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AMS in the UK

Mark Gilchrist talks about antimicrobial stewardship in the UK.
Hi. My name is Mark Gilchrist. I’m a consultant pharmacist in infectious diseases and antimicrobial stewardship at Imperial College Healthcare, NHS Trust in London. We’re a large tertiary referral centre crossing five sites. I’m going to talk to you today about the experiences I’ve had with our stewardship programme from its infancy all the way through to where we are now. And whilst I’ll tell you about those experiences, actually how you operate your stewardship programme or how others operate the stewardship programmes are different. And they’ll be different in set up and the way in which they operate. But actually, there’ll be core principles. And those core principles will be fundamental.
And there’ll be fundamental around the resource that you have back at base, the problems that you are seeing on the ground, and the practises you’re seeing on the ground and the infrastructure that you have and how stewardship is prioritised within your organisation. So I guess the first question that anyone ever asked themselves when you’re trying to set up these programmes is, how do you know that you have a problem? What is driving you to set up the programme in the first place? And that might be an outbreak. It might be that you’ve got an increase in resistance. It might be that you’ve got an early signal from error rates coming through the hospital.
There might be something to do with antibiotic consumption. There might be national drivers. There might be local drivers, and IV-to-oral switches is usually an area that people get involved in. And ultimately, it’s probably around by auditing. You find that you’ve got a problem. And a lot of people do point prevalence surveys to find out really the geography of antibiotic prescribing in their local institution. So you’ve kind of got that is as a corner piece of stewardship programmes. And then it depends on the resource that you have. So who are you going to have that’s going to champion your stewardship efforts?
Is it a pharmacist who’s a clinical pharmacist with some antibiotic experience, a dedicated AMS pharmacist, a physician, ID physician, microbiologist, or a physician within a specialist area that’s got a passion for antibiotic resistance and making sure that we optimise antimicrobials appropriately? You can utilise IT specialists, epidemiologists as you become more sophisticated in your programme, specialist colleagues as I’ve said, but also nursing staff. They’re one of the huge resources that we have within our organisations. And we maybe don’t use them as well as we should do. Management, your chief pharmacists– and really who’s going to be that advocate and champion at the top of the organisation? And that then rolls into infrastructure.
So how are you going to, when you deliver your stewardship programme, pin all of those high profile events within the organisation and disseminate those through either clinical or managerial structures? And one of the ways in which we’ve done that locally is we’ve hinged a lot of our antibiotic work on patient safety, patient safety being an advocate for AMR, antibiotic resistance optimising doses, and making sure that we’re reducing resistance and reducing the overall burden of AMR. But you need to link into the levers, whether that’s locally or nationally. So, for example, within the United Kingdom where we’ve been very successful in trying to raise AMS is either by linking it to infection control profiles and infection control ways of operating.
So within our local institution in Imperial, we have an AMS and IPC joint committee. We have joint ways of working, joint ways of delivering information through our divisional and management colleagues and clinical colleagues on the ground. But also, we use the levers that are available to us nationally. So there’s been a lot of work to reduce consumption– so antibiotic consumption– at a national level by introducing targets to reduce the percentage that we use annually within our organisation and nationally. And when you have those drivers and you have those levers, it rings with performance metrics that our management suite look at.
And if you can get onto that same sort of levelled playing field as the other management metrics, then you’ve got some buy in, and you’ve got something tangible to work with; and also so that the divisions and the organisations can work to that as well. So I would argue understanding your infrastructure is really important. For us, at Imperial, we’re sort of in our 20th year of point prevalence studies. And ultimately, when we set out, we set out to do the geography of antibiotics within the organisation. We wanted to know who was using the most, who was using the least, the combinations, IV-to-oral switching.
And from that we, were able to develop task and finish groups and small discrete pockets of work. And since that, we’ve been able to build our stewardship programme really around four main pillars. One is a clinical pillar, which looks around clinical advice to patients, so that’s your pharmacy micro, your IPC advice, your infectious diseases treatment. And then we have our governance and policy arm where we look to national policy, international policy try and derive the right treatment guidelines for our front line staff. There’s the education and training arm about using the knowledge that we have to empower local teams to deliver better stewardship.
And then the final pillar in our programme is around the research and how we use the data that we collect and the views and the ways of working and how we deliver our information to almost empower ourselves to improve. The successes that we’ve had, if I take our acute admissions and elderly care populations for example, a number of years ago we had a real challenge with Clostridium difficile. And what we were able to determine is that our elderly medicine population were on antibiotics. But when you went to actually ask clinicians or the teams involved, particularly
at 2:00 AM in the morning, why is this patient on an antibiotic, there were sort of vague answers as to why they were actually on it. And if you took that all the way back to where the prescribing happened, it happened at the front door. So it happened in our EDs and emergency admissions. So we took the step to introduce the teams writing indications for antimicrobials. And when we did that, there was a little bit of noise. There was a little bit of disquiet amongst making people do that. But as we started to do it, we started to see 30% compliance, 40%.
And it probably took us about three or four years to get up to that 70%, 80%, 90% compliant of people using indications for why they’re using antibiotics. It’s not rocket science. But actually when you make people write why they’re using it, there’s a bit of accountability. There’s a bit about why you’re doing it. And so they then take that information. And it translated us into having better practise with antibiotics, better practise with stewardship, and a tightening of our regimes. And we saw the C. diff rates fall within elderly medicine. And I chose that because a lot of our patient pathways go from the acute areas into the elderly medicine because of our ageing population. And that was just an example.
It took five years to get there. And now, we were reporting it at the time every week. But it was a really good building block of how these things take time to embed. We used different modes of communication. We worked out that actually our junior medical teams, pharmacy, nursing teams didn’t respond to emails. Our managers did. You had to be there on the ward rounds to confer the information, do teaching sessions,
get there at 8:00 o’clock in the morning. And that has changed to make our acute medical teams have a huge buy in from pharmacy, nursing, and medics around down to microbial stewardship. And it’s been really pleasing to see that develop. And we’ve tried to cross-fertilise our other specialties with that as we go throughout the organisation. Sometimes it works. And as I said, sometimes, it doesn’t work because the way in which that team operates is different to other teams. So we know, for example, if we want to succeed in surgery, we have to get there when the ward rounds are.
And that’s sometimes 7:00 in the morning, half 7:00 in the morning.
By 9:00, people are in the theatre, and you’re not dealing with the people who are making the prescribing decisions. So it’s just a different way of working. And I guess the other bit that’s building on success is always just looking at your unintended consequences. So you might change a guideline, or you might change an antibiotic with a new regime, but you’ve always got to be conscious of those unintended consequences. And I would say one of the challenges that all AMS programmes face is they have to have an ability to look at their unintended consequence rate, even if it softly. Is your number of incidents going up? Are your outcomes?
What’s the general feeling of your clinicians on the ground through that change? Have you made it harder for the nursing staff to deliver medicines? Have you changed where the antibiotics are with your pharmacy provisions? So you need to just have a little bit of insight into that and not just make a change and drop it. And then, for us, the challenge going forward is making sure that we ensure that we keep AMR and IPC at the top of everyone’s agenda. We have to be dynamic. Tomorrow or yesterday, I should say, is old news in terms of AMR. We have to be thinking in advance.
We have to be thinking what the next generation of prescribers, clinicians, physicians, pharmacists, nurses are thinking and where we want to take our programme. I would say that the big gold star that we’ve had is that we’ve been able to innovate. And we’ve been able to move and not really be wedded to things so that the latest things about do we cut our length of courses to shorter is a big topic in the literature at the moment. And we’re looking at that. We’re looking at our annual resistance rates. We’re looking at how we make our information available on lots of different platforms as the IT infrastructure changes and how we deliver that to patient-facing care.
We’re starting to look at antifungals. We’re starting to look at therapeutic drug monitoring with our TDM service. Out with the normal boundaries of aminoglycosides and glycopeptides and move to sort of more penicillins and standardised, personalised medicine. So we’re doing lots of things. But we can’t become complacent. Just because we see good results in one area doesn’t mean that it’s working another. And we have to continuously review. And we do that by having great people, great dynamic, young, aspirational ideas, as well as having some organisational memory.
And it’s helpful to have the old and the wise, the young and the good, and creating an environment where we bring maybe specialties that weren’t sort of nontraditional specialties into the AMS fold and the AMS programme. It depends what works for you. It depends on your resources, as I’ve said. It depends on your infrastructure. And it depends on, ultimately, what you want to get out of your programme, what will benefit, and what will make a difference to patient care at the end of the day.

