Antimicrobial Stewardship

Transcription

1 Antimicrobial Stewardship WHAT IS THE ROLE OF THE ICU NURSE? Joan Rout CCSSA Refresher 2016

2 WHO, 2014

3 1985 first carbapenem produced (Le Dyner, 2009) Le Dyner, 2009

4 THE STATE OF THE WORLD S ANTIBIOTICS 2015 Van Boeckel et al Global trends in antimicrobial use in food animals. The Lancet Infectious Diseases.

5 THE STATE OF THE WORLD S ANTIBIOTICS 2015 BRICS Russia 19% China 37% India 66% Brazil 68% Van Boeckel et al Global trends in antimicrobial use in food animals. The Lancet Infectious Diseases.

6 THE STATE OF THE WORLD S ANTIBIOTICS 2015 BRICS Russia 19% China 37% India 66% Brazil 68% SOUTH AFRICA 219% Van Boeckel et al Global trends in antimicrobial use in food animals. The Lancet Infectious Diseases.

7 THE STATE OF THE WORLD S ANTIBIOTICS 2015 BRICS About three-quarters of the total increase in global consumption occurred in these nations; however, they accounted for only one-third of the world s increase in population from 2000 to 2010 Van Boeckel et al Van Boeckel et al Global trends in antimicrobial use in food animals. The Lancet Infectious Diseases.

8 Overuse of antibiotics Poor infection control (FIDSSA, 2012: WHO, 2013)

9 Overuse of antibiotics Poor infection control (FIDSSA, 2012: WHO, 2013)

10 Overuse of antibiotics Poor infection control FIDSSA, 2012: WHO, 2013

11 WHO, 2014 the world is heading for a post antibiotic era with the end of modern medicine as we know it in which common illnesses and minor injuries can once again kill World Health Organisation, 2014 Main factors driving resistance bacterial selective pressure transmission of pathogens by healthcare workers Rice, 2003

12 WHO, 2014 the world is heading for a post antibiotic era with the end of modern medicine as we know it in which common illnesses and minor injuries can once again kill World Health Organisation, 2014 Main factors driving resistance bacterial selective pressure transmission of pathogens by healthcare workers Rice, 2003 Overuse of antibiotics Poor infection control FIDSSA, 2012: WHO, 2013

13 Antimicrobial Stewardship Proactive approach to reduce microbial resistance by promoting the appropriate use of antimicrobial therapy and effective infection control Dellit, Owens, McGowan et al. Clinical Infec+ous Diseases, 2007

14 So what do the nurses have to say about this Infection control has become a large part of nursing responsibilities in the intensive care arena but the nurse does not yet have clear responsibilities with regards to antimicrobial therapy.

15 So what do the nurses have to say about this Although most antimicrobials are prescribed by doctors, the majority of these drugs are administered by nurses. In their role as a patient advocate, is it the role of nurses to challenge inappropriate prescribing or prolonged courses of antimicrobials? Are nurses being equipped and trained to undertake this role? Fry. 2012

16 So what do the nurses have to say about this There is very little mention of the nurse in current literature and it appears that the role of the nurse and the skills that are required of the nurse within antimicrobial stewardship have not been adequately explored Edwards, Drumright, Kiernan and Holmes, 2011; Ziady, 2012

17 So what do the nurses have to say about this Organisational role Quality improvement initiative Careful unit record keeping Data for local and national surveillance Advocatory role Promotion of AS amongst all stakeholders Observe for overuse of antimicrobials Monitor for resistant pathogens in unit Balance patient safety vs prescriber autonomy Clinical role Effective infection control in unit Monitoring for infection Giving antimicrobial therapy correctly Collaborative role Daily nursing AS rounds (bundle compliance/laboratory results/line days/duration of AB therapy) Daily interaction with doctors/ weekly telecom with microbiologists Rout, 2016

18 A T R ICU Most vulnerable patients to infection Uses the most antibiotics I S K Kaki et al. 2011

19 invasive devices debilitated state of the patient RECIPE FOR RESISTANCE lack of adequate infection control inappropriate use of antimicrobial therapy

20 ROLE OF THE ICU NURSE IN ANTIMICROBIAL STEWARDSHIP invasive devices debilitated state of the patient lack of adequate infection control inappropriate use of antimicrobial therapy Kaki et al

21 THE PATIENT AT RISK invasive devices Endotracheal tubes Arterial lines Central venous catheters Dialysis catheters Urinary catheters Intracranial pressure monitoring Chest drains Wound drains if I have someone in an ICU, that s there for longer than a week. The kind of infec;on that I expect is a very resistant bug which puts me immediately in the class of Carbapenems, as a result. (Non-nursing par.cipant) Rout,

