Project IVORY

At Hornsby Ku-ring-gai Hospital, we are working to reduce the unnecessary use of intravenous (IV) antimicrobials. Unnecessarily prolonged courses of IV antimicrobials present significant risks and minimal benefit for patients.

Risks include:

• longer stays in hospital
• IV-related complications
• antimicrobial resistance
• reduced drug effectiveness
• higher healthcare costs
• increased carbon emissions.^1-4

Our healthcare system contributes around 7% of Australia’s carbon emissions. Pharmaceuticals are a major factor due to over-prescribing, antibiotic resistance, and medication waste.^5,6 Studies show that a single dose of IV antimicrobials is significantly more resource-intensive than the equivalent oral dose, particularly if considering factors such as drug cost, administration, clinical staff time, waste disposal and environmental impact.

Switching early from IV to oral doses reduces low-value care, optimises patient health outcomes and saves IV fluids during a time of global shortages. Optimising antimicrobial prescribing aligns with the Australian Commission on Safety and Quality in Health Care’s Antimicrobial Stewardship Clinical Care Standard and global antimicrobial stewardship efforts. It also supports the triple bottom line of planetary health and environmental sustainability, economic viability and social responsibility.

Optimising antimicrobial prescribing practices

Project Intravenous to Oral antimicrobial Replacement Therapy (IVORY) promotes switching early from IV to oral antimicrobials for adult inpatients at Hornsby Ku-ring-gai Hospital. Our analysis revealed that 21% of patients prescribed IV antimicrobials where clinical suitable for oral alternatives, mirroring trends in the National Antimicrobial Prescribing Survey.

By providing resources to support behaviour change, Project IVORY aims to optimise antimicrobial prescribing practices. This will improve patient health outcomes and experiences. It will also enable more efficient resource use, lower costs and reduce our environmental footprint.

Fostering a cultural shift in antimicrobial prescribing

To achieve the project’s goals and address the root causes of antimicrobial prescribing challenges, we co-designed four solutions in collaboration with key stakeholders, subject matter experts and end-users. The solutions are part of a multidisciplinary and multifaceted approach that fosters a cultural shift toward optimising antimicrobial prescribing.

We are developing a comprehensive suite of tools and resources to help medical prescribers, clinical pharmacists and nursing staff make informed decisions at the point of care. We are implementing the solutions and supports together, including:

• Upskilling medical prescribers by running educational sessions held during department meetings, grand rounds, resident medical officer teaching sessions and at medical staff councils. We are increasing antimicrobial stewardship training and liaison during implementation and developing an online learning module.
• Upskilling clinical pharmacists are being upskilled by running interactive workshops, peer mentoring, online learning modules and implementing updated work templates. We are integrating the clinical review of IV antimicrobials and recommendations for switching into clinical pharmacists’ daily workflows.
• Developing digital support tools to improve patient care. We are creating an electronic alert system to flag when a patient may be eligible to switch from IV to oral, based on their clinical parameters.
• Training nursing and midwifery staff to identify patients who could switch from IV to oral, and how to communicate this to the treating teams through daily task lists and clinical review requests. This contributes to our multidisciplinary approach.

Evaluation and expanding to other medications

We will formally evaluate the project once it is fully implemented. The evaluation will include reviewing antibiotic prescribing again to discover any improvements to IV antibiotic prescribing practices. We will also survey medical, pharmacy and nursing staff to learn of any improvements in clinical knowledge, skills and confidence. The early IV to oral switch is not limited to just antimicrobials. This practice can also be expanded to many other medications prescribed in the hospital setting, with the same beneficial outcomes.

Seeking involvement and feedback from local clinicians and stakeholders at every stage of the project has been crucial. It helped ensure we clearly understood the issues and designed effective solutions. This collaborative approach has also ensured the behaviour change has been successful, sustainable and spread widely throughout the service – ensuring the benefits can be enjoyed by all. Staff turnover and movement between roles is common in healthcare. It is essential that solutions and supports are not reliant on individual staff members, but is integrated into routine staff practices and training. This helps ensure the change is sustainable and embedded into the service.

View this project's poster from the Centre for Healthcare Redesign graduation May 2025.

References