rational use of injection: an integrated tool for monitoring injection prescription in the kingdom...

RATIONAL USE OF INJECTION:

An Integrated Tool For Monitoring Injection Prescription

in theKingdom of CAMBODIA

Dr Sok SrunDepartment of Hospitals, MoH.

Kingdom of Cambodia

Background of Cambodia

Location : Western Pacific region, bordering with Thailand, Lao PDR and Vietnam

- Land area : 181 035 Km2- Administration areas : 24 Provinces/Municipalities,

183 Districts, 1609 Communes & 13406 Villages- Population : 11.4 Million

- Urban: 15,7% & Rural: 84.3%- Under 15: 43% & Over 65 : 3.5% - Growth rate : 2.5%- Crude birth rate : 3.8%- Total fertility rate : 5.3

- Religion : Buddhism 95%- GDP : USD 310 per Capita in 1999- Adult Literacy Rate : 79.5% ( male:67.3% & female: 57% )

Health Facilities

Health Facilities 1995 Plan 2001-Nat Hosp 8 8 8-Prov.Hosp 23 24 24-Dist.Ref Hosp 0 44 41-(Former) Dist. Hosp 164 - 112-Health Centers 0 929 769

Hospital Beds Public Private-National Hosp 1926 500*-Provinces/Districts8490 NA

1) Promote the rational use of injectables and oral antibiotics at public referral hospital level.

2) Monitor quantity and quality of injectable antibiotics and IV fluids prescription focusing on targeted diseases and using an integrated tool to promote RUD.

3) Evaluate the impact of RUD training on

prescription behaviour and particularly the use of oral and injectable antibiotics and IV fluids.

Objectives of the Tool

Methodology (1)

Review of Patient files in 8 referral hospitals for targeted diseases and interventions.

DATA COLLECTION:

- Selection of 20 patient files per disease and intervention by randomization from the last 2 or 3 months.

- Oral and injectable drug consumption focusing on 4 main diseases/interventions: (1) Severe malaria for adults; (2) ARI pediatric; (3) normal deliveries; (4) post operation in surgery

- Percentage of patients with (1) injectable antibiotics only, (2) injectable plus oral antibiotics, and (3) IV fluid.

- Calculation of the average duration of prescription of (1) injectable antibiotics only, (2) injection plus oral, and (3) IV fluid.

Methodology (2)DATA COLLECTION TEAM:

Central Supervisor Team:

• Pharmacist supervisors (DoD & F)

• Medical doctors supervisor (DoH)

Provincial Supervisor Team:

• Pharmacist from pharmacy office (PHD)

• Medical doctor from technical office (PHD)

Pharmacists checked drug stock and drug consumption in hospital pharmacy.

Medical doctors checked and analyzed patient files by using IPD check list.

Monitoring ToolHospital: Ward: Date: Target Disease: For Score

Insert Number of files analysed: 10 0 = non-appropriate treatment (Wrong choice if AB indicated or Clearly no indication of antibiotic)

1 = discutable choice or questionnable indicationA B C D E F 2 = appropriate treatment (Good Antibiotic choice if indicated or No antibiotic if no indication)

G H I J K L M N

Antibiotic Antimalarique IV Fluids

Injectable Oral

Pen

i G

Am

pi

Clo

xa

Gen

ta

Metro

Ch

lora

Ceftri

Pen

i V

Am

oxy

Clo

xa

Metro

Ch

lora

Co

trim

Eryth

ro

Cip

ro

Nalid

ix

Do

xy

day d d d d d d d d d d d d d d d d d score d d d d d d score d d score d

1 Acc-Normal Liqui-infect y 7 7 3 7 4 2 5 12 Acc-Normal Episiotom y 8 4 4 3 3 0 3 13 Acc-Normal Episiotomie y 7 5 5 1 0 2 24 Acc-Normal Ventouse y 8 5 5 5 1 1 2

5 Acc-Normal No y 5 2 1 2

6 Acc-Normal No y 4 2 1 27 Acc-Normal No y 4 2 4 18 Acc-Normal No y 5 2 4 1 09 Acc-Normal No y 3 2 5 0

10 Acc-Normal No y 5 2 1 2

11121314151617181920

ANALYSIS

% analysis impossible 0.0% Min Max 75.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! ##### ##### 0.0% 100.0% 10.0% 65.0% 0.0%

3 8 % Appropriate Antibio FALSE FALSE FALSE FALSE FALSE FALSE 2.7 1.0 FALSE

0 0 % Non-Appropriate Ab

% Appropriate Malaria

4 7 % Non-Appropriate Malaria

3 4 % Appropriate PIV

4 5 % Non-Appropriate PIVAverage duration AB (INJ) 4.5 % Total PIV 100.0%

Average duration AB (PO) 3.3 Nb Ab po 1.3100%

%R

atio

nal

Use

of

Dru

g65.0% 65.0% %patient with PIV + ORS 0%

35.0% 35.0% % patients with only ORS 0%

2.8

AB

app

rop

riate?

