Antibiotic Audit Workbook
Please complete this workbook and return to
Antibiotic Audit Workbook Contents
1. Observe practice. 52. Set standards. 63. Collect information. 8
This workbook is a practical guide to carrying out an antibiotic audit in Primary Care. It is based upon suggested guidelines produced by Camden & Islington HealthAuthority and SMAC (Standing Medical Advisory Committee). Why Audit Antibiotic Use?
There has been considerable concern raised recently over problems with antibioticresistance. This includes the House of Lords Select Committee on Science andTechnology report – “Resistance to Antibiotics and other Antimicrobial agents” and theSMAC report – “The Path of Least Resistance”
♦ Inappropriate prescribing for coughs, colds and viral sore throats
♦ Wide variations in prescribing practice
Points to note are that- 80% of antibiotic prescribing occurs in the community- antibiotic resistance has been shown to correlate with use of antibiotics by a GP
- multiresistant pneumococci & mycobacterium tuberculosis are particular
HSC 1999/049 sets out action for the NHS. It states that Primary Care Groups shouldØ reduce inappropriate antimicrobial prescribing
Ø include projects concerned with infection control and control of antimicrobial
resistance in their clinical audit and continuing professional developmentprogrammes
Ø put infection control and basic hygiene at the heart of good management and
How to use the workbook Section One of the workbook, ‘About audit,’ outlines the steps involved in carrying out any audit, and the purpose of each of these steps. Section Two, ‘Antibiotic audit,’ then takes you through how these steps can be applied to perform an audit of systems and procedures for antibiotic prescribing in your practice. Section 1 - About audit What is audit?
Everything that we do in general practice is geared towards providing a high standardof care for patients. Audit is just one method of improving care, and it involvesfollowing the ‘audit cycle.’ The audit cycle gives a framework for carrying out an auditand making sure that any changes you make to your practice are directed towardsthose areas that need to be changed. The Audit Cycle 1. Observe practice ‘What could we improve in our practice?’
This is important to ensure that the topic for audit is appropriate, and that the staffinvolved in the audit are aware of the objectives of the audit. 2. Set standards
Setting standards involves agreement within the practice about what you feel is asatisfactory level of care for the patients in your practice, and a definition of the targetpopulation. 3. Collect information
The information collected should relate to your audit standards, and should only becollected for patients in the target population. This will allow you to get an accuratepicture of what is happening in your practice. 4. Compare results with standards ‘What is the difference between what we are doing and what we should be doing?’
Comparison of what you are doing (your results) with what you feel you could be doing(your standards) allows you to direct changes that you make to your practiceappropriately. 5. Make changes ‘How can we make what we are doing the same as what weshould be doing?’
This should again involve full discussion with all members of the practice team whoare involved, about how you can improve your practice so that you meet yourstandards. 6. Re-audit
The audit process is represented as a cycle, because ideally it should not be a one- off data collection exercise, but rather an on-going commitment to a high standard of care. As such, it is better to regularly (say every year) collect data to see if you are meeting your standards and make appropriate changes. This can become much easier when the data that relate to your standards are recorded on computer. Section 2 – Antibiotic Audits 1. Observe practice ‘What could we improve in our practice?’
Before carrying out an audit of antibiotic prescribing, it is important that you confirmthat this is a suitable topic for audit in your practice.
Who is involved in antibiotic prescribing at your practice?
Who is involved in this audit of antibiotic prescribing at your practice?
Have you discussed this audit with all of these people?
Are you all concerned about appropriate antibiotic prescribing is as an important areaof practice?
2. Set standards
It is useful to make your standards achievable, realistic short-term targets for adefined group of patients.
Standards are usually expressed as a simple statement, e.g. 90% of female patientsprescribed an antibiotic for an uncomplicated UTI have prescriptions for 3 days.
Standards that you set for your practice relating to antibiotic prescribing should bebased on research evidence, national or local guidance. It is also appropriate to adaptmore general guidance to suit your local situation.
The overall aim of the audit should be to evaluate current practice use of antibioticsfor concordance with prescribing recommendations.
All that remains for you to do is to select some of the standards for which you would like to make a practice target. You may find it useful at this stage to involve your PCG prescribing advisor. NB.Band B of the 2000/01 Prescribing Incentive Scheme includes this audit. It is a clinical governance priority.
What are your target standards for the audit?
You should choose an area to audit . Some areas have been suggested below – but the practice can also develop it’s own antibiotic audit in conjunction with Janet Cree, Prescribing Adviser and/or Louise Worswick at MAAG. At least two standards should be set for your practice. Examples include: Antibiotics in uncomplicated UTIs (female patients)
♦ % of (otherwise well) female patients prescribed 3/7 course of antibiotics for
♦ % of patients (as above) prescribed empirical trimethoprim
Co-amoxiclav (Augmentin) prescribing
♦ % of patients prescribed co-amoxiclav within the suggested C&I Management of
Infections in Primary Care guidelines (see appendix)
♦ % of patients prescribed clarithromycin within the suggested C&I Management of
Infections in Primary Care guidelines or H.Pylori eradication (see appendix)
♦ % of patients prescribed ciprofloxacin within the suggested C&I Management of
Infections in Primary Care guidelines (see appendix)
Minocycline prescribing in acne
♦ % of patients prescribed minocycline first line for acne
♦ % patients who have previously been prescribed another tetracycline prior to
♦ % patients who have previously been prescribed another antibiotic (inc
Now go to stage 3, ‘Collect information.’
3. Collect information
Data collected as part of an audit project should include only information that relatesto the audit standards, or information that will be relevant when analysing the data tofind how best the standards can be met.
Once standards have been agreed, the practice team must devise a suitable meansfor collecting data. An example data collection form has been included in this packand the Camden & Islington prescribing advisors or the MAAG are also happy toadvise on this issue.
The length of time over which the audit is to be carried out must be agreed. The timeperiod selected should be manageable and reflective of the amount of work involved:
Then, go to stage 4, ‘Compare results with standards.’
4. Compare results with standards ‘What is the difference between what we are doing and what we should be doing?’
Review of the results should take place in your practice to see whether you aremeeting your standards. This process should involve all the members of the practiceteam involved in the audit, so that everyone is aware of where shortfalls may beoccurring.
It is useful to go back to your standards, and write them down next to the results tomake direct comparison easier:
% of (otherwise well) female patients prescribed 3/7 course of antibiotics foruncomplicated UTIYour result %
% of patients (as above) prescribed empirical trimethoprimYour result %
% prescribed genericallyYour result %
% of patients prescribed co-amoxiclav within the suggested C&I Managementof Infections in Primary Care guidelines (see appendix)% of patients prescribed ciprofloxacin within the suggested C&I Managementof Infections in Primary Care guidelines (see appendix)Your result %
% of patients prescribed clarithromycin within the suggested C&I Managementof Infections in Primary Care guidelines or H.Pylori eradication (see appendix)Your result %
% of patients prescribed minocycline first line for acneYour result %
% patients who have previously been prescribed another tetracycline prior tominocyclineYour result %
% patients who have previously been prescribed another antibiotic (inctetracyclines) prior to minocyclineYour result %
5. Make changes ‘How can we make what we are doing the same as what weshould be doing?’
Comparison of results with standards should have given you an idea of where youmay need to improve your practice. It is now the time to discuss what changes arepossible to make your practice meet your ideal standards.
It is possible that no changes are needed and that you are meeting all of yourstandards. More likely, you may want to consider some of the following as ways ofimproving your practice:
♦ Arrange a meeting to discuss your results with your PCG prescribing advisor
♦ Ensuring that advice given to patients is always documented on computer/in the
♦ Providing a patient information leaflet to support the advice you give.
♦ Holding a team meeting to present the audit results.
♦ Developing practice guidelines for antibiotic prescribing.
♦ Any other way that seems appropriate in the light of your results.
The changes made can be as small or as large as you feel appropriate. It may behelpful to have a timetable for change, with target objectives set within an agreedtimescale. It is also important that all members of the practice team agree toproposed action before any changes are implemented.
Please write the changes that you intend to make to your practice here:
The audit process should not be seen as a one-off exercise. It is much more usefulif you now try to ensure that the patients who are prescribed antibiotics in your practicecontinue to receive the most appropriate management of their conditioncorresponding with their presenting symptoms. That is why we refer to the audit cycle.
You should leave sufficient time between implementing your changes and your re-audit for the changes to take effect - one year may be appropriate.
Now go to Stage 1, ‘Observe practice’
Do you need help?
If you need any help or advice at all on using this workbook or performing youraudit, please contact the Janet Cree (020 7853 5578) or the MAAG office (020 72883094).
Granting Defendant’s Motion for Summary I. MOTION PRESENTED Defendant Frontier Community Services, Inc. (“FCS”) has moved for summary judgment onPlaintiff Susan Schwager’s claim that FCS interfered with her rights under the Family and MedicalLeave Act (“FMLA”), 29 U.S.C. §§ 2601-2653, by terminating her employment with FCS the dayafter she returned from FMLA-covered leave. The