Utilizing Audits for Antimicrobial Stewardship in General Practice

Audits as an antimicrobial
stewardship tool
TARGET Antibiotic Toolkit
2023
May 2023
rcgp.org.uk/TARGETantibiotics
1
Introductions
May 2023
rcgp.org.uk/TARGETantibiotics
2
Erica Elsden 
(Speaker)
Lead Medicines
Optimisation Pharmacist,
NHS Hampshire & Isle of
Wight 
Integrated Care Board
Dr Philip Anyanwu (Panellist)
Associate Professor,
Public Health, University of
Warwick
Clara Tam (Panellist)
Antimicrobial Pharmacist,
NHS Betsi Cadwaladr
University Health Board,
Wales
Introductions – TARGET and RCGP
May 2023
rcgp.org.uk/TARGETantibiotics
3
Dr Dharini
Shanmugabavan
Camilla Stevenson
Fionna Pursey
Liam Clayton
Dr Donna Lecky
Cath Hayes
Emily Cooper
Eirwen Sides
Julie Brooke
Topics to cover
1.
Background and context
2.
Why use audit and feedback?
3.
Prescribing data sources
4.
Available audit tools
5.
Practical tips
6.
Case study: How a practice improved UTI management by using
audits and other tools
May 2023
rcgp.org.uk/TARGETantibiotics
4
Antimicrobial resistance a major issue
 
Deaths attributed to AMR every year
AMR 
2050
Diabetes 
and cancer 
combined
10,000,000
9,700,000
(O ’Neill, 2016)
M
ajority of antibiotics are prescribed in
general practice
  6
(UKHSA, 2022)
Total antibiotic consumption
by setting
May 2023
Why audit antibiotic prescribing?
1.
E
valuate, support and promote good prescribing practices
2.
Improve the quality of prescriptions
3.
Improve prescribing safety in general practice
  7
May 2023
(
Burgess, 2011)
(Care in Mind, 2020)
(Hughes, 2012)
Why use audit and feedback?
  8
rcgp.org.uk/TARGETantibiotics
1.
Identify areas for improvement and areas to celebrate
2.
Personal development & reflection on own antibiotic prescribing
3.
Practice-wide reflection on antibiotic prescribing
4.
Problem solving
5.
Action to support positive change
Optimise prescribing & reduce AMR
May 2023
Audit and feedback cycle for positive change
May 2023
(Hughes, 2012)
9
Audit and feedback: effectiveness
Cochrane Review of randomised
controlled trials
Audit and feedback increases
healthcare professional  compliance
with desired practice
May 2023
(Ivers et al. 2012)
10
Feedback may be more effective when:
Baseline performance is low
The source is a supervisor or colleague
Provided more than once
Delivered in both verbal and written formats
It includes explicit targets & an action plan
Audit and feedback can reduce antibiotic
prescribing
May 2023
(Elouafkaoui et al. 2016)
11
8.3
8.5
Baseline
 
Follow-up
 
7.9
 
7.5
Control group
Audit & feedback
intervention group
(Antibiotic items per 100 NHS treatment claims)
 
- 0.4
 
- 1.0
Randomised
controlled trial
Audit and feedback thought to increase
engagement & help achieve antibiotic targets
Workshop with 
AMS leads within Clinical Commissioning Groups
(CCGs)
May 2023
(Anyanwu et al. 2020)
12
 
Audits help increase engagement between
GP practices and commissioning groups to
achieve Quality Premium antibiotic targets
What data can be used to look at
prescribing?
 
