Q Exchange
From jabs to tabs: Switching from IV to oral antibiotics
- Proposal
- 2023
Meet the team
Also:
- Caoimhe Nic Fhogartaigh, Microbiology and Infectious Diseases Consultant
- Ashley Flores, Infection Prevention & Control Lead Nurse
- Navjeet Nagi, Antimicrobial Pharmacist
- Trishna Patel, Antimicrobial Pharmacist
- Project nurse - TBC
What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?
Antibiotics are critical medicines, but excessive durations increase the risk of antibiotic resistance and difficult-to-treat infections in the future. IV antibiotics must be given through an IV line, increasing the risk of line-related complications.
Research has shown that early switch to oral antibiotics leads to better patient outcomes, including reduced time in hospital. In reality, switch is often delayed when patients move to a different ward or team, or when there is temporary junior medical staffing. Our audits show that we are slow at switching patients medication to oral.
Nurses closely monitor patients’ response to IV antibiotics, but don’t feel empowered to suggest oral switch. With training and support from pharmacy and infection specialists, nursing recommendations have been shown to improve antibiotic prescribing without any adverse effects to patients. Nurses have a key role in prompting safe IV to oral switch, getting patients home quickly and creating bed-space for admissions.
What does your project aim to achieve?
1) improve nurses’ knowledge and understanding of antibiotic prescribing through focused education and training on project wards
2) empower and support nurses to prompt the medical team to switch to tablet antibiotics at the earliest appropriate opportunity, through use of “IV to oral switch” pocket cards and peer support of the project nurse
3) reduce IV antibiotic durations and delays to oral antibiotic switch
4) train nurses to identify patients who are not suitable for oral antibiotics, but may benefit from IV antibiotics given in their home through our OPAT (outpatient parenteral antimicrobial therapy) service.
These actions should lead to shorter patient stay in hospital thus improving bed capacity for new admissions, as well as reducing antibiotic side-effects and IV line-related complications.
Our pharmacy and infection team already support the delivery of OPAT and this project could improve identification of more suitable patients who can benefit.
How will the project be delivered?
Plan:
Select project and control wards based on IV antibiotic usage.
Educate project nurse
Nominate nurse champions.
Develop IV to oral checklist pocket-cards to aid nurses to identify patients who could switch to orals, and prompt doctors to amend the prescription.
Training on pocket-cards.
Develop data collection tool with pharmacy and business intelligence unit support.
Promote project with ward managers, pharmacists and medical team to gain support.
Do:
Implement pocket-cards on project wards for 6 months.
Project nurse, pharmacist and champions join board rounds, support nurses and respond to feedback.
Study:
Project nurse collects weekly data on ward IV antibiotic use, duration, and delays to oral switch.
Collaboration with BIU to compare average length of stay for patients on antibiotics, and readmission rates compared with control wards.
Act:
Review data and progress monthly, giving feedback to wards. Amend method based on results and feedback if needed. Develop business plan for future.
How is your project going to share learning?
Project team will present results and learning points to Hospital Trust Quality and Safety committee to enable other wards to learn from our experience. Results and learning, along with suggestions for future improvement work would be presented at national Quality Improvement meeting or Antimicrobial conference as well as publishing the project.
Depending on the project results, it would be ideal to start a programme of antimicrobial and infection prevention education for nurses and nursing students
How you can contribute
- We would love your support to help us demonstrate that empowering nurses – a huge proportion of the NHS workforce – can lead to improvements in antibiotic prescribing and positive patient outcomes such as shorter length of stay, at a time when NHS beds are in huge demand.
- We plan to collaborate with the Trust Business intelligence unit on some aspects of the outcome data collection, but we would value any suggestions on how to capture this data accurately and efficiently, so that we can focus project resources on nurse education and face to face support.
