Dr Avgi Loizidou, FY1 Mr Chris Dawson, Consultant Urologist and Clinical Audit Lead

1. Audit of Drug Charts (Antibiotics and Anticoagulants)Audit no. 1898 start date: 23/01/2018, end date: 28/02/2018(Previous Audit 1384 – January 2017) Dr Avgi Loizidou, FY1 Mr Chris Dawson, Consultant Urologist and Clinical Audit Lead Urology Department Audit Meeting, June 2018

2. Contents • Why do we need (yet an other) prescribing audit? • Aims and Objectives • Methodology • Audit Standards • Key Findings • Recommendations for Improvement in clinical practice

3. Background • In the last 40 years antimicrobial resistance has increased alarmingly • We now have organisms which are incredibly difficult to eradicate including: • Extended spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria • Methicillin resistant Staphylococcus aureus (MRSA) • Clostridium difficile infection (CDI) • Which cause long lasting harmful changes to the body’s flora AMR Broad spectrum antibiotics Prolonged duration

4. Unfortunately we have not been able to keep up with the microbes and very few antibiotics with novel mechanisms of action have been developed • What’s worse, there is no money in R&D for antimicrobials • So we need to ensure that we are using effectively the antimicrobials we have in our armoury • Chances are this is all we will get… Cipro Tazocin Co-amox Meropenem Gent Urology PCH

5. Cochrane Review - interventions to improve antibiotic prescribing practices for hospital inpatients 2013 2013 - The UK government embarks on a five year antimicrobial resistance strategy Antimicrobial stewardship: Start Smart Then Focus English Surveillance Programme for Utilisation and Resistance (ESPAUR) 2014 Chief Medical Officers recommendations 2011

8. How well do we prescribe antibiotics?

9. Audit Aims and Objectives This audit aims to assess prescribing practice by the Urology department in PCH (Please see also audit 1384 – January 17) Audit Objectives: • Assess if antimicrobials are prescribed correctly on Drug Charts • Assess if the antimicrobials prescribed reflect clinical indication • Assess if the choice of antimicrobial and route of administration is reviewed at 48-72h

10. Audit methodology • Audit timeline 4th December 2017 – 4th April 2018 • Audit location PCH • Patients identified via eTrack • Sample size 50 • Prospective data collection • Sources used • ED Clerking Performa and Clinical documentation • Patient Drug charts • ICE • Discharge letters

11. Data collection audit pro-forma Peterborough City Hospital

12. PCH Drug chart

13. Audit standards

14. Audit findings

15. Making sense of the numbers 50 cases reviewed in total 35 Males, 15 Females

16. Outcome 1: Antibiotic prescribed reflects clinical indication according to local guidelines

17. Interestingly… • Co-amox has been prescribed for: • Testicular torsion + raised WCC • Urosepsis • Renal stone + pyelonephritis • Renal colic + raised WCC • Wound infection • Haematuria • Urinary retention • Epididimorchitis • Cipro has been prescribed for: • Urinary retention • Heamaturia • Epididimorchitis

18. Outcome 2: Correct prescribing of antibiotics on drug charts

19. Outcome 3: Antibiotic prescription is reviewed after 48-72h

20. Outcome 4: Duration of antimicrobial use reflects local guidelines

21. How well do we manage DVT prophylaxis?

22. Summary of principles of DVT assessment Confidential info

23. Dalteparin chart

25. Audit Aims and Objectives This audit aims to assess how we manage DVT prophylaxis in the Urology Department in PCH Audit Objectives: • Assess if we manage appropriately the need for DVT prophylaxis in our patients • If dalteparin, is this prescribed correctly?

26. Audit standards

27. Outcome 5: Is appropriate DVT prophylaxis given for each patient

28. Outcome 6: If Dalteparin is prescribed, is this done correctly

29. Audit Outcomes summary table

30. Recommendations for improvement in clinical practice • Remind junior of the PCH guidelines • Understand why we use which antibiotics and when • PCH Antimicrobial Guideline cards • Microbiology Guideline Apps

31. PCH antimicrobial guideline cards • Add photo

32. Apps that help prescribing antimicrobials!

35. Actions to be taken Actions need to be agreed by all the groups affected and an individual named to take each action forward and ensure it is completed. An estimated time for completion will assist in knowing when to check and when to schedule the remedial cycle of the audit.

36. Actions to be taken - 2

37. References • Diamantis Plachouras, Susan Hopkins. Antimicrobial stewardship: we know it works; time to make sure it is in place everywhere[editorial]. Cochrane Database of Systematic Reviews 2017;(2): 10.1002/14651858.ED000119 • https://www.nice.org.uk/guidance/ng63 • https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/417032/Start_Smart_Then_Focus_FINAL.PDF • https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/417041/Revised_SSTF_Tools_Annex_FINAL.pdf • http://www.microguide.eu/ • https://www.baus.org.uk/_userfiles/pages/files/professionals/surg/TJW-Antibiotics-and-prophylaxis.pdf