Action 3.15 states

The health service organisation has an antimicrobial stewardship program that:

  1. Includes an antimicrobial stewardship policy
  2. Provides access to, and promotes the use of, current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing
  3. Has an antimicrobial formulary that includes restriction rules and approval processes
  4. Incorporates core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard

Intent

Appropriate prescribing and use of antimicrobials are part of the broader systems to improve patient safety and quality of care, and prevent and manage infections associated with multidrug-resistant organisms.

Reflective questions

What systems, processes and structures are in place to support appropriate prescribing and use of antimicrobials?

How does the health service organisation provide access to current endorsed therapeutic guidelines for clinicians who prescribe antimicrobials?

How is information about the antimicrobial formulary, restriction rules and approval processes communicated to prescribers and clinicians?

Key tasks

  • Review the current antimicrobial stewardship (AMS) program to identify what is working well; identify gaps, risks and areas for improvement; set priorities; and inform review of the AMS program plan - use the results of this review to determine priorities for AMS
  • Identify the key membership of the AMS committee and the AMS team
  • Develop or review an AMS policy that specifies that clinicians should follow current, evidence-based Australian therapeutic guidelines on antimicrobial prescribing, or evidence-based guidelines that have been endorsed by a state or territory AMS committee, and incorporates the principles of the Antimicrobial Stewardship Clinical Care Standard
  • Develop, review and maintain antimicrobial prescribing policies and a formulary for specific infections to reflect current resistance patterns
  • Create or review an antimicrobial formulary and guidelines for treatment and prophylaxis that align with current, evidence-based Australian therapeutic guidelines
  • Review policies, clinical pathways, point-of-care tools and education programs to ensure that they incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard.

Strategies for improvement

Hospitals

Review the AMS program

All health service organisations should have an overarching AMS program. Review the current AMS program to identify what is working well, and gaps and areas for improvement. This includes:

  • Assessing current antimicrobial use, results of prescribing audits, available incident data, current AMS activities and resources to support AMS strategies
  • Mapping current governance structures, systems and processes that currently support AMS, or could be further developed
  • Using the results of this evaluation to identify risks, gaps and priorities for AMS, and to inform the AMS program plan.

Review the AMS committee and team

The AMS committee is multidisciplinary and oversees the effective implementation and ongoing function of the AMS program. Membership includes:

  • A member of the executive as an executive sponsor, who can enable change
  • Clinicians with technical expertise (for example, an infectious diseases physician, pharmacist, clinical microbiologist or infection control nurse) and other individuals who can provide day-to-day leadership and support implementation.

Check that the AMS committee has endorsement from the organisation’s executive or governing body for formal structural alignment.

Ensure that there are links between the AMS committee and the existing clinical governance framework and quality improvement systems, including having the committee represented on both the drug and therapeutics committee, and the infection prevention and control committee. These links should be clearly articulated (for example, in the organisational chart or terms of reference).

Incorporate AMS within the organisation’s safety and quality improvement systems (see Actions 1.10 and 3.2).

The AMS team is the effector arm of the AMS program. Core membership includes:

  • An infectious diseases physician or clinical microbiologist
  • A nominated clinician (for example, lead doctor)
  • A clinical pharmacist.

In larger health service organisations, the team would be on site; in smaller facilities, the pharmacist position may be part of a broader network or group of health service organisations, or support may be provided using telehealth systems. The responsibility to ensure that the AMS team is adequately resourced should be clearly outlined in organisational policies.

Implement an AMS policy

Write or review, and implement, an AMS policy that:

  • Specifies that prescribers must follow current, evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing, or evidence-based guidelines that have been endorsed by a state or territory AMS committee, and incorporates processes for informing prescribers about prescribing requirements
  • Incorporates the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • Lists restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specifies processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • References the health service organisation’s policy on liaising with the pharmaceutical industry (see Action 4.1)
  • Outlines systems for obtaining specialist advice for complex clinical conditions
  • Incorporates an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflects the AMS program’s integration within the organisation’s safety and quality systems.

