Preparing for a PPS

This brief presentation will help you prepare for participating in a Point Prevalence Survey. The previous sections of the course have considered what a PPS is and how it fits into antimicrobial stewardship programmes to help drive improvement in antibiotic prescribing. And I hope you’re now thinking positively about undertaking a survey in your own ward or working with colleagues to undertake a PPS across your hospital. You may even be considering participating in a national or international PPS, such as the global PPS. And this presentation will outline the key factors you will need to consider when planning a PPS for the first time.

Most of these factors will be relevant whether you’re planning a small-scale survey in just a number of wards or a hospital-wide PPS. So in planning a PPS, you need to think about the following factors.

It’s useful to identify a lead investigator for each hospital. It is envisaged that, in most cases, this lead investigator will be a senior clinician who will be responsible for the planning and the coordination of data collection within the hospital. The lead investigator would usually be supported by a multidisciplinary team, which may include antimicrobial pharmacists, infectious disease specialists, microbiologists, and other staff, as appropriate to local circumstances. If the PPS is part of the global PPS or another international survey, then the lead investigator will be responsible for registering the hospital to participate. Data collectors will need dedicated time to visit all wards in the hospital within the study period.

The lead investigator and their team will need to consider whether to use a large team who visits all wards over a relatively short space of time or, alternatively, to use a smaller team but accepting that it will take longer to visit all wards. If you have no idea of the prevalence of antibiotic prescribing in your hospital, remember one of the antimicrobial stewardship rule of thirds. That is, in general, one third of patients in an acute hospital will be prescribed antibiotics on any given day. So that means, for a 500-bed hospital, there could be 170 patients prescribed antibiotics.

So it is important to plan your approach well to ensure there are sufficient data collectors and that the data collectors have sufficient time to visit wards to collect that required data. The lead investigator and their team should consider whether the regular duties and commitments of the data collectors may need to be suspended for the period when data collection is underway. This may, of course, require negotiation with service managers within the hospital. If you’re considering participating within the global PPS or another international PPS, then the lead investigator will be provided with the survey protocol and also access to the data collection forms and the web-based system for data input.

Otherwise, if it is a local PPS, you will need to produce a local protocol to specify which data are to be collected. That would be the ward data to provide the denominator information and also the patient-level data– that is, information about each patient taking antibiotics. The protocol will also specify which type of antimicrobials should be included. So, for instance, some PPS will exclude topical antimicrobials but include systemic antivirals and systemic antifungals, in addition to systemic antibacterials. Any locally developed protocol will need to classify the indication for antibiotic and the anatomical site of the presumed infection. And this will be, usually, in the form of a list of codes.

The protocol will also specify the data collection period, and it may recommend specific days that are excluded. Data collection is often excluded at the weekend. Many protocols will exclude data collection on the day following a weekend or a local or national holiday to ensure that the appropriate information on surgical prophylaxis in the previous 24 hours is available. In most hospital-wide surveys, there will be a team of data collectors. To be able to interpret the data correctly, consistency of approach to data collection is required. All data collectors must be familiar with the interpretation of clinical notes and prescription records, and should have an adequate understanding of the local prescribing guidelines.

If data collection is to be undertaken by a large team of data collectors, the lead investigator and their team will be responsible for organising and delivering training. This training will focus on the completion of the paperwork in a consistent manner. It is important to ensure all data collectors understand all definitions and codes and apply these consistently. The aim of the survey is to record what clinicians intend treating, and there should be no discussion by data collectors about the appropriateness of treatment in individual cases. However, if to complete the form, additional information is required from the local clinical team, then it is appropriate to request this from nurses, pharmacists, or the doctors looking after that patient.

As the data collectors may not be well known in the ward where the PPS is being undertaken, communication with the ward staff is important. The lead investigator may consider production of leaflets and posters explaining why the survey is being conducted. It is recommended that, on the day of data collection, the data collector introduce themself to the nurse in charge and to the ward staff, and to briefly explain the purpose of the survey and that they will need access to information

about the number of patients in the ward at 8:00 AM that morning and access to the clinical records for any patient currently prescribed antimicrobials. It is always appropriate to ensure that the hospital’s clinical governance committee are aware the survey is being conducted. They will need to be reassured there are systems in place for the safe handling of information. Even if the data are entered into a web-based system, all data remains the property of the participating hospital. No patient identifiable information should be collected or input into a web-based system for analysis. If a paper-based data collection form is used, then the lead investigator must consider how the completed forms will be handled to produce a report.

In the global PPS, the data will be entered into a web-based system where data will be verified, validated, and will be routinely analysed to produce a hospital-level report. If data entry is required, then the lead investigator will need to ensure they arrange for sufficient staff to input that data. A large effort is required to collect data in a PPS. And that effort is worthless if the information is not analysed appropriately and, even more importantly, fed back to prescribers. Feedback to prescribers will feature in the next section of the course. It is, however, important for the lead investigator to plan in advance of the survey who will analyse the data and who and how the survey findings will be fed back.