antimicrobial stewardship policy - newcastle hospitals · 6 antimicrobial stewardship policy this...

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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Antimicrobial Stewardship Policy

Version No.: 1.1

Effective From: 29 November 2016

Expiry Date: 13 January 2019

Date Ratified: 16 December 2015

Ratified By: Medicines Management Committee

1 Introduction

Antimicrobial drugs treat bacterial, viral, fungal and parasitic infections. Approximately 20% of these agents are prescribed in hospitals. Unnecessary prescribing is estimated to be between 20-50%. This makes antimicrobial resistance a significant problem, adds to the potential for adverse reactions and increases the likelihood of modifying normal flora within patients culminating in colonisation and infection by resistant organisms e.g. meticillin resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing organisms (ESBL), glycopeptide-resistant Enterococci (GRE), multi-resistant Pseudomonas aeruginosa, carbapenemase-producing Enterobacteriaceae (CPE) and Acinetobacter baumanii and Clostridioides difficile infection (CDI). Healthcare-associated infections (HCAIs) caused by these organisms result in increased in-patient morbidity and mortality with the risk of spread to previously unaffected individuals. Prudent prescribing and antimicrobial stewardship (Health and Social Care Act 2008) is essential for minimising risks to hospital in-patients and the wider community. 2 Scope

This policy applies to all NUTH employees (primary and secondary care facilities) who prescribe, administer or monitor antimicrobial prescriptions. It deals with the processes by which recommendations for specific antimicrobial treatments are made and the procedures to support these recommendations. It does not provide advice on which antimicrobials should be used in specific infections as this is covered in the Antimicrobial Therapy Guidelines and individual (directorate-specific) management guidelines. Similarly it does not provide information on which antimicrobials have the highest associated HCAI risk nor advise on which antimicrobials can only be used following advice from a microbiologist or infectious diseases physician. 3 Aims

The aim of this policy is to provide a framework for appropriate antimicrobial usage, optimising treatment and minimising the risk of HAIs allowing NUTH to comply with the Health and Social Care Act 2008, a requirement for registration with the Care Quality

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Commission (CQC.) It will be overseen by the Antimicrobial Steering Group (AMSG) and the Infection Prevention and Control Committee (IPCC). 4 Duties (Roles and responsibilities)

4.1 The Executive Team is accountable to the Trust Board for ensuring Trust-wide

compliance with policy. 4.2 Directorate managers and heads of service are responsible to the Executive

Team for ensuring policy implementation. 4.3 Managers are responsible for ensuring policy implementation and promoting

awareness of this policy amongst their employees. 4.4 The AMSG is responsible for maintaining the policy and monitoring compliance

on behalf of the Medicines Management Committee (MMC) and IPCC. It is also responsible for the cascading of information on prescribing activity and standards to all relevant staff. Further information is contained within the Terms of Reference (Appendix 1).

5 Definitions

Prudent antimicrobial prescribing – using antimicrobials in the most

appropriate way to achieve optimum clinical outcomes whilst limiting selection of resistant strains and unnecessary costs. The choice of agent, route, dose, frequency and duration of administration should follow best practice guidance.

Antimicrobial Stewardship –coordinated interventions to improve and measure

antimicrobial use of by promoting optimal drug regimen, dose, duration and route of administration; a key component of multi-faceted resistance prevention.

Defined Daily Dose – World Health Authority (WHO) average daily dose for

adult patients (a denominator for expressing consumption).

Antimicrobial Steering Group (AMSG): sub group of the Trust’s Medicines

Management Committee. Specific remit: promoting and monitoring prudent antimicrobial prescribing.

Medicines Management Committee (MMC): reports to Trust’s Clinical

Governance and Quality Committee. Specific remit: ensure medicines are managed safely, effectively and economically through good practice, risk assessment and other control mechanisms.

Director of Infection Prevention and Control (DIPC): responsible for leading

the IPC agenda and advising the Trust Board on all IPC issues.

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Infection Prevention and Control Committee (IPCC): sub-committee of the

CGQC, chaired by the DIPC and overseeing all NUTH IPC issues.

Infection Prevention and Control Team (IPCT): - DIPC, Matron and Practice

Development Lead for IPC, Infection Prevention and Control Nurses, Medical Microbiologists, Antimicrobial Pharmacist, IPC Data Manager and Infection Control Healthcare Scientist.

