Guidance tes on the Antimicrobial Companion Audit Tool for the Antimicrobial Prescribing Quality Indicators 2017/18 Summary of the indicators The 2017/18 hospital antimicrobial prescribing quality indicators focus on: Documentation of the indication for antibiotic treatment Compliance of the antibiotic treatment with the local prescribing protocol Administration of all prescribed doses of Documentation of duration or stop date for oral Documentation of clinical review of IV or combination therapy within 72 hours, and outcome of the review Prescription of carbapenems N.B. These measures relate to infection episodes, rather than patients or prescriptions. These measures will be collected by staff in boards through the Antimicrobial Companion app. Sampling strategy The audit will be conducted locally by clinical staff using the Antimicrobial Companion app. Data will be collected from patients prescribed, with each data submission relating to an individual infection episode. The audit should be completed in a minimum of 3 wards in each acute hospital and should include at least one Medical and one Surgical ward with a minimum of 10 infection episodes per month in each ward*. *In Island boards, data should be collected in acute wards for 20 infection episodes per month and if there are <20 episodes, data will be aggregated over 2 or 3 months. Detail of the indicators Measure Numerator Denominator Percentage of infection episodes with an indication for antibiotic treatment documented in the medical notes. Number of episodes with an indication for the antibiotic treatment documented in the medical notes. Total number of infection episodes sampled. Target 95% of episodes with an indication documented 1
Measure Percentage of infection episodes where the choice of antibiotic(s) is compliant with the local prescribing protocol for the documented indication, or the reason for deviation is documented in the medical notes. Numerator Number of episodes where antibiotic treatment follows local antibiotic policy for the indication documented in the medical notes OR is off policy but the reason for deviation is clearly documented in the medical notes. Denominator Total number of infection episodes sampled minus those without a documented indication (as compliance with policy cannot be assessed if the indication is not known). Target 95% compliance with local policy Measure (computed for both oral and IV/combination) Numerators For oral and IV or combination, the percentage of infection episodes with all doses of all prescribed administered, or a suitable reason for omitting dose(s) documented on the medicine chart or within electronic records. For only oral and for IV or combination, the number of episodes with a signature/initials on the medicine chart or electronic record against every dose prescribed, or if one or more doses were omitted there is a suitable reason documented for each missed dose. N.B. unavailability of an antibiotic is not a suitable reason for missing a dose. Denominators Total number of episodes where only oral were prescribed and total number of episodes where IV or combination were prescribed. Target 95% of episodes have all doses administered or a suitable reason for missed doses documented, for both oral and IV Measure Numerator Denominator Percentage of episodes that have a duration or stop date documented for all oral prescribed. Number of episodes with documented evidence in the clinical notes and/or kardex that the clinical team have specified the treatment duration or a stop date for every oral antibiotic prescribed. Number of episodes where oral were prescribed. Target Duration or stop date documented in at least 60% of episodes by the end of quarter 3 and in at least 80% of episodes by the end of March 2018. 2
Measure Number of episodes where an IV carbapenem was prescribed. Target There is no target for this measure, only the numbers will be recorded. Measure Numerator Percentage of episodes with evidence of clinical review within 72 hours of commencing treatment for all IV or combination IV+oral. Number of episodes with documented evidence in the clinical notes and/or kardex that within 72 hours of commencing treatment, the clinical team have reviewed the need for all IV prescribed, or all prescribed as IV and oral combination therapy. The definition of a clinical review is: a review to assess the ongoing requirement for that is conducted by a prescriber and is documented with a date. Denominator Number of episodes where IV were prescribed, minus those where a review is not documented but where the patient has been on IV for less than 72 hours. Target Sub-measure Evidence of clinical review documented in at least 60% of episodes by the end of quarter 3 and in at least 80% of episodes by the end of March 2018. Number of episodes where if a review of all occurred, the documented outcome was to: Stop all Continue same IV/combination antibiotic(s): reason documented Continue same IV/combination antibiotic(s): no reason documented Escalate to different and/or additional IV/combination antibiotic(s) De-escalate to different IV/combination antibiotic(s) IV to oral switch Other N.B. If there was a different outcome for different in the same treatment episode, choose Other and specify in the comments section the number of with each different outcome e.g. 2 continued, 1 switched to oral. Best practice: if are continued, a reason should be given. As part of this audit, there is no requirement to assess the appropriateness of the reason or the clinical evidence for continuing the antibiotic, but these should be monitored locally. 3
