Antimicrobial Stewardship for Nurses Dr Noleen Bennett 1. acnaps Project Officer, National Centre for Antimicrobial Stewardship 2. Infection Control Consultant, Victorian Nosocomial Infection Surveillance System Coordinating Centre
Acknowledgments Ms Fiona Gotterson Senior Project Officer, Australian Commission on Safety and Quality in Health Care Assoc/Prof Caroline Marshall Head, Infection Prevention and Surveillance Service, Melbourne Health Infectious Diseases Physician, Victorian Infectious Diseases Service Principal Research Fellow, University of Melbourne
Email From: Director of Nursing Sent: Wednesday, 29 Oct 2014 3:32 PM To: Noleen Bennett Subject: Question Hi Noleen, I have just noticed the proposed UTI clinical pathway detailed in the regional newsletter. At a quick glance, the pathway looks way over the top for our purposes. It might be ok to guide medical staff but nurses do not need to know about antimicrobial use. Can you please advise where exactly this is going and what issues it is based on? DON
Response email From: Sent: NOT sent (20 th Nov 2016) To: DON Subject: Response Hi DON, Nurses DO have a role in implementing successful AMS programs.. From the 2016 ACIPC AMS for Nurses Workshop participants
Aims To highlight why it is important clinical nurses are actively involved in AMS programs. To describe the activities that clinical nurses can undertake as part of an AMS program. To outline the support systems required to successfully enable clinical nurses to be involved in AMS programs. To describe some specific nurses roles. To outline some potential research studies.
Methodology PubMed search Nurse/ Nurse Practitioner/ ICP Antibiotic/antimicrobial Resistance/Stewardship Nursing Australian College of Nursing (ACN) UK Royal College of Nursing (RCN) Australasian College for Infection Prevention & Control (ACIPC) Australian Commission Quality & Safety in Healthcare (ACQSHC) Centers for Disease Control and Prevention
To highlight why it is important clinical nurses are actively involved in AMS programs
Reasons LARGE part of the health care workforce. Are the most constant presence for patients/residents. Are patient/resident advocates. Are involved in all aspects of patient/resident care. Education Medication management Work & communicate with most other key healthcare worker groups. Work within multiple levels at the local clinical setting. Work at a local, national & international level.
AMR Strategy Goal: Minimise the development and spread of AMR and ensure the continued availability of effective antimicrobials
ACN Comment on Draft AMR Strategy Nurses are integral to much of the health care delivered in Australia & thus have a key role to play in safeguarding antibiotic s effectiveness for future generations. Nurses are involved in most aspects of the prevention & control of AMR, including through patient education, infection prevention & control, monitoring of antibiotic use, prescribing & the development of organisational policies. Engagement with nurses is an important factor in addressing the emerging threat of AMR.
UK RCN Position Statement Nurses have a significant role to play in limiting the threat posed by AMR through their leadership skills supporting infection prevention and control, antimicrobial stewardship & public health. It is essential that nurses are recognised as influential members of the multidisciplinary team in combating AMR & assuring stewardship.
To describe some activities that clinical nurses can undertake as part of an AMS programs
Activities Patient Management Plans Infection Control and Prevention Medication (antimicrobial) management Collaboration Education Surveillance
Patient management plans Assess patients risk of both acquiring & transmitting an infection. Complete nursing care plans or notes that accurately reflect infection. Facilitate efficient discharge planning. Assess patients suitability for Hospital in the Home programs.
Infection prevention & control Implement standard & traditional precautions. Correctly collect microbiological specimens if clinical need is clearly indicated. Ensure timely transfer of microbiological specimens to laboratories to maintain specimen quality. Review & recognise when treatment is not in line with microbiological result.
