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Skip to 0 minutes and 11 seconds We have already considered process and outcome measures, which are important measures to demonstrate quality improvement. However, we must also consider balancing measures to reflect what may be happening elsewhere in the system as a result of the improvement intervention. If you change one thing, what impact will this have on other things in a system? This impact may be positive or negative. If we think back to the scenario described by Doctor Seaton, where they reduced use of broad spectrum agents, such as Cephalosporin and Quinolones, leading to a deduction in CDI rates. In this scenario, we need to consider other changes that were taking place at the same time.

Skip to 0 minutes and 59 seconds For example, new infection control procedures, which may also have contributed to reduced CDI rates. But also think about consequences of using alternative antibiotics. The use of narrower spectrum agents may have unintended consequences, such as reduced efficacy in treating infections, so we need to be alert to treatment failures and increased need for critical care. Changes in antibiotic use can also lead to changes in resistance patterns.

Skip to 1 minute and 36 seconds In Scotland, following increased rates of CDI, all health boards changed their antibiotic policies to restrict Cephalosporins and Quinolones. This led to increased use of gentamicin, so we had to be vigilant for adverse consequences, such as increased adverse events, like renal impairment and autotoxicity. Following the change in policy for surgical prophylaxis and orthopaedic surgery from cefuroxime to flucloxacillin plus gentamicin, several boards noticed an increase in patients suffering renal impairment, measured as acute kidney injury. This led to a robust study in NHS Tayside to investigate this balancing measure. We will now consider the data from this study.

Skip to 2 minutes and 31 seconds This chart shows how use of the old policy antibiotic, cefuroxime, reduced overtime, and use of the new policy antibiotics, flucloxacillin and gentamicin, increased over time.

Skip to 2 minutes and 49 seconds The next two slides show acute kidney injury rates before and after the change in policy. The first slide shows how the rate of postoperative kidney injury increased following the change of antibiotic policy from cefuroxime to flucluxacillin and gentamicin. This suggests that the new policy antibiotics may be causing harm by damaging patients’ kidneys. However, we need to ensure that the other practises within the surgical procedure have not changed, and also need to carry out a robust statistical analysis of the data.

Skip to 3 minutes and 30 seconds The two charts on this slide show the results of the study that was carried out to prove the association of the new antibiotic policy with the change in acute kidney injury. The top chart shows the highest serum creatinine measured as a measure of maximum harm, and the bottom chart shows the serum creatinine measurement several days later, and confirms that for most patients the harm was transient and kidney function returned to normal afterwards.

Skip to 4 minutes and 4 seconds This work led us to reconsider antibiotic choice in this group of patients, and national advice was issued to change policy, either back to cefuroxime or to co-amoxiclav. So improving one element, the CDI rate, thus had led to an unintended consequence elsewhere in the system. This demonstrates the need to consider if the change you’re making to improve practise may affect other parameters, and the need to measure these, too. You can read more about this study at the link shown on the screen.

Balancing measures

In this video Dr Jacqueline Sneddon reflects on the importance of considering how balancing measures reflect what may be happening elsewhere in a system as a result of the improvement intervention.

For example if you change one thing what impact will this have on other things in a system and will this impact be positive or negative?

Dr Sneddon uses the CDI scenario described by Dr Seaton and data from a study in one hospital in Scotland investigating balancing measures to aid her explanation.

You can read more about this study in the Journal of the American Society of Nephrology.

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This video is from the free online course:

Antimicrobial Stewardship: Managing Antibiotic Resistance

University of Dundee