Standard 3: Healthcare Associated Infection

Antimicrobial stewardship

Action 3.15

The health service organisation has an antimicrobial stewardship program that:

a. Includes an antimicrobial stewardship policy

b. Provides access to, and promotes the use of, current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing

c. Has an antimicrobial formulary that includes restriction rules and approval processes

d. Incorporates core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard

Intent

Appropriate prescribing and use of antimicrobials are part of the broader systems to improve patient safety and quality of care, and prevent and manage infections associated with multidrug-resistant organisms.

Reflective questions

What systems, processes and structures are in place to support appropriate prescribing and use of antimicrobials?

How does the health service organisation provide access to current endorsed therapeutic guidelines for clinicians who prescribe antimicrobials?

How is information about the antimicrobial formulary, restriction rules and approval processes communicated to prescribers and clinicians?

Key tasks

  • Review the current antimicrobial stewardship (AMS) program to identify what is working well; identify gaps, risks and areas for improvement; set priorities; and inform review of the AMS program plan - use the results of this review to determine priorities for AMS
  • Identify the key membership of the AMS committee and the AMS team
  • Develop or review an AMS policy that specifies that clinicians should follow current, evidence-based Australian therapeutic guidelines on antimicrobial prescribing, or evidence-based guidelines that have been endorsed by a state or territory AMS committee, and incorporates the principles of the Antimicrobial Stewardship Clinical Care Standard
  • Develop, review and maintain antimicrobial prescribing policies and a formulary for specific infections to reflect current resistance patterns
  • Create or review an antimicrobial formulary and guidelines for treatment and prophylaxis that align with current, evidence-based Australian therapeutic guidelines
  • Review policies, clinical pathways, point-of-care tools and education programs to ensure that they incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard.

Strategies for improvement

Hospitals

Review the AMS program

All health service organisations should have an overarching AMS program. Review the current AMS program to identify what is working well, and gaps and areas for improvement. This includes:

  • Assessing current antimicrobial use, results of prescribing audits, available incident data, current AMS activities and resources to support AMS strategies
  • Mapping current governance structures, systems and processes that currently support AMS, or could be further developed
  • Using the results of this evaluation to identify risks, gaps and priorities for AMS, and to inform the AMS program plan.

Review the AMS committee and team

The AMS committee is multidisciplinary and oversees the effective implementation and ongoing function of the AMS program. Membership includes:

  • A member of the executive as an executive sponsor, who can enable change
  • Clinicians with technical expertise (for example, an infectious diseases physician, pharmacist, clinical microbiologist or infection control nurse) and other individuals who can provide day-to-day leadership and support implementation.

Check that the AMS committee has endorsement from the organisation’s executive or governing body for formal structural alignment.

Ensure that there are links between the AMS committee and the existing clinical governance framework and quality improvement systems, including having the committee represented on both the drug and therapeutics committee, and the infection prevention and control committee. These links should be clearly articulated (for example, in the organisational chart or terms of reference).

Incorporate AMS within the organisation’s safety and quality improvement systems (see Actions 1.10 and 3.2).

The AMS team is the effector arm of the AMS program. Core membership includes:

  • An infectious diseases physician or clinical microbiologist
  • A nominated clinician (for example, lead doctor)
  • A clinical pharmacist.

In larger health service organisations, the team would be on site; in smaller facilities, the pharmacist position may be part of a broader network or group of health service organisations, or support may be provided using telehealth systems. The responsibility to ensure that the AMS team is adequately resourced should be clearly outlined in organisational policies.

Implement an AMS policy

Write or review, and implement, an AMS policy that:

  • Specifies that prescribers must follow current, evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing, or evidence-based guidelines that have been endorsed by a state or territory AMS committee, and incorporates processes for informing prescribers about prescribing requirements
  • Incorporates the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • Lists restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specifies processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • References the health service organisation’s policy on liaising with the pharmaceutical industry (see Action 4.1)
  • Outlines systems for obtaining specialist advice for complex clinical conditions
  • Incorporates an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflects the AMS program’s integration within the organisation’s safety and quality systems.

