Transcript Document

Implementation of a Hospital
Paediatric Antimicrobial Stewardship
Program
Sydney Children’s Hospital
Mostaghim M, Snelling T, McMullan B, Palasanthiran P
Background
AMS programs are a core element of the National Safety and Quality Health
Service (NSQHS) Standards.3
Healthcare services are required to:
• Have an AMS program in place
• Provide prescribers access to Therapeutic Guidelines
• Monitor antimicrobial use and resistance
• Act to improve the effectiveness of AMS programs
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Paediatric Challenges
Limited consensus paediatric references to provide recommendations for
optimal antimicrobial selection, dosing, route, and duration therapy.
Frequent “off label” prescribing
• Neonates
• Specialties including Transplant, Haematology/Oncology and ICU
Standard usage measures (e.g. DDD) are not well established.
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Antimicrobial Use
Point Prevalence Survey 2011
• 55% (70/127) inpatients on antimicrobials
• 15% for targeted indications
• 154 antibiotics prescribed
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Aims
1. Optimise antimicrobial use within a tertiary paediatric hospital by
implementing an AMS program aided by an electronic approval and decision
support system
2. Achieve accreditation under NSQHS criteria 3.14 Antimicrobial Stewardship
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Methods
Risk stratification of formulary antimicrobials based on spectrum of activity,
toxicity and cost:
Green : Unrestricted
Yellow: Restricted. Electronic approvals generated.
Prospective audit and feedback model
Red: Highly restricted. Infectious Diseases Consult necessary.
Preauthorisation model
Phase 1:
Risk
Stratification
Phase 2:
Literature
Review
Phase 3:
Consensus
Building
Phase 4:
“Programming”
Phase 5:
Implementation
and
Governance
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Methods
• SCH and Network Guidelines
• Formulary Restriction
Local
State-wide
National
Other
• Guidelines and Policy Directives
• Therapeutic Guidelines: Antibiotic
• National Paediatric Guidelines and Consensus Documents
• International Paediatric References & Standard Medication texts
• Neonatal Recommendations
Phase 1:
Risk
Stratification
Phase 2:
Literature
Review
Phase 3:
Consensus
Building
Phase 4:
“Programming”
Phase 5:
Implementation
and
Governance
Methods
• Specialty Units
SCH
• Specialty Units
SCHN
Local Health
District
(LHD)
SCHN/
LHD
Phase 1:
Risk
Stratification
Phase 2:
Literature
Review
• Paediatric Units
• Drug and
Therapeutics
Committee approval
Phase 3:
Consensus
Building
Phase 4:
“Programming”
Phase 5:
Implementation
and
Governance
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Methods
Approval process integrating indication specific:
• Dose, route, duration
• Management & monitoring
Guidance on:
• IV to oral switch
• Escalation and de-escalation
• Access to endorsed guidelines
• When to seek consultation from Specialty Units
Phase 1:
Risk
Stratification
Phase 2:
Literature
Review
Phase 3:
Consensus
Building
Phase 4:
“Programming”
Phase 5:
Implementation
and
Governance
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Methods
Real time and long term collation of data and
feedback ensures:
• System remains up-to-date and integrates with
formulary changes and updates/new guidelines
• Ongoing optimisation of antimicrobial use
• Direct links to drug and therapeutics and patient
safety committees and Hospital Executive
Phase 1:
Risk
Stratification
Phase 2:
Literature
Review
Phase 3:
Consensus
Building
Phase 4:
“Programming”
Phase 5:
Implementation
and
Governance
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Methods
Evaluation Framework:
• Appropriateness of prescribing
• Usage
• Antibiograms
• Clostridium difficile rates
• Toxicity (ADRs, local incident monitoring system)
• System adherence
• User Satisfaction
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Methods
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Results
•
Approvals generated reflect hospital and
AMS activity level to date and identify
areas for further collaboration or refinement
of system.
•
No adverse events have resulted from the
use of the system recommendations
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Results
Trends identified since implementation include:
•
Improvements in antimicrobial appropriateness
•
NSQHS accreditation with merit for 3.14. Antimicrobial Stewardship
•
Reduced 3rd generation cephalosporin, gentamicin and carbapenem use
Nov 12 SCH
May 13 SCH
Dec 13 SCH
P value
Patients on antimicrobials
61/110 (56%)
71/127 (56%)
63/106 (59%)
0.66
Number of antimicrobials
prescribed
112
143
98
NA
Appropriate prescription
68/109 (62%)
99/137 (72%)
81/96 (84%)
0.0003
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Conclusion
A comprehensive multidisciplinary paediatric AMS program was successfully
implemented, performing routine evaluation and optimisation of antimicrobial
use.
1.
2.
3.
MacDougall C, Polk R. Antimicrobial stewardship programs in health care systems Clinical Microbiology Review 2005;18(4):638-656.
Dellit, T.H., et al., Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for
Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases, 2007. 44(2): p. 159-177.
Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 3: Preventing and
Controlling Healthcare Associated Infections (October 2012). Sydney. ACSQHC, 2012.
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