Decide on, and document, procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

The strategies below align with those listed in Action 3.16.

Develop an AMS program plan based on the risks, gaps and priorities identified in the initial assessment and gap analysis. Ensure that the plan details:

  • Procedures for prescription review and feedback to prescribers (for example, AMS rounds or pharmacy rounds)
  • Goals, actions, time frames, and measurement and reporting activities
  • Frequency of review and monitoring activities
  • Process and outcome indicators or measures to monitor program effectiveness
  • Roles, responsibilities and time frames for reporting on policy compliance, antimicrobial use and resistance, and prescribing according to guidelines
  • Roles and responsibilities of governance, executive, leaders, managers and clinicians for meeting and evaluating identified priorities
  • Resource allocation (for example, workforce, time, infrastructure) to support planned activities.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the start of their employment and at least annually.

Ensure that prescribing clinicians have access to, and follow, current guidelines and the local antimicrobial formulary for treatment and prophylaxis for common infections relevant to the patient population, the procedures performed and the local antimicrobial resistance profile. Therapeutic Guidelines: Antibiotic is recognised as a national guideline for antimicrobial prescribing in Australia.

Provide clinicians with ready access to the current version of Therapeutic Guidelines: Antibiotic and the local antimicrobial formulary. To promote uptake, make guidelines available in print or online formats.

Ensure that any local clinical and prescribing guidelines are consistent with recommendations in the current version of Therapeutic Guidelines: Antibiotic, and consider local microbial susceptibility patterns.

Review prescribing guidelines at least annually, or as changes are notified.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard into the AMS program

Review relevant clinical pathways to ensure that review of antimicrobial therapy and patient condition is included in the pathway. Set benchmarks for documenting in the patient’s healthcare record the clinical reason; the medicine name, dose, route of administration and intended duration; and the treatment review plan.

Implement or review the process for reporting adverse events, incidents and near misses relating to antimicrobial use, including assessment and management of reported antibiotic–allergy mismatch.

Educate patients and carers about safe and appropriate use of antimicrobials, including potential adverse reactions and what to do in the event of a reaction.

Use process measures to monitor implementation of the AMS program, and to identify opportunities for improvement. Possible measures include Antimicrobial Stewardship Clinical Care Standard indicators1 and indicators to support AMS programs.

For further strategies for improvement refer to Antimicrobial Stewardship in Australian Health Care.

Day Procedure Services

Review the AMS program

An AMS program is a combination of strategies and interventions that work together to optimise antimicrobial use.

All day procedure services that administer or prescribe antimicrobials are required to have an overarching AMS program. Depending on the governance arrangements for safety and quality, this program may be managed by an individual facility, local health network, state or territory, or private hospital ownership group. If the service is part of a broader network or ownership group, work with the governing organisation to identify the resources available to support AMS in the day procedure service and to develop the program.

Review the program to identify what is working well, and gaps and areas for improvement. This includes:

  • Assessing current antimicrobial use, results of prescribing audits, available incident data, current AMS activities and resources to support AMS strategies
  • Mapping current governance structures, systems and processes that currently support AMS, or could be further developed
  • Using the results of this evaluation to identify risks, gaps and priorities for AMS, and to inform the AMS program plan.

Review governance arrangements

To ensure the best chance of program success, incorporate AMS within the service’s quality improvement and patient safety plan.

Governance arrangements for the AMS program may involve coordination by the service’s manager, with support from specialist credentialed medical and other practitioners, and/or a pharmacist, if available.

The committee overseeing AMS requires endorsement from the executive or governing body for formal structural alignment.

Review the AMS committee and team

The committee responsible for AMS oversees the effective implementation and ongoing function of the AMS program. Membership includes:

  • A member of the executive as an executive sponsor, who can enable change
  • Clinicians and other individuals who can provide day-to-day leadership.

