a multicentre drug use evaluation in hospitals: the...

A Multicentre Drug Use Evaluation in Hospitals: The CAPTION Project

Community-acquired pneumonia: Towards improving outcomes nationally.

Final Report to the National Prescribing Service

Tools Package

September 2005

NSW TAG Project Team: Karen Kaye (Project Manager) David Maxwell (Project Officer)

NSW TAG CAPTION Tools Package

September 2005 2

Contents: Package 1. Schedule of Activities .....................................................................3 Package 2. Steering Committee.........................................................................7

2.1 Terms of reference ......................................................................................8 2.2 Membership...............................................................................................10

Package 3. Hospital Recruitment ....................................................................11 3.1 Initial expressions of interest .....................................................................12 3.2 Final sign-off..............................................................................................19

Package 4. Data Collection Tool......................................................................29 4.1 Data collection form...................................................................................30 4.2 Pilot study report .......................................................................................32

Package 5. Intervention Tools .........................................................................40 5.1 Letter of introduction..................................................................................41 5.2 Detailing card ............................................................................................43 5.3 Poster ........................................................................................................46 5.4 ID cards .....................................................................................................47 5.5 PSI calculator stickers ...............................................................................48

Package 6. Academic Detailing .......................................................................49 6.1 Workshop outline.......................................................................................50 6.2 Participants................................................................................................51 6.3 NSW TAG support structure......................................................................52 6.4 Case study ................................................................................................54 6.5 Workshop evaluation.................................................................................59

Package 7. Evaluation ......................................................................................61 7.1 Hospital profile form ..................................................................................62 7.2 Patient record form....................................................................................64 7.3 Data collection log .....................................................................................65 7.4 Intervention activity log ..............................................................................66

Package 8. Communication .............................................................................68 8.1 Reporting strategy .....................................................................................69 8.2 Hospital newsletters ..................................................................................70 8.3 NSW TAG website ....................................................................................92 8.4 NSW/ACT final wrap-up meeting...............................................................93

Package 9. Participating Hospitals..................................................................96 Package 10. Feedback Reports from Auditmaker® ........................................98

10.1 1st audit (Baseline)...................................................................................99 10.2 2nd audit .................................................................................................103 10.3 3rd audit .................................................................................................107

Package 11. Presentations and Publications ...............................................111 11.1 Conference abstracts ............................................................................112 11.2 Publication reference list .......................................................................116


September 2005 3

Package 1. Schedule of Activities

Package 1 Schedule of Project Activities


September 2005 4

Package 1 – Schedule of Activities

Activity By when Detailed tasks required CommentsExecute contract Sept

2003 • Confirm starting date √

Recruit project officer Sept 2003

• Send out EOI via TAGNet √

Formalise project structure

Oct 2003 • Write draft project description • Develop draft timetable of activities • Invite key opinion leaders to focus

group meeting

√ √ √

Gather information to confirm direction and focus of study

Oct 2003 • Meet with focus group (17/10/03) • Identify other information sources • Confer with other state groups • Gather background information from

TAG/TAGNet hospitals (sent 21/10/03)

√ √ √ √

Convene steering committee Nov/Dec 2003

• Schedule meeting times • Invite opinion leaders to be part of

steering committee • Meet with steering committee (25/11/03) • Confirm project direction • Confirm approach to background data

management • Identify key messages for engagement

of prescribers • Draft evaluation plan

√ √ √ √ √ √ √

Ethics Committee Package Dec 2003 Jan 2004

• Prepare materials for Individual Ethics Committee (IEC) with NPS and other state based groups

√

Hospital Recruitment Dec 2003Jan 2004

• Invite expressions of interest from TAG and TAGNet hospitals

√

NPS report Dec 2003 • Meet with NPS (17/12/03) • Finalise project plan • Report to NPS detailed project plan

(19/12/03)

√ √ √

Formalise project team (participating hospital representatives)

Jan - Aug 2004

• Confirm support from authoritative managers and committees at participating hospitals:

- IEC - Pharmacy - DTC - ED - CEO - Medical records

• Nominate coordinator, facilitator and team in each participating hospital and confirm contact details

• Meet with hospital coordinators to outline project plan

√

√

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Baseline data collection UQ QUM student DUE audit (I)

Feb/ July 2004

• Pilot data collection method/form • Review and update data collection form

if required

√ √


September 2005 5

Data analysis (I) • All 12 hospitals to collect retrospective data

• Analyse and report on baseline data

√

√ Prepare data collection tools and feedback report formats

June/July 2004

• Finalise data collection tool • Finalise data collection procedure • Finalise report format and procedures • Prepare materials for website

√ √ √ √

Antibiotic Usage Data

• Design pharmacy dispensing system report to collect antibiotic distribution to ED and rest of hospital

• Collect retrospective antibiotic usage data for past 12 months (monthly usage reports)

• Collate data from all participating hospitals

To be discussed with NSW CAPTION hospitals

Meet with Steering Committee August 25th 2004

• Report background data • Endorse key messages for education

√ √

Design Education Package August/ Sept/Oct 2004

• Create suite of tools for education for participating hospitals • Use barriers and key issues to

design teaching sessions with prescribers

• Include local background data • Create reminders/prompts to coincide

with education campaign

√

√

NPS Education Session (16th /17th)

Sept 2004

• Train hospital facilitators in academic detailing through NPS.

√

Annual project report to NPS Sept 2004

• 12 month DUE activity report to NPS to be written and submitted (01/10/04)

√

Engage hospital prescribers Nov/Dec 2004

• meet with hospital prescribers to present and discuss background data and key messages for the management of CAP

• identify barriers to use of the guidelines and key areas for education

√ √

Education cycle (I) March 2005

• Meet with hospital coordinators and facilitators to train wrt education tools (17/11/2004)

• Deliver initial education program • Evaluate education sessions

√ √ √

DUE audit (II)

Complete by June 2005

• Data collection • Data collation • Data analysis

√ √ √

Data analysis (II) June 2005

• Format data into reporting document • Distribute report on first cycle to

participating hospitals, DUESG and Steering Committee

√ √


September 2005 6

Hospital feedback sessions June 1st 2005

• Feedback meeting with all hospital co-coordinators/facilitators

• Write report on feedback session distribute to steering committee and DUESG

√ √

Review/Update • Review and update education/DUE activity if required as per feedback and steering committee

√

Education cycle (II) July/ August 2005

• Education sessions in hospitals • Evaluation of education session

√ √

DUE audit (III) August/Sept 2005

• Data collection • Data collation (completed 06/09) • Data analysis

√ √ √

Data analysis (III) Sept 2005

• Data analysis • Format data into reports

√ √

Wrap up and reporting Sept 2005

• Meet with steering committee (19/09/2005)

• Conduct face-to-face meeting with NSW/ACT hospital coordinators (21/09/05)

• Feedback second data collection results to participating hospitals, NSW DUESG and the Steering Committee

• Begin to write up the final report

√ √ √ √

Final Report 30th Sept 2005

• Final national meeting at NPS (28/09/2005)

• Submit final project report to NPS, project Steering Committee, TAG members and participating hospitals

• Thank you letters • Avenues for publication • Celebrate

√ √ √ √ √


September 2005 7

Package 2. Steering Committee

Contains: 2.1 Terms of Reference 2.2 Membership

Package 2 Steering Committee


September 2005 8

Package 2 – Steering Committee 2.1 Terms of reference Composition The committee will have representation from the following areas: Emergency Medicine Emergency Nursing Microbiology/Infectious Diseases Consumer Respiratory Medicine Quality Improvement Staff Clinical Pharmacology National Prescribing Service (NPS) General Practice Clinical Pharmacy (DUE and Emergency)

Therapeutic Guidelines Staff NSW TAG

Responsibilities The committee will advise the project team on achieving: 1. Project objectives 2. Development of tools and interventions 3. Data collection and feedback processes for DUE cycles 4. Identification of appropriate outcome measures 5. Evaluation plan and reports This will take into account the methodology as set out in the document “Project Description”. Meetings It is expected that meetings will be held in November 2003, February, May, October 2004, January, May and October 2005. Other meetings may be called if required as the project progresses. NSW TAG will provide the secretariat. Reporting Meeting minutes will be available to NPS, the project team and TAG members. The Project Group will report, via meeting minutes, to the Steering Committee. Communication from NPS and other states will be available to the steering committee (see reporting structure). Timeframe The project will be conducted from October 2003 to September 2005. The funding body, NPS, will receive a detailed project plan at 3 months, and written project progress reports at 12 and 24 months. These will also be sent to the steering committee. Upon completion NPS, participating hospitals and the steering committee will receive a project report including:


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- A written summary of data and main findings of the DUE/Education intervention.

- Identification of issues and barriers for prescribing behaviour change in the areas studied.

- Recommendations for future activity in the prescribing area studied - Recommendations for linkages between hospital and community

prescribing in the area studied. - Recommendations on sustainable roll out of social marketing

interventions in the hospital sector. Presentations and publications regarding the project will be prepared during the course of the project. Members of the Steering Committee and participating hospitals will be acknowledged in all these ventures.


