Sticking to minimum standards: implementing antibiotic stewardship in intensive care.
BACKGROUND
In Australia, antimicrobial stewardship programmes are a compulsory component of hospital accreditation. Good documentation around anti-microbial prescribing aids communication and can improve prescribing practice in environments with multiple decision makers.


AIM
This study aims to develop and implement an intervention to improve antimicrobial prescribing practice in a 24-bed intensive care unit in a tertiary referral adult hospital.


METHODS
We conducted a four-phase (observation, reflection, implementation, evaluation) prospective collaborative before-after quality improvement study. Baseline audits and surveys of antimicrobial prescribing practices identified barriers to and enablers of good prescribing practice. A customised intervention was then implemented over 6 weeks and included a yellow medication record sticker, quarterly education sessions and intensive care unit-specific empiric antimicrobial prescribing guidelines. Post-implementation, the effects were monitored by serial antimicrobial prescribing audits for 1 year. The primary outcomes were clear documentation of the start date, the planned stop date or review date and the indication for an antibiotic. These were all considered the 'minimum standards' for an antimicrobial prescription on the medication record.


RESULTS
Documentation of minimum standards specifically addressed by the sticker improved (start date (72% to 90%, P < 0.001), stop date (16% to 63%, P < 0.001), antimicrobial indication documented on medication chart (58% to 83%, P < 0.01)). Overall, adherence to all three minimum standards (start date, stop date and indication) improved from 41/306 (13%) to 306/492 (63%) (P < 0.001). One-year post-implementation, the yellow sticker had become embedded into daily practice.


CONCLUSION
A systematic approach to quality improvement combined with the implementation of a tailored, multi-faceted intervention can improve antimicrobial prescribing practices.
['Chaves|N J|NJ|', 'Ingram|R J|RJ|', 'MacIsaac|C M|CM|', 'Buising|K L|KL|']
D000900:Anti-Bacterial Agents D001315:Australia D054869:Clinical Audit D003299:Cooperative Behavior D003422:Critical Care D019983:Guideline Adherence D019538:Health Care Surveys D007722:Health Knowledge, Attitudes, Practice D006801:Humans D007362:Intensive Care Units D010818:Practice Patterns, Physicians' D011446:Prospective Studies D058996:Quality Improvement
anti-infective agent attitude of health personnel clinical audit clinical competence inappropriate prescribing reminder system