Antimicrobial Lead: named consultant within a directorates’/specialties’ clinical

governance structure acting as a link to the AMSG

6 Antimicrobial Stewardship Policy

This policy is a framework to ensure appropriate usage of antimicrobial agents within the Newcastle upon Tyne Hospitals. It will be overseen by the AMSG. 6.1 Polices and guidelines

The following core policies, guidelines and principles underpin antimicrobial stewardship:

Antibiotic Stop / Review Date and Indication Policy

Clostridium difficile Policy

Medicines Policy

Access to Medicines Policy

Procedures for the prescribing, recording and administration

Severe Sepsis Screening tool (bundle)

Guide to Antimicrobial therapy

Start Smart then Focus (DoH)

6.2 Governance processes

The Trust Guide to Antimicrobial Therapy is reviewed regularly under the auspices of the AMSG and approved by the MMC.

Other relevant antimicrobial related guidelines must be approved by the AMSG and/or the IPCC.

Directorate/speciality specific guidelines that contain recommendations for antimicrobials must be approved by the AMSG and/or the microbiologist responsible for that directorate/speciality.

All antimicrobials must be prescribed in accordance with The North of Tyne Area Prescribing Committee Formulary. The use of all non-formulary antimicrobials should approved by the chair of the MMC or nominated deputy, as described in the Access to Medicines Policy.

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All antibiotic specific Patient Group Directions (PGDs) will be assessed for appropriateness by the AMSG prior to approval by the MMC.

6.3 Specific responsibilities

6.3.1 Responsibilities of prescribers

Individual prescribers are responsible for any prescription they sign.

Prescribers must follow the Start Smart then Focus principles.

When prescribing urgent stat doses (e.g. severe sepsis) they must inform the patient’s nurse that the dose is required.

If the prescriber is uncertain as to what to prescribe and there are no specific Trust-wide or departmental guidelines they must seek the advice of a senior colleague, microbiologist or infectious disease physician. Advice can also be obtained from the ward and antimicrobial pharmacist when appropriate.

If a patient develops C. difficile infection (CDI), it is the responsibility of the consultant in charge of the patient to ensure a review of recent antimicrobial treatments (last 3 months) and ensure that this is recorded in the Root Cause Analysis (RCA.) This can be done by a specialty trainee under supervision. The consultant should also include a summary of this evaluation in the Root Cause Analysis, which may be discussed at the subsequent Serious Infection Review Meeting (SIRM). The consultant may be required to present the case at the SIRM.

6.3.2 Responsibilities of nursing staff

Patients must not miss doses of antimicrobials. The nurse should ensure that the patient/carer understands the importance of not missing doses of antimicrobials. Patient’s communication needs and ability to understand information needs to be taken into account in any explanation.

In situations where a dose of an antimicrobial is not administered and the matter cannot be resolved immediately the nurse must inform the patient’s medical team. For urgently required antimicrobials please call the inpatient dispensary or for out of hours refer to the following guidance: http://nuth-vintranet1/cms/ClinicalDirectorates/Pharmacy/OutOfHours.aspx.

Nursing staff administering antimicrobials must check if the drug chart contains patients’ allergy histories, indication for the antibiotic and stop/review date.

Incomplete documentation (e.g. missing indication or stop/review date) must be highlighted with patients’ medical teams as soon practically possible.

If past the review date without a documented decision to continue, inform the medical team and document this information in the medical notes.

If no documented review date, request a prompt medical review and administer as prescribed until the review is completed

http://nuth-vintranet1/cms/ClinicalDirectorates/Pharmacy/OutOfHours.aspx

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6.3.3 Responsibilities of the Medical Microbiologists/Virologists and Infectious Disease Physicians/Paediatricians

Policy implementation by the AMSG is assisted by Medical Microbiologists/Virologists and Infectious Diseases physicians/paediatricians who will produce Antimicrobial Prescribing Guidance, support Antimicrobial Champions with monitoring of prescribing practice and ensure timely provision of advice on appropriate antimicrobials.

The Microbiology/Virology Department is responsible for the provision of timely and accurate reports to aid prescribers’ decision processes.

6.3.4 Responsibilities of the ward pharmacy teams

Perform regular medication reviews as deemed appropriate by the clinical pharmacist

Highlight any concerns to the base medical team about antimicrobial prescriptions (choice, dose, frequency, route, allergy, contraindication) with reference to either the Trust’s Guide to Antimicrobial Therapy or directorate/specialty guidelines. This includes incomplete documentation (e.g. missing indication or a stop/review date) should be raised with the patient’s medical team.