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Package 2 – Steering Committee 2.2 Membership NSW TAG CAPTION Steering Committee Membership Alice Mckellar Clinical Pharmacy Goulburn Base Andrew Finckh Emergency Medicine St. Vincents Catherine Dobbin Respiratory Medicine Royal Prince Alfred David Maxwell Project Officer NSW TAG Deborah Marriot Microbiology St. Vincents Jeremy Bunker General Practice General Practice Jo-anne Brien Clinical Pharmacy University of Sydney John Ferguson Microbiology/

Therapeutic Guidelines John Hunter Karen Kaye Executive Officer NSW TAG Kathleen Ryan Quality Improvement Staff South Eastern Area Health Kylie Easton National Prescribing Service NPS Rachel West Emergency Nursing Westmead Richard Day Clinical Pharmacology St. Vincents Simon O’Connor Respiratory Medicine Tamworth Base Susie Welch Clinical Pharmacy St. Vincents Timothy Green Emergency Medicine Royal Prince Alfred


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Package 3. Hospital Recruitment

Contains: 3.1 Initial Expressions of Interest

3.1.1 Letter of invitation to express interest 3.1.2 Project description 3.1.3 EOI fax-back form

3.2 Final Sign-Off

3.2.1 Letter to Drug and Therapeutics Committee 3.2.2 CEO and Departmental heads ‘sign-off’ form 3.2.3 Institutional Ethics Committee information kit

3.2.3.1 Letter to the IEC Chair 3.2.3.2 Answers to FAQs commonly asked by IECs 3.2.3.3 Information on proposed data collection Reporting structure (See package 8 – Communication)

3.2.4 Final response checklist and fax-back form

Package 3 Hospital Recruitment


September 2005 12

Package 3 – Hospital Recruitment: 3.1 Initial expressions of interest 3.1.1 Letter of invitation to express interest. Dear NSW TAG/TAGNet Member, Re: Expression of Interest - the CAPTION Study NSW TAG is coordinating the NSW component of a national multi-centre DUE project funded by the National Prescribing Service. The primary objective of the project is to improve patient care in the management of Community Acquired Pneumonia (CAP). The project is also known as the ‘CAPTION Study’ – Community Acquired Pneumonia: Towards Improving Outcomes Nationally. CAPTION will incorporate the introduction and implementation of the Therapeutic Guidelines – Antibiotics 12th Edition management strategies for CAP in to hospital emergency departments. For further details of aims and methodology etc. please see the “Project Description”. (Attachment 1) NSW TAG is in the process of recruiting twelve NSW hospitals to participate in this project. Eligible hospitals may be public or private, but must have an Emergency Department. The recruitment process involves four steps (all four steps may not be applicable to all institutions): • Initial expression of interest (EOI) from TAG/TAGNet hospitals • Formal support from the Drug and Therapeutics Committee (DTC) • Approval, if required, from the Institutional Ethics Committee (IEC) • Sign-off from the Chief Executive Officer (CEO) and other appropriate

departmental heads After NSW TAG has received initial EOI the order in which the other steps for recruitment occur will be directed by each individual hospital. CEO and DTC support is required for project participation. NSW TAG will provide the following tools to facilitate the recruitment process at each hospital: • A covering letter addressed to the chair of the DTC • An IEC package, including a covering letter to the chair of the IEC, a list of

answers to questions frequently asked by IECs and copies of the data collection instrument(s) to be used in the project

• A letter indicating support to be signed by the CEO and other hospital authority figures

• A project description and project reporting structure


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• A “Response Form” for you to complete and send to NSW TAG after local support has been finalised

Please note that all tools provided by NSW TAG will be presented in a generic format that can be adapted to suit the needs of your hospital. Please indicate your initial EOI by completing the “EOI response form” (Attachment 2) and fax/email to David Maxwell, Project Officer, fax: 02 8382 3529 or email: [email protected] before 15/12/2003. Tools to facilitate the recruitment process within your hospital will be circulated after NSW TAG has received your initial EOI. The final “Response Form”, included in the tools package, should be returned to NSW TAG (via fax/email as above) with indication of support, no later than 27/02/04. If you have any questions about the project or the recruitment process please do not hesitate to contact David Maxwell, ph 02 8382 3328, or myself ph 02 8382 3097. We look forward to hearing from you and hopefully working with you on this project soon, Karen Kaye Executive Officer


September 2005 14

Package 3 – Hospital Recruitment: 3.1.2 Project Description

CAPTION Study – Community Acquired Pneumonia: Towards Improving

Outcomes Nationally

Background: NSW Therapeutic Advisory Group (TAG) is an independent, non-profit organisation funded by NSW Health Department, which promotes quality use of medicines in NSW hospitals through collaboration and consensus. Teaching hospital Drug Committees and academic units are represented by Clinical Pharmacologists, Directors of Pharmacy and other clinicians. NSW TAG also supports a network of rural and metropolitan non-teaching hospitals (TAGNet), which shares information via a web site (www.nswtag.org.au), accessible via the NSW Health’s Clinical Information Access Program. NSW TAG has received funding from the National Prescribing Service (NPS) to participate in a national collaborative quality improvement activity and to coordinate activity in NSW hospitals. The NPS is an independent, non-profit organisation funded by the Commonwealth government, which aims to improve the health of Australians through quality prescribing of medicines.

Project Rationale: There is evidence that knowledge of and adherence to the CAP and bronchitis management guidelines from the Therapeutic Guidelines – Antibiotics (TGAB) in Australian hospitals are sub optimal. An unpublished Victorian Drug Usage Evaluation (DUE) project(1) demonstrated prescribing of 3rd generation cephalosporins in the management of respiratory tract infections (RTIs) complied with the TGAB in only 25% of cases reviewed. A recent study in a large NSW teaching hospital(2) demonstrated 66% of ceftriaxone prescribed for RTIs was not concordant with the TGAB. A Victorian based Emergency Department (ED) physicians survey(1) demonstrated that the treatment for severe community acquired pneumonia was not in concordance with national prescribing guidelines. The routine use of third generation cephalosporins (ceftriaxone or cefotaxime) for non-severe CAP provides no additional benefit over the penicillins(3).

There are a number of potential benefits of improving concordance with TGAB12thEd guidelines: • Reduction in overall use of antibiotics • Increase in use of narrower spectrum antibiotics • Broad-spectrum antibiotics being reserved for more acutely unwell patients • More appropriate drug choice in the management of CAP and bronchitis • Reduction in development of resistant organisms in hospital setting • Patients being offered treatment that represents the most up to date evidence based therapy, resulting in the highest standard of medical care and service


September 2005 15

Community Acquired Pneumonia – Management Guidelines (TGAB 12thEd) CAP is defined as pneumonia occurring in individuals who are not in hospital (or have been in hospital for less than 48 hours) and who are not significantly immunocompromised.

The guidelines are based the Pneumonia Severity Index (PSI), a scoring system that was developed and validated by a large number of North American studies. The PSI stratifies patients with CAP according to their risk of mortality. The PSI score allows for greater confidence in patient triage and can help direct the appropriate choice of antibiotics. The PSI is calculated according to individual patient demographics and clinical signs/symptoms upon presentation. The final score is used to classify the patient to a PSI risk class ranked from 1 to 5, with class 1 being the lowest risk of mortality and class 5 the highest. A management algorithm is then applied, using the PSI severity class, to determine the most appropriate treatment. The PSI risk class is used to determine appropriate antibiotic choice and the most suitable place for management i.e. at home, at a general ward level or an intensive care unit. Drug choice is also influenced by the potential for tropical or non-tropical sources of infection.

Bronchitis – Management Guidelines (TGAB12thEd) Acute bronchitis in an immunocompetent patient is most often viral, not bacterial, and does not require antibiotic therapy. Pneumonia should be considered in patients with more severe illness.

More often than not, acute exacerbations of chronic bronchitis are due to non-infective causes. Chronic bronchitis sufferers may be persistently colonised with bacteria and hence a positive sputum culture does not always indicate an acute infection. Antibiotic therapy may not be appropriate in these situations. Antibiotics have only been shown to be effective when all 3 cardinal symptoms of acute bacterial exacerbations are present: increased dyspnoea, increased sputum volume and sputum purulence.

Amoxycillin or doxycycline are the drugs of choice when a patient has a true acute bacterial exacerbation of chronic bronchitis. Other antibiotics such as macrolides, cephalosporins, amoxycillin+clavulanate and fluoroquinolones have not been shown to be superior and are not recommended by the TGAB12thEd.

Project Aim: This project aims to: • Introduce and implement the CAP and bronchitis management guidelines (TGAB 12th Ed.) into the ED • Influence and improve the prescribing practice in the management of CAP and bronchitis in the ED


September 2005 16

• Train hospital health care professionals in appropriate techniques for influencing and improving prescribing practice. Project Methodology: NSW hospitals with an ED, public or private, will be eligible to participate. A maximum of 12 hospitals will be included in the final study group. The project will employ established DUE methodology, which has been successfully implemented by NSW TAG previously. This involves data collection, evaluation of data against the TGAB12thEd guidelines, feedback of evaluated data and targeted educational interventions. Multiple DUE cycles will be implemented during the course of the 2-year project.

A steering committee will be convened comprising ED specialists, respiratory specialists, microbiologists, infectious disease specialists, clinical pharmacologists, pharmacists, ED nurses, NPS staff members, quality improvement staff, consumers, TG editors and other stakeholders. It will provide advice for project direction, development of feedback and educational materials and mechanisms for on-going sustainability of the program. Each hospital will be asked to nominate a project coordinator. The hospital coordinator will be responsible for liaison with ED staff, hospital Drug Committee and other authoritative hospital committees and for coordinating the data collection and feedback programs in the hospital. NSW TAG will provide information and support to hospital coordinators to facilitate these processes. Hospitals will: • Allocate a hospital coordinator, who will become a member of the NSW

TAG project group, to coordinate the project at a local level. The coordinator will: 1. act as the point of contact between the hospital and NSW TAG 2. be part of the local project team (see below) and report to the NSW TAG

project group 3. coordinate and facilitate DUE cycles within their institution 4. collate and send all relevant data to NSW TAG

• Recruit a hospital project team to oversee the project at a local level. It is envisaged that the local teams might include a medical officer from emergency, respiratory medicine and infectious diseases, a pharmacist, an emergency nurse, a representative from medical records and the hospital coordinator.

• Allocate a hospital facilitator to facilitate the education sessions at the hospital. The facilitator would be expected to attend the academic detailing training course offered through the project (The facilitator and the coordinator may be the same person).

