Antimicrobial Prescribing Practice in Australia Results of the 2015 National Antimicrobial

40 Pages·2017·2.1 MB·English

Antimicrobial
prescribing
practice
in Australian
hospitals
Results of the 2015 Hospital
National Antimicrobial
Prescribing Survey
December 2016
Published by the Australian Commission on Safety and Quality in Health Care
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© Commonwealth of Australia 2016
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the following citation:
National Centre for Antimicrobial Stewardship and Australian Commission on Safety and Quality in Health
Care. Antimicrobial prescribing practice in Australian hospitals: Results of the 2015 National Antimicrobial
Prescribing Survey. Sydney: ACSQHC; 2016.
Enquiries regarding the use of this publication are welcome and can be sent to
[email protected].
Antimicrobial prescribing
practice in Australian hospitals
Results of the 2015 Hospital National Antimicrobial Prescribing Survey
December 2016

Contents
Abbreviations .......................................iv Most commonly prescribed 
antimicrobials ........................................................16
Executive summary ...............................1
Appropriateness for the 20 most
Background ............................................3 commonly prescribed antimicrobials ...........16
Poorly prescribed antimicrobials ....................19
Methods ..................................................4
Most common indications ..............................20
Timing ........................................................................4
Appropriateness of prescribing for the
Recruitment ............................................................4
20 most common indications .........................22
Auditors ....................................................................4 Prophylaxis ...............................................................22
Indications for which prescribing was
Limitations in methodology .............................5
most commonly assessed as
Modifications for the 2015 survey. .................5 inappropriate. ..........................................................22
Revision of survey methodology ......................5 Compliance with guidelines for the
20 most common indications .........................24
Modifications to data set specifications .......6
Support for auditors ............................................7 Feedback ..............................................26
Expert assessments ................................................7 Local use of NAPS results ..............................26
Development of templates to help
Conclusion ...........................................27
hospitals communicate local
survey results .............................................................7
Appendix 1 Hospital NAPS data
collection form ..............28
Findings...................................................8
Appendix 2 Participating
Participation .............................................................8
public hospitals, by
State and Territory ...................................................8
peer group, 2015 ...........29
Peer group ...................................................................8
Appendix 3 Participating private
Remoteness classification ....................................9
hospitals, by peer
Types of surveys performed and group, 2015 ....................30
number of prescriptions .................................10
Appendix 4 Numbers of
Key indicators .......................................................11 prescriptions, by
hospital peer group,
Documentation of indication ............................15
2015 ..................................31
Documentation of review or stop date........15
Appendix 5 Hospital NAPS
Surgical prophylaxis for more than
definitions of
24 hours ......................................................................16
appropriateness ............32
Compliance with guidelines ..............................16
Appropriateness .....................................................16
Antimicrobial prescribing practice in Australian hospitals iii
Abbreviations
AMS antimicrobial stewardship
COPD chronic obstructive pulmonary disease
ICP infection control practitioner
NAPS National Antimicrobial Prescribing Survey
NCAS National Centre for Antimicrobial Stewardship
PPS point prevalence survey
PePS period prevalence survey
sPPS serial point prevalence survey
iv Australian Commission on Safety and Quality in Health Care
Executive summary
The National Antimicrobial Prescribing Survey • supporting education and training of the
(NAPS), which is conducted by the National Centre workforce by informing local AMS programs
for Antimicrobial Stewardship (NCAS), is in its • providing flexible and useful benchmarking
fourth year. NAPS has become an important tool within hospitals across units and wards, and
for hospitals to support their local antimicrobial between hospitals and jurisdictions.
stewardship (AMS) programs, and to meet the
The uptake of the Hospital NAPS by Australian
requirements for accreditation against National
hospitals has continued to grow, with
Safety and Quality Health Service (NSQHS)
representation across all states and territories. In
Standard 3: Preventing and Controlling Healthcare
2015, 83% of principal referral hospitals and 74%
Associated Infections. The NSQHS Standards
of large acute public hospitals participated in the
were developed by the Australian Commission on
survey. In the private hospitals, 50% of group A
Safety and Quality in Health Care (the Commission)
and 42% of group B hospitals participated. The
to protect the public from harm, and to improve
greatest increases in participation occurred in
the quality of care provided by health service
inner and outer regional centres. Overall, there was
organisations through the implementation of quality
assurance and quality improvement mechanisms.1 a 13.3% increase in participation compared with
the 2014 Hospital NAPS.
NAPS is a component of the Antimicrobial Use
Each year, the Hospital NAPS is reviewed and
and Resistance in Australia (AURA) Surveillance
modified to support the requirements of end users.
System, which the Commission established
For the 2015 survey, recommendations regarding
with funding provided by the Australian
survey methodology according to hospital size
Government Department of Health. NAPS uniquely
were included, together with documentation of
focuses on measuring the appropriateness of
review or stop date for antimicrobials as a new key
antimicrobial prescribing.
indicator.