22 ROLE OF THE ICU NURSE Daily nursing AS rounds bundle compliance line days laboratory results duration of AB therapy ICU Nurse Infection bundles of the Best Care, Always campaign (2009) the preven.on of central line infec.ons (CLABSI) the preven.on of ven.lator-associated pneumonia (VAP) the preven.on of surgical site infec.on (SSI) the preven.on of catheter-associated (CAUTI) urinary tract infec.ons Cleghorn, FIDSSA, 2011; Ziady,

23 THE PATIENT AT RISK invasive devices debilitated state of the patient debilitated state of the patient invasive devices prolonged length of stay mechanical ventilation impaired immune defence mechanism lack of adequate infection control inappropriate use of AB therapy lack of antimicrobial protocols Richards, 2010; Lucet et al. 2014

24 (Non nursing par-cipant) Rout, 2016 ROLE OF THE ICU NURSE ICU Nurse ICU Nurse Very important role... I mean the intensive care nurse is there, you know, all the 9me. They are monitoring the trends... they can pick up the li=le subtle things that happen in change of condi9on. We re there twice a day for a short period of 9me. The ICU nurse is vital in the care of the pa9ent... it's a massive responsibility...

25 MASSIVE RESPONSIBILITY Nurses are the only members of the ICU team to be with the patient at all times

26 COMPONENTS OF MONITORING -ongoing observation and assessment -recognition of changes -understanding of significance of changes enhanced by educational background clinical experience specialist competencies Kutney-Lee, Lake and Aiken, 2009 Temp WCC PCT

27 THE PATIENT AT RISK invasive devices primary reason for admission to ICU 21% non-infected patients after 24 hours of ICU 10% rate of infection for more than 7 days in ICU 70% debilitated state of the patient lack of adequate infection control The average ICU patient has been estimated to receive 178 interactions with providers daily Decker and Masur. 2015

28 THE PATIENT AT RISK invasive devices primary reason for admission to ICU 21% non-infected patients after 24 hours of ICU 10% rate of infection for more than 7 days in ICU 70% debilitated state of the patient lack of adequate infection control The average ICU patient has been estimated to receive 178 interactions with providers daily Decker and Masur. 2015

29 THE ROLE OF THE ICU NURSE ICU Nurse ICU Nurse Hand hygiene compliance nurses doctors physios lab technicians cleaners Du Toit, 2012 ICU Nurse

30 WELL DONE Infection prevention and control is the responsibility of every one working in a hospital Du Toit. 2012

31 THE PATIENT AT RISK invasive devices debilitated state of the patient lack of adequate infection control 50% antibiotics is unnecessary increases ICU stay overuse of broad spectrum delayed de-escalation Brink et al. SAMJ, 2007; Dellit et al inappropriate use of antimicrobial therapy

32 Sample patients from 40 ICUs (both the private and public healthcare sectors) Findings within the private patient group were:- 1) inappropriate antibiotics were prescribed in 60.8% of patients 2) de-escalation was used in only 19.7% of patients 3) antibiotic duration was inappropriate in 81.7% of patients All these figures were higher than that for the public sector patients Paruk, Richards, Scribante et al. SAMJ, 2012

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34 THE ROLE OF THE ICU NURSE What is the PCT/WCC/Temp What is the bug What was the specimen Is it colonised or an infection Is the AB correct for the MCS Hang time Note AB days Prompt de-escalation ICU Nurse ICU Nurse ICU Nurse ICU Nurse

35 START SMART THEN FOCUS JOAN ROUT

36 OVERUSE OF ANTIBIOTICS The South African Antibiotic Stewardship Programme (SAASP) promotes the monitoring of antibiotic use by hospital pharmacists, microbiologists, doctors and nurses Mendelson, Whitelaw, Nicol et al JOAN ROUT

37 What s missing? necessary to consider the influence that Other healthcare professionals have on prescribers Nurses can be influential at point of care consider whether more should be invested in the training and education of nurses to bring promotion of prudent antibiotic prescribing into the compass of their profession

38 INFLUENCING PRESCRIBER BEHAVIOUR the nurse is underused in providing a foundation for antimicrobial stewardship nurses possess a vast amount of clinical and microbiological information about the patients in their care and the trends of antimicrobial usage the nurse has the potential to influence decision-making. Charani, Castro-Sánchez and Holmes. Infectious Disease Clinics North America, 2014

39 INFLUENCING PRESCRIBER BEHAVIOUR 1. cultures not done before commencement of empirical antibiotics 2. > 7 days of antibiotic treatment 3. > 14 days of antibiotic treatment 4. > 4 antibiotics at the same time 5. concurrent double or redundant antibiotic coverage ALERTS Antimicrobial stewardship across 47 South African hospitals: an implementation study. Brink, Messina, Feldman et al. June,

40 INFLUENCING PRESCRIBER BEHAVIOUR 1. cultures not done before commencement of empirical antibiotics 2. > 7 days of antibiotic treatment 3. > 14 days of antibiotic treatment 4. > 4 antibiotics at the same time 5. concurrent double or redundant antibiotic coverage ALERTS Antimicrobial stewardship across 47 South African hospitals: an implementation study. June, Brink, Messina, Feldman et al.

