailing was offered to one representative (‘academic detailer’) from
each participating hospital across NSW and the ACT.
CAPTION project key messages:
1. Use a systematic approach to assessing severity.
2. Penicillins are the first choice for non-severe CAP.
3. Consider atypical pneumonias when deciding on antibiotic regimen.
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Intervention materials available through the project to influence prescribing
included:
 Letters to prescribers: available to be sent to ED prescribers, outlining the
aims of the project and raising the awareness of the Guidelines.
 Identification-card (ID) sized reminders: for distribution to ED staff at the
end of a group education session.
 Laminated wall posters: displayed in the ED to reminder ED staff about
the project.
 PSI calculator stickers: placed in the ED to be included in the patient notes
to assist in the calculation of the PSI score.
 Academic detailing cards: used during the one-on-one academic detailing
visits and were presented to the health professional as a gift and the end
of the visit.
 Auditmaker® automated feedback reports: used as part of the group
sessions, informing prescribers on changes in practice after each
intervention phase.
 PowerPoint® slides for group presentations: a generic set of slides
produced to assist in providing feedback to ED prescribers and other
health professionals.
Audit and feedback, group education sessions and a series of slide presentations
were also offered to assist in educating health professionals about CAP and the
recommendations of the Guidelines. A detailing script and a case presentation
were distributed to each of the detailers to assist in the academic detailing visits.
All interventions were delivered by the local hospital coordinator and/or members of
the hospital project team.
A baseline audit of local CAP management was conducted in order to describe
current practice in participating hospitals. Two DUE cycles (intervention, data
collection, evaluation and feedback) were conducted during the project period.
Results of the baseline audit were used to direct the first intervention phase.
Results of subsequent audits were used to inform future intervention phases.
Two process indicators were used to measure the impact of the intervention
phases:
1. Documented use of the Pneumonia Severity Index (PSI)
2. Concordant antibiotic prescribing.
Average length of stay and inpatient mortality were included as part of the final
dataset.
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Major Findings
Twelve hospitals from NSW and the ACT volunteered to participate in the NSW
arm of the project. All twelve hospitals participated in the baseline audit. During the
course of the project one hospital withdrew due to lack of consensus
amongst local opinion leaders on the specific recommendations made by the
Guidelines and another hospital was not able to participate in the intervention
phase(s) due to lack of local resources and time. The remaining ten hospitals
completed two DUE cycles.
Baseline audit results (n=225; patient presentations) indicated that prior to project
commencement use of the Guidelines across participating hospitals was low
(rates of documented PSI and concordant antibiotic prescribing were 6% and
13%, respectively).
An intervention log was maintained by each hospital during the two intervention
phases. All ten hospitals reported using the posters, ID cards and PSI stickers.
Academic detailing was used in nine hospitals. The number of group sessions
and academic detailing visits performed in participating hospitals varied. There
was a general decline in the number of group sessions and academic detailing in
the 2nd intervention phase.
A significant increase in both process indicators was observed after the first
intervention phase (n=195). There was a significant increase in documented PSI
use compared to baseline 27% vs. 6% (p<0.0001) and concordant antibiotic
prescribing increased 25% vs. 13% (p=0.004). The significant increase in
documented PSI use was sustained after the second intervention phase (n=176)
compared to baseline, 24% vs. 6% (p<0.0001), however there was no difference
in the rate of concordant antibiotic prescribing, 19% vs. 13% (p=0.14).
Barriers to the uptake of Guideline recommendations by prescribers included:
lack of confidence in the PSI as an assessment tool; the time required to
calculate the PSI score; concern regarding the prevalence of penicillin-resistant
Streptococcus pneumoniae and hence caution over the use of penicillin as a first
line empiric antibiotic; the lack of availability of specific antibiotics within their
hospital compared to those recommended in the Guidelines; and the fact that
use of discordant therapy (e.g. use of broad spectrum antibiotics) was not likely
to result in any immediate negative patient outcomes, therefore reducing any
impetus to change current practice. A barrier to implementation of educational
interventions was the large number of prescribers in the ED, some of whom may
not have been involved in the educational interventions.
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Conclusion
The baseline audit demonstrated that empiric management of CAP in hospital
EDs varied compared to the CAP management recommendations in the
Guidelines. The project team, including the academic detailer, were successful at
influencing a change in local CAP management and antibiotic prescribing as
demonstrated by the increase in documented PSI use and rate of concordant
antibiotic prescribing. The suite of interventions offered to the local project team,
including academic detailing, facilitated an improvement in prescribing practice.
However, not all improvements were sustained over the duration of the study
period.
Social marketing techniques appear to influence prescribing practice within the
hospital setting, but are resource intensive. Consideration should be given to
providing specified staffing resources in hospitals to facilitate sustained impacts.
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Recommendations
Quality Improvement Methodology:
o Clinical guidelines must exist for areas of program activity and they should
be simple and easy to use. Local support and endorsement of chosen
guidelines is a critical step in engaging support for program activities.
o Hospital opinion leaders should be involved at a local level throughout the
duration of the project, including the steps of gaining initial support,
planning and executing project activity as well as reporting the findings to
key stakeholders.
o Auditmaker® is a useful audit tool and should be considered for use in
future DUE/QI activities. Training in how to tailor Auditmaker® for local
needs, as offered by the Australian Centre for Evidence Based Practice,
should be planned for state-based project coordinators of future multi-site
projects. Consideration should also be given to the training of hospital
coordinators as a possible future activity.
o Recruitment of interested state-based groups responsible for managing
future projects should be conducted in a timely manner, ensuring that all
groups are able to collaborate and work together on all stages of the
project. Participating state-based groups should agree to complete the
various stages of future projects within a similar time frame, to facilitate the
processes of sharing and learning from each other.
o The NSW TAG communication strategy developed for CAPTION was
essential in the overall progress and success of NSW project activity. As
such a clear communication strategy should be developed as part of each
project plan and should make use of a variety of formats. Site visits to
participating hospitals by the project officer during the initial stages of
project planning or implementation should be incorporated into the
statebased communication strategy.
o An education package on change management should be developed and
offered to all hospital project teams. Topics covered in this package
should include: tools to facilitate change (summary of evidence on
effective interventions etc.), communication and negotiation training as
well as the impact of relationships and establishing rapport with opinion
leaders.
o Opportunities for sustaining/consolidating existing activities should be
considered in the development of future work programs.