• Commit to completing the required tasks for the project duration. NSW TAG will:


September 2005 17

• provide support to hospital coordinators at each stage of the project • provide guidance regarding data collection and management • prepare templates for data collection and feedback • prepare and distribute materials to facilitate and support educational

interventions • facilitate on-line and teleconference discussion forums for hospital coordinators

to allow sharing of information (eg, about successful interventions and strategies)

NPS will: • oversee all aspects of the national project • provide education to all hospital coordinators in the areas of social marketing

and academic detailing • facilitate communication between state-based groups coordinating DUE activity

Project Group This collaborative project will be managed under the auspices of the National Prescribing Service and will be conducted by the NSW TAG through the NSW TAG Drug Use Evaluation Support Group.

Further information can be obtained by contacting David Maxwell, Project Officer, NSW TAG or Karen Kaye, Executive Officer, NSW TAG. Telephone: 02 8382 2852 Facsimile: 02 9360 1005 Email: [email protected] Web site: www.nswtag.org.au

References: 1. Personal communication, S. Kirsa, VDUEG. 2. “Antibiotic Restrictions – Comply or Resist” DUE report, Pharmacy Department, Therapeutics Centre, St. Vincent’s Hospital, Darlinghurst, NSW 3. Therapeutic Guidelines: Antibiotic – 12th Edition, 2003


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Package 3 – Hospital Recruitment: 3.1.3 EOI fax-back form

Initial Expression of Interest Form Please complete the details in this table and FAX or email to:

David Maxwell NSW Therapeutic Advisory Group Fax: 02 8382 3529 Email: [email protected] Tel: 02 8382 3328

FAX Date:

Contact Name Hospital Address Telephone Our hospital would like express an interest to participate in the CAPTION Study

Yes / No

To be returned to NSW TAG by 15/12/2003


September 2005 19

Package 3 – Hospital Recruitment: 3.2 Final sign-off 3.2.1 Letter to Drug and Therapeutics Committee Dear Drug and Therapeutics Committee Chair, Re: CAPTION Study – Community Acquired Pneumonia: Towards Improving Outcomes Nationally The NSW Therapeutic Advisory Group (TAG) in conjunction with the National Prescribing Service (NPS) would like to invite your hospital to participate in this project aimed at improving patient care in the management of Community Acquired Pneumonia (CAP). One of the primary objectives of the study is to introduce and implement the Therapeutic Guidelines Antibiotic Guidelines 12th Edition (TGAB12thEd) recommendations for the management of CAP in the hospital environment. Background: A multi-centre Drug Usage Evaluation (DUE) investigating the treatment of lower respiratory tract infections in emergency departments was conducted across Victorian hospitals in 2001. The project, funded by the NPS, demonstrated a low level of concordance with the TGAB (11th Edition [current at the time]). Since the time of the study there have been major changes to the recommendations for treatment of community-acquired pneumonia in the new edition of the guidelines (TGAB12thEd) involving more precise assessment of the severity of the illness using the Pneumonia Severity Index (PSI). The PSI is a scoring system that involves assigning a numerical value to elements of clinical history and simple physical signs that are commonly assessed in patients with suspected CAP. The advantages of using the PSI include: • Reducing uncertainty in the diagnosis • Better placement of patients (home, ward, ICU) • Consistency of drug choice for empiric treatment. Calculation of the PSI is an additional step in the management of the patient and as with guidelines generally it is unlikely to be taken up widely within an institution or an emergency department without the help of specific intervention.

For these reasons NPS is supporting an Australia-wide project to implement the TGAB12thEd recommendations for the treatment of CAP and exacerbation of chronic and acute bronchitis in emergency departments over a two-year period. NSW TAG has been commissioned to facilitate the project across 12 NSW hospitals as part of the national study involving 40 hospitals.


September 2005 20

Project details: Through a planned intervention process NSW TAG aims to simplify the use of PSI and hence to increase physician confidence in assessment and prescribing of antibiotics for CAP. As a result of this approach it is hoped to not only improve patient placement and diagnosis but also potentially decrease length of stay and the length of therapy within the hospital as a result of more consistent use of the guidelines. It is expected that the study will occur in three phases: • Phase 1 – A retrospective review of management of CAP will be conducted

in each participating hospital to provide baseline data. As well, local prescribers will be interviewed with the aim of identifying attitudes and perceptions towards the management of CAP and the new TGAB12thEd recommendations.

• Phase 2 (intervention phase) – An education package will be presented to hospital staff. A hospital employee, who will be trained by NPS in social marketing techniques, including academic detailing, will facilitate implementation of the education package. Hospital facilitators will have access to a range of nationally developed intervention tools including computer based systems for antibiotic decision support or simply for calculating the PSI, laminated scoring cards or worksheets. Each hospital will have the opportunity to choose and/or customise one or more of the intervention tools. Phase 2 is likely to involve several iterative DUE cycles with regular audit of prescribing data and feedback to prescribers.

• Phase 3 is optional to all participating hospitals and will commence after phase two. It involves the implementation of the TGAB12thEd recommendations for management of acute and chronic bronchitis.

Documents to assist in facilitating Institutional Ethics Committees approval of the project will be developed by NPS and NSW TAG and will be made available to hospitals through the NSW TAG Project Officer. What’s in it for the hospital? 1. Staff training in social marketing techniques – an integral part of the study is

to provide at least one staff member from each participating site the opportunity to attend a 3 day course in developing skills associated with social marketing. This course is organised by the NPS and run by the Drug and Therapeutics Information Service group from South Australia.

2. Audit and feedback tools for evaluating empiric treatment of CAP - this will enable your Emergency Department (ED) to demonstrate the level of concordance with the recommendations in the TGAB12thEd and to provide feedback to ED doctors.

3. Participation will allow staff to develop quality improvement and change management skills in a supportive environment. These skills will be transferable to other projects the team may wish to undertake. The project would provide the opportunity to benchmark with other participating hospitals,


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demonstrate use of evidenced based medicine and demonstrate achievement at best practice level for the management of patients presenting with CAP.

What is required of the hospital? 1. Allocation of a hospital coordinator, who will become a member of the NSW

TAG project group, to coordinate the project at a local level. The coordinator will: • act as the point of contact between the hospital and NSW TAG • be part of the local project team (see below) and report to the NSW TAG

project group • coordinate and help facilitate DUE cycles within their institution • collate and send all relevant data to NSW TAG.

2. Recruitment of a hospital project team to oversee the project at a local level. It is envisaged that the local teams might include a medical officer from emergency, respiratory medicine and infectious diseases, a pharmacist, an emergency nurse, representative from medical records and the hospital coordinator.

3. Allocation of a hospital facilitator to facilitate the education sessions at the hospital. The facilitator would be expected to attend the academic detailing training course offered through the project (the facilitator and the coordinator maybe the same person).

4. Commitment to completing the required tasks for the project duration. Please call or email David Maxwell: [email protected], NSW TAG project officer, to indicate your interest in participating in the project. If you have any concerns or questions please contact David or myself on 02 8382 2852. Yours sincerely, Karen Kaye Executive Officer


September 2005 22

Package 3 – Hospital Recruitment: 3.2.2 CEO and Departmental Heads sign-off form Ms Karen Kaye Executive Officer NSW Therapeutic Advisory Group Inc. Level 5, 376 Victoria Street PO Box 766 Darlinghurst NSW 2010 Dear Karen, Thank you for the opportunity to review the information for a multi-centre drug use evaluation project entitled: CAPTION Study. This organisation supports the project and is interested in participating. Director, Emergency Department Director, Pharmacy Department Chief Executive Officer


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Package 3 – Hospital Recruitment: 3.2.3 Institutional Ethics Committee Information Kit 3.2.3.1 Letter to the Chair of the IEC To Whom It May Concern: Re: A Multicentre Drug Use Evaluation in Hospitals – The CAPTION Study This project is a national collaborative quality improvement project involving twelve hospitals in NSW and up to 40 hospitals nationally. It aims to introduce and implement the new Therapeutic Guidelines – Antibiotics 12th Edition for the management of Community Acquired Pneumonia (CAP) and bronchitis in the Emergency Department. The introduction and implementation of the guidelines will be facilitated through local hospital employees who will coordinate a number of education interventions within their institution. Audit and feedback processes will be used at intervals through out the project period as part of the intervention program and to assist in evaluating the impact of the project. The project is funded by the National Prescribing Service (NPS) and is coordinated by the New South Wales Therapeutic Advisory Group (NSW TAG). NSW TAG is an independent, incorporated association of clinical pharmacologists, pharmacists and clinicians committed to promoting quality drug use in hospitals and the wider community. Its members represent Drug Committees from the teaching hospitals in New South Wales. The NPS is an independent, non-profit organisation funded by the Commonwealth government, which aims to improve the health of Australians through quality prescribing of medicines. The project will utilise iterative Drug Use Evaluation (DUE) methodology, which is a well established methodology for facilitating implementation of best practice. Hospital personnel normally involved in patient care will undertake the data collection required for the project. The provisions of the NSW Privacy Act will be maintained at all times. As this is a quality improvement project, patient consent to review prescribing records will not be sought. All data will be de-identified before being sent to NSW TAG for aggregation. Hospitals will be de-identified in aggregated reports. A list of participating hospitals will be included in the final report, but data will not be published without permission from each participating hospital. Please find attached a project description, the proposed project reporting structure and a copy of the data collection instrument for your information. The data collection instrument may be updated after pilot testing and through revision by the project Steering Committee, and all, if any, alterations will be forwarded to your committee for approval prior to utilisation. Thank you for considering this project for approval by your committee.