Medication management Question suboptimal antimicrobial management & documentation. Recognise when patients are able to tolerate oral intake & could change from IV to oral antimicrobials. Ensure timely administration of antimicrobials & follow up on missed doses. As applicable, administer antimicrobials at the right rate. Undertake timely therapeutic drug monitoring to ensure antimicrobials that perform optimally within a specific therapeutic level are in line with recommended guidance. Monitor the patient to ensure antimicrobial has the intended effect. Recognise antimicrobial allergies & side effects. Support the use of standardised medication charts that document for each prescribed antimicrobial its generic name, dose, time, route, reason for administration, review & stop date. Accurately & clearly document the administration of any antimicrobials. Correctly dispose of unused antimicrobials
Medication management FIVE rights 1. Right patient 2. Right drug 3. Right route 4. Right time 5. Right dose NINE rights Five rights plus 7. Right documentation 8. Right action 8. Right form 9. Right response Ref: Elliott M & Liu Y. 2010
Collaboration Participate in (AMS) ward rounds. Participate in the development of guidelines & policies that detail the use of medications. Suggest antimicrobial choices to medical staff in line with guideline recommendations. Liaise between (offsite) doctors, microbiologists, pharmacists, patients/residents and families.
Education Provide patient (consumer) education about antimicrobials, especially prior to discharge. Educate (new) colleagues about the appropriate use of antimicrobials, especially in relation to a specialist area. Encourage patients & other colleagues to question suboptimal antimicrobial management & documentation.
Consumer education About actions consumers can take to help tackle AMR & how to correctly use antimicrobials. Includes explaining: Differences between bacteria and viruses & why viruses do not respond to antibiotics What AMR is What antimicrobial allergies mean Why the antimicrobial is needed How & when antimicrobials should be taken How long antimicrobials should be taken for Not to share antimicrobials with others Not take antibiotics left over from a previous illness.
Surveillance Audit medical records and collect data. Analyse data and present in easy to understand formats. Feedback analysed data to the team Instigate as necessary (and review) new interventions.
Surveillance To register: naps.org.au
Surveillance: Example UK point incidence study Aim: To investigate delayed & omitted antimicrobials Measurement No (%) Participating organisations 45 Patient records audited 17,470 Patients prescribed antimicrobials (% total patient records) 5899 (33.7%) Doses prescribed 21,390 Doses omitted (% doses prescribed) 1120 (5.2%) Patients missing one or more doses (% prescribed antimicrobials) 781 (13.2%) Ref: Wright J. 2013
Surveillance: Example REASONS RECORDED FOR OMITTED DOSES 12% 12% 3% 29% Left Blank Other reason Drug not available 19% 25% Patient refused Route not available Patient away from ward Ref: Wright J. 2013
To outline the support systems required to enable nurses to be successfully involved in AMS programs
Leadership commitment Formal statements that the facility supports efforts to improve antimicrobial use are developed. Participation in AMS programs is expected from key groups. Stewardship-related duties are detailed in job descriptions & annual performance reviews Staff are given sufficient time to participate in AMS activities. Ref: CDC 2014
Nurses knowledge Australian private hospital Percentage Heard of AMS Willingness to participate in AMS Anaesthetists 36 51 Pharmacists 80 100 Physicians 64 55 Surgeons 37 48 Nurses (n=105) 22 43 The Scottish Antimicrobial Prescribing Group identified 21.5% of nurses had heard of AMS. Refs: Cotta M.O, Robertson M.S, Tacey M, Marshall C, Thursky K.A, Liew D and Buising K.L. 2014. McGregor W, Brailey A, Bayne G, Sneddon J and McEwen J. 2015
Education Under & post graduate Content Antimicrobial resistance Antimicrobial stewardship Infectious diseases Microbiology Specimen collection Pharmacology Principles of surveillance
National medication charts National Inpatient Medication Charts Acute (public and private) Long stay (public and private GP e-version National Residential Medication chart
NRMC
To describe the ICP (nurse) role
ACIPC Position Statement AMR is a serious & significant problem. Reducing AMR by prudent & rational antibiotic use is the responsibility of all healthcare workers. ICPs & nursing staff should play a role in AMS programs as part of their role in preventing & containing HAIs & antimicrobial resistant organisms.
