| 4. In which ways is the initiative creative and innovative?
|
|
A restriction in antibiotics use can be only achieved with strict monitoring system of prescribing and dispensing the medications with frequent feedback between the infectious diseases department , pharmacy and involved specialty.
This can be achieved by devoted infectious disease specialists reviewing patient file, progress, cultures and sensitivity and giving advice regarding the best choice of antibiotics.
In order to monitor the progress and efficacy of the program we established computerized antibiotics prescription database, and we created a modified version of WHO antibiotics use calculator to suites our needs but still internationally approved.
Innovative elements:
- Computerized antibiotics consumption database which as modified according to our needs
- self developed form for the cultures and recommendations by the team for measuring the compliance and the effect of the recommendations
- No extra costs
- No extra manpower, it is just simple training of the existing staff
- devoted infectious diseases specialists available 24 hours a day
- empowering the concerned to help through continuous education and transparency
- The team ambitious goal was to achieve the main objective with less resistant from the health care workers which we achieved by improving the communications skills and assuring their satisfaction
|
|
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
|
|
he program was implemented by two teams and monitored and followed by the higher authority in the ministry :
In the first stages it was only one team: with all the stakeholders but with the expansion of the program , there were two teams
The two teams were :
1. a team which involve all the stakeholders as advisory team
2. the field team who are conducting the daily rounds , data collection , data entry and data analysis
the program is now covering all the patients that access the ministry of health care system ( which represent 80% of the population of Bahrain )
|
| 6. How was the strategy implemented and what resources were mobilized?
|
|
The evolving public health threat of antimicrobial resistance (AMR) is driven both by the appropriate and inappropriate use of anti-infective medicines for human and animal health and food production. Recognizing this public health crisis, several nations, international agencies, and many other organizations worldwide have taken action to counteract it through strategies applied in the relevant sectors
Several World Health Assembly resolutions have called for action on specific health aspects related to AMR, and the World Health Organization (WHO) published its global strategy for containment of antimicrobial resistance in 2001, and on World Health Day (WHD) 2011 called on countries in a six-point policy package
In 2012, the ministry of health in Bahrain adopted the world health organization initiative for antibiotics stewardship in order to decrease the rate of multi drug resistant organisms and the initiative was taken by the medical department by medical department under leadership of an infectious diseases consultant. The rate of antibiotic is a global threat to the health system and the kingdom if Bahrain is of no exception.
The antibiotics restriction program was implemented in 2012 , initially we started in intensive care unit, then we included high dependency ward, and later one general medical ward.
Dates:
11/2012- start with one ward the medical intensive care unit , we continued working on it for 12 months then we included the surgical intensive care unit. After this piloting period we included more wards (with a capacity of 26 beds)
January 2014 we included the intermediate care units in medical wards (with a capacity of 35 beds )
July 2014 , when were able to sustain the progress and we expanded the program to include the extra five medical wards and five surgical wards
In 2015 start to involve the rest of the hospital
In 2016 hospital full covered
2016: primary care involved
Planning:
Our main aim in starting the program was to target the areas with the highest rate of antibiotics use especially broad spectrum antibiotics.
Planning:
- A multidisciplinary team was created including the following members: headed by infectious disease consultant, infectious disease medical residents, infection control, clinical pharmacist, head of the pharmacy, information technologist, and two microbiologists.
- Based on the existing data provided from the pharmacy about the antibiotic use and the rate of infections and the rate of multidrug resistant organisms and the culture results obtained from microbiology, to find the areas we need to focus on.
- We found that the highest rate of consumption of antibiotics is in the intensive care units and then the medical wards. We found also that are certain antibiotics are over used and that we need to work on. After analyzing the data we found that ICU has the highest rate of use of broad spectrum antibiotics so we decide to start in the intensive care units , then in second stage to include high dependency wards , then third stage to include all medical wards, fourth stage surgical wards and final stage gynecology + ENT + ophthalmology wards
- We met several times to discuss the current problems and how to solve them especially with limited resources and manpower.
- We revised the existing guidelines and the experience of other countries , were we did not find anything that meet our expectations and can really give us results with the limited resources
- We created out own forms which have been modified several times to make sure that provide all the data we needed to create a database and start out implementations
- We started with the first of collecting antibiotic consumption for short period and followed in 2 weeks by implementation of the recommendations form based on the updates international guidelines.