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Package 3 – Hospital Recruitment: 3.2.3.2 Answers to FAQs commonly asked by IECs The following questions may be included in Ethics Committee application forms. Suggested answers are provided for your information. Has this project been submitted to other Ethics Committee’s already? If so indicate the status of each application. This multi-centre quality improvement project is in the process of being submitted to other ethics committees. The outcomes of the other ethics committees’ deliberations are not yet known. How will the results of this project be disseminated? The results of this project will be disseminated via a report to the National Prescribing Service (NPS). A manuscript will be prepared for publication in a peer-reviewed journal. All data will be de-identified. Participating hospitals will only be acknowledged if they agree to do so. What is the proposed storage of, and access to, files etc during the study? How long will the data files etc be retained after the study and how will they be disposed of? Data collection forms will only be accessible to the hospital staff members involved in the project. The hospital staff involved in the project will code and/or de-identify all patient data before recording. De-identified data may be submitted to New South Wales Therapeutic Advisory Group (NSW TAG) for aggregation, with participating hospitals coded for de-identification purposes. NSW TAG will not be provided with codes used by the hospital. All de-identified data forwarded to NSW TAG will be stored in a password protected Microsoft Access Database. As this is a quality improvement project, all data will be destroyed by the hospital staff members involved in the project once the results have been reported. Will this research be undertaken on behalf of (or at the request of) a pharmaceutical company, or other commercial entity, or any other sponsor? This project will be undertaken by NSW TAG Inc and is funded by the NPS. NSW TAG is a committee of clinical pharmacologists, pharmacists and clinicians which promotes quality drug use in hospitals and the wider community. It is an independent, incorporated association whose members represent Drug Committees from NSW teaching hospitals. The NPS is an independent, non-profit organisation funded by the Commonwealth government, which aims to improve the health of Australians through quality prescribing of medicines. Will the entity undertake in writing to indemnify the institution, the HREC(s) and the researchers? No


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Does the sponsor hold a current insurance policy to cover the project? No. This is a quality improvement project, with no research involved. Do the researchers have any affiliation with, or financial involvement in, any organisation or entity with direct or indirect interests in the subject matter or materials of this research? No


September 2005 26

Package 3 – Hospital Recruitment: 3.2.3.3 Information on proposed data collection Background: During the planning of the NPS funded Community Acquired Pneumonia (CAP)/Bronchitis project it was identified that a review of local (NSW) practice in CAP management might assist in demonstrating to medical officers in NSW hospitals the potential benefits of new guidelines (Therapeutic Guidelines – Antibiotics 12th edition [TGAB12]). Aim: To review current practice in the management of CAP in 12 NSW teaching hospital Emergency Departments (ED) (pre-intervention). Method: • A retrospective medical records audit will be conducted in each participating

hospital • Patients will be identified through the ICD-10-AM codes using J13.0 – J18

that code for bacterial pneumonia (and exclude viral pneumonia) • Each hospital will review 20 consecutive patient episodes involving the

management of CAP admitted through the ED • Hospitals will need to document the time period (days/months) that was

required to capture the 20 patients and also the time of year that the patient presented to the ED

• Data collected for each episode will include patient demographics, signs and symptoms upon presentation and initial test results (see data collection form)

• The Pneumonia Severity Index score would be calculated using the above data (as per the TGAB12)

• After calculation of the PSI management will be compared to the TGAB12: - antibiotic choice - duration of antibiotic therapy - place of treatment (home/ED/ward/ITU)

• Communication to GP (via discharge summary) will also be reviewed Data Analysis: • The data will be used to investigate and demonstrate any variations in

prescribing practice across the state and provide a comparison with the TGAB12 guidelines.

• The data will also be used to investigate if in fact current practice does reflect the TGAB12 and medical officers are treating in concordance with the guidelines without using the PSI scoring system and algorithm.

Results: The results of the audit will be fed back to the participating hospitals. Each hospital will receive their own local data as well as the overall grouped results.


September 2005 27

The results will also be used as part of an education campaign/intervention to introduce the TGAB12 into emergency departments. Background Data Collection: (after patient medical records have been identified) Step 1. Calculate the PSI. Step 2. Assign PSI classification (I – V) based on PSI calculated in step 1. Step 3. Identify recommended treatment pathway in management algorithm. Step 4. Document initial antibiotic selection, duration of treatment, changes to therapy and antibiotics on discharge. Step 5. Compare results of step 4 to the guidelines (TGAB12) identified in step 3. Step 6. Document any other relevant information including, where relevant, any communication to the GP via the hospital discharge summary.


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Package 3 – Hospital Recruitment:. 3.2.4 Final Response Form Please complete the details in this table and FAX or email to:

David Maxwell NSW Therapeutic Advisory Group Fax: 02 8382 3529 Email: [email protected] Tel: 02 8382 3328

FAX Date: Number of pages:

Hospital

Address

Telephone

Our hospital project co-ordinator is: His/her telephone number is:

His/her email address is: Administrative approval / support for this quality improvement program in our hospital has been given. (Please attach letter or other evidence.) (CEO and DTC approval is required for participation. Other approval is at the discretion of the hospital.)

Chief Executive Officer: Yes / No Drug and Therapeutics Committee: Yes / No Quality Committee: Yes / No Ethics Committee: Yes / No

To be returned to NSW TAG by the 27/02/2004


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Package 4. Data Collection Tool

Contains: 4.1 Data collection form 4.2 Pilot study results

Package 4 Data Collection Tool


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Package 4 - Data Collection Tool: 4.1 Data collection form


September 2005 31


September 2005 32

Package 4 – Data collection tool 4.2 Pilot study report Background: Community Acquired Pneumonia (CAP) is a common worldwide disease1. A recent report in Australia has shown that it accounts for 2% of hospital admission with a death rate as high as 7 to 10%1. CAP is defined as an infection of the lower respiratory tract of an individual who contracted pneumonia outside hospital or has been in hospital for less than 48 hours2. Although there has insufficient information on the incidence of CAP in Australia, there has some evidence that treatment strategy of CAP was not in concordance with the Therapeutic Guidelines for Antibiotics (TGAB version 12)3. The current treatment strategies for CAP are empirical whereas the Australian guidelines advocate the use of Pneumonia Severity Index4 (PSI) score to classify patients with CAP into 5 classes for management. This score assists clinicians in making an initial assessment in regards to disease severity and hence minimize any unnecessary hospitalization4. The CAPTION (Community Acquired Pneumonia: Towards Improving Outcomes Nationally) project is multi-centre evaluation of the treatment strategies of patients with CAP in emergency department in Australian hospitals. This project is funded by National Prescribing Service and the NSW Therapeutic Advisory Group is responsible for the co-ordination of all NSW project activities. The main objective is to introduce and implement Australian guidelines of CAP management into emergency departments (ED) of hospitals in Australia. The study utilises Drug Usage Evaluation (DUE) methodology, which is a continuous process, includes investigative and interventional phases5. DUE in this Quality Use of Medicines (QUM) project focused mainly on data collection and evaluation of the appropriateness of the data collection form. The baseline data collection form was developed by the state based project group and endorsed by the relevant steering committee. Objectives: • To investigate how DUE cycle plays an important role in quality use of

medicines • To pilot national data collection form for the CAPTION project at St. Vincent’s

Hospital • To evaluate the appropriateness of the draft data collection form • To suggest methods of improvement Method: A retrospective review of patient records was conducted at St. Vincent’s Hospital. Patient records with ICD-10-AM (ICD-10-AM: International Classification of Diseases-10th Revision-Australian Modification) codes classified as J12, J13, J14, J15, J16, J17.8, J18 and J44.0 were selected. All identified patient records


September 2005 33

met the inclusion criteria and were further reviewed for exclusion criteria (Table 1). The follow patient data were collected: demographics, principle of diagnosis, data required to calculate PSI score, antibiotic therapy, and discharge summary details. Data collected from this review will be used to calculate PSI score and hence determine the concordance with the implementation of antibiotic guidelines in hospital setting. The following data were collected: demographics, initial diagnosis, data required to calculate PSI, initial antibiotic regimen, initial changes to the antibiotic regimen and discharge summary details. The exact location of data that was found within the medical notes was documented. Evaluation of the data collection process was made in terms of the difficulty in finding the relevant date, adequate space for documentation, and the ease of interpreting data. A summary of suggested methods for improvement would be fed back to the project committee. Results: Records of 50 patients were assessed with 22 patients had CAP that met the criteria for this project. One of the 22 selected records was excluded because incompleteness of medication chart had been reported. One record included had a diagnosis from doctor’s notes as LLL pneumonia immuno-compromised patient but there was no evidence to support that patient was immuno-compromised during this admission. There were four records which were included although their discharge summaries were missing. The exact location of data (Table 2) Discussion: It was found that a check list including ICD-10-AM code, inclusion and exclusion criteria and definition of all co-existing illnesses may help. It was also important to determine which terms will be commonly written as abbreviations or reviewed as synonyms and made known to data collectors. Part I: demographics In general, it was found that demographic data were written in an order that was easy to follow. Some questions such as 4 and 7 may need to include the words “not documented” to fit the question. This was because in most of the cases the source of admission was not documented in either Progress notes or ED registration form. In addition to this, it was suggested that question 5 may include an option showing whether a patient is allergic to penicillin. Part II: data essential for PSI calculation It was found that only one of the selected records had a diagnosis written as CAP. All the others were not documented as specific as such. Therefore, the wordings of inclusion criteria may need to be modified. In regards to the finding on patient’s co-existing illnesses, it was suggested that any information found from the first page of progress notes needed to be confirmed by further reading with few more notes or ED assessment records in order to get complete and reliable data.


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There was some confusion in regards to recording the true oxygen saturation value when patients had already been put on mask or nasal prong. Therefore, whether the data was recorded from room air condition may need to be documented. A table format for question 12 may be useful for data collector to avoid any misreading and putting of figures into a wrong space. In addition, it would be much easier for recording if the sequence of the required data is the same as the order of data presented in the pathology notes. There were some cases in which patients had multiple illnesses and hence the reason why antibiotic(s) had been administrated may not be easily identified. Part III: discharge summary details Question 19 may include “not applicable” in case where patients died during the admission and it may be put in an order that is next to Q 20. For a similar reason, Q 22 may be put after Q8 to avoid confusion with the previous question which was related to re-admission. Conclusion: DUE is an important tool to achieve QUM. By taking part of DUE evaluation, the suggested modification of the data collection form may give potential benefits for further investigation on this project and accuracy could be enhanced in the future.


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Table 1: CAPTION inclusion/exclusion criteria

Patients with age > 18 Inclusion criteria

A diagnosis of CAP made by ED practitioners in medical records

1. Immunocompromised patients :

• HIV positives

• Patients on chemotherapy

• Patients on prednisolone at home

2. Patients recently discharged from hospital for less than 14

days

3. Patients with any of the following co-existing condition:

• Suspected tuberculosis

• Cystic fibrosis

• Bronchiectasis

• Aspiration pneumonia

Exclusion criteria

4. Patients admitted from another hospital


September 2005 36

Table 2: Location of data and Evaluation Part I: Demographic Factors: Question number: Source* comment Is difficult to assess the

data (Yes/No) 3. Date of birth E

- No

M/F E - N0

Pregnancy - Not documented -

4.Gender

breast-

feeding

- Not documented -

5. History of an immediate penicillin hypersensitivity documented

EDAR, M,

P

Mainly from P No

5a. Previous adverse reaction(s) to antibiotics documented

EDAR, P - No

6. Date of admission to

ED

E - No

7. Admitted to ED from EDRF, P Usually not documented if patients were admitted

from home

Yes

8. Discharged from ED to E Need to read a few more pages to get the data

No


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Part II: Diagnosis, Signs, and Co-existing illness Question Number Source* Comment Is difficult to assess

the data (Yes/No) 9. Diagnosis (from Dr’s notes)

P No

10. Evidence consistent with pneumonia in Dr/Radiology notes

C, P No

11. Documented - Not documented - 11. PSI 11a. calculated prior AB were given

- Not documented -

Neoplastic disease EDAR, P Mainly from P - liver disease EDAR, P Mainly from P - Congestive cardiac failure

EDAR, P Mainly from P Yes

Cerebrovascular disease


12. co-existing illness

Chronic renal disease


Acutely altered mental state

EDAR, P Mainly from EDAR No

respiratory rate EDAR, May be on EDRF No systolic blood pressure

EDAR, May be on EDRF No

Temperature EDAR May be on EDRF No

12. signs on exam-ination

pulse rate EDAR May be on EDRF No arterial pH C Not always found No serum urea C - No serum sodium C - No serum glucose C Not always found No Haematocrit C - No paO2 C Not always found No O2 saturation EDAR - Yes

12. Results of investing-ations

pleural effusion on chest X-ray

C - No

13. Use of AB in the 7 days prior to admission to ED documented

EDAR, P Need to check both No

AB prescribed in the ED

P, M Much easier to assess data from M

No 14.

Details of initial AB regimen


No

15. Person recommended / prescribed AB documented

P Not always documented

No

16. Changes of AB regimen + details documented


No


September 2005 38

Part III: Follow up after discharged from hospital / ED Question Number Source* comment Is difficult to assess the

data (Yes/No)

17. Date of discharge E Clearly printed No

18. Diagnosis documented on discharge summary

D Sometimes it was missing

No

I9. Information on AB / follow-up appointments provided

D - No

20. Loss of patient during admission

D - No

21. Re-admission within 14 days of discharge with a LRTI

O (from the

next record)

- No

22. Other factors contributed to the re- admission

P - No

*C: Computer with sub title as Clinical pathology (blood chemistry, blood gas) & Medical Imaging; D: Discharge Referral Letter; E: Emergency Cover Sheet; EDAR: Emergency Department Assessment Record; EDRF: Emergency Department Registration Form; M: Medication Chart; P: Progress notes; O: Others (specify).


September 2005 39

References: 1. Andresen DN, Collignon PJ. Antibiotics for community-acquired pneumonia:

time to return to the straight and narrow? MJA 2001; 174:321-3. 2. Barlow GD, Lamping DL, Davey P, Nathwani D. Evaluation of outcomes in

Community Acquired Pneumonia: a guide for patients, physicians, and policy-makers. The Lancet 2003; 362:1991-7.

3. Antibiotic Writing Group. Therapeutic Guidelines: antibiotic (version 12). North Melbourne: Therapeutic Guidelines Ltd; 2003.

4. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Eng J of Med 1997; 336:243-50.

5. Dartnell JGA. Understanding, influencing and evaluating drug use. North Melbourne: Therapeutic Guidelines Ltd; 2001.


September 2005 40

Package 5. Intervention Tools

Contains: 5.1 Letter of introduction 5.2 Detailing card 5.3 Poster 5.4 ID cards 5.5 PSI calculator stickers

Package 5 Intervention Tools


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Package 5 – Interventions Tools: 5.1 Letter of introduction Your Hospital Name YOUR HOSPITAL ADDRESS Insert date Dear Dr _____________ Re: Community-acquired pneumonia: towards improving outcomes nationally (CAPTION) The NSW Therapeutic Advisory Group (NSW TAG), in conjunction with the National Prescribing Service (NPS), would like to make you aware of an exciting new community acquired pneumonia project that insert your hospital name is participating in. The CAPTION project aims to implement the Therapeutic Guidelines: Antibiotic Version 12 recommendations for treating community acquired pneumonia into the Emergency Department (ED). The recommendations include the use of a structured approach to severity assessment and selection of antibiotic therapy according to disease severity. Background: A recent review of antibiotic treatment in lower respiratory tract infections in EDs, conducted by the Victorian Drug Usage Evaluation Group (VDUEG), indicated a particularly low rate of concordance with the national antibiotic prescribing guidelines (Therapeutic Guidelines: Antibiotic [version 11]). Since the review, Therapeutic Guidelines have made a number of changes to the recommendations for management of community-acquired pneumonia (version 12), with the inclusion of a structured approach to the assessment of illness severity, using the Pneumonia Severity Index (PSI). The PSI is a scoring system, assigning numerical values to elements of clinical history and physical signs/symptoms commonly assessed in patients presenting with suspected CAP. The sum of these values stratifies patients according to risk of mortality. Antibiotic therapy is directed by disease severity. Advantages of this approach include:

Reducing uncertainty in the assessment of disease severity Appropriate placement of patients (home, ward, ICU) Consistency of drug choice for empiric antibiotic therapy.


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Calculation of the PSI is an additional step in the management of the patient and, as with guidelines generally, it is unlikely to be taken up widely within an institution or an ED without the help of specific intervention. For these reasons the NPS is supporting an Australia-wide project to implement the Antibiotic Guidelines Version 12 CAP management recommendations. NSW TAG has been commissioned to carry out this project in 12 NSW / ACT hospitals as part of a national study in 40 hospitals. Project details: The recommendations of the Therapeutic Guidelines will be introduced through a planned intervention/education process. A review of current practice at this hospital has been completed and these baseline data will be used as part of the education campaign. CAPTION intervention activities include academic detailing, small group education sessions and grand round presentations as well as point of prescribing reminders, such as ID card PSI calculators, posters and adhesive PSI score cards for patient notes. The interventions are being implemented with the assistance of the clinical champion, Dr XXXX, and project coordinator YYYY.

Please do not hesitate to contact me or XXXX/YYYY if you have any questions or would like any further information about CAPTION.

Yours Sincerely,

David Maxwell Project Officer NSW TAG


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Package 5 – Intervention Tools: 5.2 Detailing card Page 1:


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Page 2 and 3:


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Page 4:


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Package 5 – Intervention Tools: 5.3 Poster


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Package 5 – Intervention Tools: 5.4 ID cards


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Package 5 – Intervention Tools: 5.5 PSI calculator stickers


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Package 6. Academic detailing

Contains 6.1 Workshop outline 6.2 Participants 6.3 NSW TAG support framework 6.4 Case study 6.5 Workshop evaluation log

Package 6 Intervention Tools


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Package 6 – Academic Detailing: 6.1 Workshop outline Day One Day Two

Start 9.00 am Start 8.30 am

Session 1:

Therapeutic briefing presentation

Questions and discussion

Session 5:

Objectives of the visit

Exploring features and benefits of key messages.

Exploring barriers of the key messages

Morning tea 11.00 am to 11.30 am Morning tea 10.30 am – 11.00am

Session 2:

Outline of workshop

An overview of academic detailing

Structure of academic detailing visit

Session 6:

Handling challenging responses

Practicing verbal skills

Closing the loop and role plays

Lunch 12.30 pm to 1.00 pm Lunch 1.00 pm to 1.30pm

Session 3:

Demonstration of academic detailing (video)

Role plays

Exploring values and beliefs

Barriers to communication

Session 7:

Structure of the visit

Role play

Afternoon tea 3.00 pm – 3.15pm Afternoon tea 2.45 pm – 3.00pm

Session 4:

Emergency department panel discussion

Dr James Edwards, Dr Janet Talbot-Stern

Building trust and credibility

Putting these skills together

Role play

Demonstration (video)

Session 8:

Making your video with nurse and doctor

Dr Tim Green, Dr Digby Green, Ms Nerida Bell, Ms Marianne Gayed

Debriefing

Taking detailing back to your hospital (final 30 minutes until 5pm)


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Package 6 – Academic Detailing: 6.2 Participants Chair: David Maxwell Trainers: Deborah Rowett, Andrea Mant Facilitators: Kylie Easton, Karen Kaye, Cate Kelly Therapeutic Educator: John Ferguson ED physician panel discussion: James Edwards, Janet Talbot-Stern Practice Visits: Tim Green (ED doctor), Digby Green (ED doctor), Nerida Bell (Nurse) and Marianne Gayed (Pharmacist). Hospital Name Representative Profession St. Vincents Hospital Bret Ryder Pharmacist Broken Hill Hospital Coral Bennett Nurse Concord Repatriation Hospital

