IV to Oral Review Switch

1
IV to Oral Review / Switch

• Debbie Cumming - Isle of Wight

2
Isle of Wight NHS Primary Care TrustIV to Oral
Review / Switch

• 140,000 population
• 2.6m visitors annually
• 3,000 staff
• Budget 220m
• Dinosaurs .. and
• The Needles!!

3
IV to Oral Review Why bother?

• As a general rule IV antimicrobials should only
  be prescribed for two days, after which the
  prescription should be reviewed and, if
  appropriate the patient switched to an oral
  equivalent.
• Antimicrobials should generally be prescribed
  for a maximum of seven days
• Saving Lives Reducing Infection, Delivering
  Clean and Safe Care D of H June 07

4
IV to Oral Review Why Bother?

• Hospital acquired bacteraemia (HAB) USA 8th
  leading cause of death (Wenzel EID 01)
• 2/3 of bacteraemias (of known source) were
  associated with intravascular device or with
  device related infection
• Line related bacteraemia (11-25K per case)
• Clostridium difficile (DGH each case 4K, 21 bed
  days)
• Prolonged stay
• Further increases in chance of HCAI
• Blocking beds / isolation facilities
• HCAI - death . 7.1 times more likely to die.

Dr Alison Holmes MSc in Infection Management
Imperial College London
5
IV to Oral Review Why Bother?

• Why stick with the iv route ? or. Perceived
  risks of oral
• Drs caution, Drs clinical experience,
• Drs dont want to be told off, treatment
  failure, peer pressure,
• Drs want to wait for ward round

• What are some the risks of iv?
• Infection, resistance,
• Non administration, delay in administration
  Dodgey venflon
• Risk of phlebitis
• Checking preparation not enough trained manpower
• Cost
• Patient discomfort and reduced mobility
• Delay to discharge (eg. pneumonia literature)

• Professor Bryony Dean Franklin MSc in Infection
  Management - Imperial College London

6
When to switch?

• gt24 or 48 hours iv
• Temp lt 380C and downward trend
• WCC, CRP returning to normal
• No unexplained tachycardia
• Not NBM
• No disease likely to affect absorption form GI
  tract
• No vomiting or diarrhoea
• Consider CURP65 score for assessing severity
• Patient does not have for example septicaemia,
  meningitis, necrotising fasciitis, endocarditis,
  osteomyelitis, septic arthritis, staph
  bacteraemia, CF, empyema,
• (Or some cellulitis and some diabetic foot
  ulcers)
• . And oral preparation available!
• UKCPA website numerous hospitals iv to oral
  switch policies

7
How to encourage switch or review?

• Then
• .Part time Project Pharmacist for Antibiotics
• Now
• HCAI money for WTE Antimicrobial Technician and
  extra hours for Antimicrobial Pharmacist
• What did we do?To change culture

8
IV to Oral Review /SwitchRaising the Profile of
Antibiotics

• New Antibiotic Policy - post D of H visit
• Antibiotic Prescribing Stop / Review Date and
  Indication Policy
• (Oxford, Nottingham and St Georges Hospital)
• 3. Extended our Intervention Note practice to
  focus on Antibiotics
• (NPSA)
• Swamped the wards. Time on the wards .. Not in
  an Office
• (CMM ward roundsstill trying!)

