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Quality measures

Aalaa Afdal discusses quality measures.
When we need to conduct quality measures, we need to measure the quality of service provided by the programme and also by the health care professionals. To measure the quality of services or interventions conducted, we have to go through some different antimicrobial stewardship interventions that we have to measure the compliance to these interventions or strategies. ASP strategies are divided into three major criteria– general interventions, such as antibiotic time outs. That’s to check the antimicrobial prescribing after 48 to 72 hours from starting therapy, or pre-authorisation and restrictions of some antimicrobials, and also prospective audit and feedback intervention. There are also some pharmaceutical interventions, such as automatic change from IV to oral therapy.
Those adjustments, automatic alerts for unnecessary duplicative therapy or automatic stop orders at the end of the predefined duration by the prescriber, and also detection and prevention for antimicrobial-related drug-drug interactions or even adverse effect. There are also some infection-specific interventions, which is improving antimicrobial prescribing in some infections, using a bundle or checklist, such as community-acquired pneumonia, urinary tract infections, empiric coverage of methicillin-resistant staph aureus, C. difficile, sepsis, or so on. So what we have to do if you want to measure the quality of antimicrobial prescribing in our Institute– there are many ways to assess quality of antimicrobials prescribing patterns, such as indications, selection, dose, regimen, time outs, frequency of deescalation, duplicative therapy, culture withdrawal, and so on.
The easiest tool and a very useful one is a Point Prevalence Survey. One useful project that provide a very easy and useful tool for estimating the prevalence is the Global Point Prevalence Survey Project, Global PPS. This can help you to identify targets for quality improvement. You have to share your results with other healthcare professionals in your hospital to increase awareness. You can conduct such survey regularly so that you can monitor your intervention success or failure. And you can tailor your survey according to your scope of intervention. Scope of interventions like the targeted ward targeted intervention, targeted antimicrobial, or targeted dose formulation, either. It’s advisable to pick one intervention and then focus hard to improve this practice.
After that, you can take the second one and work on it and so on. You can visit and explore it just after these lessons end. So what’s next? After identifying targets for improvement, you can prioritise your targets and pick the first one and work on it. But how? You can follow the model for improvement developed by Institute for Healthcare Improvement, IHI. You have to answer these three questions. What are we trying to accomplish? How will we know that a change is an improvement? What changes we can test that will result in an improvement?
This suggests that you have a very high intravenous drug use and your team have decided to target the high use of intravenous antimicrobials at your hospital or ward. How will you measure this intervention? We have to follow a template to answer these questions. Let’s have a look at the template first, then try to fill it answering our case. We have to answer the three questions using this template. What are we trying to accomplish? It’s like setting our higher goals. The more specific, the better. It must show how good by when. Also, we have to spread awareness and indication about our goal to all participants involved in the goal-setting. Second, how will we know that a change is an improvement?
We have to identify outcomes and involve participants in data collection as a self-monitoring behaviour for the participants. Also, we have to receive feedback and find the feedback frequency, content, format, and delivery. Finally, what changes we can make that will result in an improvement, by setting sub goals, such as providing the participants with information about the steps required to achieve that goal. And finally, action planning using PDSA cycle– Plan, Do, Study, Act, or any other methods used to test change. You will learn later this week. Let’s try to answer the case using this template. First, what are your higher goals? Increase the percentage of IV prescriptions, shift into oral therapy when appropriate, or you can say it in any way.
Second, you have to show how you would engage clinical teams in a self-monitoring in defined steps. Third, what are your targets? And our target should be very, very clear. Increase the percentage of intravenous prescription, shift into oral therapy when appropriate, more than x percentage within defined period of time, days, weeks, or months. How will you deliver the feedback? The feedback, like the percentage of prescriptions compliant with the IV to oral checklist. And you have to define the frequency and the format and so on as we mentioned earlier. To conclude, what are we trying to accomplish is to decrease unnecessary intravenous antimicrobial use. How will we know that a change is an improvements? Which means, what are our measures?
What changes we can test that will result in an improvement? Developing checklists for intravenous to oral shift therapy. Then we have to apply the PDSA cycle, plan a small test, do and carry your plan, study your data, and summarise what you have learned from results. Finally, act and take actions. The Institute for Healthcare Improvement is providing more detailed explanation for the PDSA cycle. I advise you to go through it and have a look. There are also some important measures type that we need to identify. And preferably we have to define at least one measurements from each type. We have process measures, outcome measures, and balancing measures. Process measures answers our questions.
Are the steps in the system performing as we planned? Are we on the track in our efforts to improve the system? For example, is everybody adherent to the checklist developed? It will be in the form of percentage adherence to the IV oral therapy shift checklist. On the other hand, outcome measures answer the questions, how does a system impact the values of patients, their health, and well-being? For example, the percentage decrease in the IV drug consumption or cost. While balancing measures answers the question, are changes designed to improve in one part of the system, causing new problems in the other parts of the system? For example, measurements of cure of infection rate.

In this video Aalaa Afdal explains the reason to measure and how to measure the quality of antibiotic prescribing.

You may want to look at the Global PPS tool she mentions in the video, as well as the Institute for Healthcare Improvement website.

BSAC have developed a course Challenges in Antibiotic Resistance: Point Prevalence Surveys which you might wish to take a look at.

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Antimicrobial Stewardship for Africa

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