Evette Buono Pharmacist

Royal North Shore Hospital

Roseleen O’Doherty Pharmacist

Royal Prince Alfred Hospital

Sue Aran Pharmacist

Goulburn Base Hospital Alice McKellar Pharmacist Moruya District Hospital Joanne McMahon Pharmacist Batemans Bay Hospital Joanne McMahon Pharmacist Calvary Hospital Alison Hulse Pharmacist Canberra Hospital Natalie Bula Pharmacist Lismore Base Hospital Margaret Hewetson

Paul Laird Pharmacist Physician


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Package 6 – Academic Detailing: 6.3 NSW TAG support structure Overall Support to Participating Hospitals: - Project officer employed by NSW TAG four days/week. - NSW CAPTION hospital newsletters issued monthly, available on the Drug Utilisation page of the NSW TAG website. - Teleconference meetings conducted on an ‘as needed’ basis. - Email support for the facilitation of questions and answers to all aspects of the CAPTION project. - Consultation with a local expert to answer any clinical issues arising in participating hospitals - Site visits to each participating hospital. - Secretarial service (minute taking, facilitation of communication etc.) Academic Detailing: Role of NSW TAG - The project officer will act as the contact person at NSW TAG to answer any questions raised and provide information requested by those trained in academic detailing and the local clinical champion for the CAPTION project. - Where possible detailers will be given the opportunity to practice their skills by conducting a one-on-one visit with the NSW TAG CAPTION project officer. - Teleconferences will be conducted at regular intervals for all detailers, to share experiences and debrief. Expert advice will be sought from external professionals e.g. Deborah Rowett, Jenny Shaw and members of the SHPA detailing Committee of Specialty Practice will be invited to participate in the teleconferences. Typical items on the meeting agenda would include: sharing of detailing experiences, positive experiences, challenging visits, frequently asked questions, tips and questions and moving forward. Key points raised in the meeting will be noted by the NSW TAG project officer and circulated to all participants. Role of Hospital Clinical Champion and Project Team - The clinical champion will provide opportunities for the academic detailer to practice or ‘role play’ a number of visits and provide feedback on presentation and content. - The clinical champion will be responsible for ensuring that the visits are being conducted. The CC will ensure that hospital staff attend the sessions. - The project team will be responsible for developing an academic detailing strategy and will discuss their strategy with the state project officer.


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- The project team will also be responsible for completing the intervention log pertaining to all academic detailing activities.


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Package 6 - Academic Detailing: 6.4 Case study CAPTION – CAP: Clinical Presentation The following ‘Clinical Presentation’ and questions have been circulated for the purpose of stimulating discussion and promoting the recommendations of the Therapeutic Guidelines: Antibiotic version 12 to manage CAP. It is intended for use by the CAPTION trained academic detailers only, as an exercise to familiarise themselves with the process of PSI calculation, appropriate antibiotic selection and identifying the key features in diagnosing CAP. All answers and/or points for discussion should be returned to NSW TAG, this can be anonymous. A review/summary of responses will be provided to all participants, along with some general comments from a clinical expert. Clinical Presentation* Mr D.N, a 57 year old male, is seen in the Emergency Department with the chief complaint of severe right-sided chest pain. Two hours earlier, he felt feverish and experienced a ‘teeth chattering’ chill. Shortly after this episode, his chest began hurting; the pain has increased in intensity over the last 30 minutes to the point now where it is quite difficult for him to breathe. He has a productive cough and his sputum is pinkish or ‘rusty’ in appearance. His respirations are shallow and rapid. Significant medical history only includes a flu-like syndrome which began 7 days ago. On examination D.N.’s blood pressure 130/81 mmHg, heart rate 106 beats/min, respirations 28/min and temperature 38.2 degrees Celsius. Chest examination reveals that D.N. is tachypnoeic and favours his right side with inspiration. He has light crackling rales over his right lung base on auscultation and complains of tenderness and dullness to percussion in the same area. There is no neck stiffness, or joint pain, or swelling, or abdominal complaints. Laboratory results are as follows: WBC count 18.6 x 109/L, haematocrit 0.425 (or 42.5%), serum sodium 131 mmol/L, serum urea 12 mmol/L and serum glucose 12 mmol/L. An arterial blood gas was drawn on room air: pH 7.46, pO2 52 mmHg, pCO2 35 mmHg, and HCO3 24 mEq/L. The chest x-ray demonstrates a patchy infiltrate in the right lung accompanied by a mild pleural effusion. Gram’s stain of the sputum reveals multiple gram-positive cocci pairs (diplococci). D.N. is admitted to the hospital with the diagnosis of pneumonia.


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Questions to consider

1. What features of D.N.’s initial presentation are consistent with pneumonia?

2. Is any other additional information required to diagnose D.N. with community-acquired pneumonia?

3. Does D.N. need a PSI calculated? If no, why not? If yes, what factor(s)

indicate that a PSI calculation is required?

4. What is D.N.’s PSI score? What class does this score represent? What % of risk of 30 days mortality does this represent?

5. According to the Therapeutic Guidelines: Antibiotic 2003 CAP

recommendations where should D.N. be treated? Do you require any further information to make this decision? If yes, what else would you like to know?

6. What antibiotics are appropriate in this situation? Do you require any

further information to make this decision? If yes, what else would you like to know?

Upon further conversation with D.N. it is noted that he suffers from a type 1 penicillin allergy. 7. What is the definition of a type 1 penicillin allergy? What impact does this

have on the choice of antibiotics for D.N.? 8. According to the Therapeutic Guidelines: Antibiotic 2003 what antibiotics

are recommended in patients with type 1 penicillin allergy?

9. Is there any other information that you would like to know relating to D.N.’s presentation to ED before any final decisions are made?

*The case is based on a clinical scenario in: Applied Therapeutics – The clinical use of drugs. 6th ed. Young LE, Koda-Kimble MA (editors). Vancouver, WA: Applied Therapeutics, Inc; 1995.


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Suggested answers to the clinical presentation

1. What features of D.N.’s initial presentation are consistent with pneumonia?

D.N. presents to ED with typical features of pneumonia. The history of chest pain, a productive cough (with ‘rusty’ sputum), fevers and rigors are all consistent with pneumonia. The chest x-ray demonstrating a patchy infiltrate increases the likelihood pneumonia.

2. Is any other additional information required to diagnose D.N. with

community-acquired pneumonia?

Yes, you would need to know if the patient has been in hospital in the past two weeks or not. The definition of community-acquired pneumonia in the CAPTION project is a ‘pneumonia occurring in individuals who have not been in hospital (or have been in hospital for less than 48 hours), have not been hospitalised in the past fourteen days, and who are not significantly immunocompromised’. The fact that there is no other significant history other than a flu-like syndrome we can assume that he is not immunocompromised. Patients who are immunocompromised may have pneumonia due to other pathogens that are not included in the CAP guidelines. See Therapeutic Guidelines: Antibiotic 2003.

3. Does D.N. need a PSI calculated? If no, why not? If yes, what factor(s)

indicate that a PSI calculation is required?

Yes. The patient is above 50 years of age and according to the PSI algorithm any patient above 50 years of age should have a PSI calculated. If a patient is less than 50 and does not have any of the given comorbidities and/or particular signs on presentation then a PSI score does not need to be calculated (they would be class I).

4. What is D.N.’s PSI score? What class does this score represent? What %

of risk of 30 days mortality does this represent? Is there any other information you would like to know in order to calculate the PSI score?

The score is calculated below, 97, Class IV, with a risk of 30-day mortality of 9.3%. This score has been calculated on the assumption that the patient is not a nursing home resident. That is one piece of information that I would like to know before I calculate the PSI score. The table below highlights the variables that increase the risk of 30-day mortality for D.N.


September 2005 57

FACTOR SCORE

Patient age Age in years (male) or age in years – 10 (female) 57 Nursing home (but not hostel) resident (+10) ND Co-existing illness: · neoplastic disease (+30) - · liver disease (+20) - · congestive cardiac failure (+10) - · cerebrovascular disease (+10) - · chronic renal disease (+10) - Signs on examination: · acutely altered mental state (+20) ND · respiratory rate >30 per minute (+20) - · systolic blood pressure <90 mm Hg (+20) - · temperature <35°C or >40°C (+15) - · pulse rate >125 per minute (+10) - Results of investigations: · arterial pH <7.35 (+30) - · serum urea >11 mmol/L (+20) 20 · serum sodium <130 mmol/L (+20) - · serum glucose >14 mmol/L (+10) - · haematocrit <30% (+10) - · pO2 <60 mmHg or O2 saturation <90% (+10) 10 · pleural effusion on chest X-ray (+10) 10

PSI Score: 97

5. According to the Therapeutic Guidelines: Antibiotic 2003 CAP recommendations where should D.N. be treated? Do you require any further information to make this decision? If yes, what else would you like to know?

Class IV patients should be admitted to hospital to the general ward area. I would like to confirm that D.N. is not suffering from any other co-existing infections, or suffering from any co-morbidities that may warrant an ICU review. I would also like to know if the patient is able to tolerate oral medication.

6. What antibiotics are appropriate in this situation? Do you require any

further information to make this decision? If yes, what else would you like to know?


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CAP may be of viral or bacterial origin. The most common cause of CAP is Streptococcus pneumoniae. Penicillin is considered the standard choice to treat S pneumoniae CAP- a targeted drug choice with a narrow spectrum of activity. The incidence of penicillin resistant S. pneumoniae in Australia is rare, and there is evidence that ‘resistant’ strains of S. pneumoniae (MIC < 4mg/L) respond to high dose oral and intravenous amoxicillin, and high doses of benzylpenicillin. Therefore appropriate therapy would be benzylpenicillin 1.2g IV, 6th hourly until significant improvement, then amoxicillin 1g orally, 8-hourly for a total of 7 days PLUS roxithromycin 300mg orally once daily for seven days. Alternative antibiotics include amoxy/ampicillin 1g IV, 6th hourly instead of benzylpenicillin and doxycycline 200mg orally, for the first does, then 100mg daily for a further 5 days instead of roxithromycin.