Template Data Collection Form. (For use if you prefer not to input data directly through the app). Board Hospital Specialty Ward Month Year Possible outcomes of review: 1) Stop 2) Continue same IV/combination, reason given 3) Continue same IV/combination, no reason given 4) Escalate to another and/or additional IV/combination antibiotic(s) 5) De-escalate to another IV/combination antibiotic(s) 6) IV to oral switch 7) Other Episode Indication documented? If indication documented, compliant with policy? Only oral If only oral administered? All durations/ stop dates documented? IV or IV+oral combination 4 Carbapenem If IV or IV+oral combination prescribed administered? Documented review of all by 72 hours? If no review, has it been <72 hours? If reviewed, what was the outcome? 1 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 2 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 3 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 4 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 5 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 6 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 7 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 8 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 9 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 10 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 11 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 12 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 13 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 14 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 15 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 16 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 17 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 18 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 19 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 20 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 21 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 22 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 23 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 24 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 25 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 26 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 27 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 28 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 29 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7 30 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N 1 2 3 4 5 6 7
Example of Data Collection Hospital and board Infection episode Indication documented? / with policy? / Only oral / If only oral administered? / All duration/ stop dates documented? / IV or IV+oral combination / Carbapenem / If IV or IV+oral combination prescribed administered? / Documented review of all drugs by 72 hours? / If no review has it been <72 hours? / If reviewed, what outcome? 1 N/A N/A N/A IV to oral 2 N/A N/A N/A N/A N/A 3 N/A N/A N/A N/A 4 N/A N/A N/A 5 N/A N/A N/A N/A N/A 6 N/A N/A N/A Stop ABs Example results Hospital and board Sample size 6 Indication documented 5/6 83% with policy 4/5 80% Only oral prescribed 2/6 33% If only oral administered 1/2 50% All duration/ stop dates documented 1/2 50% IV or IV+oral combination prescribed 4/6 67% Carbapenem prescribed If IV or IV+oral combination prescribed administered 1 4/4 100% All IV or IV+oral prescribed for >72 hours have documented clinical review 2/3 67% Outcome of reviews 1 IV to oral, 1 stop ABs 5
Flowchart showing options for data collection. (The audit tool will guide you through this, enabling options based on your previous responses). Infection episode that is being treated with Indication for antibiotic treatment documented in the medical notes? Only oral IV or combination of IV+oral Antibiotic treatment compliant with local prescribing policy for the documented indication? n-compliant All prescribed doses administered as documented on the medicine chart? Duration or stop date for all oral documented in medical notes or medicine chart? Carbapenem Count Count All prescribed doses administered as documented on the medicine chart? Documented evidence of clinical review of all within 72 hours of starting treatment in medical notes or medicine chart? Reason for non-protocol choice documented? n-compliant Suitable* reason for each missed dose documented on the medicine chart? n-compliant n-compliant n-compliant What was the outcome of review? 1. Stop 2. Continue, reason given 3. Continue, no reason 4. Escalate 5. De-escalate 6. IV to oral switch 7. Other Were IV/combination started <72 hours before data collection? Exclude from denominator n-compliant * An antibiotic not being available is not a suitable reason for missing a dose. 6
