Antimicrobial Stewardship Procedure.docx



Canberra Hospital and Health ServicesClinical ProcedureAntimicrobial StewardshipContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc508194413 \h 1Purpose PAGEREF _Toc508194414 \h 2Scope PAGEREF _Toc508194415 \h 2Section 1 – Roles and Responsibilities PAGEREF _Toc508194416 \h 2Directors of Infectious Diseases/Pharmacy PAGEREF _Toc508194417 \h 2Executive Staff, Directors, and Senior Prescribers PAGEREF _Toc508194418 \h 2Prescribing Staff (including JMOs, registrars, advanced trainees, senior and other prescribers) PAGEREF _Toc508194419 \h 2Ward Pharmacist PAGEREF _Toc508194420 \h 3Dispensary Pharmacist PAGEREF _Toc508194421 \h 3Nursing Staff PAGEREF _Toc508194422 \h 3AMS Team PAGEREF _Toc508194423 \h 3Infectious Diseases Service PAGEREF _Toc508194424 \h 4Pharmacists and the AMS team are authorised to: PAGEREF _Toc508194425 \h 4Section 2 – Antimicrobial Prescribing PAGEREF _Toc508194426 \h 4Section 3 – Canberra Hospital AntiMicrobial Protocols on the Mobile Device PAGEREF _Toc508194427 \h 53.1 Purpose and Scope PAGEREF _Toc508194428 \h 53.2 Roles and Responsibilities PAGEREF _Toc508194429 \h 6Section 4 – Inpatient Management of Restricted Antimicrobials PAGEREF _Toc508194430 \h 64.1 Antimicrobial Categories PAGEREF _Toc508194431 \h 64.2 Highly Restricted Antimicrobials PAGEREF _Toc508194432 \h 74.3 RED and ORANGE Antimicrobials PAGEREF _Toc508194433 \h 7Implementation PAGEREF _Toc508194434 \h 8Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc508194435 \h 9References PAGEREF _Toc508194436 \h 9Search Terms PAGEREF _Toc508194437 \h 9PurposeThe Antimicrobial Stewardship (AMS) procedures provide systematic approaches for monitoring and improving the use of antimicrobials in Canberra Hospital and Health Services (CHHS).Compliance with this procedure is mandated by the directive of the National Safety and Quality Health Service Standards (2011), Standard 3 the Preventing and Controlling of Healthcare Associated Infections Standard. ScopeThis procedure applies to the following professionals at CHHS:Medical OfficersNursing StaffPharmacy StaffAllied HealthSection 1 – Roles and ResponsibilitiesDirectors of Infectious Diseases/Pharmacy Ensure that their staff provide timely clinical oversight of restricted antimicrobials as defined in this procedure Ensure that clinical and operational procedures within the department support this procedureFacilitate implementation of a sustainable and effective AMS Program Executive Staff, Directors, and Senior PrescribersTake steps to ensure that prescribing within their division, department and clinical workgroup aligns with this procedure Collaborate with the AMS team to ensure the optimal use of antimicrobials at CHHSPrescribing Staff (including JMOs, registrars, advanced trainees, senior and other prescribers)Attend AMS training and education, ensuring that they are familiar with how to access Therapeutic Guidelines and other local Procedures and Guidelines relating to antimicrobial useEnsure that they have a personal ACT Health Active Directory login and that they use this when using electronic AMS systemsTo engage with pharmacists, Infectious Diseases Service and the AMS team to clarify the rationale for the use of antimicrobials if requiredTo alert the AMS team if there is disagreement between the prescribing team and recommendations provided by AMS or Infectious DiseasesWard PharmacistProvide clinical review and feedback for antimicrobial prescriptions with priority applied to review of restricted antimicrobial prescriptionsEngage prescribers to be compliant with restricted antimicrobial procedure and refer non-compliant cases to the AMS team if unsuccessfulDispensary Pharmacist Collaborate with ward pharmacist to promote compliance with restricted antimicrobial procedure including contacting the prescriber if necessaryEscalate non-compliance to the Dispensary Manager and AMS team if requiredNursing StaffEnsure that any requests for non-urgent supply/dispensing of restricted antimicrobials are delivered to pharmacy within business hours where feasibleRaise any concerns regarding antimicrobials for their patients, including the need to seek approval codes and/or document indications on the medication chart AMS TeamAssist with orientation and education of staffRespond to approval requests for restricted antimicrobials in a