May 2023
rcgp.org.uk/TARGETantibiotics
13
 
Fingertips
PrescQIPP
OpenPrescribing
ePACT/ePACT2
May 2023
rcgp.org.uk/TARGETantibiotics
14
https://www.prescqipp.info/our-
resources/webkits/antimicrobial-stewardship/
PrescQIPP: Accessing prescribing data
Gloucestershire ICB (Mar 2022 – Feb 2023)
May 2023
15
Open access
Drug prescribing
Monthly prescribing alerts
May 2023
rcgp.org.uk/TARGETantibiotics
16
openprescribing.net/
OpenPrescribing
May 2023
17
1. Choose prescribing drug
2. Compare against
Nothing
Drugs or BNF sections
Total list size
STAR-PUs for antibiotics
3. Highlight
Practice(s)
Sub-ICB location(s)
PCN(s)
ICB(s)
Region
OpenPrescribing: Run your own analysis
May 2023
rcgp.org.uk/TARGETantibiotics
18
Gloucestershire ICB
Open access
Browse indicators at different
geographical levels
Benchmark against the
regional or England average
Export data to use locally
fingertips.phe.org.uk/
May 2023
May 2023
20
Registration with ePACT2
Dashboards
Prescribing reports
Customised for your GP/ICB
ePACT2 
www.nhsbsa.nhs.uk/access-our-
data-products/epact2
May 2023
22
May 2023
rcgp.org.uk/TARGETantibiotics
23
ePACT2 
www.nhsbsa.nhs.uk/access-our-
data-products/epact2
May 2023
24
ePACT2 
www.nhsbsa.nhs.uk/access-our-
data-products/epact2
TARGET audit templates
Audits adherence to NICE antimicrobial
prescribing guidelines
MS Word and Excel
Includes step-by-step instructions
Calculates % adherence to guidelines
Summary report
Performance reflection questions
Allows to track performance
May 2023
rcgp.org.uk/TARGETantibiotics
25
rcgp.org.uk/TARGETantibiotics
TARGET audit templates
RTI audits
Acute cough
Acute otitis media
Acute rhinosinusitis
May 2023
rcgp.org.uk/TARGETantibiotics
26
UTI audits
UTI non-catheterised patients over 65
Uncomplicated UTI for women under 65
UTI for catheterised patients
Antibiotic specific
 ‘4Cs’ broad-spectrum antibiotics
Uncomplicated UTIs
for women under 65
27
rcgp.org.uk/TARGETantibiotics
May 2023
Patients with specific condition/ prescription
Evidence of diagnostic/ management decision
Antibiotic choice
Dose/ frequency
Course length
Providing advice: self-care, safety netting, use
of TARGET leaflet
Tailoring your approach to suit your
practice: practical tips & ideas
May 2023
(RCGP, 2022)
28
Identify an audit lead
Incorporate as part of standard practice e.g. once every year/
quarter/ month
Audit and reflect on your own prescribing and/or the practice as a
whole.
Coding of infections:
Inconsistency can impact data accuracy, search for specific antibiotics
Improving coding will make audits easier
Carry out audit
Tailoring your approach to suit your
practice: practical tips & ideas
May 2023
(Ivers et al. 2012)
29
Consider factors that might impact results e.g. data availability,
seasonal variation, population demographics
Feedback: clear, visual, use strategies including verbal, paper,
electronic
Compare results against targ
ets
Use practice meetings to present results, engage & develop an
action plan
Interpret &
feedback results
Tailoring your approach to suit your
practice: practical tips & ideas
May 2023
rcgp.org.uk/TARGETantibiotics
30
Develop action plan tailored to specific roles, with timelines
Whole practice approach
TARGET Toolkit has resources to help implement action plan
Re-audit regularly to monitor progress & change
Action plan &
positive change
Case study: How a practice improved UTI
management by using audits & other tools
May 2023
(RCGP, 2021)
31
Dr Linda Strettle,
GP, The Village Surgery, Rotherham
UTI audit case study: The issue
May 2023
32
In 2020, 20-30 urine samples per day dropped to reception by
patients, with incomplete forms
Further treatment prompted by urine dipstick result
Inefficient & risk for patient safety
Identify area for
review
(RCGP, 2021)
UTI audit case study: Championing change
May 2023
33
 
 
Needed evidence and guidance to engage the practice team
TARGET AMS workshop & UTI resource suite
Carried out TARGET UTI over 65s patient audit to assess practice
diagnosis & management against national guidelines
Carry out audit
(RCGP, 2021)
UTI audit case study: Whole practice
approach
May 2023
34
 
Audit showed that:
Urine dipstick results were driving diagnosis & treatment of UTIs in
over 65s: 
not recommended in guidance
Above national average on trimethoprim prescribing compared to
nitrofurantoin
Issuing longer courses of antibiotics than recommended by NICE
Interpret &
feedback results
(RCGP, 2021)
UTI audit case study: Whole practice
approach
May 2023
35
 