- We were followings the patients on daily basis to review the clinical presentations and adjust the antibiotics accordingly
Piloting:
- We started the piloting in the medical intensive care unit with data collection and in two weeks with the recommendations form
- Then we added the surgical intensive care unit ( total beds of 26)
- The period lasted for 12 months
- In this period there was a lot of discussion about how to improve it
Scaling:
- After the analyses of the initial results and the very good results , we decided to expand the project to include the two more wards in the intermediate care level ( more 35 beds)
- Then we expanded the project to include five medical wards and five surgical wards. ( 220 beds)
- Along with the conducing the project and doing the rounds we started a serial of educational sessions for the health care workers
- The antibiotic guidelines were published and distributed
- The antibiotic policy was published and distributed
Monitoring and refinement
- Along the process we have a very close monitoring system though the daily rounds
- Regular meeting and discussions with all the stakeholders
- We made the team more accessible to staff by the availability of the infectious disease consultant 24 hours a day
- We worked though educational sessions to change the organizational culture as there was a lot of resistant initially from the health care workers
- Our forms had several editing based on the needs and the observations of the health care workers
Currently
The program covers all the wards in major hospital and primary care sectors
We decrease rate of MDRO and stabilized some
We decrease the rate and costs of antibiotic utilization upto hundredths thousands of Bahraini Dinnars
Increase the level of knowledge of health care workers about the better utilization of antibiotics
The antibiotic form has been integrated in the electronic health records system
The antibiotic policy has been strengthened
The antibiotic guidelines have been established and published , we have the second edition
|
|
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
|
|
The stakeholders:
Pharmacy:
- Clinical pharmacist played a critical role in the initial design and implementation of the project
- Clinical pharmacists playing important role by providing a daily report of requested and dispensed antibiotics, giving information about available alternative treatment.
- Urgent notification form is sent from the pharmacy to antibiotics committee in case of prescribing a broad spectrum antibiotic >48 hrs without a follow up from he infectious disease team
- They were involved in Teaching lectures and seminars for the safe use of antibiotics
Infectious diseases specialists
- Played a critical role in the initial design and implantation of the project
- Daily rounds in the targeted areas, reviewing the current antibiotics doses, interaction, indication, culture results and latter giving most appropriate recommendations.
- Giving educational sessions to all health care workers
- Analyze the results and give feedback to the end users to empower them with a high degree of transparency
- Provide regular report to the high authority to help in decisions making
- Conducting regular meeting with the microbiologists to follow the trends in multidrug resistant organisms
Microbiologist
- Played a critical role in the initial design and implantation of the project
- Providing weekly and monthly reports about the isolated organisms and immediate reporting of emergence of resistant strains. Rapid processing of cultures and sensitivity.
- Giving educational sessions to all health care workers
Infectious disease and medical Residents:
-Played a critical role in the initial implantation of the project
- Play a critical role in the designing the forms
- Their main role is Data entry and analysis
-Daily rounds in the targeted areas, reviewing the current antibiotics doses, interaction, indication, culture results and latter giving most appropriate recommendations.
Infection control officer:
-Main task is teaching and implementation of infection control measures, insuring prevention of hospital acquired infections and reporting of any cases and act accordingly.
Administration:
- A critical role in the initial establishment of the team
- Giving the needed support in from of issuing the guidelines and the antibiotic policy and publishing
- In the support of the educational plan form the team
The main amitotic committee
- A critical role in the initial establishment of the team
- Giving the needed support in from of issuing the guidelines and the antibiotic policy and publishing
- In the support of the educational plan form the team
- other sub specialities : surgeon and general medicine as they will be the advocate for the best use of antibiotics
|
|
| 8. What were the most successful outputs and why was the initiative effective?
|
|
The goal of antimicrobial stewardship is to optimize antimicrobial therapy with maximal impact on subsequent development of resistance. Infection with multidrug-resistant pathogens adversely affects quality of medical care. It is cost-effective to implement a multidisciplinary Antimicrobial stewardship program in acute service hospitals as the program reduces antibiotic consumption and results in overall cost savings. The quality of medical care is not jeopardized as the important clinical outcomes are not adversely affected.
We were able through this project to provide an excellent service in treating infectious disease with international standards with no extra cost. This project can guarantee an equal level of care delivery to all who attended our major public hospital.
From economic prospective, unlike other initiatives, we did not need any additional funding, and on the other hand restriction and monitoring of use of antibiotics decreased the cost of dispensed medications which give the hospital additional budget which was used in expansion and development of other facilities.
We were able to accomplish the followings:
- Decrease unjustified antibiotic use, which in turn decrease the length of stay in hospital, less side effects from prolong use, ability to discharge patients on oral antibiotics if needed providing a free bed for other patient. Though this we were able to save a lot in relation to decreasing the hospital stay and in relation to decreasing the costs of the antibiotics.