I would like to know if the patient has been travelling recently. Travel to tropical regions would expose the patient to organisms such as Burkholderia pseudomallei and Acinetobacter baumannii that can cause CAP. Patients with less severe pneumonia (Class IV or lower) in tropical regions should receive empiric cover for B. pseudomallei and A baumannii ONLY IF they have one of the following risk factors: diabetes, alcoholism, chronic renal failure or chronic lung disease. All class V patients in tropical regions should be treated empirically for B. pseudomallei and A baumannii. I would also like to know if N.D. has any drug allergies, particularly to penicillin.

Upon further conversation with D.N. it is noted that he suffers from a type 1 penicillin allergy. 7. What is the definition of a type 1 penicillin allergy? What impact does this

have on the choice of antibiotics for D.N.?

Type one penicillin allergy is also known as immediate-penicillin hypersensitivity. The reaction may involve development of urticaria, angioedema, bronchospasm or anaphylaxis (with objectively demonstrated hypotension, hypoxia or trpytase elevation) within one hour of drug administration. Type one penicillin allergy contradicts any further exposure to penicillins and other beta-lactams.

8. According to the Therapeutic Guidelines: Antibiotic 2003 what antibiotics are recommended in patients with type 1 penicillin allergy?

Moxifloxacin or gatifloxacin 400mg orally, daily as monotherapy.

9. Is there any other information that you would like to know relating to D.N.’s

presentation to ED before any final decisions are made?


September 2005 59

Package 6 – Academic Detailing: Workshop Evaluation 6.5 Workshop evaluation


September 2005 60


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Package 7. Evaluation

Contains: 7.1 Hospital profile 7.2Patient record form 7.3 Data collection log 7.4 Intervention activity log

Package 7 Evaluation


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Package 7 – Evaluation: 7.1 Hospital profile form


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Package 7 – Evaluation: 7.2 Patient record form


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Package 7 – Evaluation: 7.3 Data collection log


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Package 7 - Evaluation: 7.4 Intervention activity log


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Package 8. Communication

Contains: 8.1 Reporting strategy 8.2 Hospital Newsletters 8.3 NSW TAG website 8.4 NSW/ACT final wrap-up meeting

8.4.1 Agenda 8.4.2 Generic slide presentation

Package 8 Communication


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Package 8 – Communication: 8.1 Reporting Strategy

Steering Committee Includes: • Emergency physician • Respiratory physician • Microbiologist • Emergency pharmacist • DUE pharmacist • Emergency nurse • Clinical pharmacologist • Quality coordinator • Consumer • General practitioner • Other state group

representatives

Meets quarterly

Hospital stakeholders • ED staff • Respiratory staff • ID staff • Drug Committee • Opinion leaders • CEO • Others

CAPTION Secretariat • Project Officer (David Maxwell) • Executive Officer NSW TAG (Karen Kaye)

NSW Therapeutic Advisory Group Executes contractual arrangements

Reports to NPS

Other State Project Groups Victoria

Queensland Tasmania

South Australia

CAP Project Group Representatives from participating hospitals

(ie hospital coordinators)

Meets monthly

DUE Support Group Steering Committee

for all TAG DUE projects


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Package 8 – Communication: 8.2 Hospital newsletters – Volume 1


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Volume 2


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Volume 3


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Volume 4


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Volume 5


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Volume 6


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Volume 7


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Volume 8


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Volume 9


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Volume 9.1


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Volume 10


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Volume 11


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Volume 11.1


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Volume 12


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Volume 13


September 2005 85

Volume 13.1


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Volume 14


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Volume 15


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Volume 16


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Volume 17


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Volume 18


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Volume 19


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Package 8 – Communication: 8.3 NSW TAG website Link to drug utilisation page

CAPTION Information


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Package 8 – Communication 8.4 NSW/ACT final wrap-up meeting 8.4.1 Agenda

NSW/ACT Final CAPTION Wrap-Up Meeting 10.00am – 3.00pm, Wednesday 21st September 2005, NPS Boardroom, Level 7,

7/418A Elizabeth Street, Surry Hills, NSW. Attendees: Bret Ryder SVH David Maxwell NSW TAG Sue Aran RPA Karen Kaye NSW TAG Margaret Duguid RNSH Angela Wai NPS Alice Mckellar GBH Joanne McMahon MDH / BBH Ian Mawbey DBH Margaret Hewetson LBH Liisa Nurmi Calvary Evette Buono CRH Time Presentation Presenter 9:30am – 10.00am Coffee 10.00am – 10.15am

Welcome and overview David

10.15am – 12.00pm Individual hospital reports: Batemans Bay Calvary Concord Repatriation Dubbo Base Goulburn Lismore Base Moruya Royal North Shore Royal Prince Alfred St. Vincents

Hospital coordinators: J McMahon L Nurmi E Buono I Mawbey A McKellar M Hewetson J McMahon D Maxwell S Aran B Ryder

12.00pm – 1.00pm Lunch 1.00pm – 1.30pm State report and up-date on

national activity David/Angela

1.30pm – 2.30pm Lessons learned and sustainability

Everybody

2.30pm – 2.45pm Looking to the future

Karen

2.45pm – 3.00pm Farewell and thanks

David/Karen


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Package 8 – Communication 8.4 NSW/ACT final wrap-up meeting 8.4.2 Generic slide presentation

NSW final faceNSW final face--toto--face face meetingmeeting

Insert nameInsert Institution

CAPTION PROJECTCAPTION PROJECT

Local Project TeamLocal Project Team

List the names/profession of team List the names/profession of team membersmembers

Briefly outline the role of each Briefly outline the role of each membermember

Intervention Activities Intervention Activities

Summarise your activity logs hereSummarise your activity logs here

Did you do anything extra?Did you do anything extra?

Intervention Activities Intervention Activities

What was the easiest intervention What was the easiest intervention to use? Why?to use? Why?

What was the hardest What was the hardest intervention to use? Why?intervention to use? Why?

Which intervention was best Which intervention was best received by prescribers?received by prescribers?

Summarise the PSI use and concordant Summarise the PSI use and concordant antibiotic prescribing for the three audit antibiotic prescribing for the three audit cycles.cycles.

Identify any unique points or features that Identify any unique points or features that you highlighted to your prescribers.you highlighted to your prescribers.

ResultsResults

What issues or barriers did you come across What issues or barriers did you come across when trying to influence prescribing in the when trying to influence prescribing in the management of CAP?management of CAP?

To influence prescribing in the management of To influence prescribing in the management of CAP in the future you would………..CAP in the future you would………..

DiscussionDiscussion


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The best thing(s) about The best thing(s) about CAPTION………CAPTION………

The worst The worst thing(sthing(s) about ) about CAPTION……..CAPTION……..

What I would do differently What I would do differently next time……….next time……….

Keeping on with CAPTIONKeeping on with CAPTION

How do you think you will sustain How do you think you will sustain the impact and success of the impact and success of CAPTION in the future?CAPTION in the future?


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Package 9. Participating Hospitals

Package 9 Participating Hospitals


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Package 9 - Participating Hospitals Hospitals

New South Wales Bateman’s Bay Hospital, Bateman’s Bay Broken Hill Base Hospital, Broken Hill Concord Repatriation Hospital, Concord Dubbo Base Hospital, Dubbo Goulburn Base Hospital, Goulburn Lismore Base Hospital, Lismore Moruya District Hospital, Moruya Royal North Shore Hospital, St Leonards Royal Prince Alfred Hospital, Camperdown St. Vincent’s Hospital, Darlinghurst

Australian Capital Territory Calvary Hospital, Jamison Centre Canberra Hospital, Garran

Project Coordinators

New South Wales

Alice McKellar Goulburn Base Hospital Bret Ryder St. Vincent’s Hospital Coral Bennett Broken Hill Base Hospital Ian Mawbey Dubbo Base Hospital Joanne McMahon Bateman’s Bay Hospital Moruya District Hospital Margaret Hewetson Lismore Base Hospital Paul Laird Lismore Base Hospital Roseleen O’Doherty Royal North Shore Hospital Sue Aran Royal Prince Alfred Hospital Yvette Buono Concord Repatriation Hospital

Australian Capital Territory

Alison Hulse Calvary Hospital Liisa Nurmi Calvary Hospital Natalie Bula Canberra Hospital


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Package 10. Feedback reports from Auditmaker®

Contains: 10.1 1st audit (baseline) 10.2 2nd audit 10.3 3rd audit

Package 10 Feedback Reports from

Auditmaker®


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Package 10 – Feedback reports from Auditmaker®: 10.1 1st audit (Baseline)


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Package 10 – Feedback reports from Auditmaker®: 1st audit (Baseline)


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Package 10 – Feedback reports from Auditmaker®: 10.2 2nd audit


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Package 10 – Feedback reports from Auditmaker®: 2nd audit


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Package 10 – Feedback reports from Auditmaker®: 10.3 3rd audit


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Package 10 – Feedback reports from Auditmaker®: 3rd audit


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Package 11. Presentations and Publications