6.3.5 Responsibilities of the Directorates

Ensure that an Antimicrobial Lead is in post. Where none, responsibilities fall to the Clinical Governance Lead.

Ensure antimicrobial prescribing is a standing item in directorate clinical governance/quality meetings or equivalent.

Ensure evidence of antimicrobial stewardship within the directorate is included in the Directorate Healthcare Associated Infection Action Plan.

Ensure that guidelines relating to antimicrobial prescribing recommendations are approved by the AMSG and/or the microbiologist responsible for that directorate/speciality.

6.3.6 Responsibilities of the Directorate Antimicrobial Leads

To champion appropriate antimicrobial prescribing by example.

To ensure completion and return of monthly clinical audit of antimicrobial prescribing (‘Take five’) against guidelines by junior staff using the audit tool, report the results back to the AMSG (see section 6.2.4 and Appendices 3-5).

To disseminate results of monthly audits and annual point prevalence audit to prescribers within department/directorate.

To help or delegate the development of specific departmental clinical guidelines where indicated and to ensure they are followed.

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Ensure root cause analyses are performed within the department, disseminating feedback and lessons learnt.

Liaise with the infection control team during investigations of outbreaks and periods of increased incidence (PIIs).

Attend biannual Antimicrobial Leads’ Forum or ensure a deputy attends.

To be full members of the Antimicrobial Steering Group; to attend meetings where necessary, and to act as representatives for the departments/directorates to this group, feeding back relevant information.

6.3.7 Responsibilities of the Antimicrobial Pharmacist (Secretary of AMSG)

Works with the AMSG Chair and DIPC to promote antibiotic stewardship.

Co-ordination of audit and subsequent dissemination of the results.

Monitors antibiotic consumption producing quarterly benchmarked reports (see section 6.4)

Direct liaison with Pharmacy Clinical Informatics ensuring e-prescribing supports optimal antimicrobial prescribing of agents.

Advises AMSG on utility and role of new antimicrobial drugs.

6.3.8 Responsibilities of the IPCC/IPCT

Determine current and future strategies for antimicrobial stewardship with the AMSG

Provide the AMSG with relevant surveillance data on HCAIs

Assist the AMSG in implementing targeted plans to influence antimicrobial prescribing in specific clinical areas.

6.4 Monitoring and evaluating antimicrobial prescribing 6.4.1 Annual Point Prevalence Audit of Antimicrobial Prescribing

Trust wide, led by the AMSG and based on the DoH ‘Start smart, then focus’ strategy. The audit team comprises a microbiologist or infectious diseases physician/paediatrician and a pharmacist, and may include a representative of the Directorate Antimicrobial Lead.

The report (undertaken by the Antimicrobial Pharmacist) is fed back to AMSG and directorates and forms part of the DIPC’s annual report to the Trust Board.

Additionally a programme for undertaking antimicrobial audits within the Trust’s community services is in development.

6.4.2 Antibiotic Stop / Review Date and Indication Policy

The Antimicrobial Pharmacist undertakes an annual audit (reviewed by the AMSG) of the Antibiotic Stop /Review Date and Indication Policy.

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6.4.3 Trust antimicrobial consumption data

Pharmacy reports are produced monthly for all antimicrobial agents. This is converted into defined daily doses (DDDs) and expressed as DDDs/1000 bed days. Total usage of DDDs is also compared against finished consultant episodes (FCEs) annually.

Data are used to pinpoint unusual patterns of prescribing triggering in-depth audits. Trends are monitored and acted upon accordingly.

6.4.4 Monthly Audits (‘Take Five’)

In addition to the point prevalence audit Directorate/Specialty Antimicrobial Leads should lead an independent antimicrobial audit using the audit tool ‘Take Five’ (appendices 3-5).

These audits should be discussed at directorate level and the results fed back to AMSG.

Return rate data (and compliance against audit standards) from directorates will be fed back monthly to the Clinical Policy Group (CPG) and quarterly to the Trust Board.

6.5 Surveillance data

The IPCT will provide the AMSG with relevant surveillance data on HCAIs including susceptibility data.

6.6 Benchmarking

Trust consumption will be formally benchmarked with other acute Trusts through participation in the English Surveillance Programme for Antimicrobial Utilization and Resistance (ESPAUR) project.

The Define system (Rx-info) is used when assessing Trust consumption data. 6.7 Providing regular feedback to prescribers including patient safety incidents

Serious Infection Review Meetings: key messages and lessons learnt are fed back to dierctorates (immediately following a meeting), quarterly to other directorates and annually to the Trust Board

Patient Safety Briefings

The Antimicrobial Leads are members of AMSG.

