CHHS18/078

Canberra Hospital and Health ServicesClinical ProcedureAntimicrobial StewardshipContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Roles and Responsibilities......................................................................................2

Directors of Infectious Diseases/Pharmacy...........................................................................2

Executive Staff, Directors, and Senior Prescribers.................................................................2

Prescribing Staff (including JMOs, registrars, advanced trainees, senior and other prescribers)...........................................................................................................................2

Ward Pharmacist...................................................................................................................3

Dispensary Pharmacist..........................................................................................................3

Nursing Staff..........................................................................................................................3

AMS Team.............................................................................................................................3

Infectious Diseases Service...................................................................................................4

Pharmacists and the AMS team are authorised to:...............................................................4

Section 2 – Antimicrobial Prescribing........................................................................................4

Section 3 – Canberra Hospital AntiMicrobial Protocols on the Mobile Device.........................5

3.1 Purpose and Scope..........................................................................................................5

3.2 Roles and Responsibilities...............................................................................................6

Section 4 – Inpatient Management of Restricted Antimicrobials..............................................6

4.1 Antimicrobial Categories.................................................................................................6

4.2 Highly Restricted Antimicrobials.....................................................................................7

4.3 RED and ORANGE Antimicrobials....................................................................................7

Implementation........................................................................................................................ 8

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References................................................................................................................................ 9

Search Terms............................................................................................................................ 9

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Purpose

The 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.

Scope

This procedure applies to the following professionals at CHHS: Medical Officers Nursing Staff Pharmacy Staff Allied Health

Section 1 – Roles and Responsibilities

Directors 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

procedure Facilitate implementation of a sustainable and effective AMS Program

Executive Staff, Directors, and Senior Prescribers Take 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 CHHS

Prescribing 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 use

Ensure that they have a personal ACT Health Active Directory login and that they use this when using electronic AMS systems

To engage with pharmacists, Infectious Diseases Service and the AMS team to clarify the rationale for the use of antimicrobials if required

To alert the AMS team if there is disagreement between the prescribing team and recommendations provided by AMS or Infectious Diseases

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Ward Pharmacist Provide clinical review and feedback for antimicrobial prescriptions with priority applied

to review of restricted antimicrobial prescriptions Engage prescribers to be compliant with restricted antimicrobial procedure and refer

non-compliant cases to the AMS team if unsuccessful

Dispensary Pharmacist Collaborate with ward pharmacist to promote compliance with restricted antimicrobial

procedure including contacting the prescriber if necessary Escalate non-compliance to the Dispensary Manager and AMS team if required

Nursing Staff Ensure that any requests for non-urgent supply/dispensing of restricted antimicrobials

are delivered to pharmacy within business hours where feasible Raise any concerns regarding antimicrobials for their patients, including the need to

seek approval codes and/or document indications on the medication chart

AMS Team Assist with orientation and education of staff Respond to approval requests for restricted antimicrobials in a timely manner Negotiate and manage situations of non-compliance with AMS recommendations Engage 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 program

o Antibiotic usageo Antibiotic prescribing auditing and benchmarkingo Review Antibiogram and Healthcare Associated Infection/Multi-resistant

organism acquisition data from Microbiology and Infection Prevention and Control

o Any 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 serviceo The 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 team

o It is not within the scope of an AMS review to clinically examine the patient or provide definitive diagnostic advice

An AMS review may involve: o Review of antimicrobial prescribing for a range of infective syndromes where

Infectious Diseases are not usually involvedo Review of medication chart, progress notes, investigations, pathology and

radiologyo Discussion with prescribing team regarding the patient’s progress

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o Dosage and Therapeutic Drug Monitoring recommendationso Recommendation of alternative therapy or cessation of therapyo Recommendation of additional investigations or microbiology samplingo Recommendation of an Infectious Diseases consult if diagnosis is difficult and in-

depth specialist review required

Infectious Diseases Service Respond to approval code requests for Highly Restricted antimicrobials at the time of

prescription Alert the AMS team if the prescribing team disagrees with Infectious Diseases

recommendations Clearly document duration or date of review for antimicrobial recommendations Refer 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 procedure

Pharmacists and the AMS team are authorised to: Request the prescribing team to review antimicrobial therapy and provide the indication

for use Request justification and documentation for deviation from approved Therapeutic

Guidelines or CHHS Hospital Policy and Procedures Request for prescriptions to be ceased or changed based on a review of appropriateness

within their scope of practice Identify antibiotic prescribing practices that are not in line with hospital procedure to

the AMS team for further action

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Section 2 – Antimicrobial Prescribing