Decide on, and document, procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

The strategies below align with those listed in Action 3.16.

Develop an AMS program plan based on the risks, gaps and priorities identified in the initial assessment and gap analysis. Ensure that the plan details:

  • Procedures for prescription review and feedback to prescribers (for example, AMS rounds or pharmacy rounds)
  • Goals, actions, time frames, and measurement and reporting activities
  • Frequency of review and monitoring activities
  • Process and outcome indicators or measures to monitor program effectiveness
  • Roles, responsibilities and time frames for reporting on policy compliance, antimicrobial use and resistance, and prescribing according to guidelines
  • Roles and responsibilities of governance, executive, leaders, managers and clinicians for meeting and evaluating identified priorities
  • Resource allocation (for example, workforce, time, infrastructure) to support planned activities.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the start of their employment and at least annually.

Ensure that prescribing clinicians have access to, and follow, current guidelines and the local antimicrobial formulary for treatment and prophylaxis for common infections relevant to the patient population, the procedures performed and the local antimicrobial resistance profile. Therapeutic Guidelines: Antibiotic2 is recognised as a national guideline for antimicrobial prescribing in Australia.

Provide clinicians with ready access to the current version of Therapeutic Guidelines: Antibiotic and the local antimicrobial formulary. To promote uptake, make guidelines available in print or online formats.

Ensure that any local clinical and prescribing guidelines are consistent with recommendations in the current version of Therapeutic Guidelines: Antibiotic, and consider local microbial susceptibility patterns.

Review prescribing guidelines at least annually, or as changes are notified.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard into the AMS program

Review relevant clinical pathways to ensure that review of antimicrobial therapy and patient condition is included in the pathway. Set benchmarks for documenting in the patient’s healthcare record the clinical reason; the medicine name, dose, route of administration and intended duration; and the treatment review plan.

Implement or review the process for reporting adverse events, incidents and near misses relating to antimicrobial use, including assessment and management of reported antibiotic–allergy mismatch.

Educate patients and carers about safe and appropriate use of antimicrobials, including potential adverse reactions and what to do in the event of a reaction.

Use process measures to monitor implementation of the AMS program, and to identify opportunities for improvement. Possible measures include Antimicrobial Stewardship Clinical Care Standard indicators1 and quality use of medicines indicators.

The Antimicrobial Stewardship Clinical Care Standard is available on the Commission’s website.1

Day Procedure Services

Review the AMS program

An AMS program is a combination of strategies and interventions that work together to optimise antimicrobial use.

All day procedure services that administer or prescribe antimicrobials are required to have an overarching AMS program. Depending on the governance arrangements for safety and quality, this program may be managed by an individual facility, local health network, state or territory, or private hospital ownership group. If the service is part of a broader network or ownership group, work with the governing organisation to identify the resources available to support AMS in the day procedure service and to develop the program.

Review the program to identify what is working well, and gaps and areas for improvement. This includes:

  • Assessing current antimicrobial use, results of prescribing audits, available incident data, current AMS activities and resources to support AMS strategies
  • Mapping current governance structures, systems and processes that currently support AMS, or could be further developed
  • Using the results of this evaluation to identify risks, gaps and priorities for AMS, and to inform the AMS program plan.

Review governance arrangements

To ensure the best chance of program success, incorporate AMS within the service’s quality improvement and patient safety plan.

Governance arrangements for the AMS program may involve coordination by the service’s manager, with support from specialist credentialed medical and other practitioners, and/or a pharmacist, if available.

The committee overseeing AMS requires endorsement from the executive or governing body for formal structural alignment.

Review the AMS committee and team

The committee responsible for AMS oversees the effective implementation and ongoing function of the AMS program. Membership includes:

  • A member of the executive as an executive sponsor, who can enable change
  • Clinicians and other individuals who can provide day-to-day leadership.

The AMS team is the effector arm of the AMS program. Membership may include:

  • The service’s manager, a nurse, credentialed medical and other practitioners, a surgeon, an anaesthetic representative
  • If available, a pharmacist; the pharmacist position may be part of a broader network or group, or contracted service, or accessed using telehealth systems.

