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Tasmanian Infection Prevention and
Control Unit
Antimicrobial Utilisation
Surveillance Protocol
Version 1.0
(April 2010)
Department of Heal th & Human Services
Editors:
• Catherine Drake, Drug Utilisation & Evaluation Pharmacist, RHH (behalf of TIPCU)
• Duncan McKenzie, ID Pharmacist, RHH (behalf of TIPCU)
• Dr Alistair McGregor, Specialist Medical Advisor, TIPCU, DHHS
• Amber Roberts, State-wide Medication Co-ordinator, DHHS
• Mr Brett Mitchell, Director, TIPCU, DHHS
3
Contents
FOREWORD 5
BACKGROUND 6
INCLUSION CRITERIA 7
EXCLUSION CRITERIA 11
DENOMINATOR DATA 11
SPECIFICS & DEFINITIONS 12
PROCESS OF SURVEILLANCE 13
DATA COLLATION 14
REPORTS 14
QUALITY IMPROVEMENT 14
REFERENCES 15
5
FOREWORD
Health care associated infections (HAIs) can have a significant impact on the functioning of a health
service and more importantly, have an impact on patients and the quality of health care we provide for
the population.
Within the health care system and related environment, we strive to prevent infections. The patient
must be at the centre of what we do with the desired outcome of care being to minimise and reduce
the risk of infection. The prevention and control of infection must be the responsibility of many
disciplines, involve all members of the health care team, and not simply be the role of a professional
trying to manage this solo.
The Department of Health & Human Services has taken a proactive step in the prevention and control
of health care associated infections by establishing the Tasmanian Infection Prevention & Control Unit.
One of the functions of Unit is to co-ordinate and implement surveillance programs for health care
associated infections in Tasmania. Surveillance of health care associated infections is crucial in
understanding the current infection control issues in Tasmania and provides a means by which
performance can be monitored. It also prepares Tasmania for any future changes in the epidemiology
of health care associated infections.
Patterns of antimicrobial usage within healthcare facilities have an important impact on HAIs. The
inappropriate and over use of antibiotics results in increased rates of antimicrobial resistant micro-
organisms, which in turn are responsible for an increasing and difficult to manage proportion of HAIs.
The monitoring and evaluation of patterns of antimicrobial use is an important aspect of addressing this
problem.
Surveillance is just one of many aspects needed for the successful prevention and control of infections
and we welcome, support and fully endorse the surveillance program outlined in this document.
Dr Roscoe Taylor Dr Craig White
Director of Public Health Chief Health Officer
BACKGROUND
During 2008, the Australian Commission on Safety & Quality in Healthcare recommended monitoring
and analysis of antibiotic usage. This surveillance protocol supports this recommendation.
It is widely understood that the inappropriate and overuse of antimicrobials is a major driver of
increased rates of antimicrobial resistance amongst bacteria, particularly in hospital settings. Many of
these resistant bacteria (such as Methicillin resistant Staphylococcus aureus, Vancomycin resistant
Enterococci and Clostridium difficile) are important and increasingly reported causes of HAIs.
Institutions and countries that have successfully minimised the inappropriate and excessive use of
antimicrobials have seen reductions in the rates of resistant bacteria and infections caused by these.
An essential first step in this process is the accurate monitoring and analysis of antimicrobial usage, as
detailed in the following protocol.
The methodology used is consistent with that used in the Australian National Antimicrobial Usage
Surveillance Program (NAUSP) which currently collates data from approximately 50% of Australia’s
principal referral hospitals.
7
INCLUSION CRITERIA
• Surveillance is restricted to Tasmanian acute hospitals, with the following inclusions:
Clinical areas to be included in monthly datasets
• Acute adult in-patient antibiotic use only (to include imprest and individual patient supply) • Exclude outpatient and discharge drug issues • Includes Emergency Department use (i.e. imprest and inpatient use, not outpatient dispensing)
o Any overnight bed-stay figures allocated to Emergency Departments are included in the bed-stay figure for the hospital
• Exclude paediatric/neonatal use (where possible - it may not always be possible to exclude all paediatric use if not with specialist wards or units)
• Exclude use by psychiatric units • Exclude use by rehabilitation units • Exclude Hospital-in-the Home use • Exclude same-day procedure areas • Exclude palliative care inpatients if they can be separated (e.g. such as off-site ward associated with
RHH) • Separate datasets for ICU and 'non-ICU' (i.e. other wards, theatres etc) where possible.
o If pharmacy data cannot be supplied separately for ICU, a single 'total hospital ' dataset. o Note: In general ‘ICU’ should not include use by high dependency, CCU or similar units. If these
categories can not be excluded from the usage reported from the ICU imprest, then a ‘total hospital’ dataset should be submitted.