CHHS prescribers should: Prescribe antimicrobials on reasonable clinical grounds, having taken into account

previous microbiology results, allergy history & travel history Utilise the following guidance for antibiotic prescribing, in order of preference

1. CHAMP-MD mobile device application (downloadable via the ACT Health library website)

2. For indications not listed in CHAMP-MD, in adherence to local policies, procedures and guidelines published on the Policy Register

3. If local guidelines do not exist, in adherence to the current version of Therapeutic Guidelines: Antibiotic, or

4. On advice from Infectious Diseases Service or AMS team Prescribe 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 Committee

Document the indication for using an antimicrobial on the medication chart and patient notes

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Document intended review or cessation date in the medical record Review microbiology results and narrow the antimicrobial choice accordingly as soon as

possible Regularly review whether IV to oral switch or cessation is appropriate Regularly review the ongoing need for IV access and prompt removal of cannulas/long

lines Discuss antimicrobial treatment with the patient in accordance with the Australian

Commission for Safety and Quality in Healthcare AMS Clinical Care Standard Follow the procedure for the Management of Restricted Antimicrobials as described

below

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Section 3 – Canberra Hospital AntiMicrobial Protocols on the Mobile Device

3.1 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.

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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.

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Section 4 – Inpatient Management of Restricted Antimicrobials

A 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 Category

Approval Requirements Drug

REDApproval within 24

hours

Amikacin IVAmoxicillin-clavulanate IVAnidulafungin IVAmphotericin IVAztreonam IVCefepime IVCeftazidime IVDaptomycin IVErtapenem IVFosfomycin POFlucytosine POGanciclovir IV Linezolid IV/PO

Meropenem IVMoxifloxacin IV/POPentamidine IVPiperacillin/Tazobactam IV (Tazocin®)Pristinamycin PORifampicin IVTeicoplanin IVTigecycline IVVoriconazole IV/POVancomycin IV/POValganciclovir PO

ORANGERequire

approval after 3 days

Azithromycin IV/POCefotaxime IVCeftriaxone IVClindamycin IV/PO

Ciprofloxacin IV/PONorfloxacin POTobramycin IVGentamicin IV

GREEN Nil All other antimicrobials on the Hospital Formulary

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Short 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 pharmacy Approval 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 occur A request for re-approval is required to be made on the day of expiry if treatment needs

to continue ICU is not exempt from seeking approval for these agents prior to prescription

4.3 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.

ExemptionsDrug Indication Specialty Generic code Duration of

approval from date of initiation+

IV amoxicillin-clavulanic acid

Infected bite wounds

Plastics BIT DDMM* 02 2 days

IV piperacillin-tazobactam

Febrile Neutropenia

Haematology FN DDMM 05 5 days

IV gentamicin Early onset Sepsis Neonatology EOS DD MM 05 5 daysLate onset sepsis LOS DD MM 05 5 daysNEC NEC DD MM 07 7 days

DDMM = 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 approval

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Requesting Approvals Approval requests are to be lodged online through the intranet via the AMS Approvals

Request page The 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 request Approval 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.

Weekends RED antimicrobials – contact Infectious Diseases physician on call during business hours ORANGE antimicrobials – submit an online approval request as above to be reviewed

next business day

Supply 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 information

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Implementation

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 Updates Pharmacy Unit HP1/HP2 Meeting Pharmacy Clinical Lead Meeting Intern and medical officer orientation Resident Medical Officer Education meetings Incorporation into orientation documentation for new senior medical officers

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Annual promotion at Unit Meetings The annual Antibiotic Awareness Week

Changes 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 Divisions Medical and Nursing Midwifery Executive Clinical Development Nurses Education Updates Pharmacy Unit HP1/HP2 Meeting Pharmacy Clinical Lead Meeting Resident Medical Officer Education meetings Promotion at Unit Meetings Distribution via the Medical and Dental Professional Standards Unit Distribution via the Medical Officer Support Credentialing Education and Training Unit

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Related Policies, Procedures, Guidelines and Legislation

Procedures Medication Handling Policy Healthcare Associated Infection Standard Operating Procedure

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References

1. Duguid M and Cruickshank M. Antimicrobial Stewardship in Australian Hospitals 2011. Australian Commission on Safety and Quality in Healthcare.

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Search Terms

Antimicrobial stewardship, AMS, Antibiotic, Restricted, Antimicrobial, Approval, Sharepoint Infectious, Diseases, Prescribing

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Disclaimer: 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 Amended Section Amended Divisional Approval Final Approval 21 February 2018 Complete Review Lisa Gilmore, A/g ED CSS CHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS16/022 Antimicrobial Stewardship Procedure

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