Antimicrobial Stewardship

for Nurses

Dr Noleen Bennett

1. acNAPS Project Officer, National Centre for Antimicrobial Stewardship

2. Infection Control Consultant, Victorian Nosocomial Infection Surveillance System

Coordinating Centre

Acknowledgments

• Ms Fiona Gotterson – Senior Project Officer, Australian Commission on Safety and Quality in

Health Care

• Assoc/Prof Caroline Marshall – Head, Infection Prevention and Surveillance Service, Melbourne Health

– Infectious Diseases Physician, Victorian Infectious Diseases Service

– Principal Research Fellow, University of Melbourne

Email

From: Director of Nursing Sent: Wednesday, 29 Oct 2014 3:32 PM To: Noleen Bennett Subject: Question

Hi Noleen,

I have just noticed the proposed UTI clinical pathway detailed in the regional newsletter.

At a quick glance, the pathway looks way over the top for our purposes. It might be ok to guide medical staff but nurses do not need to know about antimicrobial use.

Can you please advise where exactly this is going and what ‘issues’ it is based on?

DON

Response email

From: Sent: NOT sent (20th Nov 2016) To: DON Subject: Response

Hi DON,

Nurses DO have a role in implementing successful AMS programs……..

From the 2016 ACIPC AMS for Nurses Workshop participants

Aims

• To highlight why it is important clinical nurses are

actively involved in AMS programs.

• To describe the activities that clinical nurses can

undertake as part of an AMS program.

• To outline the support systems required to successfully

enable clinical nurses to be involved in AMS programs.

• To describe some specific nurses’ roles.

• To outline some potential research studies.

Methodology

• PubMed search – Nurse/ Nurse Practitioner/ ICP

– Antibiotic/antimicrobial

– Resistance/Stewardship

• Nursing – Australian College of Nursing (ACN)

– UK Royal College of Nursing (RCN)

• Australasian College for Infection Prevention & Control (ACIPC)

• Australian Commission Quality & Safety in Healthcare (ACQSHC)

• Centers for Disease Control and Prevention

To highlight why it is

important clinical nurses

are actively involved in

AMS programs

Reasons

• LARGE part of the health care workforce.

• Are the most constant presence for patients/residents.

• Are patient/resident advocates.

• Are involved in all aspects of patient/resident care. • Education

• Medication management

• Work & communicate with most other key healthcare

worker groups.

• Work within multiple levels at the local clinical setting.

• Work at a local, national & international level.

AMR Strategy

Goal:

Minimise the development

and spread of AMR and

ensure the continued

availability of effective

antimicrobials

ACN Comment on Draft AMR Strategy

• Nurses are integral to much of the health care

delivered in Australia & thus have a key role to play in

safeguarding antibiotic’s effectiveness for future

generations.

• Nurses are involved in most aspects of the prevention

& control of AMR, including through patient education,

infection prevention & control, monitoring of antibiotic

use, prescribing & the development of organisational

policies.

• Engagement with nurses is an important factor in

addressing the emerging threat of AMR.

UK RCN Position Statement

• Nurses have a significant role to play in limiting the

threat posed by AMR through their leadership skills

supporting infection prevention and control,

antimicrobial stewardship & public health.

• It is essential that nurses are recognised as influential

members of the multidisciplinary team in combating

AMR & assuring stewardship.

To describe some

activities that clinical

nurses can undertake as

part of an AMS programs

Activities

• Patient Management Plans

• Infection Control and Prevention

• Medication (antimicrobial) management

• Collaboration

• Education

• Surveillance

Patient management plans

• Assess patients risk of both acquiring & transmitting

an infection.

• Complete nursing care plans or notes that accurately

reflect infection.

• Facilitate efficient discharge planning.

• Assess patients’ suitability for Hospital in the Home

programs.

Infection prevention & control

• Implement standard & traditional precautions.

• Correctly collect microbiological specimens if clinical

need is clearly indicated.

• Ensure timely transfer of microbiological specimens to

laboratories to maintain specimen quality.

• Review & recognise when treatment is not in line with

microbiological result.

Medication management

• Question suboptimal antimicrobial management & documentation.

• Recognise when patients are able to tolerate oral intake & could change from IV to oral

antimicrobials.

• Ensure timely administration of antimicrobials & follow up on missed doses.