In this video, Mark Gilchrist, Consultant Pharmacist in Infectious Diseases at Imperial College Healthcare NHS Trust, discusses his experience with developing the AMS program within a large NHS hospital trust that comprise five hospitals in London, UK.

Mark emphasises the importance of considering the local context when identifying priority areas for improvement and highlights specific challenges and opportunities his team has faced over the years.

At Imperial, audits and point prevalence surveys provide an important source of data, and they have a 20-year history of using and enhancing these datasets to understand the geography of antibiotics in their institution. From this, they were able to form a stewardship program around 4 key pillars:

  1. Clinical: providing up-to-date evidence-based advice to patients and staff on antimicrobials.

  2. Governance and policy: deriving the right treatment guidance for all staff by involving key stakeholders, and supporting timely changes in response to drug shortages and the latest evidence.

  3. Education and training: empowering local teams by using their own knowledge and adapting education and training needs to facilitate uptake.

  4. Research: being able to use data, obtain staff feedback, and explore innovative ways of using technology to further provide insight into where the gaps are and how to deliver information so that the program is always improving.

Mark Gilchrist ended the video by emphasising how important it is to always look at unintended consequences, to have continuous monitoring and review, and to involve a multi-disciplinary team (including disciplines that are not all necessarily traditionally associated with antimicrobial use) in order to further improve the AMS program.

If you wish to find out more out point prevalence surveys, there is a free FutureLearn course which provides further insight into this topic.

In the comments below please let us know:

  • Are there factors which are similar to AMS in your area?
  • Are there factors which differ to AMS in your area?
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