outlining use of the same ams model to target other ... · • as a result, it provides a...

Adrian Brink Clinical Microbiologist, Ampath National Laboratory Services, Milpark Hospital,

Johannesburg and Honorary Senior Lecturer, Division of Infectious Diseases and HIV Medicine,

Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa

Outlining use of the same AMS model to target other interventions in low-resource

settings

Improving time form prescription to infusion

“Hang-time”

•  Ensuring timely administration of antimicrobials is critical in the management of patients with infections particularly in cases of septic shock, where mortality increases by 7.6% for every hour of delay in the administration of antimicrobial therapy.

•  The time elapsed from the written antibiotic order to actual intravenous administration or ‘hang-time’ can often be several hours due to inefficient institutional delivery within the hospital.

•  The following barriers are common reasons for the delay of antibiotic administration in South African hospitals: •  Use of paper charts •  Delays in delivery of the prescription order to the pharmacy •  Delays in prescription chart assessment •  Processing time in pharmacy •  Delivery delays in the transportation of medication from the pharmacy to the

wards •  Delays in reconstitution of IV antibiotics by nursing staff at the patient bedside.

AMS model for “hang-time”

Messina et al. Infect Dis Ther 2015;4:S5-S14

•  Ensuring the first dose antimicrobial is available at the time of required administration, without delay, is not only a good practice supported by the literature but also forms the foundation of any AMS program as the practice of AMS ultimately aims to optimize antimicrobial therapy to improve patient outcomes.

•  Hang-time, referred to as the ‘‘golden hour’’ of antibiotic administration, is a fundamental process that relies extensively on the involvement, collaboration and participation of all healthcare team members including doctors, pharmacists, nursing staff and hospital management.

•  As a result, it provides a multidisciplinary platform to augment the awareness required when initiating and driving an antibiotic stewardship program in a hospital.

•  The purpose of this study using the same AMS model described previously, was to evaluate the change in compliance with administering antimicrobials within an hour of prescription of all patients irrespective if they were in ICU (septicaemic) or not, as a measure of institutional delivery and quality of care, after implementation of a national pharmacist-driven hang-time process improvement intervention in 33 hospitals.

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Weekly antimicrobial hang-time compliance (n=33 hospitals; n= 32,985 patients)

Angeliki Messina Quality Systems and Innovation Manager, Netcare Hospital Group.

•  Outcome •  A total of 32,985 patients who received intravenous antibiotics were

assessed for hang-time compliance with first doses of new antibiotic orders

•  Over the 60-week period, 21,069 patients received antibiotics within an hour following prescription and were assessed as hang-time compliant.

•  The change in improvement of hang-time compliance following implementation of a pharmacist-driven hang-time process improvement protocol was 41.2% pre-intervention week 1 (164/398) to 78.4% post-intervention week 60 (480/612; P<0.0001)



Adherence to peri-operative antibiotic prophylaxis guidelines

Knox et al. Surgical Infections 2016;17: 224-8

Clinician-focused educational interventions alone are mostly ineffective

Knox et al. Surgical Infections 2016;17: 224-8 Brink AJ et al. J Antimicrob Chemother Advance Access published December 20, 2016. doi:10.1093/jac/dkw523

�  Surgical site infections (SSIs) account for 14 -16% of all HAIs, occur in 2-5 % of patients after clean extra-abdominal operations and in up to 20% of patients undergoing intra-abdominal procedures.

� Patients who develop SSIs are up to 60% more likely to be admitted to the ICU, 5 times more likely to be readmitted to hospital, and 2 times more likely to die relative to uninfected surgical patients.

� Thus for patients who require surgery, the prevention of infection is a major objective in the provision of effective healthcare and the creation of evidence-based peri-operative antibiotic prophylaxis (PAP) guidelines is critical to achieving this.


Brink AJ et al. J Antimicrob Chemother 2016. Advance Access published December 20, 2016. doi:10.1093/jac/dkw523

� Although the principles of PAP are clearly established and have been shown to be effective, despite tangible evidence of the beneficial impact on SSIs, global adherence to these guidelines is generally poor.