AURA and NAPS directly support a number of key
The 2015 data from 281 hospitals (213 public
objectives of Australia’s first National Antimicrobial
Resistance Strategy.2 NAPS advances the and 68 private) and 22 021 prescriptions shows
similar results to the 2013 and 2014 Hospital
appropriate and judicious use of antimicrobials by:
NAPS. Analysis of all prescriptions showed that
• facilitating effective audit and review of documentation of indication remained steady at
antimicrobial use, including compliance 72.5%, noncompliance with guidelines was 23.3%,
with prescribing guidelines and and inappropriateness of prescribing was 21.9%.
prescribing appropriateness The addition of ‘review or stop date’ as a new
• facilitating effective communication about indicator revealed very low levels of documentation
antimicrobial use and identifying key areas (35.5%), identifying this as an area for future
of concern improvement.
In 2015, there was a reduction in the proportion
of surgical prophylaxis prescriptions continuing
beyond 24 hours (27.4% in 2015, compared with
35.9% in 2014). However, it is unclear whether
this is due to changes in the characteristics of
participating hospitals or to real improvement
1 Australian Commission on Safety and Quality in Health
across all facilities.
Care. National Safety and Quality Health Service Standards.
Sydney: ACSQHC, 2012.
2 Commonwealth of Australia. Responding to the threat The most common indications for prescribing
of antimicrobial resistance: Australia’s first National antimicrobials were surgical prophylaxis (15.5%),
Antimicrobial Resistance Strategy 2015–2019. Canberra:
community-acquired pneumonia (10.5%), medical
Commonwealth of Australia, 2015.
Antimicrobial prescribing practice in Australian hospitals 1
prophylaxis (7.6%), sepsis (5.7%) and urinary The results of the Aged Care NAPS pilot3
tract infection (5.0%). Some specific observations highlighted key areas for quality improvement,
included high levels of prescribing for surgical including prolonged durations of therapy, and poor
prophylaxis, exacerbations of chronic obstructive documentation.
pulmonary disease and asthma, and bronchitis.
Findings from each NAPS module help
The most common antimicrobials prescribed were to strengthen AMS programs by building
cefazolin, ceftriaxone, metronidazole, amoxicillin– competencies, increasing awareness of
clavulanate and piperacillin–tazobactam. The appropriate prescribing and guidelines, informing
appropriateness of prescribing for these five education and targeted quality improvement, and
antimicrobials ranged from 65.1% to 77.6% in monitoring performance over time.
2015, a slight increase from the 2014 Hospital
NAPS scores of 63.1% to 76.9%. The high rates of
inappropriate prescribing of cephalexin (39.2%)
remain a concern. Most inappropriate use of I loved this audit. I really
cephalexin occurred in surgical prophylaxis,
appreciated the timeliness in which
urinary tract infections and pneumonia.
I could access expert opinion
Feedback on the 2015 Hospital NAPS was positive.
Participants reported that yearly participation and felt supported in conducting
formed an integral part of their AMS programs,
the audit. Local medical officers
and that they appreciated the support and
educational sessions provided by the NAPS team. appreciated the audit and feedback,
Many participants also reported that their facility’s
which we turned into an education
NAPS results were presented to high-level AMS,
medical advisory, and drug and therapeutic session. Very beneficial all round!
governance committees. NAPS results were used
to design local education programs, support – regional hospital ICP
hospital accreditation and improve the standard of
clinical care.
The professional breakdown of auditors included
pharmacists (61.1%), nurses and infection control
practitioners (19.9% combined), and doctors
(13.3%). There was a substantial difference in
auditor profession between public and private
hospitals, with the majority of auditors in private
hospitals being nurses and infection control
practitioners (51.2%).
The NCAS and the Commission are committed to
supporting strategies to enhance AMS in Australia.
With support from the Commission, the NCAS
has expanded NAPS audits to include residential
aged-care facilities and multipurpose services, and
surgical prophylaxis.
3 National Centre for Antimicrobial Stewardship, and
Australian Commission on Safety and Quality in Health
Care. Antimicrobial prescribing and infections in Australian
residential aged care facilities: results of the 2015 Aged
Care National Antimicrobial Prescribing Survey pilot.
Sydney: ACSQHC, 2016.