Implement an AMS policy

Write or review, and implement, an AMS policy that:

  • Specifies that prescribers must follow current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing, or evidence-based guidelines that have been endorsed by a state or territory AMS committee
  • Incorporates processes for informing prescribers about prescribing requirements
  • Incorporates the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • Lists restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specifies processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • References the health service organisation’s policy on liaising with the pharmaceutical industry (see Action 4.1)
  • Outlines systems for obtaining specialist advice for complex procedures or conditions
  • Incorporates an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflects the AMS program’s integration within the organisation’s safety and quality systems.

Decide on, and document, procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

The strategies below are aligned with those listed in Action 3.16.

Develop an AMS program plan based on the risks, gaps and priorities identified in the initial assessment and gap analysis. Ensure that the plan details:

  • Procedures for prescription review and feedback to prescribers
  • Goals, actions, time frames, and measurement and reporting activities
  • Frequency of review and monitoring activities
  • Process and outcome indicators or measures to monitor program effectiveness
  • Roles, responsibilities and time frames for reporting on policy compliance, antimicrobial use and resistance, and prescribing according to guidelines
  • Roles and responsibilities of governance, executive, leaders, managers and clinicians for meeting and evaluating identified priorities
  • Resource allocation (for example, workforce, time, infrastructure) to support planned activities.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the start of their employment and at least annually.

Ensure access to current guidelines

Ensure that prescribing clinicians have access to, and follow, current guidelines and the local antimicrobial formulary for treatment and prophylaxis for common infections relevant to the patient population, the procedures performed and the local antimicrobial resistance profile. Therapeutic Guidelines: Antibiotic2 is recognised as a national guideline for antimicrobial prescribing in Australia.

Provide clinicians with ready access to the current version of Therapeutic Guidelines: Antibiotic and the local antimicrobial formulary. To promote uptake, make guidelines available in print or online formats.

Ensure that any local clinical and prescribing guidelines are consistent with the recommendations in the latest version of Therapeutic Guidelines: Antibiotic, and take into account local microbial susceptibility patterns.

Review prescribing guidelines at least annually, or as changes are notified.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Specify restriction rules and approval processes within the formulary, including restriction of broad-spectrum and later-generation antimicrobials to patients in whom their use is clinically justified.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard into the AMS program

Review relevant clinical pathways to ensure that review of antimicrobial therapy and patient condition is included in the pathway. Set benchmarks for documenting in the patient’s healthcare record the clinical reason; the medicine name, dose, route of administration and intended duration; and the treatment review plan.

Implement or review the process for reporting adverse events, incidents and near misses relating to antimicrobial use, including assessment and management of reported antibiotic–allergy mismatch.

Educate patients and carers about safe and appropriate use of antimicrobials, including potential adverse reactions and what to do in the event of a reaction.

Use process measures to monitor implementation of the AMS program, and to identify opportunities for improvement. Possible measures include Antimicrobial Stewardship Clinical Care Standard indicators1 and quality use of medicines indicators.

Examples of evidence

Select only examples currently in use:

  • Policy documents about the AMS program
  • Examples of how the quality statements from the Antimicrobial Stewardship Clinical Care Standard have been incorporated into the AMS program
  • Membership lists and role descriptions for the AMS committee and team
  • Committee and meeting records in which performance of the AMS program was discussed
  • Communication with the workforce promoting the use of current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing
  • Observation that current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing are available to the workforce
  • Training documents about AMS and attendance records
  • Antimicrobial formulary that includes restrictions and approval procedures that align with current endorsed therapeutic guidelines
  • Audit results of antimicrobial use, especially for high-risk antimicrobials or high-risk clinical areas
  • List of high-risk antimicrobials used in the health service organisation or high-risk clinical areas.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established AMS program.