- general awareness of physician towards the correct use of antibiotics, following international and local best practice guidelines which will improve patient management outcomes and quality of life.
- Re alignment of the exiting budget: saving budget from unneeded prolonged/inappropriate use of antibiotics, in which saved money is being used for development of other projects and renovation of existing facilities
- An organizational culture changes : where the people working in different subspecialties learn how to share knowledge and exchange information and experience.
- Full comprehensive electronic database providing information about the indication for the use of antibiotics, dosage, duration, culture results, and recommendation by antibiotics committee.
this will create a great impact on the future planning and it will help the higher authority for the decision making in regard of allocating budgets , educations, training ,manpower planning and other resources allocation.
- Empowering the health care workers , especially the junior residents to be a role model and building their capacity as new leaders
- We would like to set as a role model and provide a Roadmap for other local regional or international health care facilities. As this project can be applied in other settings with limited resource settings.
- This project has been recognized and appreciated by the different stakeholders; the administration, antibiotic committee , health care workers, pharmacists and microbiologists.
1. Decrease the costs of the antibiotics
Based in the above output we were able as an indirect output to decrease the costs related to the antibiotic in the areas we were following and auditing. There was a major saving in the costs of the antibiotics reaching couple of millions dinnars per year
2. Improve the knowledge of the health care workers :
-We were able through this project and in order to achieve the main objectives to increase the level of knowledge of the health care workers.
-A major point in the action plan was the increase the knowledge to create a partnership with all the stakeholders
-we were able to disseminate the knowledge by expanding the project and replicate the same steps in all the involved area.
3. Improving the compliance rate with the infectious disease recommendations.
In the initial phase in the medical intensive care unit, the rate of compliance with the recommendations was zero, and then it improved within one month to 50%. By the end of the pilot period it increased to 90%.
Currently we are maintaining 100% compliance rate in the initial areas. We are facing the same progress in the rating in the other areas in the same pattern where the compliance start low and then increase with continuous auditing , educations and meetings with the end users.
4. Decreasing the length of stay
By following the international guidelines for antibiotic duration for the major infectious disease we were able to decrease the length of stay for
The ultimate end point is decreasing the rate of multidrug resistant organism which we are hoping to accomplish in the next couple of years as this endpoint usually takes long time ( years after implementation as per the most recent studies in the field.
5. decreasing the rate of antibiotic consumption and now we can benchmark ourselves with other international figures using specific indicators and rates such as the daily divided dose and duration of therapy
6. we started a national antibiotic campaign to address the importance of the proper use of antibiotics the public
7. we got recognition as one of the top three government practices in the kingdom of Bahrain in 2016 and was honored by the his majesty the prime minister
|
|
| 9. What were the main obstacles encountered and how were they overcome?
|
|
1- No available database:
Challenge: The main obstacles we found at beginning of the strategy, that there was no available data of any kind that we can start with or to compare our results with.
The other major point that it was difficult for us as when we started there was a lot of paper work , and it was difficult to retrieve data.
Solution:
- we created the checklist for data collection
- we created the checklist for infectious disease recommendations
- We established an electronic database.
- We modified the WHOI antibiotic calculator and utilized
Outcome:
- better and easier access for the data
- Facilitate data analysis, and daily updated data.
- Created a Database for future studies
2- Shortage of well trained staff about antibiotic stewardship:
Challenge:
- shortage of well trained staff, including infectious disease specialist, clinical pharmacist, and microbiologist
Solution:
- A serial of educational lectures to all the health care workers and the stakeholders
- A serial workshops in the best management of antibiotics and the best line of antibiotic stewardship program
- we started in one ward with most of antibiotics overuse
- more staff were recruited and trained mainly junior residents to ensure the sustainability of the project, more efficient data collection and analysis.
Outcome:
- more well trained health care workers are available to maintain the sustainability
3- Miss communication between physicians/ pharmacist/ microbiologist
Challenge
-there was no communication between the main end-users, which make delay in obtaining the culture results, clinical pharmacist opinion and decision of the physician.
- this was clearly reflected on the pattern of overuse and misuse of antibiotics
Solution:
- Regular meetings between involved specialties with a high degree of transparency
- Availability of the forms with the recommendations inside the patients chart
- Availability of infectious disease consultants 24 hours a day
- Urgent notification from microbiologist if a resistant strain was isolated
- Notification from pharmacist if broad spectrum antibiotic used >48 hrs without infectious disease follow up
Outcome:
- More cooperation and collaboration between different specialties which improved the choice of antibiotic and better control over the use antibiotics
|