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Management of Community-Acquired Pneumonia:
o Therapeutic Guidelines should incorporate recommendations to guide
health professionals in the management of Class I and II patients
presenting to hospital who have been commenced on oral antibiotic
therapy in the community.
o Therapeutic Guidelines should acknowledge that other severity
assessment tools for CAP exist and these may be used instead of the PSI.
o In addition to the existing caveat that some patients in Class I and II may
require admission to hospital for social reasons, the Therapeutic
Guidelines should include a comment on the potential need to admit all
hypoxic patients regardless of disease severity (as identified in the
discussion section of the Fine paper, NEJM, 1997).
o Guideline writers (or local hospital policy writers) should explicitly define
the accepted contra-indications for gentamicin use. E.g. what degree of
renal impairment etc.
o Therapeutic Guidelines should include reasons behind the choice of one
antibiotic within a class of antibiotics. E.g. the recommendation of
roxithromycin over other oral macrolides.
o Therapeutic Guidelines should include the reference list in the hard copy
editions of the Guidelines. It is acknowledged that a reference list is
included in the electronic version, however all hospital coordinators
agreed that this list should be included in the ‘pink book’.
o Therapeutic Guidelines should publish agreed management
recommendations for CAP in a medical journal, as do the Infectious
Diseases Society of America and the American Thoracic Society.
Linkages between hospital and community prescribing in the area studied:
o Hospital prescribers should include in the discharge summary for each
patient a clear and accurate record of antibiotic therapy prescribed during
hospital admission and clear advice about antibiotic therapy to continue
upon discharge.
o Links should be developed between project hospitals and the NPS
facilitators within the local General Practice Divisions to ensure alignment of
messages, to facilitate access to GP prescribers and to provide
additional support for academic detailers.
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Sustainable roll out of social marketing interventions in the hospital sector:
o If social marketing techniques, including academic detailing, are to be
used in future quality improvement programs within the hospital
environment, appropriate staffing resources should be allocated to ensure
that this type of intervention activity is sustainable.
o
A minimum of two staff members in each participating hospital should be
trained in the use of academic detailing for future work programs.
o
The role of hospital project coordinator and academic detailer should be
shared by two separate project team members.
o To assist in the overall training and up-skilling of ‘detailers’ more time
should be committed to providing education and support on the
therapeutic area of interest in future activities. A one day therapeutic
briefing should be provided in the training program.
o The profile of the National Prescribing Service should be raised at an
individual hospital prescriber level to ensure that any future NPS quality
improvement projects are not perceived to be a commercial, money
making exercise.
A detailed description of all project activity conducted in NSW/ACT through NSW
TAG, results of the project and lessons learned through the quality improvement
model of CAPTION are included in this final Project Report. A supplementary
Tools Package has also been prepared, including state-based Auditmaker®
feedback reports and tools developed to assist completing the CAPTION project.
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Introduction
Background
The National Prescribing Service (NPS) convened a meeting of all state-based
drug use advisory/quality use of medicines (QUM) groups in April 2003 to
discuss previous drug use evaluations (DUE) undertaken with NPS support and
priorities for future collaborations. State-based groups in attendance were the:
New South Wales Therapeutics Advisory Group (NSW TAG), Western Australian
TAG, South Australian TAG, Victorian Drug Use Evaluation Group (VDUEG),
University of Tasmania and the University of Queensland/Queensland Health
Department.
Previous NPS funded hospital-based DUEs include:
The NSW TAG coordinated a DUE on proton pump inhibitor use in 30
hospitals, involving more than 900 patients over a one week period.1
The VDUEG conducted an audit in 12 hospitals Emergency Departments
(ED) investigating antibiotic use for lower respiratory tract infections. 2
Queensland Health, in collaboration with the University of Queensland
undertook a DUE, involving over 300 patients in 11 hospitals, of
ipratropium use.3
Priorities for future collaborations identified at this meeting were peri-operative
use of insulin, analgesia in medical patients and treatment of communityacquired pneumonia (CAP). Antibiotic use was identified as an area of interest
and of relevance to both hospital and community prescribing practice. After some
discussion it was agreed that a national collaborative quality improvement project
focusing on the management of CAP in the hospital setting be conducted.