Biannual Antimicrobial Leads’ Forum

Relevant Datix reports: referred to the antimicrobial pharmacist for review.

IPCT assists the AMSG in implementing targeted plans to influence antimicrobial prescribing in specific clinical areas.

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6.8 Electronic prescribing

All adult inpatient prescriptions are prescribed electronically.

Stop dates for antimicrobials are mandatory, with the prescriber getting an alert when this has passed.

Default review dates for IVs at 72hr (to cover for weekends).

Decision support though the use of order sentences and pop up alerts.

A rolling programme of targeted, pro-active, antimicrobial reviews to be planned where microbiologist/ID physician/pharmacist team review the prescribing of a specific antimicrobial, in a given area. The electronic prescribing system will alert this team of new prescriptions allowing to be reviewed quickly.

7 Education of staff on appropriate prescribing

This is the most important method of ensuring appropriate antimicrobial prescribing is in accordance with Antimicrobial Therapy Guidelines or directorate protocols.

The AMSG will ensure that all relevant clinical staff receive appropriate education on the prescribing of antimicrobials.

It forms part of the induction training for new staff undertaken by microbiology.

On-going mandatory training (e-learning package) is to be developed and undertaken as a three-year cycle by all staff who prescribe antimicrobials to patientsrepeated every three years.

Nursing staff who administer antimicrobials and pharmacists who dispense them will also require training.

Final aim: to ensure all relevant staff understand the potential hazards of antimicrobials and how the risk of HCAIs can be minimised.

8 Equality and Diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed.

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9 Monitoring Compliance

Standard / process / issue Monitoring and audit

Method By Committee Frequency

All prescriptions of antibiotics should be compliant with the standards set out in Start Smart then Focus

Monthly audit cycle

Antimicrobial Leads

AMSG

Monthly

Annual Point Prevalence Survey

AMSG

Annually

Annual Stop/Review and Policy audit

Antimicrobial Pharmacist

Annually

Antibiotic recommendations within Trust guidance should take account of local resistance patterns

Annual review of resistance surveillance data

IPC Healthcare Scientist

AMSG Annually

Antimicrobial consumption should be monitored and unexpected activity investigated

Monthly review of usage data

Quarterly report of usage data

Antimicrobial pharmacist

AMSG Monthly

10 Consultation and review

Initial draft of this policy was produced by Kathy Gillespie, Matthew Lowery, Ali Robb, Louise Hall and Ashley Price. Consultation of this policy was undertaken by members of AMSG, IPCC and MMC. This policy will be reviewed every three years by AMSG or as and when significant changes make earlier review necessary. 11 Implementation (including raising awareness)

Heads of service should ensure that relevant staff are aware of this policy. This policy is available for staff to access via NUTH intranet. 12 References Department of Health (2007). Saving Lives: reducing infection, delivering clean and safe care. DoH, 2007. Department of Health (2015). The Health and Social Care Act 2008. Code of practice for health and adult social care on the prevention and control of infections and related guidance. DoH, 2015. Available at :

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http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122604 (accessed 19.11.15). Goff D (2011). Antimicrobial stewardship: bridging the gap between quality care and cost. Current Opinion in Infectious Diseases 24(1):S11–20. Mauldin PD et al. (2010). Attributable Hospital Cost and Length of Stay Associated with Health Care-Associated Infections Caused by Antibiotic-Resistant Gram-Negative Bacteria. Antimicrob. Agents Chemother.54(1):109. NICE (2015). Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE Guideline 15 (CG15). Available at: https://www.nice.org.uk/guidance/ng15. Plowman R, Graves N, Griffin M, Roberts JA, Swan AV, Cookson B et al. (2000). The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed. Journal of Hospital Infection 3:196-209.). Public Health England (2014). Start Smart – Then Focus. Antimicrobial stewardship toolkit for English hospitals. Department of Health. 13 Associated documentation (if not mentioned in 6.1) HCAI strategy HCAI action plan C difficile action plan Mandatory training policy

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122604

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122604

https://www.nice.org.uk/guidance/ng15

http://policies.app/launchit.asp?launchit=839

http://policies.app/launchit.asp?launchit=480

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Appendix 1

NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

Antimicrobial Steering Group Constitution - December 2015

1. Terms of Reference

The main aims of the group are to:

Promote high quality, cost effective prescribing of antimicrobial agents across the Trust.

