Antibiotic stewardship - a methodology

After a very productive meeting in primary care today talking about antibiotics, here are some new thoughts on what I think we need to do to improve antibiotic stewardship.

The learning environment is important.

1. Groups of about 15 seem good. A mix of GPs, nurse prescribers, pharmacists with access to data, and 'infection experts' seems to work well.

2. Clinical leasdership is important. This is not about being heroic. It's about having someone stand up and say "This matters, and as a group we agree this matters". It is important that this sentiment comes from those 'doing the work'. Experts need to be invited in, as part of the dialogue, not as the solution. Without this, most education is perhaps verging on the pointless. I'm sure there is a literature on this.

3. All participants need to feel 'safe' and able to contribute to any discussion in a non-judgemental way

Data and cases get you started and can build trust and common purpose

4. Practice data is a good way to start any discussion. Continuous ranking data relative to peers is probably a better way of tracking changes in prescribing habits than actual items per STAR-PU. The latter is too sensitive to seasonal and secular trends, and other external forces (eg. guidelines).

Graph showing rolling 12 month average rank of one practice vs peers

5. Individual prescribing data is a good way to continue discussion. GP prescribing systems allow this to be cut in many ways - by sex, age, type of antibiotic, time of week, phone vs face to face. This is a good way to start exploring beliefs. Be very careful about drawing any conclusions at this stage. People will get defensive if you are not careful. You just want to get interest at this stage, There are many valid reasons for variation in prescribing patterns. There are also many ways to explain away variation - you need to be careful!

6. Serious untoward events, or other 'interesting' cases, or a good way to 'reground' the discussion in 'what matters' to the patient.

Using expert opinion to guide discussion

7. The role of the 'expert' is perhaps just to facilitate discussion. Frankly, those 'doing the work' are far more aware of what the issues are.

8. The 'expert' must provide information that is salient. So for GPs these are things like : "What will this do to my workload?"; "Is it safe?"; "What will my patients think?"

9. The 'expert' can help define the unknown knowns, the known unknowns and the unknown unknowns. A lot of primary care happens in this space - and exploring it can be a rich experience for all.

So it feels this is where we got to today. The next step is to form a smaller group of nurse prescribers and GPs and do some case reviews. I think we need to focus on a specific topic. For instance, why is flucloxacillin prescribing so seasonal? Are people misdiagnosing the erythema of insect bites as cellulitis? Or are there other reasons for seasonality that we haven't thought about? Or, why are we prescribing so many antibiotics to women aged 20-39? Can we find better strategies for helping them manage without antibiotics?  Or do we feel particularly sorry for harassed young mothers, and just want to 'do something', even though we know it won't help?

I think we need to invent a structure for this peer-led case review that is helpful for driving improvement. I think this could take the same structure we are using to drive improvement in diagnostics (see other blogs). It has to avoid being process focussed, it needs to reflect the real uncertainties in this area, and it needs to be a method for promoting improvement rather than compliance. Something like :

Clean start

1. Do we think antibiotics were indicated? (Almost definitely / probably / possibly / almost definitely not). 

2. Do we think the antibiotics were appropriate (ie treating likely pathogens) - (Almost definitely / probably / possibly / almost definitely not).

3. Do we understand the 'red flags' for this condition and did the patient know these?

Clean continuation

4. Do we think diagnostics were used optimally? 

5. Do we think antibiotics were given for a reasonable duration (Almost definitely / probably / possibly / almost definitely not).

6. Do we think antibiotics should have been modified at any point? (Almost definitely / probably / possibly / almost definitely not).

Clean stop

7. Do we think the patient knows how to manage this condition in the future, if appropriate?

8. Does the patient know what they have to do to prevent recurrence?

9. Have we done everything to prevent recurrence (eg. vaccinate)?

Not sure how contrived they are, or whether there are bigger things, but structure and method for doing this feels important. We then have measures that we can use to experiment with improvement. For instance, does having better guidance for patients and their carers make any difference to any of these measures?

UKAS, ISO15189 and laboratory accreditation

So we come to the end of a hard week of full laboratory assessment to ISO15189 standards. As readers of the blog will be aware, I have never been a fan of the philosophy of inspection as it tends to pull us away from purpose and towards an inside-out view of the world, where we do things to keep inspectors happy, rather than because they are the right thing for our customers / citizens / patients. But what a pleasure it is to say that I have almost completely been proved wrong.

The UKAS team have been an interesting mix of peers, who, by and large, have asked fair and challenging questions. What they really liked about our lab are things like ;

- we have an approach to 'measurement of uncertainty' that reflects the genuine importance of this in managing patients.

- the palpable sense of teamwork and 'ownership'. The staff here are connected to the relevance of why they are doing what they are doing.

- the way we work collaboratively with users towards an optimised service, as defined by what matters to the patient, rather than what matters to us.

I think the assessment could be better. There is still too much focus from some assessors on things that are not important, not recognising that there is opportunity and financial cost to their recommendations. There is, on the other hand, not enough focus on things that we know really make a difference to patient care. For instance, are the clinical decisions before and after specimens hit the lab as good as they can be, and what are labs doing to address these?

But I get the impression that there are green shoots in the assessment process that could embrace these concepts. I have loved working with assessors who bring a degree of external challenge and support that is invaluable, They have identified areas that are weak and we need to sort. They have identified many more areas that are strong, and they have said this. To get this external validation is so important to hear. There has been a real sense of excitement in the lab today, as we hear yet more glowing reports about the quality of the work. We don't get this from anybody else. And we can be blind to it ourselves, focussing as we tend to do mainly on things that could be better. To hear that assessors would like to work here, would be happy to have their child's specimens tested here, and that that is most definitely not the case for many laboratories in the UK has just capped a great week.

A final observation about purpose. This lab is beginning to see quality as something that falls out of 'doing the right thing'. I know many labs would say that they do this, but I think many are missing the real opportunities that are out there. It is very hard to see how consolidated labs, that have lost their direct clinical connections, can do this. I wonder if the horror stories that abound about others' experiences of UKAS inspections is a direct result of this loss of purpose - it is translated into low quality work. I think our experience over the last week shows that quality flows from purpose, not the other way round. So thank you UKAS, I eat most of my previous words, and I look forward to working with you more in the future.