CAP is a common, serious respiratory disease, producing significant worldwide
morbidity and mortality.4 Use of antibiotics in the management of respiratory tract
infections, including CAP, has been estimated to represent 75% of total global
antibiotic consumption,5 thus judicious antibiotic prescribing for respiratory
conditions is essential. Australian data on the incidence and management of
CAP is lacking,6 although it has been estimated that CAP occurs in 2 per 1000 of
the adult population per year and that it represents 2% of all overnight hospital
admissions.7
Initial antibiotic management of CAP in hospital EDs is mostly empiric. Causative
organisms are typically unknown at the time of presentation and are not always
detected despite extensive diagnostic testing.8 It is therefore important to ensure
that initial antibiotic choice covers the key bacterial pathogens likely to be
responsible for the disease,4 which are Streptococcus pneumoniae, Mycoplasma
pneumoniae, Chlamydophila pneumoniae and Legionella species.6, 9
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There is evidence that current antibiotic prescribing practice in the management
of lower respiratory infections, including CAP, is varied and not consistent with
national antibiotic guideline recommendations (Therapeutic Guidelines:
Antibiotic).10-16
A telephone survey of Australian EDs doctors revealed that in a given scenario of
a patient with severe CAP only 50% of respondents would prescribe a macrolide
and one third of respondents would initiate third generation cephalosporin
monotherapy.10 A retrospective audit of the management of lower respiratory
infections, conducted in twelve hospital EDs across Australia, demonstrated that
concordance with the Therapeutic Guidelines: Antibiotic version 11 was low
(7%).15 The main variation in prescribing from the above guidelines for patients
with mild to moderate CAP was use of third generation cephalosporins with or
without other antibiotics. In patients with severe CAP reasons for variations in
antibiotic prescribing included ceftriaxone use, with or without other antibiotics, in
patients without a contraindication to penicillin and use of oral antibiotics where
intravenous antibiotics were indicated due to disease severity.15 A number of
single site studies conducted in Australian hospitals have identified similar
variations in antibiotic therapy for the management of CAP.12, 13, 16 Both local and
international opinion leaders have raised concerns of the ‘collateral damage’
associated with the inappropriate use of broad spectrum cephalosporins and
support the use of narrow spectrum antibiotic therapy in the empiric treatment of
CAP. 10, 17, 18 19
Disease severity is a predictor of mortality for patients with CAP. Therefore initial
assessment of disease severity is an issue of interest for health care
professionals responsible for managing patients with CAP. A number of severity
assessment tools have published in the literature to aid health professionals
place patients in an appropriate setting for care (e.g. home, a general ward or
intensive care unit {ICU}). 8, 20 21, 22 Each assessment tool uses a different
number of variables (demographic data, signs and symptoms etc.) to stratify
patients according to mortality risk. The Pneumonia Severity Index (PSI), has
been validated as a prognostic predictor using data from separate cohorts of
38,039 adult inpatients and 2,2287 inpatient and outpatients with CAP. 20 Data
emerging from the ongoing Australian Community Acquired Pneumonia Study
(ACAPS) indicates that the PSI is superior to either of the British Thoracic
Society’s or modified American Thoracic Society’s criteria in predicting CAP
severity.23
The current version of the Therapeutic Guidelines: Antibiotic, version 12, 2003
(Guidelines) incorporates the PSI as a tool to assess disease severity and a
series of empiric antibiotic recommendations based on the common bacterial
causes of CAP and severity of disease.9
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Aims
1. To implement the CAP recommendations of the Guidelines in NSW/ACT
hospital Emergency Departments.
2. To train health professionals in the use of social marketing techniques,
including academic detailing, to influence and improve prescribing practice, as
part of a suite of interventions.
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Methods
A schedule of all CAPTION project activity within NSW/ACT is outlined in
Package 1 of the Tools Package.
Project Set Up
An initial focus group (Group) meeting was held in October 2003 to confirm the
aims and scope of the project at a state level. The Group represented specialists
in the fields of Respiratory Medicine, Emergency Medicine, Infectious Diseases,
Clinical Pharmacy, Quality Improvement and Drug Use Evaluation. The aims and
scope of the project were supported by the Group. The Group proposed that a
Steering Committee be established for the purpose of providing ongoing direction
for the project and be responsible for the endorsement of all project materials
and activities within NSW/ACT.
A state-based Steering Committee (Committee) was established, with
representation reflecting the focus group membership, and additional
representation from General Practice, Emergency Nursing and Clinical
Pharmacology. One notable absence within the Committee was Consumer
representation. The Steering Committee terms of reference were ratified and
endorsed by the Committee (Package 2).
Hospital Recruitment
Invitations seeking expressions of interest to participate in the CAPTION project
were circulated to all NSW TAG and TAG Net members (circulated December
2003). Interested hospitals were then required to obtain support from the local
Chief Executive Officer (CEO), Director of Emergency, Director of Pharmacy,
Chair of the Drug and Therapeutics Committee (DTC) and/or other key leaders
identified by the interested hospitals. Endorsement of project activity by the local
Human Research and Ethics Committee was also a requirement for participation.
A number of tools were provided to interested hospitals to assist in the
recruitment process, including a project description, letters addressed to DTC
Chair and hospital administration as well as a recruitment checklist to be returned
to NSW TAG after local approval and endorsement had been sought (Package
3).
Each participating hospital was required to nominate a hospital coordinator,
responsible for the management of all project activity within their hospital. A local
project team was established in each hospital. It was recommended by NSW
TAG and the NPS that these teams include, at a minimum, the hospital
coordinator, a clinical champion within the ED, an opinion leader in the area of
CAP management and the ‘academic detailer’ (see Intervention Tools).
Patient Identification
Eligible patients were required to have been documented to have a presumptive
diagnosis of CAP upon assessment by the attending ED medical officer. A set of
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exclusion criteria were established based on the patient population in which the
PSI had been validated as well as criteria identified by the state-based project
steering committees (Table 1).
Potential CAP patients were identified retrospectively through medical record
coding using the International Classification of Diseases - 10th revision,
Australian Modification, for respiratory diseases (specifically J13 - J16, J17.8
and J18).24 Potential patients were also identified through ED electronic
information systems. All identified ED presentations and or medical records were
then reviewed according to the patient exclusion criteria.
Baseline Data Collection Tool and Pilot Study
Data elements identified through the Guidelines CAP management algorithm
were collated, including variables required to calculate the PSI. A national
minimum data set was endorsed by the state-based project steering committees.
