Rising antimicrobial resistance (AMR) is a recognised threat to global health. There is a perception that poor prescribing practices contribute to the problem, although data confirming this are limited. Reliable data on the quality of antimicrobial prescribing in UK hospitals are not available, with hospital drug-purchasing data most often being used as a proxy measure.
Having complete and consistent data about the prescribing and administration of antimicrobials is vital for quality improvement interventions to reduce AMR, but this is a major challenge for hospitals — particularly for those that have not implemented electronic prescribing (EP). Even in hospitals with EP, the ability to analyse data is not always available.
The project, ‘Antimicrobials in hospitals — development of advanced e-prescribing tools and analytics’ (ADAPTA) aims to:
- Visualise and increase understanding of antimicrobial prescribing, and support antimicrobial stewardship initiatives;
- Develop novel analytics enabling antibiotic prescribing to be evaluated and tracked by linking diagnosis, outcomes and resistance for individual and cohorts of patients;
- Increase the analytical capability and capacity within the University Hospital Southampton (UHS) NHS Foundation Trust .
The project started in January 2018 and was conceived by the pharmacy antimicrobial and research teams at UHS, in collaboration with the University of Edinburgh and the hospital prescribing analytics company, Triscribe. Funding was provided by the Health Foundation — an independent charity committed to bringing about better health and healthcare for people in the UK — in the first round of their ‘advancing applied analytics’ programme.
Cohort analysis through advanced analytic methods will allow areas for improvement to be identified, along with an understanding of the clinical impact of the changes to antibiotic prescribing provoked by both national targets and drug shortages.
ADAPTA involves creating an antibiotic prescribing database linked to patient clinical acuity measures, laboratory tests, medical imaging and clinical outcome data. This allows for cleansing, normalising and processing the data to better understand antibiotic prescribing and administration, describe antibiotic variations by prescriber/specialty, and create a dashboard to visualise individual patient clinical status and standardise analytical outputs.
Data from the trust’s ePrescribing systems (JAC and Metavision) from September 2017 are being analysed using Triscribe’s software, allowing trends in all prescribing data to be reviewed.
There are three main phases of work; the project is currently at phase two and undergoing validation. In phase one, a ‘ward round viewer’ brought all relevant data on a single patient together to allow efficient review. This included prescribing, vital signs, biochemistry, haematology, microbiology and radiology, and was presented as a chronologic view of the previous 14 days.
Phase two allows users to search for patients with a group of specific criteria: for example, raised C-reactive protein or a prescription for a carbapenem and a carbapenem-resistant blood culture isolate. The search criteria are fully customisable and allow users to prioritise their work accordingly. Recent feedback from our consultant microbiologists and pharmacists has focused our priorities on identification of both sick patients on antimicrobials as well as patients who may not require them and can be de-escalated.
Phase three will allow trends in outcome and resistance patterns to be analysed and reviewed to understand the impact of national targets and antimicrobial shortages.
In addition to antimicrobial reports (e.g. course lengths, activity spectrum), reports on omitted doses, anticholinergic burden, hypnotic use and anti-Parkinsonian prescribing are being developed.
Since starting the project we have:
- Set up user group workshops;
- Recruited a data analyst;
- Completed data specification;
- Extracted data with more than 200 variables from six different systems;
- Gained all information governance permissions;
- Completed mobile ward round visualisation;
- Linked all data streams;
- Developed draft visualisations;
- Assessed the impact of our five-day course initiative on antibiotic course lengths;
- Identified the presence or absence of prescribing trends in relation to infection control issues.
The next steps will involve the prioritisation dashboard, which will highlight the patients that are most likely to benefit from a microbiological review, such as those patients with a drug/bug mismatch or worsening signs despite antimicrobial treatment or patients worsening who may require an antibiotic.
Andy Fox, project lead, and consultant pharmacist in medicines safety;
Kieran Hand, specialist antimicrobial pharmacist, pharmacy antimicrobial team;
Jackie Swabe, specialist antimicrobial pharmacist, pharmacy antimicrobial team;
Mike Vickers, specialist antimicrobial pharmacist, pharmacy antimicrobial team;
Alex Tonkyn, information analyst;
Ian Brewer, head of information technology;
Luke Winstone, integration and development analyst;
All at University Hospital Southampton NHS Foundation Trust.
Correspondence to: andy.fox@uhs.nhs.uk
