Reducing antibiotic prescribing through system leadership

by Katie Perkins, Medicines Management Adviser Hastings & Rother Clinical Commissioning Group

At the end of 2018 I took on the role of CCG medicines management lead for antimicrobial prescribing (alongside promotion to Medicines Management Adviser and respiratory lead). I work across two CCGs which cover 43 GP practices.

RPS AMS training

The RPS AMS training programme became available at just the right time in terms of my new role and immediately before the start of our 2019/20 prescribing support scheme. I was already out and about talking to GPs about their antibiotic prescribing and in particular three out of the 10 practices that I look after were particular outliers for antimicrobial prescribing. The learning that I undertook as part of the course, particularly in Quality Improvement (QI) methodology was invaluable and we were given a brilliant opportunity to “try this out in practice” with tutor support.

My QI project

The QI project I chose was to reduce inappropriate prescribing of antibiotic rescue packs for COPD exacerbations and ultimately for this to help reduce the total number of antibiotic items (per STAR PU) prescribed by the practice.

I carried out a patient level search at the practice to identify people with COPD who were prescribed an antibiotic rescue pack on repeat prescription. 22 people were identified and 9 of these had received six or more courses in the preceding twelve months.

In preparation for presenting this to the practice I met with a nurse at another practice which had robust and effective processes in place for the issue and follow up of COPD rescue packs – this was helpful in ensuring that I had a realistic handle on what is reasonable to expect in practice.

I met with the four practice GPs, pharmacist and practice manager and presented them with the list of these patients. I asked them to review each one to determine if the antibiotic remains appropriate. I provided them with current national guidance from NICE on this area as well as our local formulary guidance.

Where an antibiotic rescue pack was appropriate, the GPs were asked to consider only prescribing this as an acute prescription (not on repeat) or, as a compromise, if they would prefer to keep them on repeat, to consider a maximum of two issues before the patient was reviewed. I was surprised that the practice agreed to move all prescriptions to acute and for all new rescue pack prescribing to be issued only on acute.

They also agreed to include instructions in the rescue pack directions for the person to contact the surgery when they started taking it. The practice already had a leaflet that they give out to people when they are first prescribed a rescue pack – they now aim to give this out more consistently.

Results and impact of my QI project

Before the QI project (February 2019) the practice was the highest prescriber of antibiotics in the CCG (total items/STARPU). The latest data from PrescQIPP (August 2019) shows that the practice has dropped to the 9th highest (out of 23 practices) and reduced their total antibiotic prescribing by 10%.

Practice bar charts Antibacterial items/STAR-PU showing 12 months rolling data to August 2019

This is likely to be in part due to the reduction in rescue pack prescribing but I suspect that the project may also have provided a renewed focus on reducing inappropriate antibiotic prescribing more generally.

Getting all the GPs and the practice pharmacist together and presenting the data to them face to face really got them thinking about the possible consequences of these repeat prescriptions. They all committed to reviewing these patients and they have changed their behaviour when it comes to managing COPD rescue pack prescribing.

Next Steps

As mentioned previously the response to my QI project proposal by the practice pleasantly surprised me and this has given me the confidence to roll the QI out to the other 42 practices across the CCGs. I also plan to look at other areas of repeat prescribing of antibiotics such as UTI prophylaxis and long term prescribing for acne and rosacea.

Find out more about our AMS training in England

Strengthening Antimicrobial Stewardship through training

by Vincent Ng, Professional Development Pharmacist

The challenge   

This year the UK Government updated its 5 year action plan on Antimicrobial Resistance (AMR), which details ambitious goals such as reducing antimicrobial usage in humans by 15% and halving gram negative blood stream infections by 2024.

A major part of this plan involves improving how antimicrobials are used through Antimicrobial Stewardship, for example by reducing inappropriate prescribing. As experts in medicines and advocates for medicines optimisation, all pharmacists have a role to play.

Supporting pharmacists through training

Earlier this year, we delivered a 3-month training programme to pharmacists from primary and secondary care in London, Kent, Surrey and Sussex, funded by the Health Education England AMR Innovation Fund. This was an exciting opportunity for us to support pharmacists from a range of settings and scopes of practice to learn about Antimicrobial Stewardship and get involved in their workplace.

What did the training involve?

  • Face-to-Face training day delivered by national experts
  • Quality improvement project in the workplace, supported by online group feedback sessions facilitated by UKCPA Pharmacy Infection Network tutors
  • Structured self-assessment and self-directed learning
  • GPhC revalidation entries
  • End of training assessment with experts from our Antimicrobial Expert Advisory Group

What our learners are saying

“I was given the opportunity to be part of the AMR programme this year and found the programme very useful. It has propelled me in the right direction with regards to leading on AMR within my organisation.  The key resources provided during the programme and the link to a tutor gave the confidence I needed to complete my project. My quality improvement project involved the review of patients with UTI to ensure appropriate prescribing and accurate documentation process.  Although the project was only focused on a small cohort it was very useful to see the changes and improvement that was made. I have not just stopped with the project but have also made myself an AMR champion with AMR now formally included in my work plan. I am now creating a training matrix to increase awareness within my organisation.”

Jenkeo Olowoloba, Community Health Specialist Pharmacist, Medway Community Healthcare

“The training helped me develop my skills as a competent and confident AMS practitioner. Participating in this training programme enabled me to significantly improve my quality improvement skills, extending my skills beyond audits and re audits. I demonstrated QI methodology and embedded behavioural interventions to improve the quality of the 72-hour antibiotic review carried out by clinicians.  I also designed a scoring tool on the Perfect Ward App to measure the quality of an antibiotic review which led to reducing data collection time from 15 minutes to 5 minutes. I enjoyed the entire experience and valued the constant support provided by our tutors, RPS team and colleagues. The practice-based discussions benefitted my practice significantly, being able to share ideas and learn from experts as well as each other. Thank you RPS for an amazing opportunity!

Bairavi Indrakumar, Senior Clinical Pharmacist, Royal Free London NHS Foundation Trust

Getting started

Take the first step by finding out more about how your organisation is doing against key AMS indicators. Work with your peers and colleagues to better understand how things are working. PHE Fingertips and OpenPrescribing.net are examples of useful open-access sources of data that you can explore.

Talk to your key stakeholders to come up with shared objectives and work together on a plan to make improvements.

Inspire and get inspiration

Why not link up with others who are also working on AMS and AMR?

Update! We’ve been commissioned to provide AMS training in England in 2020. Find out more and book your place.