These data set were formatted into a data collection form comprising a number of
closed-ended questions (yes/no/not documented) and the documentation of
numerical values (e.g. blood test results, date of birth etc.)(Package 4). A pilot
study of the data collection tool was conducted by NSW TAG in February/March
2004. Results of the pilot study were distributed to NPS and the other statebased project groups (Package 4).
Intervention Tools
Key messages (see box) of the Guidelines were identified at a national level
through consensus of expert opinion and endorsed by the state-based project
steering committees. A suite of intervention tools were developed by the
statebased project groups in collaboration with NPS based on the key messages
(Package 5). Similarly all intervention materials were reviewed and endorsed by
the state-based project steering committees.
CAPTION project key messages:
1. Use a systematic approach to assessing severity.
2. Penicillins are the first choice for non-severe CAP.
3. Consider atypical pneumonias when deciding on antibiotic regimen.
Intervention materials available through the project to influence prescribing
included:
 Letters to prescribers: were available to be sent to ED prescribers,
outlining the aims of the project and raising the awareness of the
Guidelines.
 Identification-card (ID) sized reminders: for distribution to ED staff at the
end of a group education session.
 Laminated wall posters: displayed in the ED to reminder ED staff about
the project.
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
PSI calculator stickers: placed in the ED to be included in the patient notes
to assist in the calculation of the PSI score.
 Academic detailing cards: used during the one-on-one academic detailing
visits and were presented to the health professional as a gift and the end
of the visit.
 Auditmaker® automated feedback reports: used as part of the group
sessions, informing prescribers on changes in practice after each
intervention phase.
 PowerPoint® slides for group presentations: a generic set of slides
produced to assist in providing feedback to ED prescribers and other
health professionals.
A two-day academic detailing workshop was convened by NSW TAG and NPS
on the 16th and 17th September, 2004. The aim of the workshop was to introduce
the principles and practice of academic detailing to a representative from each
participating hospital. A therapeutic briefing on CAP was presented during the
workshop. See Package 6 for the full outline of the two day workshop. Academic
detailers were offered ongoing support by NSW TAG throughout the project
(Package 6). A case-study of a typical CAP presentation was written by NSW
TAG to assist the detailers in familiarising themselves with the intervention
material (Package 6). This case-study was subsequently distributed to all
academic detailers across the five states participating in the project.
Intervention Plan
It was agreed that each hospital would complete two cycles of interventions, data
collection, audit and feedback between October 2004 and August 2005.
Hospitals developed a local intervention plan, aimed to coincide with the rotation of
junior medical staff through the ED. A multi-faceted intervention approach,
based on current evidence in the literature, including academic detailing, was
encouraged. Activity at an institutional level was monitored through the CAPTION
intervention activity logs (Package 7).
All interventions, including the educational group sessions and academic
detailing, were delivered by the hospital coordinator and/or member of the local
CAPTION project team, in addition to any existing workloads. A small amount of
funding was made available to each participating hospital to assist with any minor
incidentals or activities related to the project.
Data Management
Participating hospitals were assigned a unique code for de-identification
purposes. Data relating to individual CAP episodes of care were de-identified at an
institutional level. A patient recording form was provided to each participating
hospital to assist in the de-identification process (Package 7).
Data were entered into Auditmaker®, a generic audit tool that was tailored for use
in the CAPTION project. Auditmaker® was programmed to calculate a PSI score
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and evaluate antibiotic prescribing according to disease severity in comparison
with the Guidelines. An automated feedback report was also generated by
Auditmaker® that summarised patient demographics and reported on various
aspects of CAP management within the hospital including average length of stay,
inpatient mortality, documented use of the PSI and overall concordance with the
Guidelines.
Evaluation
Empiric antibiotic therapy was grouped into monotherapy, dual therapy and
‘other’. If two antibiotics of the same class were prescribed concurrently, e.g. two βlactams, these two agents were treated as a single drug. Use of antibiotic
therapy was investigated further and grouped according to disease severity,
using the PSI score calculated by Auditmaker®.
The impact of the interventions was measured through two key process
indicators in the management of CAP:
1. Documented use of the PSI
2. Concordant antibiotic prescribing.
These indicators were measured at baseline and at the end of each intervention
period. Results were compared using the chi-squared test.
Data collection logs, intervention activity logs and hospital profile forms were
used to evaluate project methodology (Package 7).
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Communication Processes
A communication plan for the NSW arm of CAPTION was outlined at the
commencement of the project (Package 8).
NSW TAG CAPTION Newsletter - A monthly newsletter was produced and
distributed electronically to the hospital project coordinators as well as key
stakeholders in the project: NSW CAPTION Steering Committee, NSW TAG and
TAGNet members, National Prescribing Service and the other state-based
project groups. A total of 19 newsletters were distributed from March 2004 September 2005 (Package 8).
Drug Utilisation Webpage: CAPTION Information - All NSW TAG CAPTION
newsletters and contact details of the NSW TAG CAPTION project officer were
listed on the DU webpage hosted on the NSW TAG website
(www.nswtag.org.au).
NSW TAG Teleconferences - NSW TAG scheduled regular teleconferences for
all NSW/ACT hospital project coordinators throughout the course of CAPTION. A
total of 4 teleconferences were conducted: 17th November 2004; 9th March 2005;
6th April 2005 and 1st June 2005. These meetings provided an opportunity for
each of the project coordinators to share information and inform others on project
progression at an institutional state level. Key issues and themes of discussions
during these meetings were fed back to the NPS via email/telephone
conversations.
NSW TAG final face-to-face meeting - A final face-to-face meeting was held at
the NPS offices on September 21st, 2005. This meeting provided an opportunity
for all hospital coordinators to present to each other their final results and
describe their experience in participating in CAPTION at the hospital level. The
agenda and generic hospital slide presentation for this meeting are included in
Package 8.
