Our pharmacist-led, virtual antimicrobial stewardship (AMS) program rounding is a coordinated effort to optimise the use of antimicrobial medications in Southern NSW Local Health District (SNSWLHD).
We have developed a telehealth case-based review program using a centralised infectious diseases (ID) physician from ACT health and on-site medical officers and pharmacists. We worked within our limited staffing and budget restraints to improve patient outcomes, reduce antimicrobial resistance and ensure cost-effective therapy.
The virtual model allows for weekly telehealth review of antimicrobial prescribing in all facilities, with patients for discussion identified by pharmacists, and focused discussion on antimicrobial agent prescriptions directly with prescribers, ID physicians and pharmacists.
Addressing challenges in rural settings
Providing patient-centred antimicrobial stewardship services to regional Australia faces challenges. Adaptions to routine AMS programs are necessary in regional areas to:
- ensure equity for all patients no matter the size of the facility they are in
- increase clinician engagement
- increase antibiotic guideline prescribing concordance.
SNSWLHD is a rural-based health service covering 44,534km2, 9 secondary hospitals and 3 multi-purpose services. Southern NSW is divided in to two Networks: Inland and Coastal. Each Network has a Chief Pharmacist. Unlike other local health districts within NSW, SNSWLHD does not have tertiary referral facility; all of our AMS strategies prior to implementing this model have been solely pharmacist-led.
Empowering staff in antimicrobial stewardship
In July 2022, we began the development of a pharmacist-led telehealth case-based review program, after we were approached by an infectious disease physician from ACT Health, looking to undertake work in Southern NSW as part of a scholarship. We undertook a PDSA (Plan, Do, Study, Act) cycle, allowing the model to evolve as we went.
Each week, the network Chief Pharmacist co-ordinates a Teams meeting for their sites. All treating teams in the network have a standing invitation to attend. Patients are selected for review using the reporting function within eMR, with those on restricted antimicrobials prioritised. The list of patients is distributed prior to the meeting so busy clinicians can dial in and out of the meeting when their patient is due for discussion. The meetings are held in an open and collaborative style which facilitates uptake of recommendations and promotes education around key AMS strategies.
A critical component in implementing the model has been gaining the support of consultants, registrars and junior medical officers (JMOS), and encouraging their attendance at virtual rounds. We have prioritised encouraging attendance with JMOS, and we have seen their enthusiasm for the model filter up to more senior staff.
24% improvement in concordance with antimicrobial stewardship guidelines
We found that median in-hospital prescribing concordance rates with therapeutic guidelines across all sites increased from 40% in January 2022 to 64% after establishing the program. Over the 12-month study period, we flagged 1581 patients for use of restricted antibiotics by pharmacists. ID clinician review occurred in 1320 cases (83%) across 128 virtual rounding's. In these reviews, 1243 recommendations were made regarding antimicrobial therapy.
Recommendations were categorised as the following:
- 125 recommendations to change antimicrobial choice
- 157 recommendations to cease antimicrobials
- 249 recommendations to de-escalate antimicrobials, including intravenous to oral switch or narrowing spectrum of antimicrobials
- 32 recommendations to change dose or frequency of antimicrobials
- 446 further plans made for antimicrobial use, including duration and future stepdown plan
- 39 cases of education on antimicrobial use, including education on ideal first line treatment for future cases
- 206 recommendations for further investigations and diagnostics, including pathology, radiology and microbiology
- 5 other recommendations, including vaccination and ceasing contributing medications.
This unique virtual model for AMS rounding has allowed personalised, patient-centred review via telehealth into multiple regional hospitals. Optimisation of finite infectious diseases specialist resources are necessary to increase access to personalised AMS services in rural and regional Australia. This pharmacist-led program also provides education and support to local pharmacists and medical officers. Ongoing program extension to other rural and remote sites should be considered.
