Documentation of antibiotic prescribing controls in UK NHS hospitals

Objectives: To identify the types, prevalence and nature of antibiotic prescribing control documents within NHS hospitals in the UK. Methods: A self-completion postal questionnaire was sent to each Chief Pharmacist at 465 NHS hospitals in 2001/2002. This contained questions covering hospital demographics, and hospital antibiotic prescribing control documentation, including format, dissemination, approval and review processes. Results: In total, 253 (54%) completed questionnaires were returned. Of these, 168 respondents' hospitals had an antibiotic formulary, 107 had a policy for antibiotic prescribing and 216 had guidelines on antibiotic use. All three types of antibiotic prescribing documents were used by 82 hospitals but 18 did not have any documents; 44% of formularies, 45% of policies and 35% of guidelines were available electronically. The Drug and Therapeutics Committee was the most frequently cited body for document approval and approximately one-third of documents had been approved during the current year of the questionnaire. Only about one-half of responding hospitals had an annual review of documents. Conclusions: Despite publication of high-profile national guidance in response to growing concerns regarding antimicrobial resistance, there has been little increase in the use of antibiotic prescribing control documents in NHS hospitals over the past decade. It is clear that appropriate controls for antibiotic prescribing are not yet universally applied in the UK and recommendations for action have been proposed. © The British Society for Antimicrobial Chemotherapy 2004; all rights reserved.

Control of antibiotic prescribing in UK NHS hosptials. Available in 2 volumes.

This thesis is an evaluation of practices to control antibiotic prescribing in UK NHS hospitals. Within the past ten years there has been increasing international concern about escalating antibiotic resistance, and the UK has issued several policy documents for pmdent antibiotic prescribing. Chief Pharmacists in 253 UK NHS hospitals were surveyed about the availability and nature of documents to control antibiotic prescribing (formularies, policies and guidelines), and the role of pharmacists and medical microbiologists in monitoring prescribers' compliance with the recommendations of such documents. Although 235 hospitals had at least one document, only 60% had both an antibiotic formulary and guidelines, and only about one-half planned an annual revision of document(s). Pharmacists were reported as mostly checking antibiotic prescribing on every ward whilst medical microbiologists mostly visited selected units only. Response to a similar questionnaire was obtained from the Chief Medical Microbiologists in 131 UK NHS hospitals. Comparisons of the questionnaires indicated areas of apparent disagreement about the roles of pharmacists and medical microbiologists. Eighty three paired-responses received from pharmacists and medical microbiologists in the same hospital revealed poor agreement and awareness about controls. A total of 205 institutional prescribing guidelines were analysed for recommendations for the empirical antibiotic prescribing of Community-Acquired Pneumonia (CAP). Variation was observed in recommendations and agreement with national guidance from the British Thoracic Society (BTS). A questionnaire was subsequently sent to 235 Chief Pharmacists to investigate their awareness of this new guidance from the BTS, and subsequent revision of institutional guidelines. Documents had been revised in only about one-half of hospitals where pharmacists were aware of the new guidance. An audit of empirical antibiotic prescribing practices for CAP was performed at one hospital. Although problems were experienced with retrieval of medical records, diagnostic criteria were poorly recorded, and only 57% of prescribing for non-severe CAP was compliant with institutional guidelines. A survey of clinicians at the same hospital identified that almost one-half used the institutional guidelines and most found them useful. However, areas for improvement concernmg awareness of the guidelines and ease of access were identified. It is important that hospitals are equipped to react to changes in the hospital environment including frequent movement of junior doctors between institutions, the employment of specialist "infectious diseases pharmacists" and the increasing benefits offered by information technology. Recommendations for policy have been suggested.

Professionals' awareness of operational antibiotic prescribing controls in UK NHS hospitals

In recent years, there have been increasing recommendations for multidisciplinary collaboration between clinical pharmacists and medical microbiologists in an attempt to control the quality (and quantity) of antibiotic prescribing. A questionnaire addressing the utilization of antibiotic prescribing controls was sent to the chief pharmacist and medical microbiologist in UK NHS hospitals. Responses were received from both the chief pharmacist and the medical microbiologist employed in the same hospital from 83 hospitals (a 30% response rate from two independent studies). A high level of disagreement and poor awareness was identified between the interprofessional staff groups regarding the existence of antibiotic formulary (with disagreement between the two groups, or not known by one or both respondents, in 46% of the paired hospitals, N=38) and guideline documents (13%, N=11), performance of antibiotic prescribing audits (40%, N=33), and whether pharmacists (52%, N=43) and medical microbiologists (77%, N=64) monitored physician compliance with antibiotic prescribing control documents. This study has identified poor knowledge of the existence of basic antibiotic prescribing control mechanisms and the role of professional colleagues. It is suggested that there is some way to go before 'Agenda for Change' principles of flexible and collaborative roles are met. © 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

An analysis and comparison of commonly available United Kingdom prescribing resources

Background and objective: Safe prescribing requires accurate and practical information about drugs. Our objective was to measure the utility of current sources of prescribing guidance when used to inform practical prescribing decisions, and to compare current sources of prescribing guidance in the UK with idealized prescribing guidance. Methods: We developed 25 clinical scenarios. Two independent assessors rated and ranked the performance of five common sources of prescribing guidance in the UK when used to answer the clinical scenarios. A third adjudicator facilitated review of any disparities. An idealized list of contents for prescribing guidance was developed and sent for comments to academics and users of prescribing guidance. Following consultation an operational check was used to assess compliance with the idealized criteria. The main outcome measures were relative utility in answering the clinical scenarios and compliance with the idealized prescribing guidance. Results: Current sources of prescribing guidance used in the UK differ in their utility, when measured using clinical scenarios. The British National Formulary (BNF) and EMIS LV were the best performing sources in terms of both ranking [mean rank 1·24 and 2·20] and rating [%excellent or adequate 100% and 72%]. Current sources differed in the extent to which they fulfilled criteria for ideal prescribing guidance, but the BNF, and EMIS LV to a lesser extent, closely matched the criteria. Discussion: We have demonstrated how clinical scenarios can be used to assess prescribing guidance resources. Producers of prescribing guidance documents should consider our idealized template. Prescribers require high-quality information to support their practice. Conclusion: Our test was helpful in distinguishing between prescribing resources. Producers of prescribing guidance should consider the utility of their products to end-users, particularly in those more complex areas where prescribers may need most support. Existing UK prescribing guidance resources differ in their ability to provide assistance to prescribers. © 2010 Blackwell Publishing Ltd.