Prioritise the activities of the antimicrobial pharmacist in their work towards encouraging optimal use of antimicrobials in the Trust.

Facilitate the review of current practice, development, implementation and audit of new policies and protocols related to antimicrobial prescribing, with reference to local variations in antibiotic susceptibility.

Review the release of new antimicrobials and liaise with North of Tyne Area Prescribing Committee on their adoption.

Facilitate education and awareness for all staff involved in the prescription, administration and monitoring of antimicrobials.

Maintain and monitor the Antimicrobial Stewardship Policy.

Advise, as required, the Medicines Management Committee on issues relating to antimicrobial prescribing.

Liaise with the North of Tyne Area Prescribing Committee in relation to antimicrobial prescribing as required.

2. Procedures

A sub-committee of the Trust Medicines Management Committee, the steering group will meet at least every 3 months. Minutes of all formal meetings of the committee will be produced and circulated, for information, to members and to relevant parties (see below).

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Minutes will be submitted to the Medicines Management Committee (MMC) and the Infection Prevention and Control Committee (IPCC) every three months. The AMSG Chair is a member of both MMC and IPCC.

3. Membership

To include the following members: Chairperson Secretary Preceding Chairperson All Consultant Microbiologists All Adult Infectious Diseases Consultants All Paediatric Infectious Diseases Consultants Consultant Virologist representative

One Microbiology SpR/StR One Adult Infectious Diseases SpR/StR One Paediatric Infectious Diseases SpR/StR Antimicrobial pharmacist (if not secretary or chair) Formulary pharmacist

Assistant Director of Pharmacy – Clinical Services or nominated deputy One infection control pharmacist (from two representatives)

Senior Nurse representative Representative from Primary Care

Director of Infection Prevention and Control Directorate/departmental Antimicrobial Champions

All members are invited to designate a deputy if they are unable to attend.

Other infection trainees are invited to attend to present eg. audits or guidelines.

The group will be considered a quorum with the presence of one microbiologist (who may or may not be Chairperson) plus three other members.

The chairperson will be a microbiologist, an infectious diseases physician, virologist or a pharmacist and have a tenure of 3 years.

The secretary will be a pharmacist, normally the antimicrobial pharmacist.

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4. Relevant parties

Minutes will be circulated to the following in addition to the members: Chair of Medicines Management Committee Assistant Director of Pharmacy – Governance and Patient Services

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Appendix 2

Antimicrobial Lead

The Antimicrobial Leads should be consultant medical practitioners with a remit to help ensure that antibiotics are used judiciously and appropriately. They may be responsible for their department or their directorate and are responsible to the Directorate Clinical Governance Leads. In departments or directorates without a named Antimicrobial Lead, these responsibilities fall to the directorate Clinical Governance Leads. Responsibilities

To champion appropriate antimicrobial prescribing by example.

To ensure completion and return of monthly clinical audit of antimicrobial prescribing (‘Take five’) against guidelines by junior staff using the audit tool, report the results back to the AMSG (see section 6.2.4 and Appendices 3-5).

To disseminate results of monthly audits and annual point prevalence audit to prescribers within department/directorate.

To help or delegate the development of specific departmental clinical guidelines where indicated and to ensure they are followed.

Ensure root cause analyses are performed within the department, disseminating feedback and lessons learnt.

Liaise with the infection control team during investigations of outbreaks and periods of increased incidence (PIIs).

Attend biannual Antimicrobial Leads’ Forum or ensure a deputy attends.

To be full members of the Antimicrobial Steering Group; to attend meetings where necessary, and to act as representatives for the departments/directorates to this group, feeding back relevant information.

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Appendix 3

TAKE FIVE - ANTIBIOTIC AUDIT: INPATIENT

This audit helps monitor appropriateness of antibiotic prescribing. Good antibiotic prescribing contributes to less antibiotic resistance and shorter

hospital stay, whilst improving patient experience and reducing patient harm.

This tool must be completed for every inpatient ward, every month. Please submit your responses using the unique link sent to each Antimicrobial Lead

each month by email.

Please take five charts of patients who have been prescribed antibiotics. If you cannot find five patients on antibiotics on the same day, please indicate

this on the audit chart. ANSWER ALL QUESTIONS WITH Y (YES) OR N (NO).

PATIENT 1 PATIENT 2 PATIENT 3 PATIENT 4 PATIENT 5

Date Was the antimicrobial's intended course duration or review date documented on prescription chart?

Was the dose of antimicrobial appropriate for the therapy choice?