Average duration AB (PO+INJ) 5.3 Nb AB inj 2.0 100.0% #DIV/0! % patient with PIV only

Average Prescription Score

PIV

Ap

pro

priate?

Malaria A

pp

rop

riate?

To

taln

um

ber

of

differen

td

rug

sp

rescribed

(All categ

ories)

To

tal nu

mb

er of N

ON

-ED

LIS

T p

rescriptio

n

AB

All

Average number Drugs prescribed (all) 5.6 Only Inject 10.0%% Total AB 40.0%

0.0% #DIV/0!

All patients when prescribed

75.0% 37.5%25.0% 62.5%

Ratio Essential / total drugs 100%

Average nb of Non ED drugs prescribed #DIV/0! Inject+PO 20.0%

Only PO 10.0% Average duration PIV

Co

mm

ents o

n d

iagn

osis

analysis is n

ot p

ossib

le

Staung Maternity Jan-00 Delivery

IMPORTANT: Do not enter ZERO value "0" EXCEPT FOR THE COLUNM SCORE (I or K or M)

Patien

t Nb

Diag

no

sis or su

rgical p

roced

ure

OR

SQu

inin

e INJ

Arth

emeter

Qu

inin

e PO

Meflo

qu

ine

Artem

isine

Artesu

nate

D5/D

10/NS

S/L

R

Macro

Dia

gn

ost

ic

Co

mm

ent

Total number of All different drugs prescribed durining hospitalisation. 1)-Oral, 2)-Injection, 3) -IV FluidNote: TB, Exclude TB Drugs

Number of NON Essential Drug Prescribed

Total day with prescription

antibiotic, Oral and Injection

For each of these Antibiotic For there of these IV Fluid

For each of these Antimalaria Drug For SRO

How many day?

Score012

Score012

Score012

Field Implementation of the Tool• 2 surveys using the tool were implemented: one in1999 and one

in 2000 covered 8 referral hospitals, targeting the same diseases/interventions;

• After the 1999 survey, 9 meetings were organized to discuss treatment protocols among medical specialists, professors and national program managers (TB, malaria..) and to achieve therapeutic guidelines;

• From this group, 5 doctors from referral hospitals participated to the training of trainer sessions and became facilitators on RUD trainings;

• Before the 2000 survey, training on RUD were conducted on each referral hospital that had participated to the survey in 1999 and the new therapeutic guidelines and protocols were distributed to prescribers.

RESULTS (1) Percentage of patients with injectable

antibiotics prescription only

15.7

57.1

14.8

32.3

13.9

51.7

18.7

46

0

10

20

30

40

50

60

Medicine Pediatric Maternity Post OP

% p

ati

en

ts w

ith

inje

cta

tble

a

nti

bio

the

rap

y

Survey 1999 Survey 2000

RESULTS (2)

Percentage of patients with antibiotics prescription (injectable and oral forms)

17.9

27.4

9.4

51.3

9.9

42.9

2.4

39.3

0

10

20

30

40

50

60


% p

atie

nts w

ith a

ntib

ither

apy


RESULTS (3) Average duration of injectable

antibiotics prescription only

3.7

5.1

3.9

5.9

3.4

4.2

3.3

4.4

0

1

2

3

4

5

6


Ave

rage

nu

mb

er o

f d

ays


RESULTS (4)

Average duration of antibiotherapy prescription

(Injectable and oral forms)

6.17.1

5.6

9.1

4.4 4.8

1.8

5.1

012345

6789

10


Ave

rage

num

ber

of d

ays


RESULTS (5) Percentage of patients with IV fluid prescription

89.2

62

29.6

87.185.279.6

18.1

88.7

01020304050

60708090

100


% p

atie

nts


RESULTS (6) Average duration of IV fluid prescription

4.7

3.8

1.6

4.54.1

3.6

1.1

3.6

0

0.51

1.5

22.5

3

3.5

44.5

5


Ave

rage

nu

mb

er o

f d

ays


Conclusions

Integrated Tool for Monitoring Injection Prescription:

• Useful for monitoring RUD in referral hospitals (quantitative and qualitative);

• Provision of 29 indicators to measure RUD;

• Promotion of rational IV free prescription (antibiotics);

• Good participation from prescribers to the survey and revision of guidelines and protocols;

• Impact on the reduction of injection prescription;

• Limited only to public sector.

Perspectives

• Extend the IPD training and MTP process.

• Train supervisors on RUD/Hosp management.

• Review the IPD training contents on RUD.

• Update the clinical & therapeutic guidelines.

• Develop human resources involved in RUD .

rational use of injection: an integrated tool for monitoring injection prescription in the kingdom...

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