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AUSTRALIA has national standards that guide the safety and quality of care in hospitals. Antimicrobial stewardship – which refers to safety and quality initiatives for antimicrobial prescribing and use – has been incorporated into these standards. The way these standards have been implemented nationally is unique and, from an international perspective, exemplary.
However, we know that remoteness from metropolitan centres of care can influence health care delivery, and that many hospitals outside metropolitan areas, with fewer resources, may need additional support to fully operationalise these standards.
A national program dedicated to the monitoring of antimicrobial use and prescribing enables analysis of use in hospitals by remoteness classification. A newly published study, by National Centre for Antimicrobial Stewardship (NCAS) research fellow Jaclyn Bishop and colleagues, highlights differences in the quality of antimicrobial prescribing between metropolitan and non-metropolitan hospitals in Australia.
Particular areas highlighted include differences in the treatment of cellulitis, Gram-positive bacteraemia with sepsis and endocarditis, and empiric therapy for sepsis. These findings point to a need for support for infection management and antimicrobial stewardship in regional and remote hospitals.
Distance from metropolitan centres of acute care (and associated resource constraints) can play an important role in determining clinicians’ approaches to, and ability to support, stewardship activities.
A qualitative study involving clinicians in regional hospitals, also by Jaclyn Bishop and colleagues, highlights a number of factors that can influence how clinicians perceive and approach efforts aimed at optimising infection management and antimicrobial prescribing. These include factors that can act as barriers to, and enablers of, stewardship, and should ideally inform planning and decision making around all quality initiatives.
Regional hospitals may not have adequate resources to cover the different elements and types of activities, such as decision support for antimicrobial prescribing and review of prescriptions, that antimicrobial stewardship encompasses.
Specialised infectious diseases expertise may be limited to a few hospitals, and pharmacists may not have sufficient time allocated for systematic audit and review activities. Clinicians in regional areas may work across multiple facilities and campuses, which can make dedicated site-specific programs difficult to sustain. Additionally, staff turnover or frequent changes in the workforce can have a disruptive impact on, and act as a barrier to, longer-term safety and quality programs.
When auditing is undertaken as part of quality improvement and accreditation processes, smaller numbers of patients are usually audited; as such, the observed and reported patient cohort sizes or burden of infections may not be recognised by the local hospital executive as warranting additional staff resources, particularly for systematic programs. When audits identify areas of concern, the lack of local expert guidance may hinder translation of the findings into quality improvement actions.
Regional and remote hospitals may not have the resources to procure and maintain the information technology tools that facilitate surveillance and review of antimicrobial prescribing and consumption in some better resourced metropolitan hospitals.
Working in regional and remote areas entails and necessitates developing close relationships with other practitioners. Therefore, recommendations about feedback mechanisms and communication of advice to individual prescribers (and, indeed, review processes) need to adequately take the intricacies of the local professional and social context into account.
While clinicians who participated in this study credited the national standards with having raised the profile of antimicrobial stewardship, they argued that regional and remote hospitals have not necessarily been able to successfully navigate or incentivise practice changes, or increase resource allocation, in response to the adoption of these standards. Clinicians expressed concerns about potential discrepancies in quality improvement efforts between metropolitan and regional hospitals.
Strategies
Dr David Kong is the deputy director of pharmacy at Ballarat Health Services in Ballarat, Victoria, and a chief investigator at NCAS. He says that participating strategically in quality audits, when resources allow time for such participation, and using the findings for feedback and comparison can help instil a culture of continuous improvement.
“Undertaking audits and feeding back results to end-users provides the end-user an opportunity to reflect on their practice,” he says. “If the feedback and results are provided to multiple end-users or units within the same institution, these results may also facilitate competition between groups and drive improvement.”
Regional clinicians report that having opportunities to “benchmark” local patterns of antimicrobial use against patterns in similar facilities would benefit their quality programs. Australia’s antimicrobial use surveillance programs aim to facilitate this form of benchmarking.
Evette Buono is the New South Wales Clinical Excellence Commission’s knowledge, evaluation and research program’s senior manager, and an associate investigator at NCAS. Referring to recent initiatives by regional and small metropolitan hospitals in NSW, she highlights the potential benefits of collaboration across facilities and networks as a strategy:
“Infectious diseases physicians, clinical microbiologists and antimicrobial stewardship pharmacists play a critical role in determining the success and credibility of an antimicrobial stewardship program, but smaller health care facilities are less likely to have these experts available on-site to provide hands-on support and advice,” she says.
“Collaborative antimicrobial stewardship efforts across multiple facilities offer a viable model of care for rural, regional and small metropolitan hospitals, where dedicated time and resources for antimicrobial stewardship are scarce. They also allow individuals from participating hospitals to learn from one another, building expertise and capability across the district or network, and are more likely to result in sustainable improvement.”
Dr Thomas Schulz is an infectious diseases physician at the Royal Melbourne Hospital and an associate investigator at NCAS. Dr Schulz runs telehealth services for some regional and small metropolitan hospitals in Victoria, and has described the benefits of telehealth for patients and clinicians who live in regional areas.
Education
The National Antimicrobial Resistance and Stewardship Forum was held at the University of Melbourne on 1 and 2 November 2018. Hosted by the NCAS and co-sponsored by Safer Care Victoria, this forum included a number of specialised workshops for different professional groups, and presentations on antimicrobial resistance and stewardship in diverse settings, including regional and remote areas.
Dr Arjun Rajkhowa is centre manager of the National Centre for Antimicrobial Stewardship at the Department of Medicine, University of Melbourne, the Doherty Institute and Royal Melbourne Hospital.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.