Antimicrobial resistance is unlikely to be at the front of anyone’s mind at the moment. I know that many of you do not have the time and possibly the energy just now. The pressure to ensure that you have COVID prevention strategies in place is a complex task not to be underestimated. Then there are those of you who are actually dealing with COVID cases, again this is complex in a dynamic environment.
On top of these pressures, it is business as usual, or as some would say – unusual! You continue to provide care and support to your residents, their families; you continue to work with staff who are possibly stressed, frightened and tired. The day to day running of your service or shift and all that it entails continues.
Think of this blog as light reading, a refresher and possibly a guide to some resources on antimicrobial stewardship (AMS) and the prevention of antimicrobial resistance (AMR).
The AURA 2021 report
The Commission released its Fourth Australian report on antimicrobial use and resistance in human health (AURA 2021) in August 2021. On reading it, I noted that there are a great number of key messages throughout the report, all excellent points, which I will discuss across two blog posts.
I must confess that the first point was a reality check for me, specifically this extract (emphasis my own):
Key AMR message 1
Antimicrobial resistance (AMR) continues to be an increasing risk to patient safety because it reduces the number of antimicrobials available to treat infections. AMR increases morbidity and mortality associated with infections caused by multidrug-resistant organisms. AMR may limit future capacity to perform medical procedures such as organ transplantation, cancer chemotherapy, diabetes management and major surgery, because of a lack of effective antimicrobials.
This point is a bold reminder that we cannot dismiss AMS responsibilities if we are committed to obliterating the catastrophic health outcomes of AMR.
It would be remiss of me if I did not acknowledge that AMS is everyone’s responsibility: healthcare workers, microbiologists, educators, policy makers, legislative bodies, the pharmaceutical industry and the public.
Let’s face it, there is a real probability for any one of us or a loved one at some stage to get infected with a pathogen that is resistant to antibiotic treatment. I have witnessed this in my career when I worked in an MRSA unit, sadly I nursed people of all ages who died from infections that were no longer responsive to antimicrobials.
As a registered nurse working for an aged care provider, you have a social and professional obligation to minimise the risk of AMR. You may not be aware that under the Aged Care Act 1997- Quality of Care Principles 2014 and subsequent amendments, you also have a legal obligation to adhere to organisational systems and processes that promote both a culture and practices that support optimal antimicrobial prescribing practices.
It is the Aged Care Quality and Safety Commission (ACQSC) that monitors compliance with this requirement. The Aged Care Standards 2019 that are specific to AMS and AMR are as follows:
Governance-Standard 8(3) (e) a legislative requirement for age care providers to implement antimicrobial stewardship systems and practices to reduce inappropriate antimicrobial usage and resistance. Effective organisation wide systems required for preventing managing with controlling infections and antimicrobial resistance this contributes to the broader national if it improves outcomes for resident.
Personal care and clinical care- Standard 3. Requirement (3) (g) Minimisation of infection-related risks through implementing:
a. standard and transmission-based precautions to prevent and control infection; and
b. practices to promote appropriate antibiotic prescribing and use to support optimal care and reduce the risk of increasing resistance to antibiotics.
Quality of Care Principles 2014 (legislation.gov.au)
Antimicrobial resistance in the workplace
At this point it would be good to reflect on the systems and practices, policies, guides, and education and training that you have in your place of work.
If you are unsure of what you need to have in place, then you can refer to the ACSQHC; AMS Clinical Care Standards – these eight quality statements will guide you when establishing policies, education and practices. They are a good reference point and I have captured these below.
We all know that the resident is the most important person in this and at all times must be consulted, advised and informed so that they can make health decisions in their best interest. Lastly, we all know that antimicrobials are prescribed by a medical officer, however, registered nurses have great influence, they provide the practitioner with important information that has impact on the medical decisions being made. Hence clinical information such as signs, symptoms, actions taken, results and outcomes need to be timely, accurate and well communicated and documented.
The AMS Clinical Care standards are best practice. Let’s have a look at the AMS Clinical Care Standards; we've listed them below but they've been sourced from the Safety and Quality Commissions website. Consider how these can be applied.The AMS Clinical Care standards are best practice. Let’s have a look at the AMS Clinical Care Standards. Consider how these can be applied.
A resident with a life-threatening condition due to a suspected infection receives an appropriate antimicrobial immediately, without waiting for the results of investigations.
To ensure access to timely and appropriate antimicrobial treatment for resident with suspected life-threatening infections that can lead to sepsis (as defined by Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)) , septic shock, bacterial meningitis, febrile neutropenia or necrotising fasciitis, when clinically appropriate.