The AMS team is the effector arm of the AMS program. Membership may include:

  • The service’s manager, a nurse, credentialed medical and other practitioners, a surgeon, an anaesthetic representative
  • If available, a pharmacist; the pharmacist position may be part of a broader network or group, or contracted service, or accessed using telehealth systems.

Implement an AMS policy

Write or review, and implement, an AMS policy that:

  • Specifies that prescribers must follow current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing, or evidence-based guidelines that have been endorsed by a state or territory AMS committee
  • Incorporates processes for informing prescribers about prescribing requirements
  • Incorporates the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • Lists restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specifies processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • References the health service organisation’s policy on liaising with the pharmaceutical industry (see Action 4.1)
  • Outlines systems for obtaining specialist advice for complex procedures or conditions
  • Incorporates an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflects the AMS program’s integration within the organisation’s safety and quality systems.

Decide on, and document, procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

The strategies below are aligned with those listed in Action 3.16.

Develop an AMS program plan based on the risks, gaps and priorities identified in the initial assessment and gap analysis. Ensure that the plan details:

  • Procedures for prescription review and feedback to prescribers
  • Goals, actions, time frames, and measurement and reporting activities
  • Frequency of review and monitoring activities
  • Process and outcome indicators or measures to monitor program effectiveness
  • Roles, responsibilities and time frames for reporting on policy compliance, antimicrobial use and resistance, and prescribing according to guidelines
  • Roles and responsibilities of governance, executive, leaders, managers and clinicians for meeting and evaluating identified priorities
  • Resource allocation (for example, workforce, time, infrastructure) to support planned activities.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the start of their employment and at least annually.

Ensure access to current guidelines

Ensure that prescribing clinicians have access to, and follow, current guidelines and the local antimicrobial formulary for treatment and prophylaxis for common infections relevant to the patient population, the procedures performed and the local antimicrobial resistance profile. Therapeutic Guidelines: Antibiotic is recognised as a national guideline for antimicrobial prescribing in Australia.

Provide clinicians with ready access to the current version of Therapeutic Guidelines: Antibiotic and the local antimicrobial formulary. To promote uptake, make guidelines available in print or online formats.

Ensure that any local clinical and prescribing guidelines are consistent with the recommendations in the latest version of Therapeutic Guidelines: Antibiotic, and take into account local microbial susceptibility patterns.

Review prescribing guidelines at least annually, or as changes are notified.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Specify restriction rules and approval processes within the formulary, including restriction of broad-spectrum and later-generation antimicrobials to patients in whom their use is clinically justified.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard into the AMS program

Review relevant clinical pathways to ensure that review of antimicrobial therapy and patient condition is included in the pathway. Set benchmarks for documenting in the patient’s healthcare record the clinical reason; the medicine name, dose, route of administration and intended duration; and the treatment review plan.

Implement or review the process for reporting adverse events, incidents and near misses relating to antimicrobial use, including assessment and management of reported antibiotic–allergy mismatch.

Educate patients and carers about safe and appropriate use of antimicrobials, including potential adverse reactions and what to do in the event of a reaction.

Use process measures to monitor implementation of the AMS program, and to identify opportunities for improvement. Possible measures include Antimicrobial Stewardship Clinical Care Standard indicators1 and indicators to support AMS programs.

For further strategies for improvement refer to Antimicrobial Stewardship in Australian Health Care.

Examples of evidence

Select only examples currently in use:

  • Policy documents about the AMS program
  • Examples of how the quality statements from the Antimicrobial Stewardship Clinical Care Standard have been incorporated into the AMS program
  • Membership lists and role descriptions for the AMS committee and team
  • Committee and meeting records in which performance of the AMS program was discussed
  • Communication with the workforce promoting the use of current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing
  • Observation that current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing are available to the workforce
  • Training documents about AMS and attendance records
  • Antimicrobial formulary that includes restrictions and approval procedures that align with current endorsed therapeutic guidelines
  • Audit results of antimicrobial use, especially for high-risk antimicrobials or high-risk clinical areas
  • List of high-risk antimicrobials used in the health service organisation or high-risk clinical areas.

MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established AMS program.

Small hospitals that are not part of a local health network or private hospital group should:

  • Review the current AMS program to identify what is working well; identify gaps, risks and areas for improvement; set priorities; and inform review of the AMS program plan – use the results of this review to set priorities for AMS
  • Identify the key membership of the AMS committee and the AMS team
  • Develop or review an AMS program plan
  • Develop or review an AMS policy that specifies that clinicians should follow current, evidence-based Australian therapeutic guidelines on antimicrobial prescribing, and incorporates the principles of the Antimicrobial Stewardship Clinical Care Standard
  • Develop, review and maintain antimicrobial prescribing policies and a formulary for specific infections to reflect current resistance patterns
  • Create or review an antimicrobial formulary and guidelines for treatment and prophylaxis that align with current, evidence-based Australian therapeutic guidelines
  • Review policies, clinical pathways, point-of-care tools and education programs to ensure that they incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard.

The governance structure of the AMS program should incorporate formal structural alignment to relevant committees and be endorsed by the hospital executive.

The group responsible for AMS is generally multidisciplinary and oversees the effective implementation and ongoing function of the AMS program. Membership will depend on the available workforce and may include those with network or contracted roles. Committee membership includes:

  • A member of the executive or nominated executive sponsor, who can enable change
  • Clinicians with technical expertise (for example, an infectious diseases physician, pharmacist, clinical microbiologist or infection control nurse) and other individuals who can provide day-to-day leadership and support implementation.

The AMS team is the effector arm of the AMS program. Depending on the local circumstances, the team may be at the level of the facility, local health network or private hospital group. It should reflect the local context, including the complexity of services offered. Membership will depend on the local context but should include:

  • A prescribing clinician
  • A clinical pharmacist, if available.

The AMS team needs to receive input from an infectious diseases physician or clinical microbiologist.

Implement an AMS policy

The AMS policy should:

  • Specify that prescribers must follow current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing
  • Incorporate processes for informing prescribers about prescribing requirements
  • Incorporate the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • List any restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specify processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • Outline systems for obtaining specialist advice for complex clinical conditions
  • Incorporate an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflect the AMS program’s integration within the organisation’s quality improvement and patient safety governance structure, and the organisation’s safety and quality strategic plan
  • Describe procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

Develop an AMS program plan based on the risks, gaps and priorities identified in the assessment and gap analysis. The plan should include documented processes for seeking expert specialist advice from infectious diseases physicians and/or clinical microbiologists to support the local AMS team and program implementation. Ensure that the plan includes procedures for prescription review and feedback to prescribers (e.g. AMS rounds or pharmacy rounds), and that the strategies in the plan align with those listed in Actions 3.16.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the beginning of their employment and at least annually.

Ensure access to current guidelines

Ensure that prescribing guidelines are consistent with current evidence-based Australian therapeutic guidelines. Therapeutic Guidelines: Antibiotic is recognised as a national guideline for antimicrobial prescribing in Australia. Provide clinicians with access to guidelines for treatment and prophylaxis for common infections relevant to the patient population, the local antimicrobial resistance profile and the surgical procedures performed. Review prescribing guidelines at least annually, or as changes are notified.

Ensure that evidence-based, endorsed state, territory or national guidelines and clinical pathways are available for management of suspected life-threatening bacterial conditions, including sepsis.

Establish or review clinical pathways for high-risk or high-volume conditions; examples might include Staphylococcus aureus bacteraemia, bone and joint infections, community-acquired pneumonia, catheter-associated and other urinary tract infections, and management of antimicrobial-related allergy.