Plan timeline
| 1 May 2023 | Recruitment/secondment of project nurse |
|---|---|
| 1 Jun 2023 | Planning phase. Stakeholder engagement |
| 1 Jul 2023 | Implementation phase and data collection |
| 1 Jan 2024 | Data analysis and data comparison. Shared learning |
Comments
Thomas John Rose 14 Mar 2023
Could you add a bit more detail on the data collection during the 'DO' stage of the PDSA cycle.
Mrs Rachael Ben Salem 12 Mar 2023
Post pandemic with CDT rates still high this is a well timed project to help focus the clinical team to switch iv to oral antibiotics using a project nurse and integrated approach. Well thought out and planned project so we can get this well underway before this winter 2023-this so much deserves funding-great work everyone!
Mark Dalauidao 8 Mar 2023
I agree with everyone that this initiative is really a good one given the current situation we are in now on antibiotic use cross sites, the number of infection we are seeing related to inappropriate use of antibiotics and the compliance of our colleagues especially when prescribing and reviewing them.
Expect that there will be mixed responses to this one from the nurses especially now that staffing is an issue cross sites. On the other hand, I am pretty sure there are also nurses who are willing to further develop and are empowered enough to be an antimicrobial stewards. We must think of the sustainability of this initiative, if we wanted for it to be a success, there must be a solid support for these nurses ie, training and education.
Martin Neville Brown 7 Mar 2023
This sounds like a great idea to improve patient experience and to improve antimicrobial stewardship.
If the initial project leads to sustained intervention is there any possibility of comparing antibiotic resistance data pre and post intervention to longer term impact on antimicrobial resistance?
Carmel Curtis 7 Mar 2023
This sounds like such a great idea. Nurses know their patients well and can be instrumental in helping prescribers understand that if the patient is eating and drinking they may well be suitable for oral antibiotics.
Rashmi Anu Thomas Thannikkal 7 Mar 2023
This is an amazing approach! This project will definitely help in Antimicrobial stewardship!
Catherine Ganda 7 Mar 2023
This sound brilliant as it will empower nurses to influence and contribute towards improving antimicrobial prescribing and reduction in infections like Clostridium Difficile.
Laura-Jane Smith 3 Mar 2023
This has real potential and it’s great to see nurses as the focus as they are more permanent on the wards than rotating staff so empowering them could have sustained impact. Have you thought about capturing additional benefits: time for nurses as ivs take longer? Sustainability benefits - carbon footprint of oral abx much lower than iv - there is precedent for this eg Kidzmedz project. This would mean impact/learning would be even greater.
Caoimhe Nic Fhogartaigh 6 Mar 2023
Thanks LJ! True, nurses are a fantastic resource. I feel as though we are always asking them to do more, but in this case, a small action from them could help to reduce their workload and benefit the patient too. Will think about how we can capture the nursing time saved.
Michael Bartley 2 Mar 2023
This looks like a very exciting project. I think the study would have a positive impact on potentially increasing both compliance and adherence to the Antibiotic stewardship audits.
Trishna Patel 7 Mar 2023
Thank you Michael. Very exciting project!
Biba Stanton 1 Mar 2023
This sounds like it could be very "scaleable" and practical to implement if it works. Have you thought about comparing wards with and without the intervention rather than using retrospective control data?
Caoimhe Nic Fhogartaigh 1 Mar 2023
Thanks Biba! That's a great suggestion. We could certainly try to "match" wards based on specialty and antibiotic use and compare them. I will talk to the team and review our methodology before the next stage of the process.
John Lodge 28 Feb 2023
I can see the potential for reducing length of stay on this project, and how the insights from it could help other Trusts.
Caoimhe Nic Fhogartaigh 1 Mar 2023
Thanks John, we agree! Even for the patients that aren't suitable for oral switch but are otherwise medically stable, the nurse role could prompt referral to OPAT (outpatient parenteral antimicrobial therapy). This service has recently been set up at King's and, although still gaining momentum, is shortening patients' hospital stay and getting lots of positive feedback.