� Recent reviews and studies have demonstrated non-compliance in up to 88% of surgical cases.

�  Hence, it appears that it is a challenge to disseminate evidence-based PAP measures systematically into clinical practice.

�  Alternative strategies to significantly improve adherence to evidence-based measures are warranted.


Collaborative AMS model for PAP

Brink et al. J Antimicrob Chemother 2017;72:1227-1234

•  The aims of the 2 ½ yr study were to implement an improvement model for PAP utilizing existing resources to achieve a reduction in surgical site infections (SSIs) across a heterogeneous group of 34 urban and rural South African hospitals.

•  Similar methodology i.e. Netcare adaption of IHI model targeting compliance to 4 antibiotic measures was used (Drug choice, Drug dose, Drug timing, Drug duration). Results: •  For 70 weeks of standardized measurements and feedback, 24 206 surgical

cases were reviewed. •  The baseline survey revealed a composite compliance of 66.8% (95% CI,

64.8%-68.7%) and a mean group SSI rate of 2.46 (95% CI, 2.18-2.73). •  Compared to the pre-implementation phase, there was a significant

improvement in compliance with all process measures. •  Composite compliance increased by 24.7% to 83.3% (95% CI 80.8%-85.8%)

(P<0.0001) whilst the SSI rate decreased by 19.7% to a mean of 1.97 (95% CI 1.79-2.15) (P=0.0029).



SSI,Surgicalsiteinfection;M,Month Themedianmonthlysurgicalsiteinfectionrateduringtheimplementationphasesoftheperi-operativeantibioticprophylaxisinterventionNBDataonfile–DrAdrianBrink

The mean monthly surgical site infection rate during the pre- and post- implementation phases

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Group SSI rate Median: SSI rate

Post implementation phase (16m) Pre implementation phase (14m) May 2014

Mean rate of compliance with the process measures during the pre and post implementation phases

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AB choice AB dose AB timing AB duration Overall compliance

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Theerrorbarsdenotethe95%confidenceintervalforthemeanAB,Antibiotic*DenotesstatisticaldifferenceincomplianceNBDataonfile–DrAdrianBrink

•  Although significant improvements in all the measures were documented, the low overall non-compliance with the timing measure warrants closer attention.

•  In this regard, our model led to 92% compliance with the clinician-dependent measures (antibiotic choice, dose and duration) but not for the institutional dependent timing measure, where despite a 62.4% increase in timely administration relative to the pre-implementation phase, at the end of the study this occurred in only 56.4% of cases.

•  The collaborative learning process during audit and feedback, to enable self-monitoring and provision of action plans, resulted in various institutional changes in the delivery of the antibiotics which enhanced the stewardship initiative.



•  These included, amongst others: •  Making infusions available at the patient’s bedside, either in the ward or

in theatre prior to induction •  Utilization of prompts and reminders on patient and theatre files •  Anaesthetists eventually accepting responsibility and accountability for

insertion of intravenous lines and for administration of antibiotics

•  In any event, failure to comply with the timing measure reflects the presence of poorly designed and inefficient delivery systems universal to most healthcare settings rather than cognitive deficits or individual negligence on the part of the healthcare workers

•  Our study emphasizes that changes in institutional delivery are critical to successful stewardship initiatives and that the fundamentals of drug delivery in a hospital setting are as important as clinician-dependent measures if we are to improve patient care



•  Conclusions

•  “Our study demonstrates that collaborative implementation of process improvement initiatives and principles are effective in bridging the gap between clinician guidelines and improvement in care and outcomes in surgical patients”

•  “Pivotal to our success was engagement with the clinicians, and involvement of theatre managers and anaesthetic, peri-operative and surgical ward nurses and their support for the process of change”

•  “Leadership commitment is required from all quarters, to acknowledge and support the cardinal role played by no-specialized pharmacists in recruiting multidisciplinary teams and in coordinating interdisciplinary clinician and nurse engagement in such an AMS intervention, which was key to our success”



outlining use of the same ams model to target other ... · • as a result, it provides a...

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