At a national level the NPS supported and maintained the CAPTION webpage
(www.nps.org.au/caption) providing electronic resources to all participating
hospitals. Teleconferences were conducted by NPS at regular intervals for all
state-based project officers. The teleconferences provided an opportunity for
each of the state project officers to share information and inform others on
project progression at a state level and assist NPS in planning and progressing the
project at a national level. Five face-to-face meetings were also convened by the
NPS at key stages of project activity:
17th December 2003: Start-up meeting
21st April 2004: Interventions
17th/18th June 2004: Academic detailing
3rd December 2004: Planning ahead
28th September 2005: Final wrap-up meeting.
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Results
Recruitment of Hospitals
After the initial invitation seeking expressions of interest to participate in the
project twelve NSW hospitals enrolled in the project (Package 9). Recruitment of
these final twelve hospitals was conducted between December 2003 and July
2004. The time required to finalise hospital participation was extended due the
fact that the project required full IEC review and approval in five of the 12
hospitals.
Six other hospitals expressing initial interest in the project withdrew from the
recruitment process:
Four hospitals expressed concern over the lack of internal resources
available to complete the project.
Two hospitals withdrew due to lack of local consensus with respect to the
recommendations made in the Therapeutic Guidelines: Antibiotic 2003.
1st Audit - Baseline Data Collection
All twelve NSW/ACT hospitals completed baseline data collection by July 2004,
with data on 240 patients submitted to NSW TAG. Fifteen records were excluded
from the evaluation process due to patients presenting to the Emergency
Department (ED) prior to the publication of the current version of the Therapeutic
Guidelines: Antibiotic (version 12) or patients not being prescribed antibiotics in
the ED. These data were collated and a NSW/ACT feedback report was
generated (Package 10). Data on a total of 240 CAP presentations were collated
by NSW TAG from participating NSW/ACT hospitals. Of these 15 were excluded
due to no antibiotics being prescribed in the ED and/or the time of the ED
presentation was prior to the publication of the current version of the Guidelines
(April 2003). The aggregated state-wide baseline results were distributed to
participating hospitals for use in the first education / intervention phase of the
project. Patient demographics of the baseline cohort are summarised in Table 2.
Empiric antibiotic therapy prescribed in the ED is summarised in Table 3. Use of
antibiotic monotherapy according to disease severity is described in Table 4.
Baseline process indicator results are outlined in Table 5. Of the 14 baseline
patients with a documented PSI, 5 of these (36%) were prescribed antibiotic
therapy that was concordant with the Guidelines. Similarly, of the 30 patients
prescribed concordant antibiotics, only 5 of these (17%) had a documented PSI
score.
1st Intervention cycle
Ten hospitals participated in the first cycle of interventions. Two hospitals
withdrew from future project activity, one due to lack of consensus on the
recommendations made by the Guidelines and the other due to lack of internal
resources to conduct any project related activities. The remaining ten hospitals
reported using the ID card reminders, PSI calculator stickers and posters in the
September 2005
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NSW TAG CAPTION Final Report
ED, as documented in the intervention activity logs. A summary of individual
hospital activity relating to group education and academic detailing sessions
during the 1st intervention cycle are outlined in Tables 6 and 7. One hospital was
not able to conduct any academic detailing during this intervention cycle.
2nd Audit
Results of the 2nd audit cycle are outlined in Package 10. The total of 195 CAP
presentations were included in the 2nd audit. A number of hospitals were unable
to identify 20 eligible CAP presentations within the allocated timeframe. Patient
demographics of the 2nd audit cohort are summarised in Table 2. Empiric
antibiotic therapy prescribed in the ED is summarised in Table 3. Use of antibiotic
monotherapy according to disease severity is described in Table 4. A significant
increase in both the documented use of the PSI and concordant antibiotic
prescribing was observed between the 2nd audit (1st intervention cycle and the 1st
audit (baseline data) (Table 5). Of the 52 post-intervention patients with a
documented PSI, 19 of these (37%) were prescribed antibiotic therapy that was
concordant with the Guidelines. Similarly, of the 49 patients prescribed
concordant antibiotics, 19 of these (39%) had a documented PSI score.
2nd Intervention cycle
Results of the 2nd audit were incorporated into the 2nd phase of interventions. The
same 10 hospitals that completed the first intervention cycle participated in the
2nd cycle. The intervention activity logs indicated that all ten hospitals used the
various tools during the second cycle. A summary of individual hospital activity
relating to group education and academic detailing sessions is outlined in Tables
8 and 9.
3rd Audit
Results of the third audit are outlined in Package 10. A total of 176 CAP
presentations were included in the 3rd audit. A number of hospitals were not able
to identify 20 eligible CAP patients within the allocated time period and four
records were excluded because no antibiotics were prescribed in the ED. Patient
demographics of the 3rd audit cohort are summarised in Table 2. Empiric
antibiotic therapy prescribed in the ED is summarised in Table 3. Use of antibiotic
monotherapy according to disease severity is described in Table 4. Comparison
of the two process indicators demonstrated that the increase in documented PSI
use maintained after the 2nd intervention cycle compared to baseline, however
the significant improvement in the rate of concordant antibiotic prescribing was
not sustained (Table 5). Of the 41 patients with a documented PSI, 16 (39%) of
these were prescribed concordant antibiotics. Similarly, of the 33 patients
prescribed concordant antibiotics, 16 (48%) of these had a documented PSI
score.
A summary of all presentations and publications relating to the CAPTION project
has been provided in the Tools Package (Package 11).