When a resident is prescribed an antimicrobial, this is done in accordance with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines and the antimicrobial formulary.
To ensure that the most appropriate antimicrobial treatment is given. That is, to ensure that the appropriate spectrum microbial of activity, active ingredient, dose, frequency and route of administration, and duration of therapy is chosen.
When an adverse reaction (including an allergy) to an antimicrobial is reported by a resident or recorded in their healthcare record, the active ingredient(s), date, nature and severity of the reaction are assessed and documented. This enables the most appropriate antimicrobial to be used when required.
To ensure the accurate assessment and documentation of resident adverse reaction information to allow for optimal antimicrobial prescribing. This means using the most appropriate and narrow-spectrum antimicrobial possible, while ensuring that potential harms (such as anaphylaxis) are avoided.
A resident with a suspected infection has appropriate samples taken for microbiology testing as clinically indicated, preferably before starting antimicrobial therapy.
To support appropriate antimicrobial selection with relevant microbiology testing when clinically indicated.
A resident with an infection, or at risk of an infection, is provided with information about their condition and treatment options in a way that they can understand. If antimicrobials are prescribed, information on how to use them, when to stop, potential side effects and a review plan is discussed with the resident.
To inform residents about their clinical condition so that they can participate in decision-making about their treatment options in collaboration with their clinician. This may or may not include antimicrobials.
To improve resident understanding on how to take prescribed antimicrobials and to improve concordance with therapy.
When a resident is prescribed an antimicrobial, the indication, active ingredient, dose, frequency and route of administration, and the intended duration or review plan are documented in the resident’s healthcare record.
To improve documentation of antimicrobial treatment to support effective communication among clinicians through the resident’s healthcare record. This record may include mechanisms such as paper or electronic healthcare records, the My Health Record system, prescription records or the medication chart. Documentation allows the appropriateness of the prescription to be assessed, and ensures that all clinicians involved in the resident’s care have access to consistent and current information.
A resident prescribed an antimicrobial has regular clinical review of their therapy, with the frequency of review dependent on resident acuity and risk factors. The need for ongoing antimicrobial use, appropriate microbial spectrum of activity, dose, frequency and route of administration are assessed and adjusted accordingly. Investigation results are reviewed promptly when they are reported.
To optimise residents’ antimicrobial therapy through clinical assessment and review of the appropriateness of the antimicrobial and of investigation results.
To prevent unnecessary antimicrobial use, including of the use of broad-spectrum antimicrobials where a narrow-spectrum antimicrobial could be used, to reduce the potential to drive antimicrobial resistance.
To ensure the appropriate dosing regimen and route of antimicrobials to adequately treat or prevent an infection, improve resident outcomes and reduce resident harm (for example, when a resident has renal impairment, or when oral options can replace intravenous use). This may include therapeutic drug monitoring.
A resident having surgery or a procedure is prescribed antimicrobial prophylaxis in accordance with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines. This includes recommendations about the need for prophylaxis, choice of antimicrobial, dose, route and timing of administration, and duration.
To reduce the risk of surgical site infections from procedures including surgery, dental procedures, gastrointestinal endoscopic procedures, implantable cardiac device insertions, diagnostic interventions, cleaning and debridement of traumatic wounds, and ophthalmic surgery including cataract removal.
To ensure appropriate antimicrobial prophylaxis, including avoiding the use of antimicrobials when not required.
Enacting AMS in the workplace
Remember that prior to the 1928 discovery of penicillin, populations died from infections. Despite all of the medical innovations, however, people are still dying from infections as the result of antimicrobial resistance. In America in 2020, 35,000 people died as a result of antibiotic-resistant bacteria or fungi. While you or your facility cannot eradicate AMR on your own, at the very least, consider the consequences associated with the use of antimicrobials when next speaking with your residents, their general practitioners, their pharmacist and their families. Apply your professional knowledge and skills on AMS and AMR before reaching for the medication chart or script pad.
As an exercise I suggest that you sit with your staff and examine each of the standards while asking the following:
- How do you demonstrate that you meet these standards?
- What are your systems and processes?
- Does everyone understand their roles and responsibilities?
- How do they know?
- What education is in place?
- What are the indicators that you collect?
- What are your results telling you?
- Ask can we do better?
- Do we continually look to ways that we can improve resident outcomes?
Where do you start with AMS and AMR in your facility? If you need more help than this blog post can offer, then why not get in touch with Bug Control? From environmental audits to education resources to infection control policy and procedure manuals, we can help you out. Contact us today to start improving your processes and reducing infections.
Emilia Graham is a quality compliance operations innovation and improvement clinical governance consultant.