AURA 2019: Implications for AMS and Clinical Practice

Dr Emma GoemanStaff Specialist Infectious Diseases & MicrobiologyRoyal Prince Alfred Hospital

No conflicts of interest to disclose

Views expressed are my own and not necessarily those of AURA/ ACSQHC or SLHD / RPA Hospital.

I would like to acknowledge the Gadigal of the Eora Nation, the traditional custodians of this land, and pay my respects to the Elders both past and present

• Data contributions (eg. NAPS, NAUSP, AGAR, OrgTrx, CARalert etc)• Strategic direction: priorities for intervention (align local with national)• Education and inspiration • Benchmarking / comparison• Empiric prescribing considerations• Infection prevention & control, and outbreak preparedness• Laboratory testing & reporting• Accreditation, patient safety

An individual acute hospital’s engagement with the AURA report

•diagnostic technology•drugs and vaccines• evidence based guidelines• experts in infection control, clinical infectious diseases/ microbiology, and antimicrobial use

High level of access to:

Low baseline rates of resistance compared with many other countries

Strong biosecurity measures and (relative) geographical isolation

Strong regulation of antimicrobial use in veterinary and food production sectors

Strong regulation of antibiotic quality and lack of OTC access

Why Australian hospitals are well positioned to do AMS & contain AMR well

AMS & the appropriateness “ceiling” – can we push upwards through it?

https://www.safetyandquality.gov.au/wp-content/uploads/2018/11/2017-Hospital-NAPS.pdf

0.83% increase in appropriateness in hospitals that had contributed at least twice to NAPS – statistically significant, 

but programmatically significant?

• Prescriber, pharmacy and nursing education• Provision & promotion of evidence based guidelines• Formulary restrictions / pre-authorisation• (Clinical decision support systems)• Post prescription review & feedback• Longitudinal audit & feedback• Selective antimicrobial susceptibility reporting*Essentially – diplomatic negotiation by AMS teams, with voluntary action by prescribers.

Tools in the hospital AMS armamentarium

• Fear of adverse patient outcomes, pressure to intervene• Competing priorities around what constitutes best practice – immediate or

short term individual patient risks versus longer term community / global risks

• Perceived ambiguity in infection management and antibiotic choice• Prescribing etiquette• Entrenched professional values and belief in essential benevolence of

antibiotic use• Intra-professional and workplace context• Influence of craft groups / experience vs guidelines

Barriers to improving appropriateness – a sociological perspective

Broom A et al 2016 J Sociology 52(4):824-839

• Where does, or should, the AMS team fit with respect to the prescriber-patient relationship?

Situation- specific approaches to AMS #1SituationComplex / high risk patients with known AMR, allergies, difficult to manage infections

Guidelines / evidence lacking

Diagnostic uncertainty

Highly restricted / last line antimicrobials

Response

Telephone advice and antimicrobial approvals

Individualised chart reviews and/or bedside consultation

Patient centred care

Shared responsibility and decision making

AMS team is / becomes part of the prescriber‐patient relationship 

Situation- specific approaches to AMS #2Situation

Robust evidence based guidelines

High volume antimicrobials

Clear appropriateness criteria

Protocolized indications

“Standard risk” patients

ResponseProvision of guidelines and 

education

Confirmation of guideline applicability to site / population

IT systems making it easier to do the right thing – eg care sets, order sentences

Audit and feedback

Something else?

AMS team remains outside of the prescriber‐patient relationship 

Enhanced surveillance for audit & feedback

Patient details Prescriber details

Enhanced surveillance for audit & feedback - EMM

Goeman et al 2019 poster presented at Australian Society for Antimicrobials annual scientific meeting

12 months eMeds data from RPAH1/11/2017 – 31/10/2018

• Understanding and engaging systematically with the sociological drivers of antimicrobial prescribing

• Ownership of data, the problem & solutions by craft groups / prescribers⎻ Requirement for self audit eg M&M; self-sustaining

• Formalised benchmarking of specific medical services, or, gamification• Multi-disciplinary data linkage & visually appealing dashboards in real time

- eg antimicrobial use indicators, infection control, environmental cleaning, genomics

• Culture change – all antimicrobials “restricted”; common pool resource framework

• How far can / should we restrict clinician autonomy, and who decides?

What might the “something else” look like?

Safetyandquality.gov.au

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