Monthly WebinarTuesday 14th December 2017, 16:00

“CURB Your Enthusiasm”

Event number: 847 953 303

Audio dial-in (phone): 01 526 0058

“CURB Your Enthusiasm”:Improving the Antibiotic

Prescribing for CommunityAcquired Pneumonia

Connolly Hospital BlanchardstownDr Eoghan O’Neill/Ms Bernie Love

November 2017

Quality Improvement (QI) project• In Feb 2016, "Start Smart" Antibiotic Stewardship

Quality Improvement Collaborative wasestablished by the RCPI/HSE HCAI and AMRClinical Programme

• Involved project teams from interested hospitalsattend 4-5 meetings (QI training) over 12 months,to share learning from local projects and identifyinterventions to test and feed back to subsequentmeetings

QI training undertaken by projectteams

Why did we choose CA-LRTIs?• Majority of antimicrobial use (min 30%) in CHB is

used to treat CA-LRTIs, consistent with otheracute hospitals nationally.

• Baseline data over a number years• Increasing recognition of incorrect classification

of patients admitted with CA-LRTIs…… leading toincorrect antimicrobial prescriptions….. e.g.inappropriate dual therapy, not using CURB scorefor CAP, using broader agents (e.g. Piperacillin-Tazobactam)

• Focused on initial prescription…. “Start smart….”

CHB 2017 PPS data

0 10 20 30 40 50

Bacteraemia

CNS

Lower UTI

Neutropenic sepsis

Skin/Soft tissue (surgery related)

Bone/Joint

Medical Prophylaxis

Clinical sepsis (unconfirmed)

GI infection

Bone/Joint related to surgery

Surgical propylaxis

Bronchitis

Intra-abdominal

Pyelonephritis/Upper UTI

Skin/Soft tissue

Pneumonia

Number of infections

Indication for antimicrobial therapy

Baseline audit (2012):– 74% of patients admitted with CA-LRTI were prescribed dual

therapy Co-amoxiclav + Clarithromycin (17% compliance)– >45% classified as ‘LRTI’

• Treatment algorithm devised to encompass all CA-LRTIsto aide classification & treatment choices

• Some improvement but remained sub-optimal

Baseline audit (n=47) Post introduction ofclinical pathway (n=47)

2014 (n=17) 2015 (n=20)

Guideline-adherenttherapy

17% 34% 41.2% 41.6%

CURB-65 23% 35% 10% 33.3%

Classification 46.8% 46.8% 35.2% 58.3%

Aim 1 Driver 2 Driver Change idea

Ensure ≥85% ofadults admitted toCHB with a CA-LRTIhave their diagnosis

appropriatelyclassified and

antibioticsprescribed in line

with local guidelines

Assess barriers toadherence to guidelines

Survey/Interview withprescribers

Ideas for change

Guidelines

Revise/Simplifyguideline algorithm +/-

app tool

Give assurance toprescribers re.

effectiveness; measureneed for escalation

Education

Get peer involvement

Weekly assessment ofcompliance with run

charts & feedback

Attendance at morninghandover/ED/NCHD

teaching

Design prescriber interview

Audit 20 patients to assess currentstatus of compliance & interviewprescribers where non-compliancesidentified to assess barriers

•37.5% lack of knowledge•62.5% lack of confidence inguideline•37.5% influence ofpeers/senior colleagues

Make guideline more accessible(more hardcopies)

Increase confidence/assurance fromC&S that amoxicillin will work-analyse C&S data & report

Teaching sessions

Increase awareness/inform people

Visual aides/ Laminatedcards/Checklist/Posters

Real-time reporting – run charts;assurance with Consultants present.Convincing data will influencebehaviour more positively thancritique

Driver Diagram: How do we improve compliance?

Prescriber interview to assess barriersS I R Total

numberspecimens

Streptococcus pneumoniae

PEN 56.6% 30.2% 13.2%

53ERY 62.3% 37.7%

TE 71.7% 1.9% 26.4%

Haemophilus influenzae

AMP 70.7% 29.2%

198

ERY 2.5% 91.9% 5.6%

TE 98% 0.5% 1.5%

AMC 82.3% 17.7%

• Lack of confidence inAmoxicillin noted

• C&S data for respiratorypathogens extracted for2014/2015

• Feedback to prescribersas part of educationsessions

Re-designed algorithm- Launched within CHB- Updated on app- Laminates in ED

New toy…………..

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge co

mpl

ianc

e

Run chart for compliance with CA-LRTI guidelines

Choice

CURB-65

Classification

Target

Weekly assessment of compliance with runcharts & feedback at morning handover

Key messages from weekly audits

CAP

LRTI

AECOPD

Non-pneumonicLRTI

Remember ‘LRTI’ is an umbrella term - you need to define which type of ‘LRTI’ it isbefore appropriate antibiotic therapy can be determined

•New focal consolidation on CXR = community-acquired pneumonia•CXR clear but hx COPD = AECOPD•CXR clear, no hx COPD = Non-pneumonic LRTI

1

Key messages from weekly audits

Remember CURB-65 score should be calculated for all CAP & used to guide antibiotictherapy

•CURB-65 score 0-1: Amoxicillin OR Clarithromycin OR Doxycycline•CURB-65 score 2: Amoxicillin plus Clarithromycin•CURB-65 score ≥3: Co-amoxiclav plus Clarithromycin

2

Key messages from weekly audits

Remember CURB-65 score is only validated for CAP therefore is not relevant for:•AECOPD•Non-pneumonic LRTI•HAP

3

Challenges

• Sustainability of intensive QI approach

• Ongoing support of consultant/seniorcolleagues vitals (including those outside ofthe specialty….. e.g. general medicalconsultants on-call)

• Clinical/Prescriber change over every 6-12months – starting again!

Some suggestions……• National template for CA-LRTI

• Re-inforce at undergraduate/postgraduateteaching level

• Use of algorithm and implementation at hospitalgroup/national level……

e.g. a focus for hospital group stewardship teams

• Adopt audit tool for local KPIs etc.

Thank you!