Infection Control Practitioner Dependent on facility size, type & location. Undertake a feasibility study Identify current perceptions in relation to AMS & nurses role. Assess how the nurses role can be strengthened. Identify other key groups who can support AMS. Work with other key groups To enable appropriate support systems are in place. Influence governance frameworks
Infection Control Practitioner Organise educational strategies. Co-ordinate surveillance programs. Advise on IT systems to support surveillance, education & medication management.
Education Question (79 nurses) Pre% Post% p value Unable to state what ABs patient is on 7 15.07 Able to state the duration the patient will be on ABs 50 60.11 Would consider if the AB was required before administering 14 43.001 Understands what the switch to oral program is about 24 94 <.001 Would question an AB order if thought it was inappropriate 92 97.11 Have previously questioned an AB order 71 91 <.001 Use of ABs can aid the development of resistance 59 79.003 Ref: Gillespie E et al. 2013
ICP: Leadership Pilot study to assess ICP AMS leadership role Three stages (pre, intra & post intervention) ICP responsibilities included Intermediary b/w GP & an off-site ID physician Education of GPs & nurses Surveillance Monitoring of pathology reports Result Significant decrease in total days of antimicrobials prescribed (p<0.0001) Ref: Stuart RL. et al 2014
To outline some potential research studies
Research Australian nurses knowledge of AMR & AMS. Experience of Australian clinical nurses/ ICPs/ nurse practitioners in AMS. Successful nurse led models of AMS. Perceptions of other key groups regarding nurse s role in AMS.
Summary
Response email From: Sent: NOT sent To: DON Subject: Response Hi DON, Nurses DO have a role in implementing successful AMS programs.. Why clinical nurses should be involved Activities that clinical nurses can undertake Support systems required ICP s role From the 2016 ACIPC AMS for Nurses Workshop participants
ACSQHC AMS Publication The AMS team (page 9) Multidisciplinary teams are better suited to implement the kind of improvement and change required for effective AMS. There are a range of professions and individuals that have an interest in and responsibility for AMS, each with different perspectives and skills. Involving prescribers, pharmacists, administrators, infection control experts, information systems experts, microbiologists and ID physicians into a well-managed team effectively incorporates their views and expertise.
ACSQHC AMS Publication Chapter on the Role of Nurses 2017
Contact details Noleen Bennett Email: support@naps.org.au Ph: (03) 9342 9415
References Atik A, Adherence to the Australian National Inpatient Medication Chart: The efficacy of a uniform national drug chart on improving prescription error. Journal of Evaluation in Clinical Practice 2012 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html Cotta M.O, Robertson M.S, Tacey M, Marshall C, Thursky K.A, Liew D and Buising K.L. 2014. Attitudes towards antimicrobial stewardship; results from a large private hospital in Australia. Healthcare Infection 19(3) Edwards SR, Drumright LN, Kiernan M and Holmes A. 2011 Covering to fight resistance; Consideration nurses role in antimicrobial stewardship. J Infect Prev Jan 12 (1) 6-10. Elliott M and Liu Y. The nine rights of medication administration; an overview. 2010 British Journal of Nursing Vol 19 No. 5 Gillespie E, Rodrigues A, Wright L, Williams N & Stuart R.L. 2013 Improving antibiotic stewardship by involving nurses. AJIC. 41:365-7. Royal College of Nursing Antimicrobial resistance. RCN position on the nursing contribution. Stuart R.L, Orr E et al. 2014 A nurse led antimicrobial stewardship intervention in two residential aged care facilities. Healthcare Infection Ladenheim D, Rosembert D, Hallam C & Micallef C. 2013. Antimicrobial stewardship; the role of the nurse. Nursing Standard 28 (6):46-49 Wright J. Audit of missed or delayed antimicrobial drugs. Nursing times Vol 109 no 42.
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