Ensure that clinical pathways include steps to allow appropriate investigations, routine review of therapy, de-escalation, intravenous-to-oral switch and limiting the duration of therapy. Use state, territory or national guidelines or resources to implement a formal intravenous-to-oral switch program.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Implement the Antimicrobial Stewardship Clinical Care Standard locally.1

Hospitals

Review the AMS program

All health service organisations should have an overarching AMS program. Review the current AMS program to identify what is working well, and gaps and areas for improvement. This includes:

  • Assessing current antimicrobial use, results of prescribing audits, available incident data, current AMS activities and resources to support AMS strategies
  • Mapping current governance structures, systems and processes that currently support AMS, or could be further developed
  • Using the results of this evaluation to identify risks, gaps and priorities for AMS, and to inform the AMS program plan.

Review the AMS committee and team

The AMS committee is multidisciplinary and oversees the effective implementation and ongoing function of the AMS program. Membership includes:

  • A member of the executive as an executive sponsor, who can enable change
  • Clinicians with technical expertise (for example, an infectious diseases physician, pharmacist, clinical microbiologist or infection control nurse) and other individuals who can provide day-to-day leadership and support implementation.

Check that the AMS committee has endorsement from the organisation’s executive or governing body for formal structural alignment.

Ensure that there are links between the AMS committee and the existing clinical governance framework and quality improvement systems, including having the committee represented on both the drug and therapeutics committee, and the infection prevention and control committee. These links should be clearly articulated (for example, in the organisational chart or terms of reference).

Incorporate AMS within the organisation’s safety and quality improvement systems (see Actions 1.10 and 3.2).

The AMS team is the effector arm of the AMS program. Core membership includes:

  • An infectious diseases physician or clinical microbiologist
  • A nominated clinician (for example, lead doctor)
  • A clinical pharmacist.

In larger health service organisations, the team would be on site; in smaller facilities, the pharmacist position may be part of a broader network or group of health service organisations, or support may be provided using telehealth systems. The responsibility to ensure that the AMS team is adequately resourced should be clearly outlined in organisational policies.

Implement an AMS policy

Write or review, and implement, an AMS policy that:

  • Specifies that prescribers must follow current, evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing, or evidence-based guidelines that have been endorsed by a state or territory AMS committee, and incorporates processes for informing prescribers about prescribing requirements
  • Incorporates the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • Lists restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specifies processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • References the health service organisation’s policy on liaising with the pharmaceutical industry (see Action 4.1)
  • Outlines systems for obtaining specialist advice for complex clinical conditions
  • Incorporates an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflects the AMS program’s integration within the organisation’s safety and quality systems.

Decide on, and document, procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

The strategies below align with those listed in Action 3.16.

Develop an AMS program plan based on the risks, gaps and priorities identified in the initial assessment and gap analysis. Ensure that the plan details:

  • Procedures for prescription review and feedback to prescribers (for example, AMS rounds or pharmacy rounds)
  • Goals, actions, time frames, and measurement and reporting activities
  • Frequency of review and monitoring activities
  • Process and outcome indicators or measures to monitor program effectiveness
  • Roles, responsibilities and time frames for reporting on policy compliance, antimicrobial use and resistance, and prescribing according to guidelines
  • Roles and responsibilities of governance, executive, leaders, managers and clinicians for meeting and evaluating identified priorities
  • Resource allocation (for example, workforce, time, infrastructure) to support planned activities.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the start of their employment and at least annually.

Ensure that prescribing clinicians have access to, and follow, current guidelines and the local antimicrobial formulary for treatment and prophylaxis for common infections relevant to the patient population, the procedures performed and the local antimicrobial resistance profile. Therapeutic Guidelines: Antibiotic is recognised as a national guideline for antimicrobial prescribing in Australia.

Provide clinicians with ready access to the current version of Therapeutic Guidelines: Antibiotic and the local antimicrobial formulary. To promote uptake, make guidelines available in print or online formats.