Presented audit evidence to engage whole practice:
Receptionists, nurses, GPs & management
Tailored level of information depending on role
Delivered focused adapted TARGET AMS workshop to all clinicians
Interpret &
feedback results
(RCGP, 2021)
UTI audit case study: Whole practice
approach
May 2023
36
 
Receptionists: 
Developed simple protocols & process flowcharts for
reception staff to encourage ‘consultation first’ rather than ‘dipstick
first’
Clinicians: 
Developed UTI diagnostic flowcharts, distributed to all
consultation rooms
Patients: 
If receptionists received challenges from patients about
change of policy, reached out to patient directly to explain reasons
Gathered feedback from staff throughout process
Action plan &
positive change
(RCGP, 2021)
UTI audit case study: Outcomes 2020 vs 2021
(post-policy change)
May 2023
37
 
Urine sample ‘drop offs’ dropped from 
20-30 unsolicited samples
pre-policy change to 
5 clinician-requested samples 
per day
Less total antibiotic prescriptions for UTIs post- vs pre-policy change
for similar time period
Clearer documentation of rationale for UTI diagnosis
More documented safety-netting & discussions with patients
regarding risks of antibiotics & AMR
Action plan &
positive change
(RCGP, 2021)
UTI audit case study: Outcomes 2020 vs 2021
(post-policy change)
May 2023
38
 
Positive changes for staff:
Reception staff felt empowered, had support of whole team
Nursing staff spent less time processing samples
Clinician workload shifted from managing urine sample results to
consultations to assess patients in line with national guidance
Action plan &
positive change
(RCGP, 2021)
Case study: key points
Use TARGET audit templates & other TARGET Toolkit resources to
support positive change
Whole practice approach
Problem solving
Part of a wider action plan
May 2023
rcgp.org.uk/TARGETantibiotics
39
Thank you!
May 2023
rcgp.org.uk/TARGETantibiotics
40
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Audience: Mainly primary care prescribers, GPs, nurses, clinical pharmacists, antimicrobial pharmacists, those assigned to carry out clinical prescribing audits

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The importance of audits in antimicrobial stewardship is highlighted in this informative content covering topics like why audit and feedback are crucial, sources of prescribing data, available audit tools, practical tips, and a case study showcasing the positive impact of audits in UTI management. The content also addresses the concerning rise of antimicrobial resistance and emphasizes the need for improved prescribing practices to combat this global health issue.


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  1. Audits as an antimicrobial stewardship tool TARGET Antibiotic Toolkit 2023 May 2023 rcgp.org.uk/TARGETantibiotics 1

  2. Introductions Erica Elsden (Speaker) Lead Medicines Optimisation Pharmacist, NHS Hampshire & Isle of Wight Integrated Care Board Clara Tam (Panellist) Antimicrobial Pharmacist, NHS Betsi Cadwaladr University Health Board, Wales Dr Philip Anyanwu (Panellist) Associate Professor, Public Health, University of Warwick May 2023 rcgp.org.uk/TARGETantibiotics 2

  3. Introductions TARGET and RCGP Cath Hayes Dr Donna Lecky Fionna Pursey Emily Cooper Eirwen Sides Dr Dharini Shanmugabavan Julie Brooke Camilla Stevenson Liam Clayton May 2023 rcgp.org.uk/TARGETantibiotics 3

  4. Topics to cover 1. Background and context 2. Why use audit and feedback? 3. Prescribing data sources 4. Available audit tools 5. Practical tips 6. Case study: How a practice improved UTI management by using audits and other tools May 2023 rcgp.org.uk/TARGETantibiotics 4

  5. Antimicrobial resistance a major issue Diabetes and cancer combined AMR 2050 AMR in 2050 10 million Deaths attributed to AMR every year Tetanus 60,000 10,000,00010,000,000 9,000,000 9,700,000 8,000,000 Road traffic accidents 1.2 million Cancer 8.2 million 7,000,000 6,000,000 AMR now 700,000 (low estimate) 5,000,000 4,000,000 3,000,000 Cholera 100,00 120,000 Measles 130,000 2,000,000 1,000,000 0 Diarrhoeal disease 1.4 million Diabetes 1.5 million (O Neill, 2016)

  6. Majority of antibiotics are prescribed in general practice Total antibiotic consumption by setting (UKHSA, 2022) May 2023 6