• As applicable, administer antimicrobials at the right rate.

• Undertake timely therapeutic drug monitoring to ensure antimicrobials that perform

optimally within a specific therapeutic level are in line with recommended guidance.

• Monitor the patient to ensure antimicrobial has the intended effect.

• Recognise antimicrobial allergies & side effects.

• Support the use of standardised medication charts that document for each prescribed

antimicrobial its generic name, dose, time, route, reason for administration, review &

stop date.

• Accurately & clearly document the administration of any antimicrobials.

• Correctly dispose of unused antimicrobials

Medication management

FIVE rights

1. Right patient

2. Right drug

3. Right route

4. Right time

5. Right dose

NINE rights

Five rights plus

7. Right documentation

8. Right action

8. Right form

9. Right response

Ref: Elliott M & Liu Y. 2010

Collaboration

• Participate in (AMS) ward rounds.

• Participate in the development of guidelines & policies

that detail the use of medications.

• Suggest antimicrobial choices to medical staff in line

with guideline recommendations.

• Liaise between (offsite) doctors, microbiologists,

pharmacists, patients/residents and families.

Education

• Provide patient (consumer) education about

antimicrobials, especially prior to discharge.

• Educate (new) colleagues about the appropriate use of

antimicrobials, especially in relation to a specialist area.

• Encourage patients & other colleagues to question

suboptimal antimicrobial management & documentation.

Consumer education

• About actions consumers can take to help tackle AMR

& how to correctly use antimicrobials.

• Includes explaining: – Differences between bacteria and viruses & why viruses do not respond

to antibiotics

– What AMR is

– What antimicrobial allergies mean

– Why the antimicrobial is needed

– How & when antimicrobials should be taken

– How long antimicrobials should be taken for

– Not to share antimicrobials with others

– Not take antibiotics left over from a previous illness.

Surveillance

• Audit medical records and collect data.

• Analyse data and present in easy to understand

formats.

• Feedback analysed data to the team

• Instigate as necessary (and review) new interventions.

Surveillance

To register: naps.org.au

Surveillance: Example

• UK point incidence study

• Aim: To investigate delayed & omitted antimicrobials

Measurement No (%)

Participating organisations 45

Patient records audited 17,470

Patients prescribed antimicrobials (% total patient records)

5899 (33.7%)

Doses prescribed 21,390

Doses omitted (% doses prescribed) 1120 (5.2%)

Patients missing one or more doses (% prescribed antimicrobials)

781 (13.2%)

Ref: Wright J. 2013

Surveillance: Example

Ref: Wright J. 2013

29%

25%

19%

12%

12% 3%

REASONS RECORDED FOR OMITTED DOSES

Left Blank

Other reason

Drug not available

Patient refused

Route not available

Patient away from ward

To outline the support

systems required to

enable nurses to be

successfully involved in

AMS programs

Leadership commitment

• Formal statements that the facility supports efforts to

improve antimicrobial use are developed.

• Participation in AMS programs is expected from key groups.

• Stewardship-related duties are detailed in job descriptions &

annual performance reviews

• Staff are given sufficient time to participate in AMS activities.

Ref: CDC 2014

Nurses knowledge

Refs: Cotta M.O, Robertson M.S, Tacey M, Marshall C, Thursky K.A, Liew D and Buising K.L. 2014.

McGregor W, Brailey A, Bayne G, Sneddon J and McEwen J. 2015

Australian private

hospital

Percentage

Heard of AMS Willingness to

participate in AMS

Anaesthetists 36 51

Pharmacists 80 100

Physicians 64 55

Surgeons 37 48

Nurses (n=105) 22 43

The Scottish Antimicrobial Prescribing Group identified 21.5% of nurses had heard of AMS.

Education

• Under & post graduate

• Content – Antimicrobial resistance

– Antimicrobial stewardship

– Infectious diseases

– Microbiology

• Specimen collection

– Pharmacology

– Principles of surveillance

National medication charts

• National Inpatient Medication Charts – Acute (public and private)

– Long stay (public and private

– GP e-version

• National Residential Medication chart

NRMC

To describe the ICP

(nurse) role

ACIPC Position Statement

• AMR is a serious & significant problem.

• Reducing AMR by prudent & rational antibiotic use is

the responsibility of all healthcare workers.

