Antimicrobial stewardship (AMS) can be defined as the approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness. With demands on microbiological clinical services at Basildon and Thurrock University Hospitals increasing over recent years, requests for clinical advice could no longer be facilitated by a direct telephone call from clinical teams to the pathology team. Paper referral forms used by pharmacists for AMS review were no longer effective, due to the difficulty in contacting a doctor to change prescriptions, especially for surgical wards. Increased call levels led to delays in clinic letters being sent out and outpatient investigations being organised. A novel method of generating referrals, with an increased use of automated technologies, was required to make best use of the resources available for clinical requests from hospital clinicians and pharmacists to support AMS.
The trust developed an automated intranet-based referral service using ‘concrete5’, an open source content management system, to process clinical advice requests for AMS review promptly. AMS review involves assessing patients’ inflammatory markers, clinical observations, microbiology culture and sensitivities to make appropriate treatment recommendations. This could mean to stop, escalate or de-escalate antimicrobial treatment.
Clinicians and pharmacists can make a request for AMS review from the microbiology team by completing the relevant details, including the patient’s clinical details, within the online form to request advice. Once submitted, an email is generated to a shared mailbox, which all microbiologists have access to. The form is for use during working hours only (Monday to Friday between 9:00 and 17:00, excluding bank holidays). As the data remains within the trust’s system, the form complies with information governance requirements.
The microbiology online portal was launched on 26 September 2017, with pharmacists distributing fliers on each ward to advertise the new service in the two preceding weeks. During implementation, it was noted that senior clinicians were not so keen on using the system as it required taking time to find a computer and to write the referral. However, junior doctors and pharmacists adopted the new referral methodology quickly, as it was easier than waiting on a call to the busy microbiology phone line.
The change in the referral system was an almost instantaneous switch to the intranet-based system and resulted in an increase in the median number of total referrals, from 59% to 97% more per week. The median number of referrals via medical secretaries also reduced from 61 to 6 per week, with each telephone referral taking around ten minutes on average. This created efficiencies, resulting in improved turnaround times for generation of clinical letters.
The new form has had a positive impact on AMS, allowing pharmacists to query inappropriate prescriptions easily by focusing conversations around a patient’s condition, and has increased teaching opportunities with junior medical staff related to antimicrobial prescribing.
Abiodun Ogundana, lead antimicrobial and nutrition pharmacist, Basildon and Thurrock University Hospitals;
Faisal Bin-Reza, consultant microbiologist, Basildon and Thurrock University Hospitals;
Christi Atkinson, communications officer, Basildon and Thurrock University Hospitals;
Justin Edwards, consultant microbiologist, Basildon and Thurrock University Hospitals;
ElFaith Mustafa Awad-El-Kariem, consultant, Basildon and Thurrock University Hospitals