RHH wards included in the dataset
• Last reported to the national surveillance group as equalling 261 beds. • RHH has contributed “total hospital” antimicrobial usage data to the NAUSP since mid 2004. • Separate reporting of ICU usage figures can be undertaken for RHH, as patient acuity in the unit fits
required definition (i.e. minimal numbers of CCU/HDU patients). o Separate ICU reporting has not occurred to date, but is planned to occur with the new reporting
system to be in place in 2010. o “Total hospital” usage data for the RHH will continue to be reported to allow for historical
comparison.
Table 1: RHH wards currently included in iPharmacy national antibiotic surveillance report
Site iPharmacy ward
code (cost_cntr_xid)
iPharmacy ward description
(cost_cntr_desc)
Number
of beds
RHH RHH1BN 1BN Medical Ward 27
RHH RHH1BS 1BS Oncology Inpatient Ward 20
RHH RHH2BS 2B Medical Ward 38
RHH RHH2DC 2DC Cardiology Ward 12
RHH CARD_UNIT Cardiac Unit 4
RHH RHH2DS 2DS Cardio Thoracic Surgery Ward 17
RHH RHHDEMR ED - Emergency Department n/a
RHH RHH6A GSU - General Surgical/ Gynae Ward 6A 26
RHH RHHDCCM ICU Intensive Care Unit 14
RHH RHH3D Maternity Ward 3D 26
RHH RHH1H NSU - Neurosurgery Ward 24
RHH OPER_TH Operating Theatre n/a
RHH RHH2A Orthopaedics (ORU) Ward 2A 25
RHH RHH5A SSU - Specialist Surgery Ward 5A 18
RHH RHHESSU ESSU - Emergency Short Stay Unit 10
(Note – the RHH wards and descriptors will be reviewed in light of changes that will occur with the
implementation of the iPM patient administration system at the RHH in med 2010).
LGH wards included in the dataset
• Number of beds included in the LGH dataset – 195 beds • Separate reporting of ICU usage figures cannot be undertaken for LGH, as usage includes CCU/HDU
patients
Table 2: LGH wards currently included in iPharmacy national antibiotic surveillance report
Site
iPharmacy
ward code
(cost_cntr_xid)
iPharmacy ward
description
(cost_cntr_desc)
Additional
description
Current
ward?
Number
of beds
LGH LGHED Accident & Emergency Dept Yes n/a
LGH LGHICU Intensive Care Unit Yes 11
LGH LGHW4B Ward 4B Birthing Suite Yes 6
LGH LGHW4D Ward 4D Renal/Med Yes 28
9
LGH LGHW4O Ward 4O Obstetrics Yes 26
LGH LGHW5A Ward 5A Surgical Yes 28
LGH LGHW5B Ward 5B Surgical Yes 32
LGH LGHW5D Ward 5D Oncology/Med Yes 32
LGH LGHW6D Ward 6D Stroke/Med Yes 32
LGH OPE Operating Theatre Suite Yes n/a
LGH AEIP Accident & Emergency Dept
Stock Issues No
LGH AEOP Accident & Emergency Script
Dispensing No
NWRH Burnie wards included in the dataset
• Number of beds included in the NWRH dataset – 84 beds • Separate reporting of ICU usage figures cannot be undertaken for NWRH, as usage includes
CCU/HDU patients
Table 3: NWRH Burnie wards currently included in iPharmacy national antibiotic surveillance report
Site
iPharmacy
ward code
(cost_cntr_xid)
iPharmacy ward description
(cost_cntr_desc)
Current
ward?
Number
of beds
NWRH NWRHDEM ACCIDENT-EMERGENCY NWRH Yes n/a
NWRH NWRHICU INTENSIVE CARE NWRH Yes 8
NWRH NWRHME MEDICAL WARD NWRH Yes 34
NWRH BOT OPERATING THEATRE BURNIE Yes n/a
NWRH NWRHSC SURGICAL CENTRAL NWRH Yes 26
NWRH NWRHSW SURGICAL WEST NWRH Yes 16
NWRH BAE ACCIDENT & EMERGENCY BURNIE No
NWRH BICU BURNIE INTENSIVE CARE UNIT No
NWRH BMED BURNIE MEDICAL WARD No
NWRH BSC BURNIE SURGICAL CENTRAL WARD
(B) No
NWRH BSW BURNIE SURGICAL WEST WARD (A) No
MCH wards included in the dataset
• Number of beds included in the MCH dataset – 101beds • Separate reporting of ICU usage figures cannot be undertaken for MCH, (HDU only).
