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 Postal address; GPO Box 5480, Sydney NSW 2001 Phone: (02) 9126 3600; international +61 2 9126 3600 Email: [email protected] Website: www.safetyandquality.gov.au ISBN 978-1-925224-57-3 (print) ISBN 978-1-925224-58-0 (online) © Commonwealth of Australia 2016 All material and work produced by the Australian Commission on Safety and Quality in Health Care is protected by Commonwealth copyright. It may be reproduced in whole or in part for study or training purposes, subject to the inclusion of an acknowledgement of the source. The Commission’s preference is that you attribute this publication (and any material sourced from it) using 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