Frequently Asked Questions Question. Will reporting be for overall compliance or compliance for each individual measure? Answer. Compliance will be reported for each measure. Question. Can individual measures be collected separately from different patients in different ward areas? For example could nurses collect the doses administered measure in one ward and the AMT or pharmacy team collect compliance and IV review in another ward? Answer.. We are aiming for all elements of prescribing and administration to be correct in every infection episode. Question. If data is collected for a patient on IV or combination therapy, can we collect data on the same patient when they are switched to oral therapy only? Answer. because we are interested in the process for prescribing, administering and monitoring. Question. Some patients are in hospital for prolonged periods, is it acceptable to collect data on the patient each time the drug therapy changes? Answer. because we are interested in the process for prescribing, administering and monitoring. Question. If the reason for a missed dose is documented in the notes, is it correct that we shouldn't count this as a missed dose, or is that only the case if the reason documented is acceptable? Answer. Acceptable reasons will have a code so the reason should not require interpretation. If certain codes are repeatedly used and may have an adverse effect on patient care then data should be shared with the clinical team to highlight that improvement is required. Question. These audits are assigned to downstream wards so what if the missed dose happened in the receiving ward? Staff in downstream wards may not be happy to take responsibility for doses missed prior to coming to the ward. Answer. We are just monitoring documentation so all data should be included. However the results should be shared with receiving wards if that is where the problem with missed doses lies. Question. The audit won t distinguish between an infection episode with one missed dose and an episode with many missed doses. Should we not put some kind of weighting on this measure? Answer. We are aiming for all elements of prescribing and administration to be correct for every episode but acknowledge we have a long way to go to achieve this. Detail of numbers should be shared with the clinical team who can make improvements and their response will vary depending on how bad the results are. Question. Is the medicine chart the only place a duration or review date should be recorded for oral? Answer., it could also be in the medical notes. 7
Question. For oral, does duration/stop date have to be recorded or does a review of count? Answer. A review does not count: duration or stop date should be recorded as the duration will be specified within the local guideline. An exception to this might be if the diagnosis was unclear, in which case the recommendation would be to not include the infection episode in the audit. Question. If the patient is on both IV and oral drugs (e.g. pip/taz IV and oral clarithromycin) for the same infection episode, how should this be handled? The duration for the oral drug usually depends on the diagnosis and the response to IV therapy so it is unlikely that a duration can be stated. Answer. If a patient is on combination IV and oral therapy for an infection episode, respond accordingly to the question IV or combination prescribed and complete the subsequent questions in the same way as you would if they were only prescribed IV. Question. What constitutes an acceptable documented review for IV or combination therapy? Often, continue on IV is written after routine daily review. Because of this, a duration or specific review date for IV/combination may not be recorded but the review is actually taking place. Answer. There must be documentation of a review by a prescriber with the date the review was conducted. Best practice is that when IV or combination are continued, a reason for continuing is specified, rather than simply writing continue on IV. The sub-measure of the outcome of review will capture whether a reason for continuing is documented. Question. For IV or combination therapy, if there is no evidence of a clinical review but there is a duration on the Kardex would that be considered acceptable as a review? Answer., this is not sufficient to constitute a review. Even for indications where treatment duration is known and can be documented at the time of prescribing (e.g. give 14 days of IV therapy), review of the patient should still take place to ensure they are responding to treatment. 8
Using the audit tool To submit data: Go to the QI Audit section on the mobile app, or to the website http://www.antimicrobialcompanion.scot/guidance-template/submit-audit For each infection episode sampled, select the appropriate option from each of the dropdown menus and for each radio button. Add any comments as required e.g. if you want to note that someone different to usual is collecting the data or if there are different outcomes to the review of multiple IV/combination within the same infection episode. Press Submit Audit Data. These guidance notes can be opened using the Guidance button at the top left of the page. To view audit data: Go to the admin page http://www.antimicrobialcompanion.scot/auditadmin Select a date range and the board, specialty(s), hospital(s) and ward(s) you would like to show results for. Press Generate report to view data. The results will be displayed in a table and as graphs for each of the measures. Click the View details option in the table to show each individual data entry for that month. Click outside of the table of individual entries to close it and return to the main results page. To delete an entry, press View details then Delete. Press Download to download a csv file with the data, which can be opened in a spreadsheet program such as Excel. You can also submit data from the admin page using the Add entry button. 9