Table 4: MCH wards currently included in iPharmacy national antibiotic surveillance report
Site
iPharmacy
ward code
(cost_cntr_xid)
iPharmacy ward description
(cost_cntr_desc)
Current
ward?
Number
of beds
MERSEY MCH1A SURGICAL WARD 1A MCH Yes 19
MERSEY MCH1B SURGICAL WARD 1B MCH Yes 19
MERSEY MCH3A MEDICAL WARD 3A MCH Yes 17
MERSEY MCH3B MEDICAL WARD 3B MCH Yes 17
MERSEY MCHBIRTH MATERNITY/GYNAECOLOGICAL 2B
MCH Yes 12
MERSEY MCHWCHC MATERNITY/GYNAECOLOGICAL 2A
MCH Yes 13
MERSEY MCHDEM ACCIDENT - EMERGENCY MCH Yes n/a
MERSEY MCHHDU HIGH DEPENDENCY MCH Yes 4
MERSEY MOT OPERATING THEATRE MCH Yes n/a
MERSEY M1A SURGICAL WARD MCH 1A No
MERSEY M1B SURGICAL WARD MCH 1B No
MERSEY M3A MEDICAL WARD MCH 3A No
MERSEY M3B MEDICAL WARD MCH 3B No
MERSEY M2A MATERNITY/GYNAECOLOGY MCH 2A No
MERSEY M2B MATERNITY/GYNAECOLOGY MCH 2B No
MERSEY MAE ACCIDENT & EMERGENCY MCH No
MERSEY MHDU HIGH DEPENDENCY UNIT MCH No
• Imprest medications for MCH wards are supplied by NWRH Burnie. Due to this - the following MCH wards in the NWRH iPharmacy site need to be included in the antibiotic surveillance report for MCH.
Table 5: MCH wards attached to the NWRH iPharmacy site to be included in iPharmacy national antibiotic
surveillance report
Site
iPharmacy
ward code
(cost_cntr_xid)
iPharmacy ward description
(cost_cntr_desc)
Current
ward?
NWRH MCH1A SURGICAL WARD 1A MCH Yes
11
NWRH MCH1B SURGICAL WARD 1B MCH Yes
NWRH MCH3A MEDICAL WARD 3A MCH Yes
NWRH MCH3B MEDICAL WARD 3B MCH Yes
NWRH MCHBIRTH MATERNITY/GYNAECOLOGICAL 2B MCH Yes
NWRH MCHWCHC MATERNITY/GYNAECOLOGICAL 2A MCH Yes
NWRH MCHDEM ACCIDENT-EMERGENCY MCH Yes
NWRH MCHHDU HIGH DEPENDENCY MCH Yes
NWRH HOT OPERATING THEATRE MCH Yes
NWRH HSA SURGICAL WARD MCH 1A No
NWRH HSB SURGICAL WARD MCH 1B No
NWRH HMA MEDICAL WARD MCH 3A No
NWRH HMB MEDICAL WARD MCH 3B No
NWRH HMAT MATERNITY/GYNAECOLOGY MCH 2A No
NWRH HOBS MATERNITY/GYNAECOLOGY MCH 2B No
NWRH HAE ACCIDENT & EMERGENCY MCH No
NWRH HICU HIGH DEPENDENCY UNIT MCH No
NWRH MCHWCHU 2A MCH No
EXCLUSION CRITERIA
The exclusion is implicit from the inclusion criteria.
DENOMINATOR DATA
Denominator data will be provided to the NAUSP by the TIPCU and will be consistent with the definitions
applied nationally. Examples of such include:
Bed stay data
• Matching monthly overnight stay occupied bed days are also required for both 'total hospital' and ICU - this will exclude day patients.
• Bed stay data needs to match the wards the antibiotic usage report has been limited to (i.e. the same subset of wards should be used for the bed stay data).
• If ICU and total hospital use are being reported on separately, then separate overnight bed day data needs to be submitted for ICU and the whole of hospital (including ICU).
• Overnight stay occupied bed days for the specified month can be accessed for all sites via the DHHS FYI Executive Information System.
SPECIFICS & DEFINITIONS
National data requirements requested for drug usage report confirm with the following:
• Datasets should be forwarded in Excel or .csv format each month. • The only specific requirements are 'drug description' and 'quantity'.
• Data should be aggregated to provide one line per item if possible to minimise problems associated with negative amounts from credited items.
• There is no requirement to select particular antimicrobials for inclusion or exclusion. o Provision of data for total 'anti-infectives' or 'antibacterials and antifungals' is preferred. o Antivirals, anthelmintics and other groups may also be included (not currently analysed). o Any particular agents or dosage forms not required will be discarded automatically during
processing (antibacterials are currently the only subset that is analysed by the national reporting group).