Small hospitals that are not part of a local health network or private hospital group should:

  • Review the current AMS program to identify what is working well; identify gaps, risks and areas for improvement; set priorities; and inform review of the AMS program plan – use the results of this review to set priorities for AMS
  • Identify the key membership of the AMS committee and the AMS team
  • Develop or review an AMS program plan
  • Develop or review an AMS policy that specifies that clinicians should follow current, evidence-based Australian therapeutic guidelines on antimicrobial prescribing, and incorporates the principles of the Antimicrobial Stewardship Clinical Care Standard
  • Develop, review and maintain antimicrobial prescribing policies and a formulary for specific infections to reflect current resistance patterns
  • Create or review an antimicrobial formulary and guidelines for treatment and prophylaxis that align with current, evidence-based Australian therapeutic guidelines
  • Review policies, clinical pathways, point-of-care tools and education programs to ensure that they incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard.

The governance structure of the AMS program should incorporate formal structural alignment to relevant committees and be endorsed by the hospital executive.

The group responsible for AMS is generally multidisciplinary and oversees the effective implementation and ongoing function of the AMS program. Membership will depend on the available workforce and may include those with network or contracted roles. Committee membership includes:

  • A member of the executive or nominated executive sponsor, who can enable change
  • Clinicians with technical expertise (for example, an infectious diseases physician, pharmacist, clinical microbiologist or infection control nurse) and other individuals who can provide day-to-day leadership and support implementation.

The AMS team is the effector arm of the AMS program. Depending on the local circumstances, the team may be at the level of the facility, local health network or private hospital group. It should reflect the local context, including the complexity of services offered. Membership will depend on the local context but should include:

  • A prescribing clinician
  • A clinical pharmacist, if available.

The AMS team needs to receive input from an infectious diseases physician or clinical microbiologist.

Implement an AMS policy

The AMS policy should:

  • Specify that prescribers must follow current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing
  • Incorporate processes for informing prescribers about prescribing requirements
  • Incorporate the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • List any restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specify processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • Outline systems for obtaining specialist advice for complex clinical conditions
  • Incorporate an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflect the AMS program’s integration within the organisation’s quality improvement and patient safety governance structure, and the organisation’s safety and quality strategic plan
  • Describe procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

Develop an AMS program plan based on the risks, gaps and priorities identified in the assessment and gap analysis. The plan should include documented processes for seeking expert specialist advice from infectious diseases physicians and/or clinical microbiologists to support the local AMS team and program implementation. Ensure that the plan includes procedures for prescription review and feedback to prescribers (e.g. AMS rounds or pharmacy rounds), and that the strategies in the plan align with those listed in Actions 3.16.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the beginning of their employment and at least annually.

Ensure access to current guidelines

Ensure that prescribing guidelines are consistent with current evidence-based Australian therapeutic guidelines. Therapeutic Guidelines: Antibiotic2 is recognised as a national guideline for antimicrobial prescribing in Australia. Provide clinicians with access to guidelines for treatment and prophylaxis for common infections relevant to the patient population, the local antimicrobial resistance profile and the surgical procedures performed. Review prescribing guidelines at least annually, or as changes are notified.

Ensure that evidence-based, endorsed state, territory or national guidelines and clinical pathways are available for management of suspected life-threatening bacterial conditions, including sepsis.

Establish or review clinical pathways for high-risk or high-volume conditions; examples might include Staphylococcus aureus bacteraemia, bone and joint infections, community-acquired pneumonia, catheter-associated and other urinary tract infections, and management of antimicrobial-related allergy.

Ensure that clinical pathways include steps to allow appropriate investigations, routine review of therapy, de-escalation, intravenous-to-oral switch and limiting the duration of therapy. Use state, territory or national guidelines or resources to implement a formal intravenous-to-oral switch program.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Implement the Antimicrobial Stewardship Clinical Care Standard locally.1

Action 3.16

The antimicrobial stewardship program will:

a. Review antimicrobial prescribing and use

b. Use surveillance data on antimicrobial resistance and use to support appropriate prescribing

c. Evaluate performance of the program, identify areas for improvement, and take action to improve the appropriateness of antimicrobial prescribing and use

d. Report to clinicians and the governing body regarding

  • compliance with the antimicrobial stewardship policy
  • antimicrobial use and resistance
  • appropriateness of prescribing and compliance with current evidence-based Australian therapeutic guidelines or resources on antimicrobial prescribing

Intent

The AMS program promotes safe and appropriate antimicrobial prescribing and use through ongoing monitoring, evaluation and improvement activities.

