a novel way of conducting an antibiotic management
Ministry of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Bahrain; the smallest Arab’s Region country; is the most densely populated country with around 1,454 inhabitants per square kilometer. In contrast, Bahrain has an increasing population size which ranged from 360 thousand in 1980 to approximately 1.3 million in 2010 and is expected to reach 1.8 million in 2050. Salmaniya medical complex is the main hospital in Bahrain serving approximately 1.3 million people, the hospital capacity reaching1000 beds including 34 icu beds. The recent statistics about the rate of multidrug resistant organisms and the rate of hospital acquired infection internationally, regionally and locally is on the rise. This has been associated with an increase rate mortality and morbidity and increasing costs of health care services. It is obvious that antibiotics had saved many lives since they were first introduced to medical practice. The emergence of resistant microorganisms becomes faster when antibiotic use is inappropriate . Antimicrobial stewardship is a recent concept that embodies the practical, judicious use of antimicrobials to decrease adverse outcomes from antimicrobials while optimizing the treatment of bacterial infections to reduce the emergence of resistant pathogens. Antimicrobial stewardship is defined as a collection of interventions geared toward optimizing the prescribing of antimicrobials, and includes the appropriate selection, dosing, route and duration of antimicrobial therapy with the goal of optimizing patient outcomes and decreasing adverse events related to antimicrobial therapy. Our initiative began as urgent need to control the use of antibiotics in order to decrease the rate of multidrug resistant organisms , as we are in the infectious disease services are faced with an increase mortality due to these organisms among our patients . the update mortality reports for the last two years in the medical department is that 90% are due to sepsis and pneumonia. As the main mission of the health strategy in the kingdom for 2012 is that All population have access to quality health care throughout life time. That can be accomplished about elevation of the quality of health services through providing the best medical practice. We started this innovative program with a small multidisciplinary team to assess the current situation and provide recommendations. the team conducted several meetings and worked on an action plan which included daily follow up of antibiotic consumptions and daily rounds and audit to ensure appropriate antibiotic use with recommendations to the treating physicians and we followed the degree of compliance of health care workers with the recommendations and we followed the rate of consumptions of antibiotics. It was very challenging for the team to start such project without added staff or freeing more time I order to conduct it . But because if the strong believe in its importance and the need to start it we were able to start. We were aiming to change the organization culture about the concepts of antibiotic use. Overall, we were able by this innovative project to decrease the consumption of the antibiotics in the hospital, increase the compliance of physicians with the international guidelines, create a collaborative work with other subspecialties and other departments in order to provide the best quality of care. We were able to decrease the consumption of a lot of antibiotics over two years by 94 % for ceftriaxone, by 80% for meropenem , 70% for vancomycin , 80% floroquinolnes and by 50% for tazocin in the medical ICU only. After the initial stage , we were able to expand the program to include the whole hospital , and now to cover the primary care settings .