Ensure that any local clinical and prescribing guidelines are consistent with recommendations in the current version of Therapeutic Guidelines: Antibiotic, and consider local microbial susceptibility patterns.

Review prescribing guidelines at least annually, or as changes are notified.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard into the AMS program

Review relevant clinical pathways to ensure that review of antimicrobial therapy and patient condition is included in the pathway. Set benchmarks for documenting in the patient’s healthcare record the clinical reason; the medicine name, dose, route of administration and intended duration; and the treatment review plan.

Implement or review the process for reporting adverse events, incidents and near misses relating to antimicrobial use, including assessment and management of reported antibiotic–allergy mismatch.

Educate patients and carers about safe and appropriate use of antimicrobials, including potential adverse reactions and what to do in the event of a reaction.

Use process measures to monitor implementation of the AMS program, and to identify opportunities for improvement. Possible measures include Antimicrobial Stewardship Clinical Care Standard indicators1 and indicators to support AMS programs.

For further strategies for improvement refer to Antimicrobial Stewardship in Australian Health Care.

Day Procedure Services

Review the AMS program

An AMS program is a combination of strategies and interventions that work together to optimise antimicrobial use.

All day procedure services that administer or prescribe antimicrobials are required to have an overarching AMS program. Depending on the governance arrangements for safety and quality, this program may be managed by an individual facility, local health network, state or territory, or private hospital ownership group. If the service is part of a broader network or ownership group, work with the governing organisation to identify the resources available to support AMS in the day procedure service and to develop the program.

Review the program to identify what is working well, and gaps and areas for improvement. This includes:

  • Assessing current antimicrobial use, results of prescribing audits, available incident data, current AMS activities and resources to support AMS strategies
  • Mapping current governance structures, systems and processes that currently support AMS, or could be further developed
  • Using the results of this evaluation to identify risks, gaps and priorities for AMS, and to inform the AMS program plan.

Review governance arrangements

To ensure the best chance of program success, incorporate AMS within the service’s quality improvement and patient safety plan.

Governance arrangements for the AMS program may involve coordination by the service’s manager, with support from specialist credentialed medical and other practitioners, and/or a pharmacist, if available.

The committee overseeing AMS requires endorsement from the executive or governing body for formal structural alignment.

Review the AMS committee and team

The committee responsible for AMS oversees the effective implementation and ongoing function of the AMS program. Membership includes:

  • A member of the executive as an executive sponsor, who can enable change
  • Clinicians and other individuals who can provide day-to-day leadership.

The AMS team is the effector arm of the AMS program. Membership may include:

  • The service’s manager, a nurse, credentialed medical and other practitioners, a surgeon, an anaesthetic representative
  • If available, a pharmacist; the pharmacist position may be part of a broader network or group, or contracted service, or accessed using telehealth systems.

Implement an AMS policy

Write or review, and implement, an AMS policy that:

  • Specifies that prescribers must follow current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing, or evidence-based guidelines that have been endorsed by a state or territory AMS committee
  • Incorporates processes for informing prescribers about prescribing requirements
  • Incorporates the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • Lists restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specifies processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • References the health service organisation’s policy on liaising with the pharmaceutical industry (see Action 4.1)
  • Outlines systems for obtaining specialist advice for complex procedures or conditions
  • Incorporates an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflects the AMS program’s integration within the organisation’s safety and quality systems.

Decide on, and document, procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

The strategies below are aligned with those listed in Action 3.16.

Develop an AMS program plan based on the risks, gaps and priorities identified in the initial assessment and gap analysis. Ensure that the plan details:

  • Procedures for prescription review and feedback to prescribers
  • Goals, actions, time frames, and measurement and reporting activities
  • Frequency of review and monitoring activities
  • Process and outcome indicators or measures to monitor program effectiveness
  • Roles, responsibilities and time frames for reporting on policy compliance, antimicrobial use and resistance, and prescribing according to guidelines
  • Roles and responsibilities of governance, executive, leaders, managers and clinicians for meeting and evaluating identified priorities
  • Resource allocation (for example, workforce, time, infrastructure) to support planned activities.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the start of their employment and at least annually.