Drug usage data supplied by Tasmanian hospitals to surveillance program
• Supplied in Excel format. • Monthly report of drug product name and quantity of vials/tablets used in specified month. • Includes inpatient and imprest use only. Outpatient and discharge supplies are excluded. • Includes all anti-infectives (i.e. antibacterials, antifungals, antivirals and antihelmintics). • Includes all dose forms (intravenous, oral, topical etc).
Functionality of current iPharmacy Report
• Report used for the national antibiotic surveillance is titled ‘Monthly - National Antibiotic Reporting incl ICU_TAS’.
• This report can be run centrally by any iPharmacy user with appropriate privileges.
• The report returns the aggregate quantity used of each anti-infective product during the specified timer period. If there has been no use of a product in the time period it will not be listed.
• The report limits data to: o Inpatient dispensing and imprest and requisition supplies. o Requisitions or inpatient dispensings that are cancelled or returned to pharmacy for credit are
taken into account, (if they have been credited against the patient or ward). o All drugs which are coded as anti-infectives are included (in iPharmacy this correlates to
products with SHPA Codes 4200000 to 4700000 and 4955000 to 4957000). o Wards that have been flagged to be included in the report (by adding the flag ‘abx’ into the
‘Account4’ field in the cost centre maintenance screen of iPharmacy).
• Flagging wards for inclusion in the report. o Wards to be included in the RHH, LGH and NWRH usage reports are flagged by adding the
text ‘abx’ into the ‘Account4’ field in the cost centre maintenance screen of iPharmacy. o Because in iPharmacy the MCH wards exist at both the MCH and NWRH sites, the MCH
wards to be included are flagged at both sites by adding the text ‘mch’ into the ‘Account4’ field in the cost centre maintenance screen of iPharmacy.
• New wards or new products o If new wards are created in iPharmacy or new descriptors are created for existing wards – for
these wards to be included in the report, the ‘abx’ flag (or for MCH wards the ‘mch’ flag) needs to be present in the correct field (as outlined above).
o Both ‘current’ and ‘non-current’ (old) wards are included in the report to allow retrospective reporting.
o If new products are added to iPharmacy they will be automatically added to the report if they have been assigned an SHPA code in the specified range. New drugs that do not have an appropriate SHPA code available in the system will need one to be created.
13
PROCESS OF SURVEILLANCE
A monthly report will be run for each participating hospital at one location (Royal Hobart Hospital),
using iPharmacy. The report will be sent to the TIPCU who will include the necessary bed day data.
The TIPCU will forward to the NAUSP. The NAUSP will undertake the data analysis and forward
reports back to each hospital directly and to the TIPCU.
The process is summarised by the following diagram.
Report run for all
hospitals
Data sent to TIPCU
Bed day data added
TIPCU forwards to NAUSP
NAUSP undertakes analysis /
develops reports
NAUSP sends reports
to hospitals & the
TIPCU
DATA COLLATION
Data will be analysed by the NAUSP, according to national definitions and processes.
ADDITIONAL REPORTS
Additional reports may be produced upon request on a limited basis.
DATA HANDLING
All information held by the TIPCU will be done in accordance with the information privacy principles as
set out in the Privacy Act (Cth) 1988 and the personal information protection principles as set out in the
Personal Information Protection Act 2004.
REPORTS
It is vital that hospitals can compare rates in order to comply with quality improvement and clinical
governance frameworks.
Key Principles of Reports/Data Presentation:
Reports will be sent to the each hospital (nominated person) and
• may be available on the TIPCU internet site with the above principles applied.
• results from this particular piece of surveillance may also be included in the TIPCU annual report
• reports will be developed in a manner as directed from DHHS
QUALITY IMPROVEMENT
For issues of governance and quality improvement, where results from a participating organisation
cause concern, the Chief Executive Officer of that area will be informed in line with the TIPCU
operational policy. Issues raised from surveillance are to be used within the participating organisation’s
own quality improvement frameworks and participation in the program assumes this will occur.
The HAI Steering Committee will also review and discuss results and reports pertaining to any work
undertaken by the TIPCU in respect to the DHHS.
15
REFERENCES
Australian Commission on Safety and Quality in Healthcare (2008) Reducing Harm to Patients from Health Care Associated Infection: The role of Surveillance. Commonwealth of Australia.
TASMANIAN INFECTION
PREVENTION & CONTROL UNIT
Division of Population Health
Department of Health and
Human Services
Editors: Brett Mitchell, Dr
Alistair McGregor & Saffron
Brown
GPO Box 125, Hobart 7001
Ph: 6222 7779
Fax: 6233 0553
Email: [email protected]