Evolving stewardship – roles in the antimicrobial management team

Hi there. My name’s Jo McEwan. I am the advanced nurse practitioner for antimicrobial stewardship within NHS Tayside site. My role is the first of its kind in the UK, which in itself is both exciting and challenging. I work within the larger antimicrobial management team, which consists of pharmacy, medical, and microbiology staff members, which makes it a truly multidisciplinary approach towards antimicrobial stewardship and management. My role provides both strategic and clinical leadership within the nursing and midwifery directorate, across both acute and the community sectors. In addition to this, I support medical and non- medical prescribers around antimicrobial prescribing in collaboration with the wider antimicrobial management team.

The main focus of my role is to drive improvement around antimicrobial practice and infection management by empowering nurses and midwives to actively participate in promoting good antimicrobial stewardship within the context of the wider multi-disciplinary team. A large proportion of my role is clinically based, where I conduct antimicrobial stewardship ward rounds. I actively participate and encourage and engage staff to perform clinical audit, and shadow nurses and midwives at both ward level and within the management structure to develop and promote practice development around antimicrobial stewardship. As nurses and midwives have only recently been recognised as having a pivotal role in promoting and influencing antimicrobial management, education and awareness is key to developing this role within the provision of nurses and midwives.

I provide education for nurses and midwives across the organisation, and have recently embedded antimicrobial stewardship as a topic for undergraduate nurses within a local university. By engaging nurses and midwives in antimicrobial stewardship, we can optimise clinical outcomes, ensuring that the patient is central to the delivery of high quality care and multidisciplinary care approach. What I think is important about stewardship is bringing it into day to day practise, not having it as a standalone theoretical idea. And so I like to bring the principles of stewardship with- for antibiotics into each of those roles that I have.

And as an example of that then, an acute medicine ward round is a forum where I’m working with lots of junior doctors, a pharmacist, and some nursing colleagues, and I think that’s a great opportunity to think about stewardship and how it applies to the patient. And what I like to do is encourage members of the team to ask questions about the care that the patient is having at that time. Not just about the antibiotic. Clearly that’s important. What is the root of the antibiotics? What’s the dose? Have we got the right agent? And to think about duration. But also the things that we’ve done to the patient, the devices that are in place in the patient.

So I’d like to encourage them to ask, can we remove the peripheral cannula for example? Can we remove the invasive devices? Can we remove the urinary catheter? And therefore, reduce the risk of health care associated infections and the requirement for antibiotics.

In addition to that, I think it’s really important to remind everybody that we need to have sent some samples to make a microbiological diagnosis. So that’s the other element that I like to promote is, have we sent any samples. But in particular, have we sent the right samples for this patient, and have they got to the lab in a timely fashion, and has anyone looked at the results so that we can modify therapy? And so that’s what I hope I bring to stewardship in the place that I work.

As an antimicrobial pharmacist, I have a key role to play within the antimicrobial management team. One of the main roles is supporting the team when they conduct ward rounds reviewing patients. These can be a number of different types of ward rounds. One involves patients with Clostridium difficile, and it is important that the ward round reviews all care and management of these patients. The pharmacist on that ward round has a particular role to play ensuring that there is correct management of the patients with regard to their antimicrobial therapy.

In addition to those ward rounds, there are also intravenous to oral switch ward rounds, also called IVOST ward rounds, where the pharmacist advises on conversion of patients who are on intravenous antibiotics to oral therapy, or indeed stopping antibiotic treatment altogether. In addition to those ward rounds, pharmacists attend surgical and medical and other specialty ward rounds to review particular patients on antibiotic therapy. Another key role of the antimicrobial pharmacist is the development and updating of antimicrobial prescribing guidelines. These are essential within hospitals and also primary care environments to try to ensure that the correct antimicrobials are used in patient care. These tend to be widely publicised through hospital intranets, the internet, and also using applications.

In addition to this, my role involves education of ward based staff, and also hospital managers and patients. This can take a number of formats. Education sessions are frequently on a one to one basis at ward level, or they can be to a large group of health care staff, such as non-medical prescribers. And another essential role is to educate new medical staff at the induction sessions for the new hospital doctors when they start, and also in their rotations.

In addition to this, antimicrobial pharmacists have a large role to play in promoting campaigns such as the European Antibiotic Awareness Day, which is held in November every year. And there are a number of poster campaigns advertising promotion of the Antibiotic Awareness Day to health care staff, patients, and the public. In addition to these activities, antimicrobial pharmacists are also involved in audit of prescribing, and also feedback of audit results to ward based staff. A key role is monitoring of prescribing to ensure adherence to the antibiotic prescribing guidelines as far as possible. And this involves performing a number of surveys, and recording the results, production of reports, and feedback of these reports to the ward based staff.

In addition to this, antimicrobial pharmacists also report their activities and the activity of the antimicrobial management team to the hospital management, and to influence prescribing at that level, in addition to influencing prescribers at the ward level. Antimicrobial management teams also have a key role to play in some of the major committees and groups within the hospital environment, such as the area drug and therapeutics committee therapeutics committee, who require reports on a regular basis of the influence that the antimicrobial management team has had at hospital and primary care level. And this production of reports for these committees is also a key role of the antimicrobial pharmacists.