September 2005
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NSW TAG CAPTION Final Report
Discussion
Hospital Recruitment
Enablers
The supporting information in the recruitment package was used by all hospitals
involved in the project. It was reported that the materials within the recruitment
package facilitated the overall process of gaining support by the CEO and
Departmental Managers.
Recruitment through an existing network of hospitals (NSWTAG), with an
established line of communication and previous collaborative experience,
facilitated the overall sign-off process. A large number of hospitals were
contacted within a short time frame through the TAG network.
Barriers
The process of gaining support from local Human Research and Ethics
Committees (HRECs) proved to be time consuming. The process for quality
improvement projects at the individual hospital level varied. Five hospitals
required a full submission and review by the local HREC. The time required to
complete this HREC review process was lengthy, requiring 5 months at one
institution.
Perceptions of the Key Messages (Guidelines)
Enablers
The Therapeutic Guidelines were well recognised by the target audience,
creating a positive environment for initiating dialogue around the key messages of
CAPTION.
Barriers
The PSI, although a validated severity assessment tool, was viewed by some
clinicians as time consuming, unnecessary and impractical and they therefore
challenged its utility. The number of variables required to calculate the final PSI
score was identified as a barrier to clinicians using the tool.
There were concerns regarding the prevalence of penicillin-resistant
Streptococcus pneumoniae and questions were raised over the recommendation
of penicillin as a first line empiric antibiotic. Hospital coordinators reported a lack
of local bacterial resistance data within their institution. Had these types of
reports, they may have assisted in the general antibiotic resistance debate.
One third of patients presenting to the ED were taking oral antibiotics that were
prescribing in the community setting. The absence of advice within the guidelines
concerning the management of these patients was identified as a barrier for
some prescribers. The perception of failed oral therapy by prescribers may
September 2005
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NSW TAG CAPTION Final Report
influence prescribers to initiate intravenous antibiotic therapy, even in mild cases
of CAP. This practice is not currently supported by the Therapeutic Guidelines.
Hospital drug formulary listings were varied; some institutions did not have on
their formularies specific antibiotics recommended by the Guidelines (e.g.
cefuroxime, moxifloxacin).
Use of broad spectrum antibiotic therapy was not likely to result in any immediate
negative patient outcomes, therefore reducing any impetus to change current
prescribing practice to include the use of targeted, narrow spectrum antibiotic
therapy.
Interventions
Enablers
The use of nationally developed intervention materials was well received. The
‘corporate look’ of the intervention materials gave credibility to the messages and
provided a quick reminder of the project and the key messages. ID cards were
widely distributed and popular with junior medical staff.
The academic detailing two-day training workshop was well received by the
participants. A number of detailers reported that the generic skills learned were
applicable in a number of areas outside CAPTION.
The two-day training academic detailing training workshop enabled face-to-face
interaction between project team members from the different participating
hospitals. This opportunity was invaluable in terms of relationship building and
establishing communication channels, between both NSW TAG and academic
detailers as well as between the academic detailers.
The academic detailing card being offered as a gift at the end of a visit was well
received by hospital staff. The cards acted a reminder and also raised the profile of
the project within each of the hospitals.
The generic PowerPoint® slides were extremely useful in the feedback
presentations. The slides were adapted according to local needs and provided a
guide for hospital coordinators in planning future feedback presentations.
Barriers
The NPS was not readily recognised by hospital staff. Assumptions were made
that someone must be making money out of the project as the educational
material looked like it was from the Pharmaceutical Industry.
Academic detailing as an intervention to influence prescribing did not readily suit
the ED environment. Detailers reported difficulty in finding time to visit ED staff
on top of their existing commitments. It was also reported that ED staff found it
September 2005
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NSW TAG CAPTION Final Report
difficult to be able to keep appointments due to the unpredictable work flow of the
ED.
Feedback from hospital coordinators indicated that overall enthusiasm for the
project within the local project team and ED staff may have declined after the first
DUE cycle. In the NSW arm of CAPTION the roles of hospital coordinator and
academic detailer were undertaken by one person. Therefore the majority of
project activity and overall progress of CAPTION was dependant on one person.
The feeling of a ‘one-man show’ was commonly reported by hospital
coordinators, and this was an onerous role.
Quality improvement Methodology
Enablers
The state-based collaborative model provided a unique opportunity to resource
the expertise and guidance offered by the participating stated-based DUE
groups. Specific tasks and responsibilities were able to be distributed across the
states, allowing sharing of intellectual capital and reducing the work load of
individuals.
Participating hospitals reported that working with other institutions provided
opportunities to learn and share local project successes and challenges.
Benchmarking of project progress and results across participating hospitals
provided encouragement and incentive to complete project activities.
CAPTION became ‘core business’ for a number of participating hospital Drug
and Therapeutics Committees (DTC), appearing as a permanent agenda item for
the monthly DTC meetings. All project related issues were dealt with on a regular
basis with the support of the DTC. Future projects could be ‘core business’ of
hospital DTCs and Quality Improvement units. This would ensure sustainability of
future activities and fulfil part of the proposed hospital accreditation requirements of
the Australian Council on Healthcare Standards.
The small amount of financial assistance allowed some project team members to
attend related clinical training and/or conferences during the project period.
Barriers
The execution of individual state contracts and recruitment of state-based project
officers were not aligned chronologically. The difference in starting dates, hence
finish dates, may have weakened the overall benefits of the collaborative model.
Potential barriers include: lack of ownership of work already completed prior to
starting CAPTION; lack of congruity of state-based project activity and lack of a
sense of project completion for states finishing the project at different times.
Not all hospitals utilised the funds offered through the project.