  7. Why audit antibiotic prescribing? 1. Evaluate, support and promote good prescribing practices 2. Improve the quality of prescriptions 3. Improve prescribing safety in general practice (Hughes, 2012) (Burgess, 2011) (Care in Mind, 2020) May 2023 7

  8. Why use audit and feedback? 1. Identify areas for improvement and areas to celebrate 2. Personal development & reflection on own antibiotic prescribing 3. Practice-wide reflection on antibiotic prescribing 4. Problem solving 5. Action to support positive change Optimise prescribing & reduce AMR May 2023 rcgp.org.uk/TARGETantibiotics 8

  9. Audit and feedback cycle for positive change Identify area for review Positive change Carry out audit Interpret & feedback results Action plan (Hughes, 2012) May 2023 9

  10. Audit and feedback: effectiveness Cochrane Review of randomised controlled trials Audit and feedback increases healthcare professional compliance with desired practice Feedback may be more effective when: Baseline performance is low The source is a supervisor or colleague Provided more than once Delivered in both verbal and written formats It includes explicit targets & an action plan (Ivers et al. 2012) May 2023 10

  11. Audit and feedback can reduce antibiotic prescribing Baseline Follow-up Control group - 0.4 8.3 Randomised controlled trial 7.9 Audit & feedback intervention group - 1.0 8.5 7.5 (Antibiotic items per 100 NHS treatment claims) (Elouafkaoui et al. 2016) May 2023 11

  12. Audit and feedback thought to increase engagement & help achieve antibiotic targets Workshop with AMS leads within Clinical Commissioning Groups (CCGs) Audits help increase engagement between GP practices and commissioning groups to achieve Quality Premium antibiotic targets May 2023 12 (Anyanwu et al. 2020)

  13. What data can be used to look at prescribing? PrescQIPP OpenPrescribing Fingertips ePACT/ePACT2 May 2023 rcgp.org.uk/TARGETantibiotics 13

  14. https://www.prescqipp.info/our- resources/webkits/antimicrobial-stewardship/ May 2023 rcgp.org.uk/TARGETantibiotics 14

  15. PrescQIPP: Accessing prescribing data Gloucestershire ICB (Mar 2022 Feb 2023) May 2023 15

  16. OpenPrescribing openprescribing.net/ Open access Drug prescribing Monthly prescribing alerts May 2023 rcgp.org.uk/TARGETantibiotics 16

  17. May 2023 17

  18. OpenPrescribing: Run your own analysis 1. Choose prescribing drug 2. Compare against Nothing Drugs or BNF sections Total list size STAR-PUs for antibiotics 3. Highlight Practice(s) Sub-ICB location(s) PCN(s) ICB(s) Region Gloucestershire ICB May 2023 rcgp.org.uk/TARGETantibiotics 18

  19. fingertips.phe.org.uk/ Open access Browse indicators at different geographical levels Benchmark against the regional or England average Export data to use locally May 2023

  20. May 2023 20

  21. ePACT2 www.nhsbsa.nhs.uk/access-our- data-products/epact2 Registration with ePACT2 Dashboards Prescribing reports Customised for your GP/ICB May 2023 22

  22. ePACT2 www.nhsbsa.nhs.uk/access-our- data-products/epact2 May 2023 rcgp.org.uk/TARGETantibiotics 23

  23. ePACT2 www.nhsbsa.nhs.uk/access-our- data-products/epact2 May 2023 24

  24. TARGET audit templates rcgp.org.uk/TARGETantibiotics Audits adherence to NICE antimicrobial prescribing guidelines MS Word and Excel Includes step-by-step instructions Calculates % adherence to guidelines Summary report Performance reflection questions Allows to track performance May 2023 rcgp.org.uk/TARGETantibiotics 25

  25. TARGET audit templates RTI audits Acute cough Acute otitis media Acute rhinosinusitis UTI audits UTI non-catheterised patients over 65 Uncomplicated UTI for women under 65 UTI for catheterised patients Antibiotic specific 4Cs broad-spectrum antibiotics May 2023 rcgp.org.uk/TARGETantibiotics 26

  26. Uncomplicated UTIs for women under 65 Patients with specific condition/ prescription Evidence of diagnostic/ management decision Antibiotic choice Dose/ frequency Course length Providing advice: self-care, safety netting, use of TARGET leaflet May 2023 rcgp.org.uk/TARGETantibiotics 27