Were all prescribed antimicrobial doses administered?

Was the allergy status documented on prescription chart?

Was the diagnosis or indication for therapy documented in patient's medical notes?

Were appropriate specimens requested / sent to microbiology?

Was the choice of antimicrobial in accordance with local guidelines?

Was a review within 72 hours documented?

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Appendix 4 TAKE FIVE - ANTIBIOTIC AUDIT: ED



This tool must be completed for every inpatient ward, every month. Please submit your responses using the unique link sent to each Antimicrobial Lead

each month by email.

Please take five charts of patients who have been prescribed antibiotics. If you cannot find five patients on antibiotics on the same day, please indicate

this on the audit chart. ANSWER ALL QUESTIONS WITH Y (YES) OR N (NO).


Date Was the dose of antimicrobial appropriate for the therapy choice?

Were all prescribed antimicrobial doses administered?

Was the allergy status documented on prescription chart?

Was the diagnosis or indication for therapy documented in patient's medical notes?

Were appropriate specimens requested / sent to microbiology?


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Appendix 5

TAKE FIVE - Community monthly Antibiotic Audit



This tool must be completed monthly on 5 patients seen within your service within a set month.

Please take five patients who have been prescribed antibiotics. If you can, use a mix of staff who are independent prescribers and those who use PGD’s,

please indicate this on the audit chart. ANSWER ALL QUESTIONS WITH Y (YES) OR N (NO).


Date seen. Is a PGD used ? Was the dose of antimicrobial appropriate for the therapy choice?

Was the allergy status documented on the electronic notes?

Was the diagnosis or indication for therapy documented in patient's notes?

Has a full history of the presenting complaint been documented?

Were appropriate specimens requested / sent to microbiology if required ?


If not, is there documented evidence of why this antimicrobial has been prescribed.

Was a set of observations recorded in the notes including Temp, pulse and blood pressure?

Antimicrobial Stewardship Policy- EA Page 1 of 4 Dec 2013

The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 10.12.15 2. Name of policy / strategy / service:

Antimicrobial Stewardship Policy

3. Name and designation of Author:

Ali Robb Consultant Microbiologist, Ashley Price Consultant Infectious Diseases Physician, Matthew Lowery Formulary and Audit Pharmacist, Kathy Gillespie Antimicrobial Pharmacist

4. Names & Designations of those involved in the impact analysis screening process:

Ali Robb Consultant Microbiologist, Lucy Hall Equality and Diversity Lead

5. Is this a: Policy Strategy Service

Is this: New Revised

Who is affected: Employees Service Users Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and

pasted from your policy)

The aim of this policy is to provide a framework to ensure that antimicrobials are used appropriately, in order to optimise the

treatment of infections and to minimise the risk of healthcare-associated infections.


7. Does this policy, strategy, or service have any equality implications? Yes No

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

8. Summary of evidence related to protected characteristics

Protected Characteristic

Evidence i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups related to this policy/service/strategy – please refer to the Equality Evidence (available via the intranet Click A-Z; E for Equality and Diversity. Summary on front page and more detailed information in resources section)

Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date)

Does the evidence highlight any areas to advance equal opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including gypsies and travellers)

Interpreter services provided if needed to discuss and explain treatment

Studies show that when interpreters were provided patients had a better understanding of their diagnoses and treatment plan than patients without interpreters. Communication support is available (section 6.3.2)

No

Sex (male/ female)

Prescribing takes into account any factors relating to sex

No No

Religion and Belief None relevant to this policy No No


Sexual orientation including lesbian, gay and bisexual people

None relevant to this policy No No

Age

Prescribing takes into account any factors relating to age

No No

Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section

Equality and Diversity training incorporates general principles in relation to meeting the need of disabled people. The learning disability liaison nurse is available to support staff working with patients who have a learning disability

Studies show that when interpreters were provided patients had a better understanding of their diagnoses and treatment plan than patients without interpreters. Communication support is available for patient and carers (section 6.3.2)

No.

Gender Re-assignment

None Relevant to this policy No No

Marriage and Civil Partnership

None Relevant to this policy No No

Maternity / Pregnancy

Prescribing takes into account any factors relating to pregnancy and the post natal period

No No

9. Are there any gaps in the evidence outlined above. If ‘yes’ how will these be rectified ?


No

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement No

11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and

family life, the right to a fair hearing and the right to education?

No – patients have a right to refuse treatment

PART 2 Signature of Author

Print name

Ali Robb

Date of completion

10.12.15

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)

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