timely mannerNegotiate and manage situations of non-compliance with AMS recommendationsEngage stakeholders to improve systematic antibiotic prescribing practices including facilitation of policy or procedure development and targeted Quality Improvement Regularly evaluate and review the effectiveness of the AMS programAntibiotic usageAntibiotic prescribing auditing and benchmarkingReview Antibiogram and Healthcare Associated Infection/Multi-resistant organism acquisition data from Microbiology and Infection Prevention and ControlAny other Key Performance Indicators as requested by Standards 3 committee, AMS operational leadership (Directors/Deputy Directors of Pharmacy and Infectious Disaeses), or CHHS executive.The clinical role of the AMS team is distinct to the Infectious Diseases consult serviceThe AMS team is a proactive service identifies antibiotic prescriptions for clinical review and intervention, which may be unsolicited or in response to a request for antibiotic advice or approval from the prescribing teamIt is not within the scope of an AMS review to clinically examine the patient or provide definitive diagnostic adviceAn AMS review may involve: Review of antimicrobial prescribing for a range of infective syndromes where Infectious Diseases are not usually involvedReview of medication chart, progress notes, investigations, pathology and radiologyDiscussion with prescribing team regarding the patient’s progressDosage and Therapeutic Drug Monitoring recommendationsRecommendation of alternative therapy or cessation of therapyRecommendation of additional investigations or microbiology samplingRecommendation of an Infectious Diseases consult if diagnosis is difficult and in-depth specialist review requiredInfectious Diseases ServiceRespond to approval code requests for Highly Restricted antimicrobials at the time of prescriptionAlert the AMS team if the prescribing team disagrees with Infectious Diseases recommendations Clearly document duration or date of review for antimicrobial recommendationsRefer cases to the AMS team for review that require AMS intervention but are not suitable for an Infectious Diseases consult Assist with approvals management according to this procedurePharmacists and the AMS team are authorised to:Request the prescribing team to review antimicrobial therapy and provide the indication for useRequest justification and documentation for deviation from approved Therapeutic Guidelines or CHHS Hospital Policy and ProceduresRequest for prescriptions to be ceased or changed based on a review of appropriateness within their scope of practiceIdentify antibiotic prescribing practices that are not in line with hospital procedure to the AMS team for further actionBack to Table of ContentsSection 2 – Antimicrobial Prescribing CHHS prescribers should:Prescribe antimicrobials on reasonable clinical grounds, having taken into account previous microbiology results, allergy history & travel historyUtilise the following guidance for antibiotic prescribing, in order of preferenceCHAMP-MD mobile device application (downloadable via the ACT Health library website)For indications not listed in CHAMP-MD, in adherence to local policies, procedures and guidelines published on the Policy RegisterIf local guidelines do not exist, in adherence to the current version of Therapeutic Guidelines: Antibiotic, or On advice from Infectious Diseases Service or AMS teamPrescribe according to the Hospital Formulary except in extenuating circumstances in which an Individual Patient Use (IPU) application should be made to the Drugs and Therapeutics CommitteeDocument the indication for using an antimicrobial on the medication chart and patient notesDocument intended review or cessation date in the medical recordReview microbiology results and narrow the antimicrobial choice accordingly as soon as possibleRegularly review whether IV to oral switch or cessation is appropriateRegularly review the ongoing need for IV access and prompt removal of cannulas/long linesDiscuss antimicrobial treatment with the patient in accordance with the Australian Commission for Safety and Quality in Healthcare AMS Clinical Care StandardFollow the procedure for the Management of Restricted Antimicrobials as described belowBack to Table of ContentsSection 3 – Canberra Hospital AntiMicrobial Protocols on the Mobile Device3.1 Purpose and