Establishing antimicrobial use guidelines

So just to recap in terms of antimicrobial guidelines, what we talked about in the first week, although I presented some of the challenges that were of relevance to our tertiary referral hospital, we summarised at the end by saying that, actually, many of these issues are actually common to all veterinary practices, and that when we’re developing antimicrobial guidelines, it’s important to make sure that they’re relevant to the individual situation or the place where you’re working, that we must always make sure that we’re using whatever available evidence and the most up-to-date evidence that we have when we’re creating these guidelines, that we need these guidelines to be relevant to the types of clinical cases that you are actually seeing most frequently in your practice, and that any guidelines that we develop need to be part of a workable system that is really easy to use and comprehensive so that there is good compliance from our colleagues.

So just to talk you through what we actually introduced at the Queen Mother Hospital, so we developed a tier-based system. And this is certainly not novel to us. So the World Health Organisation also developed antimicrobial guidelines based on a tiered system. But we have a three-levelled system. The first tier of antibiotics we consider to be open access within our hospital. The second tier we consider to be somewhat preserved, in the sense that we require our clinicians to be performing a culture before they use these antimicrobials, and also to complete what we call a data capture form at the time of prescribing. And I’ll talk a little bit further about what data we do capture.

And then we have a tier three, which are our reserved antimicrobials. And here, we definitely require a culture and sensitivity to be performed. We definitely want the data capture form to be completed, and we actually ask clinicians who are going to prescribe a tier three antimicrobial agent to discuss this with some colleagues so that we’re able to make sure that this is the most rational use of what we consider to be these preserved tier three antimicrobials. And this tiered system that we have is relatively straightforward to apply. It’s very clear from the documentation that we have around the hospital exactly which antibiotics fall into each tier.

But we also have a supporting document that goes with this tier system, which is contributed to by each of the services within the hospital and looks in greater detail at some of the perhaps individual service-based decisions that are being made more often. So an example here is our use of perioperative antimicrobials. And it also considers some specific situations or procedures where there may be evidence base within the literature that would go against our overarching tiered system. So we make use of a special prescribing form, which we hold at our dispensary where our antimicrobial agents are being dispensed from. And this special data capture form is completed for any tier two or tier three antimicrobial agents.

We capture on this form information about the organism that we’re treating. So for example, whether it’s considered to be a multidrug-resistant organism. And we also capture data about whether or not culture and MIC have been performed for this particular patient prior to submitting a prescription for a tier two or a tier three antimicrobial agent. And we also ask the clinicians to give us some rationale for why they’re following the tier system and prescribing either a tier two or tier three antimicrobial agent. And also, if it’s a tier three antimicrobial, they have to have a signature to authorise the use of that particular antibiotic from a member of our infection control group within the hospital.

And this data, I think, is particularly useful because it will in the future allow us to perhaps more accurately audit some of the clinical decision-making processes that we have within the hospital in terms of choice of antimicrobial agents. So what do I think has helped make this work within our hospital? Well, one of the first things that we did prior to even thinking about our antimicrobial guidelines was actually to develop an infection control group. This group has many issues that it considers. So not just antimicrobial use, but antimicrobial use was certainly one of the most important components of this group when it was first established.

I think it’s really important when establishing guidelines that are going to be used within the practise that there’s very broad representation from all of the different people that work within the hospital. And this really helps to ensure buy-in, and that everybody is going to be happy with the guidelines that are being put forwards. So we made sure that we had representation from all of the services in our hospital. Everybody had an individual that was represented when this document was being produced. And we included representation from some of the parallel services that are involved with either the administration of antibiotics or the dispensing. So this included our dispensary, and also our nursing team.

And we sought external advice and used a lot of external resources when we were developing our guideline system. We also sought engagement and support from hospital management. I think it’s very important when you’re trying to institute a change in how a system works. So if people have been used to completely open access antimicrobial prescribing, taking a stance potentially against the use of certain antibiotics means that we need to have support from higher hospital management to make these clinical decisions. And also, to make sure that everybody in the hospital is aware of what we’re trying to do and the reasons behind why we’re trying to make these changes.

And so we found that it’s quite successful to have a simple and coded tier system. This is colour-coded into the tiers one, two, and three, so that as people are in different ward areas, they have access to this information in poster format. When we were rolling out the guidelines, we also provided face-to-face information within service meetings. We provided seminars, and emailed information about the new system that was going to be in place. And as I’ve mentioned already, we make sure that there are posters available in all of the areas where we may be prescribing antibiotics so that it’s easy for people to see the system that we have in place.

We’ve also tried to have some form of monitoring of the system. So we’ve asked for feedback in terms of how easy the system is to use. We’ve looked at how compliant people are with our system, using both financial and billing data to compare the completion, for example, of the forms and the paperwork that we collect in relation to what’s actually being prescribed. And we also provide a hospital-wide support system, including all of the members of the infection control group. And so this is an email distribution list which anybody can email to say that they have a case that they want to discuss, they want to think about alternative antimicrobial agents. And we might not have the best solution.

We might not have the answer. But it’s a really good way for us all to get on board and think very carefully about why we’re prescribing antimicrobials and what alternatives might be in certain situations. We also meet on a regular basis as part of the infection control group to discuss and make sure that we review our guidelines at a regular basis. So currently, our antimicrobial guideline document is reviewed every two years. I think we have to remember that no system is ever perfect. And certainly, working within a referral hospital, we need a system that has some flexibility. We see some very complicated cases, and sometimes we have to make challenging decisions.

We need to make sure that we have good engagement from all team members. But at the same time, we need to maintain clinical autonomy. So we need clinicians to feel that they still are empowered, and that ultimately and fundamentally the clinical decisions that they make in terms of prescribing remain their own. What we provide is just some guidelines. We’re always looking to the future to see where we could improve.

And certainly, current endeavours that we’re trying to take forwards include the use of antimicrobial mortality and morbidity rounds, particularly where the focus of taking some of these more challenging cases, where we’ve found it difficult to make a decision, and to look at those cases perhaps in more detail about whether there were things that we could have done differently along the way. We’re also looking to really try and separate out our antimicrobial work from our hospital hygiene work. As you start down this route, the work and the areas that you want to improve in become larger and larger, and so the need for working groups that focus specifically, for example, on antimicrobial use becomes much more important.