Reflective questions

What processes are in place to evaluate antimicrobial use?

How does the health service organisation use surveillance data on local antimicrobial resistance and use to support appropriate prescribing?

What actions have been taken to improve the effectiveness of the AMS processes?

How are data on prescribing and use of antimicrobials reported to clinicians and the governing body?

Key tasks

  • Collect and regularly review data on antimicrobial use (volume and appropriateness) and local resistance to identify areas for improvement and ascertain the effectiveness of AMS interventions
  • Monitor quality indicators to assess prescribing practice and AMS program effectiveness
  • Use the results of monitoring activities to decide on priorities and actions for improvement
  • Set up a system that ensures that feedback is provided to prescribers on results of monitoring and assessment activity.
  • Report routinely to the organisational governing body and the chief executive on AMS processes and outcomes.

Strategies for improvement

Hospitals

Monitoring and analysing antimicrobial use are critical to understanding patterns of prescribing, the impact on patient safety and antimicrobial resistance, as well as to measure the effectiveness of, and identify means to improve, the AMS program. Antimicrobial use can be measured in terms of quantity, quality (that is, appropriateness of prescribing according to guidelines) or expenditure.

Decide on areas for monitoring and improvement

Map current data collection systems across all departments to identify those that can be used to support monitoring and evaluation of AMS (note that a lot of data are routinely collected throughout health service organisations and it is important to identify what is already available to avoid duplication of effort). Examples include:

  • Pharmacy data collection systems – for information about trends in antimicrobial use
  • Data collected as part of performance monitoring for sepsis
  • Emergency department indicators reviewing time to first dose of antibiotics
  • Healthcare record systems
  • Electronic medication management systems
  • Pathology department audits
  • Data on the incidence of surgical site infections.

Use the risk assessment principles outlined in Action 3.1 to decide on priority areas for monitoring and improvement. Ensure that antimicrobial use monitoring includes intensive care units and oncology units, as the control of resistance in these areas can affect other areas of a health service organisation. Other priorities for monitoring may include conditions commonly associated with high antimicrobial use (for example, sepsis, urinary tract infections, respiratory tract infections, surgical prophylaxis) or high-risk antimicrobials (for example, third-generation cephalosporins, carbapenems).

Take part in state or territory, or national programs to monitor antimicrobial use and appropriateness that provide readily accessible audit and monitoring tools. Examples are:

Work with clinical microbiology services to ensure reporting of selective susceptibilities, and review antimicrobial use data in association with resistance data to identify any patterns.

Act to improve prescribing

Support the AMS team to provide an AMS service that:

  • Uses data from audits of prescribing and antimicrobial use to give feedback to clinicians on prescribing appropriateness, as part of AMS team or pharmacy review
  • Publishes reports on antimicrobial use and appropriateness; this could be whole-of-organisation data or broken down into individual ward or division information.

To engage individual clinicians and focus efforts, present data and feedback focused on specific clinical conditions and appropriateness of therapy.

To inform local empirical therapy recommendations and formulary management, make antimicrobial susceptibility tables (antibiograms) available to clinicians and groups responsible for local antimicrobial therapy guidelines. Because antibiograms can be difficult to interpret, ensure appropriate expertise from clinical microbiologists or infectious diseases specialists to help analyse the antibiogram and plan appropriate actions. If antibiograms are used, they should be consistent with the national specifications for a hospital-level cumulative antibiogram.3

Provide resources and tools at the point of care to promote appropriate antimicrobial prescribing, such as:

  • Posters targeting both prescribers and patients
  • Laminated cards that can be placed in medication rooms or be developed as pocket cards as a quick reference
  • Stickers or electronic prompts that can be used as reminders to review patients and treatment.

Implement or review clinical pathways for specific infections or conditions. Ensure that clinical pathways include steps to allow appropriate investigations, routine review of therapy, de-escalation, intravenous-to-oral switch and limiting the duration of therapy.