• ICPs & nursing staff should play a role in AMS

programs as part of their role in preventing &

containing HAIs & antimicrobial resistant organisms.

Infection Control Practitioner

• Dependent on facility size, type & location.

• Undertake a feasibility study

– Identify current perceptions in relation to AMS & nurses’

role.

– Assess how the nurses’ role can be strengthened.

– Identify other key groups who can support AMS.

• Work with other key groups

– To enable appropriate ‘support systems’ are in place.

– Influence governance frameworks

Infection Control Practitioner

• Organise educational strategies.

• Co-ordinate surveillance programs.

• Advise on IT systems to support surveillance,

education & medication management.

Education

Ref: Gillespie E et al. 2013

Question (79 nurses) Pre% Post% p value

Unable to state what ABs patient is on 7 15 .07

Able to state the duration the patient will be on ABs 50 60 .11

Would consider if the AB was required before administering 14 43 .001

Understands what the switch to oral program is about 24 94 <.001

Would question an AB order if thought it was inappropriate 92 97 .11

Have previously questioned an AB order 71 91 <.001

Use of ABs can aid the development of resistance 59 79 .003

ICP: Leadership

• Pilot study to assess ICP AMS leadership role

• Three stages (pre, intra & post intervention)

• ICP responsibilities included – Intermediary b/w GP & an off-site ID physician

– Education of GPs & nurses

– Surveillance

– Monitoring of pathology reports

• Result – Significant decrease in total days of antimicrobials prescribed

(p<0.0001)

Ref: Stuart RL. et al 2014

To outline some potential

research studies

Research

• Australian nurses knowledge of AMR & AMS.

• Experience of Australian clinical nurses/ ICPs/ nurse

practitioners in AMS.

• Successful nurse led models of AMS.

• Perceptions of other key groups regarding nurse’s role

in AMS.

Summary

Response email

From: Sent: NOT sent To: DON Subject: Response

Hi DON,

Nurses DO have a role in implementing successful AMS programs……..

• Why clinical nurses should be involved

• Activities that clinical nurses can undertake

• Support systems required

• ICP’s role

From the 2016 ACIPC AMS for Nurses Workshop participants

ACSQHC AMS Publication

The AMS team (page 9) Multidisciplinary teams are better suited to implement the kind of improvement and change required for effective AMS. There are a range of professions and individuals that have an interest in and responsibility for AMS, each with different perspectives and skills. Involving prescribers, pharmacists, administrators, infection control experts, information systems experts, microbiologists and ID physicians into a well-managed team effectively incorporates their views and expertise.

ACSQHC AMS Publication

Chapter on the Role of Nurses

2017

Contact details

Noleen Bennett

Email: support@naps.org.au

Ph: (03) 9342 9415

References

Atik A, Adherence to the Australian National Inpatient Medication Chart: The efficacy of a uniform

national drug chart on improving prescription error. Journal of Evaluation in Clinical Practice

2012

CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department

of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/getsmart/healthcare/

implementation/core-elements.html

Cotta M.O, Robertson M.S, Tacey M, Marshall C, Thursky K.A, Liew D and Buising K.L. 2014.

Attitudes towards antimicrobial stewardship; results from a large private hospital in Australia.

Healthcare Infection 19(3)

Edwards SR, Drumright LN, Kiernan M and Holmes A. 2011 Covering to fight resistance;

Consideration nurses role in antimicrobial stewardship. J Infect Prev Jan 12 (1) 6-10.

Elliott M and Liu Y. The nine rights of medication administration; an overview. 2010 British

Journal of Nursing Vol 19 No. 5

Gillespie E, Rodrigues A, Wright L, Williams N & Stuart R.L. 2013 Improving antibiotic

stewardship by involving nurses. AJIC. 41:365-7.

Royal College of Nursing Antimicrobial resistance. RCN position on the nursing contribution.

Stuart R.L, Orr E et al. 2014 A nurse led antimicrobial stewardship intervention in two residential

aged care facilities. Healthcare Infection

Ladenheim D, Rosembert D, Hallam C & Micallef C. 2013. Antimicrobial stewardship; the role of

the nurse. Nursing Standard 28 (6):46-49

Wright J. Audit of missed or delayed antimicrobial drugs. Nursing times Vol 109 no 42.

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