Organisational Issues

How can a Hospital Deliver good Antibiotic Stewardship?A Clinician’s and Epidemiologist’s

(and DIPC’s) Perspective

• Effective Antibiotic Teams

• Infectious Diseases Pharmacists

• Intelligence underpinning activity

• Organisational development in Acute Trusts

• Multidisciplinary working NHS plan DoH 2000

• Recommended for antibiotic management IDSA Marr et al ’88 JID157 , EU Copenhagen Recommendations 98

• A ‘multidisciplinary and systems oriented approach catalysed by hospital leadership’- Goldmann et al ‘96 JAMA 275

• ‘Nominated lead’ for Trusts- HSC 1999/049 Resistance to Antibiotics

• Importance of respected clinical leadership Burke et al ’96 Hosp Pharm 31, Garey et al ICAAC 2000

• DIPC for each Trust ‘Authority to challenge antibx prescribing’ - Dec 2003 DoH

• Impact on clinical outcomes, LOS and cost not realisedFuture-better research, better evidence base, more analysis of policy, health care delivery and quality improvement BMJ Godlee Jan,May 2006

Antibiotic Teams

• Multidisciplinary working NHS plan DoH 2000

• Recommended for antibiotic management IDSA Marr et al ’88 JID157 , EU Copenhagen Recommendations 98

• A ‘multidisciplinary and systems oriented approach catalysed by hospital leadership’- Goldmann et al ‘96 JAMA 275

• ‘Nominated lead’ for Trusts- HSC 1999/049 Resistance to Antibiotics

• Importance of respected clinical leadership Burke et al ’96 Hosp Pharm 31, Garey et al ICAAC 2000

• DIPC for each Trust ‘Authority to challenge antibx prescribing’ - Dec 2003 DoH

• Impact on clinical outcomes, LOS and cost not realisedFuture-better research, better evidence base, more analysis of policy, health care delivery and quality improvement BMJ Godlee Jan,May 2006

Antibiotic Teams

Increasing Role and Value of Teams

• Antibiotic management part of QA programmes, Trust and Directorates Performance monitoring, Clinical Governance, KPI’s

• Integration of Antibx control with Infection Prevention and Control NAO 2004

• Some DIPCs will be pharmacists

• LOS and Care management guidelines driving change

• Greater emphasis on de-escalation and stoppingMoussaoui et al BMJ June 10th 2006

Duration of antibiotic therapy and

Microbiologist/Infectious diseases

specialist inputCorona et al. JAC 52 (5): 849.

(2003)

254 ITUs, 34 countries

The greater the specialist input, the

shorter the duration of therapy (P < 0.0001)

Teams of the Future• More systems based strategic approach

• Adopting behavioural and organisational strategiesPulcini 2006 JAC, Tan 2006 Qual Safe healthcare

• Policies to the bedside – care bundles, management pathways

• Supported by better intelligence

• Operational/strategic roles? -Do they need to be multidisciplinary operationally?

• More senior clinical roles for pharmacists, with specialist training, professional development and support

Ideal Clinical Team?• Microbiology/ID consultant• ID Pharmacist • SpR micro/ID• Directorate pharmacist• MLSO/ Technician• Hospital epidemiologist (with data manager/IT

support, electronic prescribing)• Infection control• Speciality representatives (docs and nurses)• Bed manager ( discharge planning, OPAT)

The ID Pharmacist • Education• Expert advice• Control and optimising Rx• Infection Prevention• Reduce SSI- optimise

surgical prophylaxis• Reduce C. difficile• De-escalation• Eradication protocols• IV to oral• IV management, lines on

prescription• Coated devices

The ID Pharmacist • Education• Expert advice• Control and optimising Rx• Infection Prevention• Reduce SSI- optimise

surgical prophylaxis• Reduce C. difficile• De-escalation• Eradication protocols• IV to oral• IV management, lines on

prescription• Coated devices

• Policies and implementation

• Surveillance and audit• Awareness of local

patterns of prescribing, resistance, infections, outbreaks etc

• Awareness of flagged patients/alert organisms

• Occupational health eg PEP, vaccination

• Emergency planning and preparedness

Future Role for ID pharmacist• More Strategic• Greater leadership role• Better trained• Provide more medical training• Greater clinical partnerships, and recognition• Microbiology off site and centralised• More linkage with infection prevention• Integrated into Clinical Governance• Better epidemiology and monitoring• Organisational development• Leading roles in emergency planning and

preparedness

But in UK: Need for Training

• US and Canada full time residency programmes in ID pharmacy practice, followed by fellowships in practice or research

• No postgrad training

existed in the UK

Need for Training

• US and Canada full time residency programmes in ID pharmacy practice, followed by fellowships in practice or research

• No postgrad training

existed in the UK• Until: Oct 2003

MSc programme

Imperial/ HPA /

APU Hammersmith

c.burt@imperial.co.uk

The Future for Training

• MSc -expansion to better support UK wide pharmacists

• Professional development aspects enhanced • Clinical role promoted• Graduates to provide input, support, mentorship,

shape course• PhDs encouraged• Impact of graduates assessed• Modules, seminars, lectures multidisciplinary

with ID/micro trainees etc

If Teams are to be more strategic and influential- they need:

• Local and national intelligence

• Organisational and systems based approaches to embed and sustain best practice, and address Institutional, cultural and professional barriers

Intelligence• Systems to support information gathering• Appropriate IT• Surveillance schemes • Real time monitoring• Generate triggers for action• Audit Programme• Analytical resources• Framework for feedback and action• Data informing local policies• Provide decision support

LDS Hospital, Salt Lake City team

Systems to monitor:

• Prescribing • Organisms• Resistance• Mismatch• Patient and Disease patterns• Linked to patient info, admin info, bed tracking,

theatre, pathol databases, physician info• Ability to integrate with infection control

databases, alert organisms, clinical incidents, line usage, SSI, mandatory reporting databases, appraisals, training

Organisational Change required

• Much expertise, not harnessed effectively• Small teams in huge Trusts without major strategic

input• Not closely linked to management framework• Systems based approach needed• Sustainability • To be a core part of corporate governance • Create organisational learning• Culture and behaviour of whole Trust to change

Barriers to Address

• Historically in UK -Lack of public health leadership in acute trusts

• Clinicians and managers separation from public health responsibility

• Complacency, unaware of risk• Consultant ‘autonomy’, resistance to

standardising practice• No perceived individual responsibility• Multiple parallel hierarchies• Competing priorities,clinical and managerial • Lack of shared vision

Platform for Organisational Change

• Patient care the driver• High Clinical profile essential• Multidisciplinary engagement• Multiple Leaders• Collaborative• Addressing local issues• Integrate with infection control• Use existing Clinical Governance framework• Chief executive backing• Directorate accountability

‘HOMIP’- HSJ Feb 2006

Learn from other worlds…• Industry (e.g. Airlines- safety culture, Food industry-

HACCP)

• Business and Management (organisational development and change management)

• Military ( e.g. The ‘Afterburners’: Delivering a mission in combat situation, ‘flawless execution’ in a changing and environment with ‘plan-brief-execute’ (with continuous crosschecks) then debrief, addressing task saturation and ensuring shared motivation

• Politics ( e.g. IHI 100k lives campaign- ‘’Soon is not a time, less is not a number’’ Don Berwick)

• Advertising, communications and the media• Behavioural sciences

Business and Management

• Performance monitoring

• Accountability

• Traffic lights

• Targets

• Balanced score cards

The Balanced Scorecard

• A framework to measure performance beyond finances in private industry

• Align performance measures with strategic mission and goals- so not only measure performance but factors driving performance.

• A basis for executing good strategy well and managing change successfully

• Caution: -you get what you measure -skews activity

-needs regular refreshing and updating

Kaplan and Norton 1996 Harvard Business School Press

Local Directorate Accountability

• Follows decision making and funding • GMs and Clinical Directors accountable• Clinical leaders identified• Reinforces ownership• Embed specialist surveillance • Facilitates targeted

activity and rapid adoption of best practice

HOMIP- HSJ Feb 2006

Local Performance Management

• 2004-5 Infection targets in ‘balanced score card’ for each clinical directorate, reviewed monthly

• Core infection outcome measures agreed- includes antibiotic use Dean et al Int J Pharm Prac 2002

• Supplemental speciality specific measures• Traffic light system• Information on risks

expanding• ‘Post op HAI’ if on

antibx 48 hours post elective surgery

This Framework:

• Addresses clinical governance in antibiotic prescribing

• Continually reinforces stewardship ( clinically and managerially)

• Develops supportive networks (ward pharms etc)• Effectively works cross

directorates and cross sites • Efficient engagement

with clinical teams• Promotes understanding of • risk and value of standardised systems

Systems and Standardised care

• For risk reduction and quality improvement• Check lists, aviation industry tools• Consultant autonomy challenges• NB tools for management, finance (and litigation) directed

monitoring• ICPs• Care bundles

-SSI, ventilators, Central lines etc-IHI ‘100K Lives’ and DoH ‘Saving lives’ campaign-Antibx in SSI and Sepsis critical care bundle

What Is a Bundle? A grouping of best practices with respect to a disease

process that individually improve care, but when applied together result in substantially greater improvement.

The science behind the bundle is so well established that it should be considered standard of care.

Bundle elements are dichotomous and compliance can be measured: yes/no answers.

Bundles avoid the piecemeal application of proven therapies in favor of an “all or none” approach.

The ‘Antibiotic Care Bundle’……

• Clinical criteria for initiation• Actively get microbiol specimens• Empiric initial choice based on local policy• Remove sources foreign body, surgery• Modify when microbiol results through• Daily review of antibx choice and continuation.• Regular expert input

Cooke, Holmes in press 2006

• Provides simple but rigorous check list, documentation and sign offs

• Facilitates easy performance monitoring

Effective Practice?

• Unable to apply antibiotic stewardship adequately without changing the organisational culture and behaviour

• Performance management successful in other complex organisations, and in changing directorate behaviour in other spheres

• Creates organisational learning

• Research requiredMcDonald, Wilson,Goodacre- Evaluating and Implementing new services BMJ 2006 14th Jan