September 2005
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NSW TAG CAPTION Final Report
Conclusion
The baseline audit demonstrated that empiric management of CAP in hospital
EDs varied compared to the CAP management recommendations in the
Guidelines. The project team, including the academic detailer, were successful at
influencing a change in local CAP management and antibiotic prescribing as
demonstrated by the increase in documented PSI use and rate of concordant
antibiotic prescribing. The suite of interventions offered to the local project team,
including academic detailing, facilitated an improvement in prescribing practice.
However, not all improvements were sustained over the duration of the study
period.
Social marketing techniques appear to influence prescribing practice within the
hospital setting, but are resource intensive. Consideration should be given to
providing specified staffing resources in hospitals to facilitate sustained impacts.
September 2005
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NSW TAG CAPTION Final Report
Tables
Table 1: CAPTION exclusion criteria
Exclusion Criteria
< 18 years of age
Immunosuppressed
(HIV positive or concurrent chemo/immunosuppressant therapy)
Cystic fibrosis
Bronchiectasis
Suspected or confirmed tuberculosis
Aspiration or hospital-acquired pneumonia
Discharged from hospital within the previous 14 day period
Patients transferred from another hospital*
*Within hours of presentation.
September 2005
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NSW TAG CAPTION Final Report
Table 2. Summary of patient demographics according to audit cycle
1st Audit
(n=225)
2nd Audit
(n=195)
3rd Audit
(n= 176)
64 years
66 years
66 years
Sex (female)
42%
47%
44%
Disease severity:
Class I
Class II
Class III
Class IV
Class V
22%
19%
17%
32%
10%
16%
18%
17%
36%
13%
18%
22%
12%
30%
18%
32%
32%
29%
74%
18%
4%
4%
75%
16%
6%
3%
71%
18%
7%
4%
76%
7%
17%
75%
7%
18%
72%
7%
21%
Median length of
stay (range)
5 days (0 - 92)
5 days (0 - 38)
5 days (0 - 70)
Inpatient mortality
4%
5%
8%
Average age
Prior antibiotic use
Antibiotics in ED
prescribed by:
ED team
Admitting unit
Other
Unknown
Discharged from ED
to:
Ward
ICU
Home/other
September 2005
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NSW TAG CAPTION Final Report
Table 3. Empiric CAP antibiotic therapy prescribed in EDs
Antibiotics Prescribed
1st audit
2nd audit
3rd audit
(n=225)
(n=195)
(n=176)
Monotherapy
β-lactam*
Macrolide^ or doxycycline
Moxifloxacin
39 (17%)
4 (2%)
4 (2%)
22 (11%)
10 (5%)
1 (<1%)
26 (15%)
5 (3%)
2 (1%)
154 (68%)
147 (75%)
135 (77%)
6 (3%)
2 (<1%)
1 (<1%)
5 (3%)
1 (<1%)
2 (1%)
2 (1%)
3 (2%)
-
6 (3%)
4 (2%)
2 (1%)
2 (<1%)
-
-
4 (2%)
1 (<1%)
1 (<1%)
1 (<1%)
-
-
1 (<1%)
-
-
1 (<1%)
-
-
-
2 (1%)
-
Dual therapy
β-lactam + macrolide or
doxycycline
β-lactam + gentamicin
β-lactam + metronidazole
β-lactam + moxifloxacin
Other
β-lactam + gentamicin +
macrolide or doxycycline
β-lactam + metronidazole +
macrolide or doxycycline
β-lactam + gentamicin +
metronidazole
β-lactam + gentamicin +
trimethoprim
β-lactam + vancomycin +
macrolide or doxycycline
β-lactam + moxifloxacin +
macrolide or doxycycline
β-lactam + carbapenem# +
macrolide or doxycycline
*β-lactams identified in audit: ampicillin, amoxycillin, amoxycillin/clavulanate, benzylpenicillin,
ticarcillin/clavulanate, cefaclor, cefuroxime, cephalexin, cephalothin, cephazolin, cefotaxime and
ceftriaxone.
^Macrolides identified in audit: erythromycin, roxithromycin, clarithromycin and azithromycin.
#Carbapenems identified in audit: imipenem and meropenem.
September 2005
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NSW TAG CAPTION Final Report
Table 4. Antibiotic monotherapy according to calculated disease severity*
Disease Severity
1st audit
Class I
Class II
Class III
Class IV
Class V
6 (14%)
12 (28%)
10 (23%)
9 (21%)
6 (14%)
(n=43)
2nd audit
3rd audit
(n=32)
(n=31)
8 (25%)
7 (22%)
6 (19%)
9 (28%)
2 (6%)
4 (13%)
9 (30%)
3 (10%)
7 (22%)
8 (25%)
*Excluding moxifloxacin monotherapy.
