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Review of behaviours during the MDT meeting in the scenario

The video clip sets the scene for whose behaviour needs to change in this step.
So we’ve now had an opportunity to discuss the key issues in relation to infection control and adherence to standards and transmission-based infection control precautions and I’m very grateful to all of you for that. I think it’s been very helpful. Perhaps this is a good time now to move on to some of the prescribing issues and what we need to do about them. I am assuming one of the surgeons is joining us.
No, they’re not, I’m sorry to say. We’ve asked. We asked the clinical director. He sadly is busy today. I did, and I think Gabby also was going to ask one of the attending surgeons who looked after the patient. But he’s busy in theatre and despite me suggesting how important this meeting is, he just said he was just too busy to come. So I’m sorry. Given the significance and the importance of what we’re discussing that is really disappointing. Clearly, we’ll need to pick that up outwith the meeting. Maybe this is the point. If you could help me understand what information we have in relation to the antibiotic prescribing within the wards?
Well, as you will know, and as you would expect, we have an antibiotic policy in place now for quite some time that addresses treatment as well as prophylaxis issues. But when we were developing the antibiotic policy, we did consult with many of the urologists but unfortunately, they were not very happy with many of the agents that we were recommending as part of our policy in keeping with national guidelines. They’re particularly keen on cephalosporins and certain similar broad-spectrum antibiotics, including Ciprofloxacin and they feel that these are the powerhouse broad-spectrum antibiotics that really are required for the sick patients.
And their patients are always sicker, and they felt that many of the things we were recommending were not good enough for their sick patients. We tried very hard for them to get to attend many of the meetings around the making of the policy but ultimately, I’m sorry to say, I just got so fed up that I just put the policy out and hoped for the best. I see. So do we know that they use it? That’s a good question. I can’t tell you all the time. But we have medical students, which we have persuaded to do some more. They are always looking for a project.
In fact, I remember one now around 18 months ago when we did a project with one of our medical students and she measured in a compliance rate of around 30% for the treatment bit of the guideline. I do remember sharing it with one of the urologists, who happens to be a friend of mine. We sometimes go out together. So you know, he was quite keen to hear. And he said to me that he would let his colleagues know that they were doing at that. But when I said to him that, well, 30% percent is not very good, he said, well, it doesn’t seem to be affecting or harming his patients.
They seem to be doing very fine with the treatment that they’re currently using. We have, on numerous occasions, pointed out that they’re not compliant with what we would usually recommend. Really? The registrar usually tells us not to interfere with their clinical decision, because they know what’s best for the patient. Yeah. I remember you mentioning that to me. Yeah. I see. Do you think this is impacting upon resistance? I just thought it was all down to bad hand hygiene. No. I think over the past couple of years, we have seen a gradual increase in resistance in this unit. And I’m pretty certain that poor antimicrobial prescribing will be contributing to that.
I think it demonstrates that it’s important to have prudent antimicrobial prescribing as well as the standard and transmission-based infection control precautions. One of the difficulties, of course, is that now we’ve got limited oral options. You’ve got to give it IV. And that introduces devices and can increase our risk of things like Staph aureus, bacteremias, and Clostridium difficile infection. So I think this is part of the whole problem. I see. So what about prophylaxis? That’s an indicator that we’re now being asked to monitor and clearly, I’m accountable for that. Are we doing any better there? Well, our performance is around 45 to 60% at best.
We kind of can’t measure it on a regular basis because we can never find anybody, I’m afraid. And also the types of antibiotics they like to use, they particularly like a drug called Piperacillin-Tazobactam, called Tazocin. They love it. They think it’s the best for their sick patients for prophylaxis. I think Heather would remember telling me that the stock in theatre is out on a regular basis because they use this for prophylaxis. I don’t believe it’s what we recommend as part of our guideline but our colleagues in Urology and even the anaesthetists who actually often administer the prophylaxis don’t like what we recommend.
They just don’t like Gentamicin because they think it harms patients’ kidneys and it’s dangerous and they are not prepared to use it. I am concerned about what we have in terms of a policy, compliance with that policy, and engagement with that policy. We need to sort this out.
There is a very strong evidence base for successful behaviour change techniques.
Changing practitioners’ behaviour is key to successful antimicrobial stewardship but in the complexity of clinical care there are many factors involved.
You will have an opportunity to listen to an introduction to the evidence by Professor Paul Batalden, an internationally recognised expert on the science of improvement, but before listening to Professor Batalden we would like to you consider whose behaviour needs to change.
Watch this clip of the outbreak meeting and take notes on:
  • whose behaviour needs to change to improve antimicrobial prescribing in this scenario?
  • what might the barriers be to changing their behaviour?
Professor Davey will discuss this in the next step.
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Antimicrobial Stewardship: Managing Antibiotic Resistance

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