Scope The purpose of a Canberra Hospital AntiMicrobial Protocols on the Mobile Device app (CHAMP-MD) is to provide point of care prescribers improved access to antibiotic prescribing recommendations for common infective syndromes. Prescribing practices in specialty areas that are only applicable to limited prescribing groups will generally not be included on CHAMP-MD. Guidance for these indications will continue to reside on the Policy register and/or Therapeutic Guidelines. The guidance on CHAMP-MD will reflect local policies and procedures endorsed by the Medication Management Committee, and Therapeutic Guidelines as detailed in Section 2, with the exception of changes made in situations listed below:Changes to the antimicrobial recommendations in the CHAMP-MD protocols can be implemented by the AMS team autonomously in the following circumstances:Medication recalls and shortages Changes in local antimicrobial susceptibility patterns (reviewed annually)The AMS team can autonomously add additional antimicrobial protocols to CHAMP-MD if there is a need to improve access to these at the point of care, and if the guidance already exists either on the policy register or Therapeutic Guidelines. Initiation of a protocol that is entirely new to Canberra Hospital and Health Services requires a formal policy or procedure document to be endorsed by the Medication Management Committee before it can be added to CHAMP-MD.3.2 Roles and Responsibilities Consultation and communicationThe AMS team will be responsible for ensuring adequate consultation is conducted in these circumstances, such as but not limited to consultation with Microbiology and Infectious Diseases. Changes to the CHAMP-MD protocols require an alert to be added to CHAMP-MD to inform users of the change as well as formal notification to the Drugs and Therapeutics Committee retrospectively to ensure that there is adequate documentation for these changes. Technical MaintenanceTechnical maintenance of CHAMP-MD will be performed by the ACT Health Library department. This includes the hosting of the html file on the ACT Health Library website, implementing changes to the app, and Quality Assurance testing in response to each change request from the AMS team. Back to Table of ContentsSection 4 – Inpatient Management of Restricted AntimicrobialsA multi-disciplinary approach is required to ensure that appropriate antimicrobials are prescribed in a timely manner and that harm from inappropriate antimicrobial use is minimised. 4.1 Antimicrobial CategoriesRestriction CategoryApproval RequirementsDrugREDApproval within 24 hoursAmikacin IVAmoxicillin-clavulanate IVAnidulafungin IVAmphotericin IVAztreonam IVCefepime IVCeftazidime IVDaptomycin IVErtapenem IVFosfomycin POFlucytosine POGanciclovir IV Linezolid IV/POMeropenem IVMoxifloxacin IV/POPentamidine IVPiperacillin/Tazobactam IV (Tazocin?)Pristinamycin PORifampicin IVTeicoplanin IVTigecycline IVVoriconazole IV/POVancomycin IV/POValganciclovir POORANGERequire approval after 3 days Azithromycin IV/POCefotaxime IVCeftriaxone IVClindamycin IV/POCiprofloxacin IV/PONorfloxacin POTobramycin IVGentamicin IVGREENNilAll other antimicrobials on the Hospital FormularyShort term changes to antimicrobial restrictions may be implemented at the discretion of the AMS team in response to emergencies. Refer to the CHHS Formulary for the most up to date information. 4.2 Highly Restricted Antimicrobials These antimicrobials carry strict restrictions due to their nature of complex prescribing. The prescriber must contact the Infectious Diseases Service (not the AMS team) for an approval code prior to supply from pharmacyApproval should be sought urgently via phone rather than other means to ensure that critically ill patients are reviewed and treated promptly Documentation of any approval must occurA request for re-approval is required to be made on the day of expiry if treatment needs to continueICU is not exempt from seeking approval for these agents prior to prescription4.3 RED and ORANGE AntimicrobialsRED Antimicrobials - requires an approval request submission on the same day as initiation. An approval code is required for the supply of the antimicrobial from pharmacy to continue after day 1.ORANGE Antimicrobials – requires an approval request submission by midday on day 3 of therapy. An approval code is required for the supply