September 2005
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NSW TAG CAPTION Final Report
Table 5. Process indicator results compared to baseline (1st audit)
Process
Indicator
1st Audit
(n= 225)
2nd Audit
(n=195)
p value
Documented
PSI use
6%
27%
p<0.0001
24%
p<0.0001
Concordant
antibiotic
prescribing
13%
25%
p=0.002
19%
p=0.14
September 2005
3rd Audit
(n=176 )
p value
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NSW TAG CAPTION Final Report
Table 6. Summary of 1st intervention phase activity - Group sessions
Session
Health Care Professional
Hospital
Code
BA
BB
4
4
BC
3
BD
6
BE
5
BF
3
BG*
BH
8
BI
BJ
BK*
BL
Total
1
2
3
4
1
2
3
4
1
2
3
1
2
3
4
5
6
1
2
3
4
5
1
2
3
1
2
3
4
5
6
7
8
1
1
2
3
4
5
1
2
3
1
5
3
42
September 2005
2
1
1
1
1
3
1
2
3
1
1
2
2
1
1
3
1
3
4
5
10
12
10
1
14
3
3
1
1
7
10
1
2
3
1
3
2
1
1
2
2
1
1
12
10
13
3
1
1
1
1
1
1
2
1
1
6
2
-
6
7
7
-
2
1
1
2
1
4
1
1
3
7
6
2
1
2
-
2
1
2
1
4
2
3
3
1
3
2
2
-
2
2
4
1
6
15
1
1
1
5
2
2
2
8
2
2
3
4
5
13
-
2
5
20
2
1
2
-
3
2
2
2
2
2
-
1
-
3
-
2
1
-
1
1
-
5
10
3
2
-
17
2
8
1
24
8
126
10
27
-
-
4
28
71
43
28
18
12
42
3
29
5
12
5
5
6
24
5
5
18
5
5
14
18
46
18
13
18
4
4
4
6
9
5
4
13
16
18
11
3
9
5
2
20
7
10
8
9
8
14
11
4
21
447
NSW TAG CAPTION Final Report
Table 7. Summary of 1st intervention phase activity - Academic detailing
Health Professional
Hospital
Code
BA
BB
BC
BD
BE
BF
BG*
BH
BI
BJ
BK*
BL
Total
0
6
15
39
13
11
28
4
8
16
140
September 2005
6
2
4
1
-
6
5
2
-
2
9
1
5
19
10
3
5
3
2
23
5
4
2
18
4
5
2
40
8
7
1
1
1
1
2
-
-
-
1
6
-
-
-
-
-
-
-
2
-
-
7
14
1
6
1
5
0
1
4
3
4
12
2
2
0
6
15
39
13
11
28
4
8
16
140
30
NSW TAG CAPTION Final Report
Table 8. Summary of 2nd intervention phase activity - Group sessions
Session
Health Care Professional
Hospital
Code
BA
2
BB
3
BC
BD
BE
BF
BG*
BH
BI
BJ
BK*
BL
Total
1
2
1
2
3
1
2
1
1
2
1
2
3
1
2
3
0
1
2
3
1
2
2
1
2
3
3
0
3
2
21
September 2005
2
2
1
3
2
2
5
4
6
2
2
1
2
2
2
1
1
1
1
1
2
3
2
3
3
3
3
3
3
1
1
2
12
3
2
2
8
3
1
7
-
-
-
-
-
-
2
2
2
6
1
-
4
6
-
5
25
-
3
2
2
-
-
-
-
-
-
1
-
5
22
3
20
5
29
7
17
0
7
14
11
-
-
-
2
15
2
7
-
5
-
2
30
10
31
6
6
8
8
8
10
6
12
5
2
12
3
9
14
16
22
0
4
6
10
5
20
192
NSW TAG CAPTION Final Report
Table 9. Summary of 2nd intervention phase activity - Academic detailing
Health Professional
Hospital
Code
BA
BB
BC
BD
BE
BF
BG*
BH
BI
BJ
BK*
BL
Total
0
0
10
30
5
20
19
6
6
17
113
2
5
3
2
6
4
2
6
6
4
4
4
2
1
1
5
1
6
-
-
2
-
9
8
3
2
-
12
20
28
-
-
-
-
-
-
-
17
2
4
1
-
-
-
1
1
3
2
2
1
14
20
-
3
-
-
-
-
0
4
0
3
0
0
10
30
5
20
19
6
6
17
113
* Hospital BG and BK withdrew from the project prior to the commencement of the intervention
phases.
September 2005
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NSW TAG CAPTION Final Report
Acknowledgements
The NSW TAG project team gratefully acknowledges the time and expert advice
provided by the NSW CAPTION Steering Committee:
Ms Alice McKellar (Goulburn Base Hospital), Dr Andrew Finckh (St. Vincents
Hospital), Dr Catherine Dobbin (Royal Prince Alfred Hospital), A/Prof Deborah
Marriot (St. Vincents Hospital), Dr Jeremy Bunker (General Practice), Prof
Jo-anne Brien (University of Sydney), Dr John Ferguson (John Hunter Hospital),
Ms Kathleen Ryan (South Eastern Area Health), Dr Kylie Easton (National
Prescribing Service), Ms Rachel West (Westmead Hospital), Prof Richard Day
(St. Vincents Hospital), Dr Simon O’Connor (Tamworth Base Hospital), Ms Susie
Welch (St. Vincents Hospital) and Dr Timothy Green (Royal Prince Alfred).
The hospital coordinators who have committed long hours to this project, often
on top of an already busy schedule:
Alice McKellar
Alison
Hulse
Bret Ryder
Coral Bennett
Evette Buono
Ian Mawbey
Joanne McMahon
Liisa Nurmi
Margaret Hewetson
Natalie Bula
Paul Laird
Roseleen O’Doherty
Sue Aran
Vanessa Simpson
Goulburn Base Hospital
Calvary Hospital
St. Vincent’s Hospital
Broken Hill Base Hospital
Concord Repatriation Hospital
Dubbo Base Hospital
Bateman’s Bay Hospital
Moruya District Hospital
Calvary Hospital
Lismore Base Hospital
Canberra Hospital
Lismore Base Hospital
Royal North Shore Hospital
Royal Prince Alfred Hospital
Royal Prince Alfred Hospital
Thank you to the other state-based project officers and project leaders for their
support and collaboration over the past two years of project activity and to the
National Prescribing Service, specifically to Kylie Easton, Angela Wai, Fiona
Horn and Judith Mackson for their guidance and support. We would also like to
thank Lynn Weekes for the initial concept of funding and support for the
CAPTION project.
Lastly we would like to thank our colleagues at the NSW TAG office, Ms Sharon
Davis, Ms Lyn Brignell and Ms Maria Kelly for their ongoing encouragement and
support.
September 2005
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NSW TAG CAPTION Final Report
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