Dr Shafinaz Karim & Dr Susan Benson 29 June 2015

Clinical Care Standards Appropriateness of clinical care is a major focus in improving

the quality of health care provision

Antimicrobial Stewardship - collective set of strategies

Aims to ensure that a patient with a bacterial infection receives optimal treatment with antibiotics

To minimize the adverse effects of antibiotic use including resistance, toxicity and costs

WAIDPG Guidelines

Adherence to best practice management for blood stream infections (bacteraemia) – Staphyloccocus aureus bacteraemia

Staphylococcus aureus

Skin and soft tissue infection

Systemic infection

Staphylococcus aureus is a serious blood stream infection 3 ,4

Mortality - high as 40%

Recognised complications – endocarditis, bone and joint infections

Early optimal therapy to improve outcomes led to

development of guidelines for management of SAB

(WAIDPG, Infections and Immunology Health Network, WA Health, 2012)5

Aim

To measure adherence to best practice guidelines for management of SAB

in adult patients and identify target areas for improvement.

Objectives

In adult patients with positive blood cultures of Staphylococcus aureus at

Armadale Hospital, what proportion receives best practice SAB

management outlined by WAIDPG, Department of Health WA.

Retrospective audit 31 Jan 2013 – 31 May 2014 (17 months)

Pathwest lab database- All + ve Blood cultures at AHS (Filter “S. aureus”)

Exclusion criteria: Under 18 years old Positive blood cultures after

patient transferred Files not available

Identified standards: Empiric anti-Staphyloccocal antibiotics selection and dose Proportion of S.aureus cultures that are methicillin resistant Echocardiography organized before discharge Blood culture repeated >72 hours Infectious disease physician bedside consult

Demographics: Age Gender Date of admission Health care-associated

infection (+ve b/c greater than 48hrs or

SAB at Armadale = 1-2 episodes per month

M = 15 (60%) / F = 10 (40%) Mean Age= 62 years (20-98)

HAIs = 4/25 (14%) Non-HAIs = 20/25 (80%)

MRSA = 6/25 (24%) MSSA = 19/25 (76%)

Crude mortality:

1/25 (4%)

(AIHW, 2013) A case of SAB is considered to be healthcare-associated if the first positive blood test is more than 48 hours after hospital admission HAIs more than 48 hours after hospital admission or if the first positive blood test is 48 hours or less after admission and one of the following criteria was met: 1. SAB is a complication of the presence of an indwelling medical device (for example, intravascular line, haemodialysis vascular access, cerebrospinal fluid shunt, urinary catheter). 2. SAB occurs within 30 days of a surgical procedure where the SAB is related to the surgical site. 3. An invasive instrumentation or incision related to the SAB was performed within 48 hours. 4. SAB is associated with neutropenia (

0

5

10

15

20

25

30

Concordant with guidelines Not concordant with guidelines

Nu

mb

er

of

pa

tie

nts

Antibiotic choice as per guidelines recommendations (microbiology advice)

4%

96%

0

1

2

3

4

5

6

7

8

9

10

Concordant withguidelines

Not concordant withguidelines

Nu

mb

er

of

pa

tie

nts

Given loading dose of Vancomycin

3

7

5

6

0

2

4

6

8

10

12

14

Cephazolin Flucloxacillin

Nu

mb

er

of

pa

tie

nts

B-lactams dose and dose interval

Not concordant with guidelines Concordant with guidelines

38%

46%

54%

Loading dose Vancomycin (25mg/kg)

40%

60%

62%

Cephazolin 2G TDS or Flucloxacillin 2G 6hrly (norm renal fn)

15 18

23

10 4

2

0

5

10

15

20

25

30

B/C repeated >72hours Echo performed ID Consult

Nu

mb

er

of

pa

tie

nts

Best Practice Management of SAB

Achieved standard Did not achieve standard

72%

16%

92%

8%

60%

40%

Antibiotic prescribing

96% concordance with antibiotic choice as per micro advice

40% concordance with vancomycin loading dose

54% concordance with flucloxacillin dose and dose interval

Investigations

60% achieved standard for b/c >72h

72% achieved standard for echo before d/c Bedside ID review

92% achieved standard

16% HAIs of these 75% are secondary to IV line related infection

Staphylococcal sepsis not suspected on admission, 32%

misdiagnosed as pneumonia

D/C Summaries: Diagnosis of SAB?

65% mentioned SAB

Poor documentation of antibiotic prescribing in medication chart

Critical results documentation

“Hey interns! Do you document in the progress notes when you have been called

by Micro regarding a positive blood culture?”

22 19

0

5

10

15

20

25

YES NO

Microcall documentation in MR55

Survey - 24th June 2015

“Just look on the system”

“Should we?”

“I didn’t know we had to?!”

“Next day, on ward rounds”

1. Vancomycin loading dose 2. B-lactams higher dosing 3. Critical results documentation 4. Documentation in medical notes 5. Documentation in medication chart

New vancomycin dosing flow sheet Good documentation and SAB guidelines - included in

RMO orientation and teaching NAPS audit (June 2015) and survey items were extended

to measure antibiotic documentation UNDF student audit - specifically addresses the

documentation of critical results RMO bulletin - included the need for documentation of

critical results Ongoing lobbying: SAB guideline name changed so that

it can be easier found on the local intranet

Need for safer systems, organizations & processes of care

Using opinion leaders and clinical ‘champions’

Endorsement by key clinical and administrative groups

Reminder systems incorporated in clinician’s daily work

Local involvement in evaluation

Continuing quality assurance and data feedback

Routine in Clinical Practice

Dr Susan Benson Mr Graham Francis (Microbiology Fremantle PathWest) Dr Tristan Gibbs (Microbiology RPH PathWest) Clinical quality and safety committee,

Armadale Hospital

Questions?

1. Australian Commission on Safety and Quality in Health Care (ACSQHC) (September 2011),

National Safety and Quality Health Service Standards, ACSQHC, Sydney.

2. Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship

Clinical Care Standard. Sydney: ACSQHC, 2014.

3. Australian Institute of Health and Welfare. (2013). Staphylococcus bacteraemia in Australian

public hospitals. Retrieved from

http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129542613

4. Kern, W.V. (2010). Management of Staphylococcus Aureus bacteraemia and endocarditis:

progresses and challenges. Current Opinion in Infectious Diseases, 23, 346–358

5. Management of Staphylococcus aureus bacteraemia, WAIDPG, Infections and Immunology

Health Network, WA Health, 2012