Contains: 11.1 Conferences abstracts 11.2 Publications reference list

Package 11 Presentations and Publications


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Package 11 – Presentations and Publications: 11.1 Conference abstracts Antibiotic Guidelines: How far have we come? Maxwell DJ1,2,3, Kaye KI1, Brien JE2,3,4, Easton KL5. 1. NSW Therapeutics Advisory Group (NSW TAG). 2. Faculty of Pharmacy, University of Sydney. 3. St. Vincent's Hospital, NSW. 4. Faculty of Medicine, University of NSW. 5. National Prescribing Service (NPS). Background: Judicious use of antibiotics in the hospital setting is vital in delaying the emergence of bacterial resistance. Antibiotic guidelines have been shown to be a useful tool in promoting rational antibiotic prescribing. NSW TAG is coordinating the NSW arm of a multi-centre Drug Usage Evaluation (DUE) project funded by the NPS. A primary objective of the project is to implement the Therapeutic Guidelines – Antibiotics version 12 (TGABv12) recommendations for the management of community acquired pneumonia in hospital emergency departments. Aims: A survey was conducted across NSW hospitals to investigate the current use of local antibiotic guidelines (LAGs) and investigate the prevalence of restrictions on the use of third generation cephalosporins (3rd GC). Secondly to gather information about strategies used to promote concordance with LAGs and results of any DUE activities investigating concordance with LAGs. Method: A survey was distributed electronically to 52 NSW hospitals. A reminder was sent four weeks later. Responses were collated and summarised. Results: The survey was completed by 29 (56 %) hospitals. Twenty three hospitals reported using TGABv12 as a guide for antibiotic prescribing. Additional ‘in-house’ recommendations were used in 7 of these hospitals. Restrictions on 3rd GC prescribing were reported in 12/23 hospitals using guidelines for antibiotic prescribing. Strategies to control/monitor restricted antibiotics included: implementation of an antibiotic review and approval system, use of prompts at point of prescribing and prescriber education sessions. DUE activities investigating 3rd GC use had been conducted in 5 hospitals, with concordance to LAGs ranging from 29 – 73%. Conclusion: Results suggest that guidelines are not being utilised by all NSW hospitals and when used, the recommendations are not standardized. Various strategies have been used to promote concordance with variable success. Presented at:

- National Medicines Symposium, July 28th-30th 2004, Brisbane, QLD, Australia [Poster].

- Society of Hospital Pharmacists of Australia Biennial Clinical Conference, September 29th-31st 2004, Brighton-Le-Sands, NSW, Australia [Poster].


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Community acquired pneumonia: Ceftriaxone and penicillin – a global perspective. DJ Maxwell1,2,3, KI Kaye1, JE Brien 2,3, KL Easton4 1. NSW Therapeutics Advisory Group (NSW TAG), Sydney, Australia. 2. Faculty of Pharmacy - University of Sydney, Sydney, Australia. 3. St. Vincent's Hospital, Sydney, Australia. 4. National Prescribing Service (NPS), Sydney Australia. Management of community-acquired pneumonia (CAP) in Australia is varied. The use of 3rd generation cephalosporins (3rdGCs) to treat CAP is increasing. The NPS is funding a multi-centre drug use evaluation project to improve patient outcomes through the introduction and implementation of national guidelines for the management of CAP in Australian hospitals. A literature review was conducted investigating the supporting evidence and/or the current opinion on the use of penicillin and 3rdGCs in the management of CAP. These findings were compared to the recommendations included in four published CAP management guidelines (CAPMGs) from Australia, UK, USA and Europe. The recommendations for benzylpenicillin and 3rdGCs use were not standardized across the CAPMGs reviewed. Australian and British CAPMGs recommended reserving 3rdGCs for patients with severe disease or a documented penicillin allergy (not immediate hypersensitivity). CAPMGs in the US and Europe recommended 3rdGC use as first line therapy for all CAP patients requiring intravenous antibiotic therapy. Streptococcus pneumoniae was identified universally as a predominant cause of bacterial CAP. ‘Resistant’ S. pneumoniae appeared to be the basis for recommendations of 3rdGC use. Published studies demonstrated that most ‘resistant’ strains respond to penicillin. Ceftriaxone has been shown to be effective, but the literature reported a greater negative impact on hospital ecology associated with the use of 3rdGCs. The variation in these peer reviewed and endorsed CAPMGs demonstrates that evidence may not be the only basis on which guidelines are written and endorsed. Presented at:

- 8th World Conference on Clinical Pharmacology and Therapeutics, August 1st-6th 2004, Brisbane, QLD, Australia [Poster]. Published as: Maxwell DJ, Kaye KI, Brien JE, Easton KL. Community-acquired pneumonia: ceftriaxone and penicillin – a global perspective [Abstract]. Clin Exp Pharmacol Physiol 2004;31(Suppl1):A90.



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Community-acquired pneumonia: Towards improving outcomes nationally (THE ‘CAPTION’ PROJECT) KL Easton1, JM Mackson1, LA Stanton2, GM Peterson2, DJ Maxwell3, KI Kaye3, KA McIntosh4, N Jamshidi4, SW Kirsa5, WB Dollman6, PJ O’Connor6, L Pulver7, MB Robertson8. 1. National Prescribing Service, Sydney, Australia 2. University of Tasmania, Hobart, Australia 3. NSW Therapeutic Advisory Group, Sydney, Australia 4. Victorian Drug Usage Evaluation Group, Melbourne, Australia 5. Austin Health, Melbourne, Australia 6. Department of Human Services, Adelaide, Australia 7. University of Queensland, Brisbane, Australia 8. Chair, Victorian Drug Usage Evaluation Group, Melbourne, Australia There is evidence that knowledge of and adherence to the community-acquired pneumonia (CAP) guidelines within the Therapeutic Guidelines: Antibiotic is suboptimal. The National Prescribing Service is funding a multi-centre drug use evaluation (DUE) project, CAPTION, to improve patient outcomes through the implementation of national guidelines for the management of CAP. The project engages the expertise of state DUE groups from Victoria, New South Wales, Tasmania, South Australia and Queensland. CAPTION seeks to implement the CAP recommendations of the Therapeutic Guidelines: Antibiotic, Version 12, 2003, in 40 Australian hospital emergency departments. This will be undertaken by training health professionals in the use of social marketing techniques to influence and improve prescribing practice, including diagnostic scoring and appropriate antibiotic selection. A national minimum baseline dataset has been finalised with data collection commencing in April 2004. Baseline data collected will be used to guide the social marketing strategies developed for CAPTION. The progress of the project to date highlights the advantages of specialised state groups working collaboratively to achieve the objective of improving CAP outcomes nationally. Presented at:

- 8th World Conference on Clinical Pharmacology and Therapeutics, August 1st-6th 2004, Brisbane, QLD, Australia [Poster]. Published as: Easton KL, Mackson JM, Stanton LA, Peterson GM, Maxwell DJ et al. Community-acquired pneumonia: Towards improving outcomes nationally (the ‘CAPTION’ project) [abstract]. Clin Exp Pharmacol Physiol 2004;31(Suppl1):A92.


- Australian Society for Antimicrobials 6th Annual Scientific meeting,

February 23rd-27th 2005, Lorne, VIC, Australia.


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For starters: the NSW/ACT arm of CAPTION. A taste of things to come. Maxwell DJ1, Kaye KI1 McIntosh KA2, Pulver LK3, Stanton LA4, Marwood AC5, Wai, A6. 1NSW Therapeutic Advisory Group, Sydney, Australia. 2Victorian Medicines Advisory Committee, Melbourne, Australia. 3University of Queensland, Brisbane, Australia. 4University of Tasmania, Hobart, Australia. 5Department of Human Services, Adelaide, Australia. 6National Prescribing Service, Sydney, Australia. Aim: To implement recommendations of the Therapeutic Guidelines, Antibiotic version 12, 2003 (Guidelines) for management of community-acquired pneumonia (CAP) in Emergency Departments (EDs) across five Australian states and one territory. The management of CAP before and after multifaceted interventions in NSW and ACT hospitals will be discussed. Method: A retrospective baseline audit was conducted on 20 CAP patients from each of 12 NSW/ACT participating hospitals. Key messages from the CAP management recommendations of the Guidelines were used to develop a suite of intervention strategies. Interventions included academic detailing (one-on-one educational visiting), point-of-prescribing prompts and group education sessions. A post-intervention audit was conducted. The impact of the interventions was measured through: a) documented use of the Pneumonia Severity Index (PSI) and b) concordance of antibiotic prescribing with the Guidelines. Results: Baseline audit results (n= 225 presentations) indicated that the uptake of the Guidelines was low; documented PSI use and concordant antibiotic prescribing were 6% and 13% respectively. The post-intervention audit (n=181) demonstrated an increase in the use of the PSI and concordant antibiotic prescribing compared with baseline, 6% vs. 27% (p<0.0001) and 13% vs. 24% (p=0.004) respectively. Interestingly, PSI use did not necessarily result in concordant antibiotic prescribing. Conclusion: Multi-faceted intervention strategies were effective in improving concordance with the Guidelines. Results of this audit, and results from the other states, are being used to inform a second intervention phase. We acknowledge the National Prescribing Service for their ongoing support of this project. For presentation at:

- Society of Hospital Pharmacists of Australia 27th Federal Conference, November 10th – 13th, 2005, Brisbane, QLD, Australia [Poster].


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Package 11 – Presentations and Publications: 11.2 Publication Reference List Publications:

Maxwell DJ, Kaye KI. Quality time and ethics in quality assurance [letter to

the editor]. Med J Aust 2004;181:460. Maxwell DJ, Easton KL. Community-acquired pneumonia [review]. J

Pharm Prac Res 2004;34:211-216.

Maxwell DJ, Easton KL, Brien JE, Kaye KI. Antibiotic guidelines in NSW hospitals. Aust Health Rev. In print, November 2005 issue.

Maxwell DJ, McIntosh KJ, Pulver LK, Easton KL on behalf of the

CAPTION study group. Empiric management of community–acquired pneumonia in Australian hospital emergency departments. Med J Aust. In Print.

Manuscripts submitted for consideration:

Maxwell DJ, Graudins L, Kaye KI. DUE and BTS: Improving the improvement models. J Pharm Prac Rev. (Manuscript being considered by the editor).