Reducing Unnecessary Antibiotic Prescribing in the Emergency Department
Meet the team
- Dr James Harrison
- Dr Mariyam Mirfenderesky
- Mr Geoff Benge
- Ms Semra Ali
- Ms Tracey Lee
- Ms Shivani Shah
- Divina Bunoan
What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?
Much work has already been performed through national CQUIN initiatives and antibiotic stewardship programmes to reduce unnecessary antimicrobial consumption in Secondary Care. However the Emergency department requires specific interventions more akin to primary care.
The COVID-19 pandemic saw the introduction of novel ways of streaming and cohorting patients through the emergency department. The North Middlesex Hospital, North London, was identified early in the pandemic as the second most COVID-pressured Trust in UK. General practitioners were mobilised to the front door to stream ‘well’ patients with respiratory illness to the Urgent Treatment Centre, avoiding the main department. This improved flow within the department, decreased waiting times, facilitated faster diagnosis, treatment and discharge.
Given this new triage process we wish to enable enhanced models of care within the UTC; improve antimicrobial stewardship, reduce unnecessary antibiotic prescriptions, adverse side effects and decrease antimicrobial resistance as well as realize substantial financial savings.
What does your project aim to achieve?
Antimicrobial resistance is significant global health threat. Respiratory infections are one of the most common reasons for oral antibiotic prescriptions in the NHS, with 50% of all acute respiratory infection visits leading to an antibiotic prescription compared with a warranted 9% if treatment guidelines are used.
Differentiating between bacterial and viral infections is challenging. Coupled with perceived patient wishes, often the fastest and easiest route to discharge from an outpatient setting is to prescribe an antibiotic.
POC measurements of CRP have been shown to reduce antibiotic prescribing in acute respiratory infections in primary care. We wish to trial the NICE endorsed FebriDx test which provides semi-quantitative measurement of C-reactive protein (CRP) and qualitative measurement of myxovirus resistance protein A (MxA) (a protein marker that is raised in the blood in acute viral infection); coupled with a behavioural change education programme and qualitative output metrics to reduce antibiotic prescribing in the emergency department.
How will the project be delivered?
The project wishes to investigate whether tests that improve clinical decision making in antibiotic prescribing at the point- of- care (POC) coupled with behavioural change techniques can support antimicrobial stewardship.
The project will be run from the Urgent Treatment Center at the NMUH emergency department, and will target patients presenting with acute respiratory infections. Algorithms will be developed which take into account the clinical history, examination and results of the POC test. An ED consultant and ED practice development nurse will be responsible for the implementation of the scheme in ED. The pathology manager and point of care lead for the Trust will ensure training, validation and internal quality control of POC test. The effect on defined daily doses of antibiotics, and cost implications will monitored by the ED pharmacist, Trust antimicrobial pharmacist and Trust Antimicrobial Stewardship lead. The overall project will have oversight from the Trust Improvement lead.
How is your project going to share learning?
This project is strategically aligned with the Uk 5-year action plan for antimicrobial resistance ambition to reduce antimicrobial use in humans by 15% by 2024 . Novel strategies are required to drive down antimicrobial prescribing. The ED has specific challenges as other successful primary care initiatives such as delayed scripts and reattendance are not suitable for this setting, and flow remains a primary consideration.
The FebriDx test; the combination of the CRP and the novel MxA protein has not been trialed before in this setting. The results of this project would be wide reaching, with implications for both ED and primary care departments across the country. This project requires large system and behavioural change in one of London’s busiest emergency departments, with a high turn over of staff and unpredictable external pressures.
How you can contribute
- Suggested improvements
- Behavioural change and human factors input
- Achieving system change in dynamic departments
- Collaboration; primary and secondary care, clinical commissioning groups
|1 Apr 2021||Develop a Standard Operating Procedure|
|1 Apr 2021||Develop patient education campaign material ; consider behavioural change elements|
|1 Apr 2021||Develop systems to monitor and review antibiotic prescribing|
|1 Apr 2021||Develop systems to monitor patient re-attendances to ED|
|1 Apr 2021||Generate data reports and informatics to identify patient cohort|
|1 Apr 2021||Look at systems and flow within the department.|
|1 Apr 2021||Procure and validate POC tests. Write training manual|
|5 Apr 2021||Develop prescriber educational material; behavioural change|
|5 Apr 2021||Develop prescriber questionnaires; qualitative aspects, compliance, satisfaction. Qualitative.|
|5 Apr 2021||Monthly tracking of antimicrobial consumption and cost|
|3 May 2021||Patient satisfaction surveys; develop. Consider qualitative aspects|
|3 May 2021||Training and education of doctors, nurses and HCAs|
|9 May 2021||Pilot study; 50 patients|
|2 Jun 2021||Project roll out; commencement of main project|
|3 Jun 2021||Audit and monitoring; continuous. Weekly PDSA.|
|3 Jun 2021||Feedback to prescribers and department; weekly ongoing|
|20 Jun 2021||Monthly interim analysis; for x3|
|30 Sep 2021||Project wrap up|
|29 Oct 2021||Results analysis|
|1 Dec 2021||Presentation of results at national conference or equivalent|