9
What is the Problem?Raise the Profile.
On iv antibiotic
Patient getting better .
Patient with infection
Drs to review??? Drs to switch???
.but when?
10
IV to Oral Review (1)
On iv antibiotics
Patient with infection
Patient switched to oral, (? Getting better ???)
1. DRUG CHART Indication, stop /review date as
per Trust Policy
11
IV to Oral Review (2)
12
IV to Oral Review (3)
On iv antibiotics
Patient with infection
Patient switched to oral, (? Getting better ???)
2. DISPENSARY PHARMACIST/ TECHNICIAN Writes
intervention sheets for iv abs Refers restricted
abs to AM pharmacist or CMM
1. DRUG CHART Indication, stop /review date as
per Trust Policy
13
IV to Oral Review (4)
14
Intervention Scheme
15
IV to Oral Review (5)
On iv antibiotics
Patient with infection
Patient switched to oral, (? Getting better ???)
3. ANTIMICROBIAL TECHNICIAN Talks to NURSES re
ward handover and iv abs Reviews drug charts,
using interventions as necessary Collects and
inputs data for database
2. DISPENSARY PHARMACIST/ TECHNICIAN Writes
intervention sheets for iv abs Refers restricted
abs to AM pharmacist or CMM 1. DRUG CHART
Indication, stop /review date as per Trust Policy
16
Database Setup (1)
Antimicrobial Technician collects this data.
17
IV to Oral Review (6)
4. WARD PHARMACISTS / TECHNICIANS Refer iv abs to
AM tech Write interventions Reinforce indication
stop review policy Refer queries to AM
pharmacist (Ward rounds DOCTORS now on base
wards so communication better/easier)
Patient switched to oral, (? Getting better ???)
Patient with infection
On iv antibiotics
3. ANTIMICROBIAL TECHNICIAN Talks to NURSES re
ward handover and iv abs Reviews drug charts,
using interventions as necessary Collects and
inputs data for database 2. DISPENSARY
PHARMACIST/ TECHNICIAN Writes intervention sheets
for iv abs Refers restricted abs to AM pharmacist
or CMM 1. DRUG CHART Indication, stop /review
date as per Trust Policy
18
IV to Oral Review (7)
5. ANTIMICROBIAL PHARMACIST Twice weekly print
out of iv ab database Review patients and decide
if appropriate for gt48 hours, gt72 hours or
ongoing Ensure indication and review
documented Collect data for database When
necessary communicate withDrs, Nurses, CMM Long
term antibiotics Separate database so TDM, CRP
etc can be documented Restricted antibiotics
reviewed weekly with CMM
On iv antibiotics
Patient switched to oral, (? Getting better ???)
Patient with infection
3. ANTIMICROBIAL TECHNICIAN Talks to NURSES re
ward handover and iv abs Reviews drug charts,
using interventions as necessary Collects and
inputs data for database 2. DISPENSARY
PHARMACIST/ TECHNICIAN Writes intervention sheets
for iv abs Refers restricted abs to AM pharmacist
or CMM 1. DRUG CHART Indication, stop /review
date as per Trust Policy
4. WARD PHARMACISTS / TECHNICIANS Refer iv abs to
AM tech Write interventions Reinforce indication
stop review policy Refer queries to AM
pharmacist (Ward rounds, DOCTORS on base wards so
communication better/easier)
19
Database Set Up (2)
D drug chart F found

C complete NR not reviewed
Antibiotic 3 letter code
Reviewed by 48 or 72 hours Y appropriate N not
appropriate
Consultant
20
IV to Oral Review (8)
DOCTOR Review within 48 / 72 hours
On iv antibiotics
Patient switched to oral, (? Getting better ???)
Patient with infection
4. WARD PHARMACISTS / TECHNICIANS Refer iv abs to
AM tech Write interventions Reinforce indication
stop review policy Refer queries to AM
pharmacist (Ward rounds, DOCTORS on base wards so
communication better/easier)
5. ANTIMICROBIAL PHARAMCIST Twice weekly print
out of iv ab database Review patients and decide
if appropriate for gt48 hours, gt72 hours or
ongoing Ensure indication and review
documented Collect data for database When
necessary communicate with DOCTORS, NURSES,
CMM Long term antibiotics Separate database so
TDM, CRP etc can be documented Restricted
antibiotics reviewed weekly with CMM
3. ANTIMICROBIAL TECHNICIAN Talks to NURSES re
ward handover and iv abs Reviews drug charts,
using interventions as necessary Collects and
inputs data for database
2. DISPENSARY PHARMACIST/ TECHNICIAN Writes
intervention sheets for iv abs Refers restricted
abs to AM pharmacist or CMM
1. DRUG CHART Indication, stop /review date as
per Trust Policy
21
IV to Oral Review

• Audits
• Need to be useful, carried out in timely manner
  by junior doctors
• Need to be fed back to Clinical Directorates to
  promote discussion and future practice
  development
• Junior doctors need support to deliver audits
• Next programme starting with August intake
• Monthly reports to Clinical Directorates to
  include
• Intervention analysis
• IV to oral lt48h, lt72 hours, gt72 hours or
  inappropriate
• indications found on drug chart
• DDDs for total, iv and oral antibiotics and
  specific antibiotics

22
DDDs
23
What have we achieved?

• System needs to be sustainable and therefore
  easily run at ward level
• With involvement from all the multi-disciplinary
  team
• Nearly achieved an improved iv to oral review
  system that
• Supports the junior doctors and ward teams with
  clinical input from the pharmacy team
• Reports back to Clinical Directorates
• Improves patient care
• In 6 months time
• Find out if the system is sustainable if junior
  docs feel supportedif the audits have delivered
  improved clinical engagement
• and if reports to Clinical Directorates have
  delivered..
• IMPROVED ANTIBIOTIC STEWARDSHIP.

24
At the very least.
St. Marys knows that there is ..an
Antimicrobial Pharmacist and Technician!!!