Establish clinical pathways for common, high-volume and high-risk conditions; examples might include Staphylococcus aureus bacteraemia, bone and joint infections, community-acquired pneumonia, surgical prophylaxis, sepsis and antimicrobial-related allergy.

Use state or territory, or national guidelines or resources to implement a formal intravenous-to-oral switch program.

Require all new prescribers to complete the NPS MedicineWise antimicrobial modules.

Communicate about safe and appropriate use of antimicrobials:

  • Provide regular updates about the AMS program to members of the clinical workforce using different methods, such as newsletters, screensavers, meetings and posters
  • Take part in annual Antibiotic Awareness Week activities
  • Ensure that patients and carers receive current Australian education materials on safe and appropriate use of antimicrobials.

Set up systems for communication with other clinicians about antimicrobial management. This is especially important for transitions of care, and includes internal communication, and external communication with general practitioners, members of the aged care workforce and other prescribers.

Monitor and evaluate the AMS program

Use the quality improvement framework outlined in Action 3.2 to evaluate the program, and identify opportunities and actions for improvement.

Use process and outcome measures to monitor and evaluate the program. Possible process measures include:

  • Antimicrobial Stewardship Clinical Care Standard indicators1
  • Quality use of medicines indicators
  • Infection- or antimicrobial-related incidents (for example, sentinel events such as Staphylococcus aureus bacteraemia, or adverse events relating to antimicrobial administration or dosing).

Possible outcome measures include:

  • S. aureus bacteraemia–related mortality
  • Infection-related length of stay (for example, central line-related sepsis, ventilator-related complications, multidrug-resistant organism infections)
  • Infection-related readmissions (for example, joint replacement surgery)
  • Reduced antimicrobial expenditure.

Contribute data on antimicrobial use and appropriateness to relevant state or territory, or national programs (for example, NAPS and NAUSP) to enable benchmarking as part of program evaluation.

Report on AMS program processes and outcomes

Responsibility for monitoring the effectiveness of the AMS program and ensuring accountability for actions lies with the governing body of the organisation. The governing body also has a role in allocating resources to achieve program goals and outcomes.

Provide a report every year to the chief executive and governance units that summarises:

  • Current AMS resources
  • AMS team activity
  • Performance against process and outcome indicators for antimicrobial use, appropriateness and resistance
  • Key areas of improvement
  • Areas for further improvement or priority
  • Areas in which guidance or support from chief executive and governance units is needed.

Refer to the Options for Implementing Antimicrobial Stewardship in Different Facilities resource for examples of monitoring and reporting activities in different settings.

Day Procedure Services

Monitoring and analysing antimicrobial use are critical to understanding patterns of prescribing, the impact on patient safety and antimicrobial resistance, as well as to measure the effectiveness of, and identify means to improve, the AMS program. Antimicrobial use can be measured in terms of quantity, quality (that is, appropriateness of prescribing according to guidelines) or expenditure.

Decide on areas for monitoring and improvement

Map current data collection systems to identify those that can be used to support monitoring and evaluation of AMS. Examples include:

  • Pharmacy data collection systems – for information about trends in antimicrobial use
  • Data on volume of use of antimicrobials
  • Evaluation of medicines use
  • Healthcare record systems
  • Electronic medication management systems
  • Pathology department audits
  • Purchasing data for antimicrobials.

If possible, use data that are routinely collected to avoid duplication of effort.

Use the risk assessment principles outlined in Action 3.1 to decide on priority areas for monitoring and improvement. Monitor antimicrobial use appropriate to the scope of services and procedures undertaken in the day procedure service. Priorities will include procedures associated with high levels of antimicrobial use or high-risk antimicrobials (for example, third-generation cephalosporins, carbapenems).

Conduct local audits and reviews as part of the AMS program plan, or participate in reviews and monitoring processes regarding antimicrobial use and resistance conducted by the Local Hospital Network, private hospital group, or state or territory.