2 Australian Commission on Safety and Quality in Health Care
Background
Antimicrobial resistance is a major public health practices that improve the appropriate and
concern, contributing to poor patient outcomes, judicious use of antimicrobials.
morbidity, mortality and substantial costs to the
NAPS delivers insights into the appropriateness
healthcare system. The September 2016 United
of antimicrobial prescribing at both a local and
Nations declaration on antimicrobial resistance
national level. Since the launch of the web-based
reinforces the World Health Organization’s Global
survey in 2013, NAPS has diversified and grown
Action Plan on Antimicrobial Resistance. Australia,
into a program that supports effective AMS across
as a signatory to the United Nations declaration,
Australian hospital and aged-care settings. The
is well placed to contribute effectively to the
data available from each NAPS module, especially
global response through implementation of its first
the Hospital NAPS, has contributed to local,
National Antimicrobial Resistance Strategy 2015–
jurisdictional and national antimicrobial prescribing
2019.4 Surveillance programs such as the National
strategies to improve the quality of antimicrobial
Antimicrobial Prescribing Survey (NAPS) support
prescribing and care delivered to patients. To
improved understanding of the use of antimicrobial
investigate prescribing practices for surgical
medicines in hospitals and raise awareness
prophylaxis, and the impact of compliance on
among health professionals about how to prevent
surgical site infections and patient outcomes, the
antimicrobial-resistant infections.
Surgical NAPS module pilot was launched in July
The development and implementation of NAPS 2016. As well, the development and successful
has been an ongoing collaboration between the implementation of the Aged Care NAPS in 2015
National Centre for Antimicrobial Stewardship provided Australia with valuable insights into the
(NCAS) and the Australian Commission on Safety appropriateness of antimicrobial prescribing in
and Quality in Health Care (the Commission). residential aged-care facilities and multipurpose
NAPS is developed and administered by the facilities.
Guidance Group at Melbourne Health. The data
The Hospital NAPS is the flagship survey of the
derived from the Hospital NAPS and Aged Care
NCAS. Participation has grown from 32 pilot sites
NAPS modules has significantly contributed to the
(30 public and 2 private) in 2011, when the survey
Commission’s Antimicrobial Usage and Resistance
was paper based, to 281 hospitals (213 public
in Australia (AURA) Surveillance System. The
and 68 private) in 2015. This report focuses on the
AURA Surveillance System plays a pivotal role in
results of the 2015 Hospital NAPS.
informing local, jurisdictional and national policy,
and in the development of strategies to prevent
and contain antimicrobial resistance in Australia.
In 2015, the Australian Government released
Australia’s first National Antimicrobial Resistance
Strategy 2015–2019, which outlines a framework
to address antimicrobial resistance using an
integrated and coordinated One Health approach.5
NAPS supports achievement of the objectives
of the national strategy through education
and training of the healthcare workforce, and
facilitating antimicrobial audit and review to enable
implementation of antimicrobial stewardship (AMS)
4 Commonwealth of Australia. Responding to the threat
of antimicrobial resistance: Australia’s first National
Antimicrobial Resistance Strategy 2015–2019. Canberra:
Commonwealth of Australia, 2015.
5 ‘One Health’ refers to a coordinated, collaborative,
multidisciplinary and cross-sectoral approach to the
development of health strategies for people, animals and
the environment.
Antimicrobial prescribing practice in Australian hospitals 3
Methods
Timing Auditors
The 2015 Hospital NAPS was launched in The majority of auditors were pharmacists
September 2015, and data collection closed in (61.1%), followed by nurses and infection control
February 2016. practitioners (ICPs; 19.9% combined), and
doctors (13.3%). Similar to the 2014 Hospital
Hospitals were encouraged to conduct their
NAPS, there was a substantial difference in auditor
survey before Antibiotic Awareness Week in
occupation between public and private hospitals
November 2015, so that results would be available
(Figure 1). In private hospitals, nurses and ICPs
for discussion and education.
comprised the majority of auditors (51.2%), and
only one doctor was involved in the audit. In public
Recruitment hospitals, pharmacists were the leading auditors,
followed by doctors, then nurses and ICPs.
Approximately 900 individuals across Most auditors were pharmacists across all three
400 hospitals registered on the NAPS website remoteness classifications (regional, remote and
were invited to participate in the 2015 Hospital very remote). A higher proportion of nurses and
NAPS. The Commission actively recruited ICPs completed the Hospital NAPS in regional and
hospitals, with a focus on increasing rural and remote hospitals than in metropolitan hospitals.
remote representation. Further promotion occurred
through tweets by the Commission and the NCAS
throughout October and November 2015.
Figure 1 Occupation of auditors, by hospital funding type, 2015
Figure 1 Occupation of auditors, by hospital funding type, 2015
80
80
70
65.4 70
65.4
60
60
51.2
51.2
ge 50 e 50
a g
t a
n t
ce 40 37.2 en 40 37.2
r c
e r
P e
30 P
30
20
14.3 15.5 20 14.3 15.5
10.7
10 10.7
10
4.8
4.8
0.8
0.8
0
0
Private (n = 121) Public (n = 648)
Private (n = 121) Public (n = 648)
Pharmacist Nurse or infection control practitioner Doctor Other
Pharmacist Nurse or infection control practitioner Doctor Other
4 Australian Commission on Safety and Quality in Health Care