Ensure access to current guidelines

Ensure that prescribing clinicians have access to, and follow, current guidelines and the local antimicrobial formulary for treatment and prophylaxis for common infections relevant to the patient population, the procedures performed and the local antimicrobial resistance profile. Therapeutic Guidelines: Antibiotic is recognised as a national guideline for antimicrobial prescribing in Australia.

Provide clinicians with ready access to the current version of Therapeutic Guidelines: Antibiotic and the local antimicrobial formulary. To promote uptake, make guidelines available in print or online formats.

Ensure that any local clinical and prescribing guidelines are consistent with the recommendations in the latest version of Therapeutic Guidelines: Antibiotic, and take into account local microbial susceptibility patterns.

Review prescribing guidelines at least annually, or as changes are notified.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Specify restriction rules and approval processes within the formulary, including restriction of broad-spectrum and later-generation antimicrobials to patients in whom their use is clinically justified.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard into the AMS program

Review relevant clinical pathways to ensure that review of antimicrobial therapy and patient condition is included in the pathway. Set benchmarks for documenting in the patient’s healthcare record the clinical reason; the medicine name, dose, route of administration and intended duration; and the treatment review plan.

Implement or review the process for reporting adverse events, incidents and near misses relating to antimicrobial use, including assessment and management of reported antibiotic–allergy mismatch.

Educate patients and carers about safe and appropriate use of antimicrobials, including potential adverse reactions and what to do in the event of a reaction.

Use process measures to monitor implementation of the AMS program, and to identify opportunities for improvement. Possible measures include Antimicrobial Stewardship Clinical Care Standard indicators1 and indicators to support AMS programs.

For further strategies for improvement refer to Antimicrobial Stewardship in Australian Health Care.

Examples of evidence

Select only examples currently in use:

  • Policy documents about the AMS program
  • Examples of how the quality statements from the Antimicrobial Stewardship Clinical Care Standard have been incorporated into the AMS program
  • Membership lists and role descriptions for the AMS committee and team
  • Committee and meeting records in which performance of the AMS program was discussed
  • Communication with the workforce promoting the use of current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing
  • Observation that current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing are available to the workforce
  • Training documents about AMS and attendance records
  • Antimicrobial formulary that includes restrictions and approval procedures that align with current endorsed therapeutic guidelines
  • Audit results of antimicrobial use, especially for high-risk antimicrobials or high-risk clinical areas
  • List of high-risk antimicrobials used in the health service organisation or high-risk clinical areas.

MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established AMS program.

Small hospitals that are not part of a local health network or private hospital group should:

  • Review the current AMS program to identify what is working well; identify gaps, risks and areas for improvement; set priorities; and inform review of the AMS program plan – use the results of this review to set priorities for AMS
  • Identify the key membership of the AMS committee and the AMS team
  • Develop or review an AMS program plan
  • Develop or review an AMS policy that specifies that clinicians should follow current, evidence-based Australian therapeutic guidelines on antimicrobial prescribing, and incorporates the principles of the Antimicrobial Stewardship Clinical Care Standard
  • Develop, review and maintain antimicrobial prescribing policies and a formulary for specific infections to reflect current resistance patterns
  • Create or review an antimicrobial formulary and guidelines for treatment and prophylaxis that align with current, evidence-based Australian therapeutic guidelines
  • Review policies, clinical pathways, point-of-care tools and education programs to ensure that they incorporate the principles of the Antimicrobial Stewardship Clinical Care Standard.

The governance structure of the AMS program should incorporate formal structural alignment to relevant committees and be endorsed by the hospital executive.