Take part in state or territory, or national programs to monitor antimicrobial use and appropriateness that provide readily accessible audit and monitoring tools. Examples are:

Work with clinical microbiology or pathology services to ensure reporting of selective susceptibilities, and review antimicrobial use data in association with resistance data to identify any patterns.

Act to improve prescribing

Support the AMS team to provide an AMS service that:

  • Uses data from audits of prescribing and antimicrobial use to give feedback to clinicians on prescribing appropriateness, as part of AMS team or pharmacy review
  • Publishes reports on antimicrobial use and appropriateness.

To inform local empirical therapy recommendations and formulary management, make antimicrobial susceptibility tables (antibiograms) available to clinicians and groups responsible for local antimicrobial therapy guidelines. Because antibiograms can be difficult to interpret, ensure appropriate expertise from clinical microbiologists or infectious diseases specialists to help analyse the antibiogram and plan appropriate actions. If antibiograms are used, they should be consistent with the national specifications for hospital-level cumulative antibiogram.3

Provide resources and tools at the point of care to promote appropriate antimicrobial prescribing, such as:

  • Posters targeting both prescribers and patients
  • Laminated cards or pocket cards.

Implement or review clinical pathways for specific procedures and conditions.

Require all new prescribers to complete the NPS MedicineWise antimicrobial modules.

Communicate about safe and appropriate use of antimicrobials:

  • Provide regular updates about the AMS program to members of the clinical workforce using different methods, such as newsletters, screensavers, meetings and posters
  • Take part in annual Antibiotic Awareness Week activities
  • Ensure that patients and carers receive current Australian education materials on safe and appropriate use of antimicrobials.

Set up systems for communication about patient care and antimicrobial management with other treating clinicians and caregivers. This is particularly important for transitions of care, and includes internal communication, and external communication with general practitioners, members of the aged care workforce and other prescribers.

Monitor and evaluate the AMS program

Use the quality improvement framework outlined in Action 3.2 to evaluate the AMS program, and identify opportunities and actions for improvement.

Use process and outcome measures to monitor and evaluate the program. Possible process measures include:

  • Antimicrobial Stewardship Clinical Care Standard indicators1
  • Quality use of medicines indicators4
  • Infection- or antimicrobial-related incidents (for example, sentinel events such as Staphylococcus aureus bacteraemia, or adverse events relating to antimicrobial administration or dosing).

Possible outcome measures include:

  • S. aureus bacteraemia–related mortality
  • Infection-related readmissions (for example, joint replacement surgery)
  • Reduced antimicrobial expenditure.

Contribute data on antimicrobial use and appropriateness to relevant programs to enable benchmarking as part of program evaluation. Depending on the type of service, relevant programs could include:

  • Programs undertaken between like services across provider groups
  • State or territory programs
  • National programs such as the Surgical NAPS or NAUSP.

Report on AMS program processes and outcomes

Responsibility for monitoring the effectiveness of the AMS program and ensuring accountability for actions lies with the governing body of the organisation. The governing body also has a role in allocating resources to achieve program goals and outcomes.

Provide a report every year to the chief executive and governance units that summarises:

  • Current AMS resources
  • AMS team activity
  • Performance against process and outcome indicators for antimicrobial use, appropriateness and resistance
  • Key areas of improvement
  • Areas for further improvement or priority
  • Areas in which guidance or support from the chief executive and the governing body is needed.

Refer to Antimicrobial Stewardship in Australian Hospitals5 and hospitals tab for more detailed implementation strategies for this action.

Examples of evidence

Select only examples currently in use:

  • Committee and meeting records in which compliance with the AMS policy, and antimicrobial prescribing and use were discussed, including reviews of surveillance data
  • Results of analysis of surveillance data on antimicrobial resistance and use
  • Results of NAPS or other audits and surveys about appropriateness of prescribing
  • Improvement activities for AMS that have been implemented and evaluated
  • Communications with clinicians on antimicrobial use, resistance and stewardship in the health service organisation.
MPS & Small Hospitals

Monitoring and analysis of antimicrobial use are critical to understanding patterns of prescribing, the impact on patient safety and antimicrobial resistance, as well as to measure the effectiveness of, and identify means to improve, the AMS program. Antimicrobial use can be measured in terms of quantity, quality (that is, appropriateness of prescribing according to guidelines) or expenditure.

