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Developing a Nurse – Focused An5bio5c Stewardship Interven5on at Queen Elizabeth Central Hospital, Malawi
Chimwemwe Mula( Msc. Cri5cal Care &Trauma Nursing)
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Background
- An5microbial resistance is a global problem.
- WHO recommend An5microbial stewardship programs.
- Current models/guidelines focus on doctors, pharmacists and
some5mes nurses.
- Nurses well-posi5oned to play a pivotal role.
Amabile 2010, WHO 2001, CDC, Makoka 2012, Feasey 2015, Edward 2011, Ladeinham, 2013, Dellit 2007, IDSA , SHEA , Olans 2015.
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Study focus
- Understanding nurses’ current role in an5bio5c stewardship.
- Developing and evalua5ng a pilot interven5on to strengthen
this role.
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Approach
- Primarily a qualita5ve study with quan5ta5ve as a
complimentary.
- Research ques5ons addressed through a series of phases.
Plano, Clark (2010), Doorenbos(2014), Polit (2006)
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Research questions
- How do nurses demonstrate competencies in the context of
an5bio5c management?
- How do environmental factors affect nurses an5bio5c
management related efforts?
- What is the level of nurses knowledge, aYtude and
experience in an5bio5c stewardship?
- What (and How can) nurse - focused an5bio5c stewardship
interven5on be developed and tested?
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Research Design
- Cross sec5onal mixed methods
- Sequen5al- qualita5ve (dominant) then quan5ta5ve as a
complementary
- Case study – within adult in pa5ent care seYngs
- To answer “how” ques5ons using different data sources
Sangoe 2012, Doorenbos 2014, Creswell, Polit 2006, Lacono 2009, Yin 1994,
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Methods and Analysis
Phase Methods Data sources Analysis
Mapping Focus group discussion Participant observation In depth interviews Survey Pneumonia patient, HCW Drs, Lab, Pharma. Nurses Nurses Nurses Thematic STATA Proportion, median.
interventions Participatory approach Nurses, doctors, Lab, pharmacy
assessing immediate impact. Formative: Observation, interview, case review Nurses Thematic Proportions
Meeting Stakeholders
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Triangulated Results: Qualitative
- Eight major themes emerged from analysis of qualita5ve data
- Triangula5on – verifying data between methods and different
data sources.
Sangoe ( 2012), Yeasmin (2012)Denzin (1985)
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Theme1:Nurses have mul=ple an=bio=c stewardship roles
- Facilita5ng microbiology specimen management.
- Ensuring availability and proper storage of an5bio5cs at point
- f care
- Adhering to the prescribed an5bio5c
- Mul5disciplinary team player
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Theme2:There are concerns about nurses roles
Adherence to prescribed antibiotic I have very oGen the feeling that I prefer grabbing the drug even if its worse even though its not the best choice. If its just once daily because as soon as you start prescribing the four Nmes daily its more probable that they don’t receive anything. ( Echoed by many yea………..)( female medical doctor).
They have got challenges on that in terms of frequency. Say 8 hourly drug will
be taken 8 hourly but for them they say at night we do give drugs at 10pm so every paNent has to be given at ten pm despite what were the first dose and the second dose.(male pharmacist)
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Observa=on of Adherence to 5 Rights of an=bio=c administra=on
Compliance to right:
- An5bio5c occurred in 33/49 (67.3%) pa5ents.
- Time occurred in 5 (10.1%), Poor compliance was common in
dose ini5a5on(12 cases), and the more frequent doses (25 cases)
- Dose occurred in 29/49 (59.2%)
- Route occurred in all except one pa5ent.
- Documenta5on occurred in only 12(24.5%) of pa5ents. Non
compliance to proper documenta5on was more common in dose ini5al (14 cases).
NMC Standards(2006), ICN (2013)
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Concerns about nurses role cont..
Culture specimen management It’s also a big challenge because the sample is not supposed to stay on the bench for more than one hour.( male lab. ) In the laboratory when we are doing culture and sensitivity we follow
- guidelines. …… we have them in the clinical hand book. So they are
supposed to read on what is the turnaround time for this particular test. (female , lab)
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Concerns about nurses role Cont..
