Development and validation of an Antibiotic Administration and - PowerPoint PPT Presentation

Development and validation of an Antibiotic Administration and Teaching Assessment Tool for evaluation of nurses’ antibiotic stewardship practice . Chimwemwe Mula(PhD Student) Supervisors: Dr. Lyn Middleton, Prof. Adamson Muula, Mr. Vernon Solomon Mentor: Beate Garcia UKZN INSPIRING G REA T NESS

Background • Antimicrobial resistance is a global problem associated with misuse, underuse or overuse of antibiotics • WHO recommend AMS programs. • Adherence to antibiotic guidelines is associated with minimizing antimicrobial resistance. • Current models/guidelines focus on doctors, pharmacists, lab surveillance and rarely nurses. Amabile 2010, WHO 2001, CDC, Makoka 2012, Feasey 2015, Edward 2011, Ladeinham, 2013, Dellit 2007, IDSA , SHEA , Olans 2015. UKZN INSPIRING G REA T NESS

Overall Study focus Phase 1. Understanding nurses’ role and challenges in AMS:  FGD, Observations, Interviews with Drs, pharmacists, lab, Nurses  Findings: Nurses multiple roles‐microbiology specimen management, contributing to prescription decisions, ensuring antibiotic availability at point of care, antibiotic preparation, administration and patient teaching. UKZN INSPIRING G REA T NESS

Overall study focus cont. • Challenges: competency, multidisciplinary team work, inadequate resources, workarounds • Recommendations: Training, Guidelines, Communication/ meetings/ collaboration and supervision and monitoring. UKZN INSPIRING G REA T NESS

Overall Study focus cont. Phase 2. Developing and piloting:  training and guideline intervention However guidelines don’t influence practice so well trained and supervised staff is what we need. Phase 3.  Developing an antibiotic administration and teaching assessment tool ( AATAT) UKZN INSPIRING G REA T NESS

Phase 3: Main Question • How can a Nurse ‐ Focused Antibiotic Administration and Teaching Assessment Tool (AATAT) be developed and validated for evaluation of nurses’ antibiotic stewardship practices? UKZN INSPIRING G REA T NESS

Steps in the validation process Hogli et al UKZN INSPIRING G REA T NESS

Process of developing the Intervention Based on international guidelines and local protocols:  Identified 18 QI items from AMS guidelines and others recommended by stakeholders UKZN INSPIRING G REA T NESS

Process of developing the Intervention Quality Indicator Item Following assessment and review, check that the physician has documented in the file and treatment chart: 1.Time of antibiotic prescription 2. Dose of prescribed antibiotic 3. Route of prescribed antibiotic 4. Duration of treatment or review/stop date of antibiotic 5. Ensure the prescribed antibiotic is available in the emergency department. 6. Ensure the prescribed antibiotic is available in the ward 7. Microbiology sample should be taken before the first dose of empirical antibiotic treatment is initiated. 8. Patient triaged as priority should be given initial intravenous antibiotic treatment within one hour of prescription. 9. Patient triaged as urgent and requires resuscitation should be given the initial intravenous antibiotic dose within 30 minutes of prescription. 10. Time of initial antibiotic dose administration should be documented in patient file and treatment chart. Patient/relative should be Educated about antibiotic treatment concerning: 11. The indication of the antibiotic treatment. 12. Frequency of antibiotic treatment while in hospital with times specified. 13. The duration of antibiotic treatment. 14. Importance of complying with the antibiotic treatment regimen. 15. Subsequent doses should be administered according to prescription following the medication administration standards. 16. Patient’s ability to take oral antibiotic (able to swallow, decreased temperature) should be documented. 17. Patient should be switched from intravenous to oral antibiotic upon doctor’s order. 18. Total duration of antibiotic administration should be according to prescription. UKZN INSPIRING G REA T NESS

Face validation by pharmacist:  The expert made several revisions to the items that resulted into 25 QIs Content validity‐ expert nurses:  The QI were reformulated into a questionnaire  Seven expert nurses performed the content validation and most criteria were scored 4 or 5(very relevant or very much relevant). AATAT  Converted into 25 review criteria ( standard and qualifying statement) forming the AATAT. UKZN INSPIRING G REA T NESS

Process of developing the Intervention cont. Categorised the review criteria into six domains:  assessment for infection  verification of physician’s documentation of antibiotic prescription  availability of prescribed antibiotics at point of care  timely antibiotic initiation following culture specimen collection  patient education  daily antibiotic administration (dosing intervals, switch from intravenous to oral, duration). UKZN INSPIRING G REA T NESS

Process of developing the Intervention cont. Field testing to demonstrate adherence  33 pneumonia patients.  Adherence was 100% for seven criteria: assessment of temperature; documentation of generic name of antibiotic; documentation of dose, frequency; availability of antibiotics in the ward; administration of the right dose; using the right route.  Low adherence was identified in patient education. UKZN INSPIRING G REA T NESS

Process of developing the Intervention cont Feasibility  Mean data collection for rater 1 was 4.6 days (range 1‐9 days).  Mean application time for rater 1 second time was 3.7 minutes.  For rater 2 (CM), mean application time was 4.4 minutes.  Small difference in mean application time for rater 1, 2 nd time and rater 2 indicate that different users of the tool will spend almost similar amount of time if data is already available UKZN INSPIRING G REA T NESS

Process of developing the Intervention cont. Reliability was tested using Kappa statistics for inter‐ and intra‐ rater agreement  Inter and intra‐rater agreement was high with Kappa‐values of 0.78 (95% CI: 0.76, 0.79) and 0.72 (95% CI: 70, 0.75) respectively demonstrating substantial agreement. UKZN INSPIRING G REA T NESS

Knowledge Contribution • Developed a 25‐criterion assessment tool for evaluating nurses’ antibiotic stewardship practices in hospitalized adult pneumonia patients prescribed antibiotics. • Face and content validity and high feasibility demonstrated. • Even though reliability testing showed substantial agreement between raters, there is room for improvement. • Overall adherence to the tool was intermediate, which was good adherence but areas of improvement were mainly patient education. UKZN INSPIRING G REA T NESS

Lessons and Applicability: • It is feasible to develop and validate and Antibiotic administration tool for nurses which has a gap in literature. • Patient education about their antibiotic treatment should be emphasised and monitored. • The tool can further be validated and scaled up to be used in our context to monitor and give feedback on nurses’ antibiotic stewardship practices. UKZN INSPIRING G REA T NESS

Acknowledgement This project was funded by NORHED antimicrobial stewardship project; African Doctoral Dissertation Research Fellowship award offered by the African Population and Health Research Centre ( APHRC) in partnership with the International Development Research Centre ( IDRC). UKZN, University of Malawi‐ College of Medicine and Kamuzu College of Nursing UKZN INSPIRING G REA T NESS

Thank you Zikomo UKZN INSPIRING G REA T NESS