K. A. McIntosh

A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments

OBJECTIVE The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). DESIGN and INTERVENTIONS Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. SETTING AND PARTICIPANTS Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. MAIN OUTCOME MEASURES Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. RESULTS Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4-8) at baseline to 125/503 (25%, 95% CI 21-29; P < 0.0001) and 102/462 (22%, 95% CI 18-26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16-23) to 132/462 (30%, 95% CI 26-34; P < 0.0001) and 132/462 (29%, 95% CI 24-33; P < 0.001), respectively. CONCLUSIONS Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

Antimicrobial Stewardship Activities: A Survey of Queensland Hospitals

OBJECTIVE In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. METHODS The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. RESULTS The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. CONCLUSIONS Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. WHAT IS KNOWN ABOUT THE TOPIC?: The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. WHAT DOES THE PAPER ADD?: This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities.