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Beyond PPS

A dirt road with grass either side looking to the distance.

While PPS are useful to measure the quality of prescribing, they are time consuming to plan and resource intensive to collect the data and analyse the results.

Therefore the time required from start to finish may be several months. This means that the data which you share with managers and clinicians is not ‘current’, unless you are only focusing on a few wards for frequent repeated PPS to solve a particular problem.

As stewardship programmes have become established and mature additional methods have been developed to assess the quality both of stewardship programmes themselves and of antibiotic prescribing. Quality indicators focusing on structure, process or outcome have been developed and are now being used in many hospitals in Europe, USA and Australia.

Quality indicators are explicitly defined measureable items giving a possible indication on the level of quality. They can allow trends to be measures across time, between locations and before/after interventions.

There are three main types of indicators – structural, process and outcome.

Structural indicators measure whether governance structures are in place for stewardship such as does a hospital have an Antimicrobial Team which meets regularly, reports to senior management and has an action plan?

Process indicators measure systems in place for stewardship such as a surveillance programme for antibiotic use, a programme of audits, education for healthcare staff.

Outcome indicators are used to measure the impact of a stewardship programme and should include both intended and unintended outcomes such as reduced use of restricted antibiotics (intended) and increase in resistance to recommended antibiotics (unintended). Clinical outcomes may also be included but these are more difficult to measure.

Suitable indicators for stewardship are suggested within the Public Heath England Start Smart Then Focus publication which provides a graphical presentation for antibiotic treatment of infections and for surgical prophylaxis.

Flow-chart type diagram showin 'Antimicrobial Stewardship Treatment Algorithm'. 'Start smart' - Do not start antibiotics in the absence of clinical evidence of bacterial infection. 'Then focus' - clinical review & decision at 48-72 hours. Click here to expand image

You will find the Public Health England Start Smart Then Focus for antibiotic treatment of infections and surgical prophylaxis in downloads.

In Scotland antimicrobial prescribing measures have evolved from participation in PPS to ensure data collection leads to quality improvement:

In 2007 a prevalence survey of HAI in Scottish hospitals demonstrated 32.1% of patients were prescribed antimicrobials; whilst this established a baseline of the burden of prescribing it contained no information on measures of prescribing quality[9]. In 2009 SAPG coordinated a national Scottish acute hospital PPS in collaboration with ESAC. The objectives were to identify areas of variable or poor practice with a view to developing prescribing indicators for quality improvement, establish the national baseline for these indicators and comparison against European data. After establishing the baseline, monthly measurement of prescribing indicators in key clinical areas was implemented in December 2009 to drive improvement in the quality of hospital prescribing of antimicrobials. The national prescribing indicators were reviewed and modified in March 2011. A follow up national PPS was undertaken in September 2011.

The full article can be found here: “From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals”, Malcolm et al, 2015.

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Challenges in Antibiotic Resistance: Point Prevalence Surveys

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