41 This is a time of considerable uncertainty for nurses rapid change from a purely clinical role to encompass other responsibilities such as administrative, quality initiatives, teaching, research and collaborative roles. Srivastava et al. 2008; Kleinpell, 2005

42 The caricature of the subservient whitecapped nurse passively taking orders is flawed and misleading. Taking orders often involves discussion, interpretation, clarification and sometimes correction: all areas of potential influence Jutel and Menkes, 2010

43 invasive devices So for communica+on they are important, for source control they are important, for making sure the actual an+bio+c is given they are important... Because, let's be honest, they do the actual work. (Non-nursing par.cipant) Rout, 2016 debilitated state of the patient inappropriate use of antimicrobial therapy lack of adequate infection control

44 WORKING TOGETHER TO FIGHT RESISTANCE it is our responsibility as medical staff, who are around now...to ensure that we are not handing over something that is totally uncontrollable to future genera;ons of medical staff. That we are solving problems not crea;ng one (Nursing Par.cipant) Rout, 2016.

45 THANK YOU

46 REFERENCES Bodole, F Nurses perceptions of nurse/physician collaboration in the intensive care units of a public sector hospital in Johannesburg. Submitted as a dissertation for Masters in Nursing Science. University of the Witwatersrand, South Africa. accessed August, %E2%80%99+perceptions+of+nurse%2Fphysician+collaboration+in +the+intensive+care+units+of+a+public+sector+hospital+in +Johannesburg Brink, A., Moolman, J., Cruz da Silva, M. and Botha, M Antimicrobial sensitivity profile of selected bacteraemic pathogens from private institutions in South Africa. South African Medical Journal, 97 (4):

47 REFERENCES Brink, A., Messina, A., Feldman, C., Richards, G., Becker, P., Goff, D., Bauer, K., Nathwani, D. and van den Bergh. June, Antimicrobial stewardship across 47 South African hospitals: an implementation study. Charani, E., Cooke, J. and Alison, A Antibiotic stewardship programmes- what s missing? Journal of Antimicrobial Chemotherapy, 65: Charani, E., Castro-Sánchez, E. and Holmes, A The role of behaviour change in antimicrobial stewardship. Infectious Disease Clinics North America, 28: Creswell, J Qualitative inquiry and research design. Choosing amid five traditions. United States of America: Sage publications. Decker, B. and Masur, H Bad bugs, no drugs: Are we part of the problem, or leaders in developing solutions? Critical Care Medicine, 43 (6):

48 REFERENCES Dellit, T., Owens, R., McGowan, J., Gerding, D., Weinstein, R., Burke, J., Huskins, C., Paterson, D., Fishman, N., Carpenter, C., Brennan, J., Billeter, M. and Hooton, T 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, 44: Edwards, R., Loveday, H., Drumright, L. and Holmes, A Should nurses be more involved in antimicrobial management? Journal of Infection Prevention, 12 (4): 4-5. Erlingsson, C and Brysiewicz, P Orientation among multiple truths: An introduction to qualitative research. African Journal of Emergency Medicine, 1-8. Fry, C Antimicrobial resistance, responsible prescribing - a call to action for nurses. Journal of Infection Prevention, 13 (6): 182. Fulbrook, P., Albarran, J., Baktoft, B. and Sidebottom, B A survey of European intensive care nurses knowledge levels. International Journal of Nursing Studies, 49:

49 REFERENCES Jutel, A. and Menkes, D Nurses reported influence on the prescription and use of medication. International Nursing Review, 57: Kaki, R., Elligsen, M., Walker, S., Simor, A., Palmay, L. and Daneman, N Impact of antimicrobial stewardship in critical care: a systematic review. Journal of Antimicrobial Chemotherapy, 66: Kleinpell, R Acute care nurse practitioner practice: Results of a 5-year longitudinal study. American Journal of Critical Care Kleinpell, R Acute care nurse practitioner practice: Results of a 5-year longitudinal study. American Journal of Critical Care, 14: Rice, L Controlling antibiotic resistance in the ICU: Different bacteria, different strategies. Cleveland Clinic Journal of Medicine, 70 (9): Srivastava, N., Tucker, J., Draper, E and Milner, M A literature review of principles, policies and practice in extended nursing roles relating to UK intensive care settings. Journal of Clinical Nursing, 17:

50 REFERENCES Moleki, M Critical care nursing students experience of clinical accompaniment in open distance learning (ODL): A phenomenological perspective. Submitted as a dissertation for PHD in Nursing Science, University of South Africa. Ohl, C. and Luther, V Health care provider education as a tool to enhance antibiotic stewardship practices. Infectious Diseases Clinics of North America, 28: World Health Organisation Antimicrobial resistance. Global Report on surveillance.