  27. Tailoring your approach to suit your practice: practical tips & ideas Identify an audit lead Incorporate as part of standard practice e.g. once every year/ quarter/ month Audit and reflect on your own prescribing and/or the practice as a whole. Coding of infections: Inconsistency can impact data accuracy, search for specific antibiotics Improving coding will make audits easier Carry out audit (RCGP, 2022) May 2023 28

  28. Tailoring your approach to suit your practice: practical tips & ideas Consider factors that might impact results e.g. data availability, seasonal variation, population demographics Feedback: clear, visual, use strategies including verbal, paper, electronic Compare results against targets Use practice meetings to present results, engage & develop an action plan feedback results Interpret & (Ivers et al. 2012) May 2023 29

  29. Tailoring your approach to suit your practice: practical tips & ideas Develop action plan tailored to specific roles, with timelines positive change Action plan & Whole practice approach TARGET Toolkit has resources to help implement action plan Re-audit regularly to monitor progress & change May 2023 rcgp.org.uk/TARGETantibiotics 30

  30. Case study: How a practice improved UTI management by using audits & other tools Dr Linda Strettle, GP, The Village Surgery, Rotherham (RCGP, 2021) May 2023 31

  31. UTI audit case study: The issue In 2020, 20-30 urine samples per day dropped to reception by patients, with incomplete forms Identify area for review Further treatment prompted by urine dipstick result Inefficient & risk for patient safety (RCGP, 2021) May 2023 32

  32. UTI audit case study: Championing change Needed evidence and guidance to engage the practice team Carry out audit TARGET AMS workshop & UTI resource suite Carried out TARGET UTI over 65s patient audit to assess practice diagnosis & management against national guidelines (RCGP, 2021) May 2023 33

  33. UTI audit case study: Whole practice approach Audit showed that: Urine dipstick results were driving diagnosis & treatment of UTIs in over 65s: not recommended in guidance feedback results Interpret & Above national average on trimethoprim prescribing compared to nitrofurantoin Issuing longer courses of antibiotics than recommended by NICE (RCGP, 2021) May 2023 34

  34. UTI audit case study: Whole practice approach Presented audit evidence to engage whole practice: Receptionists, nurses, GPs & management Tailored level of information depending on role feedback results Interpret & Delivered focused adapted TARGET AMS workshop to all clinicians (RCGP, 2021) May 2023 35

  35. UTI audit case study: Whole practice approach Receptionists: Developed simple protocols & process flowcharts for reception staff to encourage consultation first rather than dipstick first Clinicians: Developed UTI diagnostic flowcharts, distributed to all consultation rooms Patients: If receptionists received challenges from patients about change of policy, reached out to patient directly to explain reasons positive change Action plan & Gathered feedback from staff throughout process (RCGP, 2021) May 2023 36

  36. UTI audit case study: Outcomes 2020 vs 2021 (post-policy change) Urine sample drop offs dropped from 20-30 unsolicited samples pre-policy change to 5 clinician-requested samples per day positive change Action plan & Less total antibiotic prescriptions for UTIs post- vs pre-policy change for similar time period Clearer documentation of rationale for UTI diagnosis More documented safety-netting & discussions with patients regarding risks of antibiotics & AMR (RCGP, 2021) May 2023 37

  37. UTI audit case study: Outcomes 2020 vs 2021 (post-policy change) Positive changes for staff: Reception staff felt empowered, had support of whole team positive change Action plan & Nursing staff spent less time processing samples Clinician workload shifted from managing urine sample results to consultations to assess patients in line with national guidance (RCGP, 2021) May 2023 38

  38. Case study: key points Use TARGET audit templates & other TARGET Toolkit resources to support positive change Whole practice approach Problem solving Part of a wider action plan May 2023 rcgp.org.uk/TARGETantibiotics 39

  39. Thank you! Avril Tucker Antimicrobial pharmacist Erica Elsden Lead medicines optimisation pharmacist Busola Daramola Chief pharmacist Clara Tam Antimicrobial pharmacist Dr Harry Ahmed General practitioner Dr Linda Strettle General practitioner Camilla Stevenson Project manager at RCGP Dr Dharini Shanmugabavan Medical director at RCGP May 2023 rcgp.org.uk/TARGETantibiotics 40

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