The group responsible for AMS is generally multidisciplinary and oversees the effective implementation and ongoing function of the AMS program. Membership will depend on the available workforce and may include those with network or contracted roles. Committee membership includes:

  • A member of the executive or nominated executive sponsor, who can enable change
  • Clinicians with technical expertise (for example, an infectious diseases physician, pharmacist, clinical microbiologist or infection control nurse) and other individuals who can provide day-to-day leadership and support implementation.

The AMS team is the effector arm of the AMS program. Depending on the local circumstances, the team may be at the level of the facility, local health network or private hospital group. It should reflect the local context, including the complexity of services offered. Membership will depend on the local context but should include:

  • A prescribing clinician
  • A clinical pharmacist, if available.

The AMS team needs to receive input from an infectious diseases physician or clinical microbiologist.

Implement an AMS policy

The AMS policy should:

  • Specify that prescribers must follow current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing
  • Incorporate processes for informing prescribers about prescribing requirements
  • Incorporate the quality statements from the Antimicrobial Stewardship Clinical Care Standard
  • List any restricted antimicrobials and procedures for obtaining approval for use of these agents
  • Specify processes for monitoring antimicrobial use, resistance and appropriateness of prescribing, and providing feedback to prescribers
  • Outline systems for obtaining specialist advice for complex clinical conditions
  • Incorporate an audit and evaluation strategy for managing the policy’s effectiveness, including assessment of AMS indicators that are relevant to the organisation, such as those suggested in the Antimicrobial Stewardship Clinical Care Standard
  • Details governance arrangements; communication lines; and roles and responsibilities of facility leaders, the AMS committee and the AMS team
  • Reflect the AMS program’s integration within the organisation’s quality improvement and patient safety governance structure, and the organisation’s safety and quality strategic plan
  • Describe procedures for managing noncompliance with the policy.

Review policies relating to antimicrobial prescribing at least annually, or as changes in evidence or recommended practices are notified.

Plan the AMS program

Develop an AMS program plan based on the risks, gaps and priorities identified in the assessment and gap analysis. The plan should include documented processes for seeking expert specialist advice from infectious diseases physicians and/or clinical microbiologists to support the local AMS team and program implementation. Ensure that the plan includes procedures for prescription review and feedback to prescribers (e.g. AMS rounds or pharmacy rounds), and that the strategies in the plan align with those listed in Actions 3.16.

Ensure that clinicians who prescribe, dispense or administer antimicrobials are educated about the AMS program policy and plan at the beginning of their employment and at least annually.

Ensure access to current guidelines

Ensure that prescribing guidelines are consistent with current evidence-based Australian therapeutic guidelines. Therapeutic Guidelines: Antibiotic is recognised as a national guideline for antimicrobial prescribing in Australia. Provide clinicians with access to guidelines for treatment and prophylaxis for common infections relevant to the patient population, the local antimicrobial resistance profile and the surgical procedures performed. Review prescribing guidelines at least annually, or as changes are notified.

Ensure that evidence-based, endorsed state, territory or national guidelines and clinical pathways are available for management of suspected life-threatening bacterial conditions, including sepsis.

Establish or review clinical pathways for high-risk or high-volume conditions; examples might include Staphylococcus aureus bacteraemia, bone and joint infections, community-acquired pneumonia, catheter-associated and other urinary tract infections, and management of antimicrobial-related allergy.

Ensure that clinical pathways include steps to allow appropriate investigations, routine review of therapy, de-escalation, intravenous-to-oral switch and limiting the duration of therapy. Use state, territory or national guidelines or resources to implement a formal intravenous-to-oral switch program.

Review formulary, approval and restriction

Establish or review an antimicrobial formulary that aligns with recommendations in current evidence-based Australian therapeutic guidelines.

Ensure that the formulary specifies procedures for obtaining approval for use of restricted agents, and that systems are in place to inform prescribers of these procedures.

Implement the Antimicrobial Stewardship Clinical Care Standard locally.1

References

  1. Australian Commission on Safety and Quality in Health Care. Antimicrobial stewardship clinical care standard. Sydney: ACSQHC; 2014.