Multidisciplinary ward round
I think what is disturbing a little bit if we do ward rounds and the nurses come later start asking us questions while we are five patients away……. ( Female MD)
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Theme 3:Mul=disciplinary team culture essen=al
Because you write this drug and is not there and the nurses sometimes there is no communication between us and the nurses to say that this antibiotic is not there and also between us and the pharmacist to tell us what antibiotics are there…So communication is also a challenge (female MD) The pharmacy doesn’t know for how long the patient has taken antibiotics and then on discharge medications they haven’t indicated how many days the patient has taken the antibiotic (Pharmacy)
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Multidisciplinary team culture…
During handover when the SRN who was on day duty reports about the quantity of cefotaxime given from pharmacy: The Enrolled male nurse female nurse on night duty receiving handover says “this cefotaxime will not be enough”. We gave ceftriaxone instead
- f cefotaxime in the morning because cefotaxime was not enough.
ENM female on day duty says I don’t understand the doses others are prescribed tds, QID cefotaxime. The SRN female on day duty says but we still give tds even if prescription is QID.(Handover Observation)
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Theme 4: Resources are limited
Of course we are managing but not really because according to the environment ( mentions the ward) the number of patients I can say we have shortage of staff for example 3 nurses on duty against 60 or 70 patients . We fail to manage antibiotics properly (female SRN) But the major hiccup is inadequate resources especially the antibiotics themselves just few days ago we are talking of ceftriaxone out of stock uuu another one comes with ceftriaxone three four days out of stock ……….. not good for the outcome of the patients themselves.(male SRN )
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Theme 5:Limited/ unaware of an=bio=c management Guidelines
Aaa sometimes they (nurses) approach may be with questions how I inject it. Then I just tell them to look in the instruction, the package of the drug and ask your colleagues because I don’t know how to dissolve the powder in the liquid(female MD, ) Most of the times they just have constant figures when ordering antibiotics which makes us think that the ordering is not based on the actual need on the ground but it’s just based on figures which they are used to say like amoxyl we need 360 …….. Laughter (male pharma.)
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Theme 6:Conflict between AMS standards and rou=nes.
We start at 6am then 12MD. So 12 its lunch hour you find that the guardians are in so you can’t start giving drugs then we give at 6 pm which is also visiting hour from 5 -6 pm so we can’t give drugs that are some of the problems. (Male NMT)
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Theme 7: Workaround behaviours due to the challenging environment
When the guidelines tell us that we should use benzyl penicillin plus chloramphenicol for severe pneumonia four Nmes daily for each of those drugs aaa they would end up maybe geYng two doses so we tend to err on the side of ceGriaxone. (FGD female MD) Day duty ENM female says even those prescribed 2g we gave 1g yesterday so that it’s enough for all paNents. ( ObservaNon handover)
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Theme 8: Op=mism/ scep=cism about change
I would prefer it as the word suggest ( AMS) systemaNc; it will improve on anNbioNc administraNon. And it can even improve also paNent outcome. I believe so ( male SRN) And if it fails sNll there must be other measures which can be put in place so that it may be reinforced. (Male NMT 24y) So change will be there and we will be affected but by and by we will get
- there. (Male NMT 45y)
- scep5cism
I think improvement may be there but with difficulNes. Only if we have may be a larger number of nurses ( Male NMT ) Developing a tool means bringing something that is new so people are always resistant to change so I think the first thing would be people wouldn’t be comfortable (Female SRN )
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Recommenda=ons
- Training, Guidelines, Communica5on/
mee5ngs/ collabora5on.
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Developing Interventions ( Phase 2)
- presenta5on of baseline results to par5cipants
- Iden5fica5on of priority areas for improvement.
- Collabora5vely developed ,two components:
- Nurse Focused An5bio5c Stewardship Learning Package.
- Guideline pocket card - Op5mizing Time to An5bio5c
Ini5a5on and Con5nua5on.
Kert Lewin Theory, IDSA, SHEA, IHI (2012)
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Lessons learnt
Successes/ opportunities
provided in depth in sight
a success to change process
despite the resource challenges Challenges/Threats
the change process
an impact other practice gaps to be addressed.
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Acknowledgement
Mr Vernon Solomon ( UKZN)
- Prof. Adamson Muula ( UNIMA)
Dr Lyn Middleton ( UKZN) Funding
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Thank you Zikomo