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established process for monitoring, evaluating and reporting on the organisation’s antimicrobial stewardship program.

Small hospitals that are not part of a local health network or private hospital group should:

  • Collect and regularly review data on antimicrobial use (volume and appropriateness) and local resistance to identify areas for improvement and ascertain the effectiveness of AMS interventions
  • Monitor quality indicators to assess prescribing practice and AMS program effectiveness
  • Use the results of monitoring activities to decide on priorities and actions for improvement
  • Set up a system that ensures that feedback is provided to prescribers on results of monitoring and assessment activity
  • Report routinely to the organisational governing body and the chief executive on AMS processes and outcomes.

Take part in state or territory, or national programs to monitor antimicrobial use and appropriateness that provide readily accessible audit and monitoring tools. Examples are:

Support the AMS team to:

  • Use data on prescribing and antimicrobial use to give feedback to clinicians and clinical teams on prescribing appropriateness, as part of AMS team or pharmacy rounds
  • Publish reports on antimicrobial use and appropriateness.

Implement or review clinical pathways for specific infections or conditions. Ensure that clinical pathways include steps to allow appropriate investigations, routine review of therapy, de-escalation, intravenous-to-oral switch and limiting the duration of therapy.

Set up clinical pathways for common, high-volume and high-risk conditions; examples might include Staphylococcus aureus bacteraemia, bone and joint infections, community-acquired pneumonia, surgical prophylaxis, sepsis and antimicrobial-related allergy.

Use state or territory, or national guidelines or resources to implement a formal intravenous-to-oral switch program.

Require all new prescribers to complete the NPS MedicineWise antimicrobial modules.

Communicate about safe and appropriate use of antimicrobials:

  • Provide regular updates about the AMS program to members of the clinical workforce using different methods, such as newsletters, screensavers, meetings and posters
  • Take part in annual Antibiotic Awareness Week activities
  • Ensure that patients and carers receive current Australian education materials on safe and appropriate use of antimicrobials.

Monitor and evaluate the AMS program using process and outcome measures such as:

  • Antimicrobial Stewardship Clinical Care Standard indicators
  • Quality use of medicines indicators4
  • Infection- or antimicrobial-related incidents (for example, sentinel events such as S. aureus bacteraemia, or adverse events relating to antimicrobial administration or dosing)
  • S. aureus bacteraemia–related mortality
  • Infection-related length of stay (for example, central line-related sepsis, ventilator-related complications, multidrug-resistant organism infections)
  • Infection-related readmissions (for example, joint replacement surgery)
  • Reduced antimicrobial expenditure.

Report on AMS program processes and outcomes

Report at least annually to the chief executive and relevant governance committees on:

  • AMS resources
  • AMS team activity
  • Performance against process and outcome indicators for antimicrobial use, appropriateness and resistance
  • Key areas of improvement
  • Areas for further improvement or priority
  • Areas in which guidance or support from the chief executive and governing committees is needed.

Refer to the Options for Implementing Antimicrobial Stewardship in Different Facilities resource for examples of monitoring and reporting activities in different settings.

Last updated 21st June, 2018 at 10:03pm
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References

Australian Commission on Safety and Quality in Health Care. Antimicrobial stewardship clinical care standard. Sydney: ACSQHC; 2014.

Therapeutic Guidelines Ltd. Therapeutic guidelines: antibiotic. Melbourne: Therapeutic Guidelines Ltd; 2014.

Australian Commission on Safety and Quality in Health Care. Specification for a hospital cumulative antibiogram. Sydney: ACSQHC; 2013.

Australian Commission on Safety and Quality in Health Care, NSW Therapeutic Advisory Group Inc. National quality use of medicines indicators for Australian hospitals. Sydney: ACSQHC; 2014.

Australian Commission on Safety and Quality in Health Care. Antimicrobial stewardship in Australian hospitals. Sydney: ACSQHC; 2011.