B. Strategic Approach

 2. What was the solution?
In summary : 1. decrease the unnecessary use and abuse of antibiotics and decrease the cost 2. provide a daily guidance for the use of antibiotics for all the patients needed it 3. to decrease rate of mutltidrug resistant and the rate of hospital acquired infection 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 strategy to stop antibiotic misuse adopted to approach the target of decrease the rate of misuse of antibiotics and preventing emergence of new resistant strains. The plan was to start to divide the work in two parts: the first is one is to collect the data about the consumption of antibiotics on daily basis and we chose the medical intensive car unit as a piloting. The second part which goes parallel with that one creating a form which as approved by the administration to follow all the cultures , the results and the antibiotic used and their doses and then followed by the infectious disease consultant recommendations . Most of the current available programs in the region and internationally concentrate on the first part with limited data on the second part and how we can really make a big change. And most of them have a dedicated team to do this. Our strategy was a central representation to the health strategy in the kingdom e government plan 201-2016 for providing the best quality of care with the concentration on disease prevention and health promotion. Our strategy in overcoming the antibiotics misuse in the hospital begin in 2012 with establishing a committee to monitor the use of antibiotics, and to follow up the culture results and then change the antibiotics to most appropriate choice. Based on the available resources and after revising the data obtained from the pharmacy and microbiology laboratory, we set our goals to target the area with highest antibiotic use and resistant organisms isolated. We collaborated with the main antibiotic committee, with all other subspecialties, pharmacy, infection control, information technology specialists and nurses. Our strategy for achieving the decrease in consumption without compromising the quality of services was based on the above two points with clear focus on the training of the involved members. It involved the followings: 1. Educational sessions to all professionals in order to facilitate the process and ensure active participation of all stakeholders. 2. Regular meetings with the concerned parties to increase the level of transparency. To have a face to face discussion with the health care workers to look into their concerns and answer their questions . 3. Daily walking rounds on the areas under the project and to provide all the support needed for the health care workers in their daily work 4. After the piloting period, we expanded the services to include other areas. 5. Collecting the data 6. Creating our own forms for the antibiotic consumptions by the medial resident to empower them 7. Creating our own forms for the recommendations to ensure a better monitoring system 8. Creating a software to enter the data and analyzed 9. Provide feedback to the department involved and the higher authority for decision making policies 10. Worked on and published the antibiotic guidelines for the first time to increase the degree of accessibility of the need knowledge 11. Worked on strict antibiotic policy Most of the work done of after working hours in order to be able to accomplish the goals we set for the project. This innovative project and the way we ran it with no extra cost and limited resources and manpower and in the way we empowered our staff to communicate and take the lead for their service are a role model which we trust that can be adopted in other hospitals. By providing these services in this way by our department it provides a clear and compelling example of the way this problem can be solved. Thanks to all dedicated members of the team and the support from higher authority so our patients can receive the best kind of care. The project was started in only one ward and now it covers the whole hospital and we are covering the primary care local health centers which are 27 health centers

 3. How did the initiative solve the problem and improve people’s lives?
The strategy to stop antibiotic misuse adopted to approach the target of decrease the rate of misuse of antibiotics and preventing emergence of new resistant strains. The plan was to start to divide the work in two parts: the first is one is to collect the data about the consumption of antibiotics on daily basis and we chose the medical intensive car unit as a piloting. The second part which goes parallel with that one creating a form which as approved by the administration to follow all the cultures , the results and the antibiotic used and their doses and then followed by the infectious disease consultant recommendations 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. Through this project we were able to 1. decrease the rate of hospital mortality in relation to hospital acquired infection ( which the rate of it is very high in our institution) 2. decrease the rate of hospital acquired infection according to our latest results 3. decrease the consumption of antibiotics helped in the followings : decrease the rate of their side effects and the allergies . 4. decrease length of stay which ultimately decrease hospital acquired infection and morbidity 5. this will increase the wellbeing of the general population as we have to be directed to prevention of infection and not to treat them 6. increase the rate of people accepting supportive care for simple viral infection and not to ask for antibiotics 7. saving a lot of money which would be utilized for other health services

C. Execution and Implementation

 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

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
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.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The project absolutely decrease the corruption and improve the integrity of the health system , as through restricted antibiotic policy and close monitoring of pattern of prescription we can ensure a better and higher quality of services with no prescription according to health care or patients wishes . And since we are monitored by the higher authority and we are committed to the international organization such world health organization and united nations to address this problem and take action, the public will have more trust in the public services provided

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The project was designed to cover all the population and residents living in the kingdom which will cover all regardless of their gender or age or ethnic group

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Ministry  
Contact Person:   jameela alsalman
Title:   Head of the antibiotic team  
Telephone/ Fax:   0097336515138
Institution's / Project's Website:  
E-mail:   k.ahmadi@pmc.gov.bh  
Address:   Pobox 12 manama
Postal Code:  
City:   Manama
State/Province:  
Country:  

          Go Back

Print friendly Page
video porno.. brasileiros xxx xhamster