of the antimicrobial from pharmacy to continue after day 3.ICU is exempt from seeking approval for RED and ORANGE antimicrobials due to the level of Infectious Diseases service in ICU. However, discussion with the Infectious Diseases service is required within 24 hours when a RED antimicrobial is prescribed. ExemptionsDrugIndicationSpecialtyGeneric codeDuration of approval from date of initiation+IV amoxicillin-clavulanic acidInfected bite woundsPlasticsBIT DDMM* 02 2 days IV piperacillin-tazobactamFebrile NeutropeniaHaematologyFN DDMM 05 5 daysIV gentamicinEarly onset SepsisNeonatologyEOS DD MM 05 5 daysLate onset sepsis LOS DD MM 055 daysNECNEC DD MM 077 daysDDMM = Day and Month of initiation date e.g. 0105 (1st of May)+Continuation after once the pre-approved duration has elapsed requires referral to AMS for ongoing review and approvalRequesting ApprovalsApproval requests are to be lodged online through the intranet via the AMS Approvals Request pageThe AMS Approvals Request page can be accessed via myappsAntimicrobial StewardshipApproval Requests Approvals can only be sought by a Medical Officer Requests for extension of approval are to be made as soon as possible, ideally 24 hours before they are due, to ensure sufficient time for AMS to action the requestApproval request information may include such as the patient’s identity/URN, prescribing team, previous antibiotic allergies, clinical history, indication for treatment, and investigations The approval code is to be documented on the medication chart along with date of approval expiry If use of restricted antimicrobial is required after approval expiry, change the status of the request item to ‘Extension requested’ or contact the AMS team on ext. 43378.WeekendsRED antimicrobials – contact Infectious Diseases physician on call during business hoursORANGE antimicrobials – submit an online approval request as above to be reviewed next business daySupply from pharmacyOn weekdays, pharmacy will supply restricted antimicrobials up til midday on the day that approval is due. On weekends, RED antimicrobials will be supplied the same way. ORANGE antimicrobials supply will last until midday Monday. Pharmacy dispensing outside of these restrictions will be monitored. General QueriesFor general advice or queries about the above procedure, the AMS team may be contacted via ext. 43378 for more informationBack to Table of ContentsImplementation Education regarding the AMS procedure will be dedicated to CHHS professionals who fall under the scope of the procedure.Targeted educational for these CHHS professionals will be performed at the following educational events to ensure new staff are aware of current AMS procedure.Clinical Development Nurses Education UpdatesPharmacy Unit HP1/HP2 MeetingPharmacy Clinical Lead MeetingIntern and medical officer orientationResident Medical Officer Education meetingsIncorporation into orientation documentation for new senior medical officersAnnual promotion at Unit MeetingsThe annual Antibiotic Awareness WeekChanges in the phase of procedure that may occur outside of these educational opportunities will be notified to staff via:Notification via the Executive Directors’ of the DivisionsMedical and Nursing Midwifery ExecutiveClinical Development Nurses Education UpdatesPharmacy Unit HP1/HP2 MeetingPharmacy Clinical Lead MeetingResident Medical Officer Education meetingsPromotion at Unit MeetingsDistribution via the Medical and Dental Professional Standards UnitDistribution via the Medical Officer Support Credentialing Education and Training UnitBack to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationProceduresMedication Handling PolicyHealthcare Associated Infection Standard Operating ProcedureBack to Table of ContentsReferencesDuguid M and Cruickshank M. Antimicrobial Stewardship in Australian Hospitals 2011. Australian Commission on Safety and Quality in Healthcare.Back to Table of ContentsSearch Terms Antimicrobial stewardship, AMS, Antibiotic, Restricted, Antimicrobial, Approval, Sharepoint Infectious, Diseases, PrescribingBack to Table of ContentsDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 21 February 2018Complete ReviewLisa Gilmore, A/g ED CSSCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS16/022Antimicrobial Stewardship Procedure ................
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