Action 3.18 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 is informed by current evidence-based Australian therapeutic guidelines and resources, and includes restriction rules and approval processes
  4. Incorporates core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard
  5. Acts on the results of antimicrobial use and appropriateness audits to promote continuous quality improvement

Intent

The health service organisation has systems for the safe and appropriate prescribing and use of antimicrobials as part of an antimicrobial stewardship program.

Reflective questions

  • Is there an overarching AMS program (including policies and procedures), which supports the needs of the health service organisation?
  • What systems, processes and structures does the health service organisation have in place to support appropriate prescribing and use of antimicrobials?
  • Is antimicrobial prescribing consistent with the Therapeutic Guidelines: Antibiotic eTG?
  • Is there an infectious disease physician, clinical microbiologist or pharmacist resource available to the health service organisation if required?
  • In what ways is access provided to current endorsed Therapeutic Guidelines: Antibiotic eTG for clinicians who prescribe antibiotics?
  • How do staff access prescribing guidelines?
  • How is compliance with the policy assessed?
  • How is compliance data used to inform quality improvement activities?

Examples of evidence

  • An AMS policy incorporating:
    • governance systems, processes and reporting processes
    • prescribing processes in accordance with therapeutic guidelines
    • list of restricted antimicrobials and approval processes
    • specialist or senior clinical review and referral processes
    • education processes
    • regular policy review processes
    • review and evaluation processes to assess the effectiveness of the AMS program
  • A documented organisational chart that describes AMS responsibilities in the health service organisation
  • Results of risk assessments to identify areas of priority for an effective AMS program
  • Restriction, approval or review systems to guide the use of antimicrobials, where relevant
  • Orientation manuals, education resources and records of attendance at training by prescribers and the clinicians administering antimicrobials on antimicrobial usage, development of resistance, and judicious prescribing
  • Documented AMS improvement or action plan
  • Observation that resources and guides, such as the Therapeutic Guidelines: Antibiotic eTG are available to prescribers and the workforce
  • Relevant documentation from multidisciplinary committees with relevant expertise and other meetings where the AMS program is reviewed, discussed and decisions on actions to improve the AMS program are agreed upon
  • Referral process to infectious disease physician or clinical microbiologist for use of restricted agents, and that systems are in place to inform prescribers of these procedures
  • Access to the Therapeutic Guidelines: Antibiotic eTG is provided for all clinicians authorised to prescribe
  • Locally adapted guidelines that are consistent with current endorsed Therapeutic Guidelines: Antibiotic eTG
  • Results of risk assessments to identify areas of priority for an effective AMS program
  • An antimicrobial formulary that aligns with recommendations in current evidence-based Therapeutic Guidelines: Antibiotic eTG or local guidelines
  • Evidence of incorporating the principles of the Antimicrobial Stewardship Clinical Care Standard into the AMS program
  • Use of audits, process or outcome measures to monitor implementation of the AMS program, and to identify opportunities for improvement

See also: