He could not shake off the troubling thoughts from his mind. Yet another recovering patient had succumbed to an infection to which no antibiotic had control over. 'He was almost cured and his family had been so relieved!' his thoughts screamed back at him. Being the administrator of a reputed multispeciality hospital, he felt he had to do whatever it takes to tackle the emerging resistance of infection-causing microbes in the hospital to even the last resort antibiotics. Antimicrobial resistance was slowly but surely becoming a deadly reality worldwide.Well, I won’t let this go on in my hospital!' he resolved. He understood that fighting antimicrobial resistance was not easy and required an interdisciplinary team from varied health professionals to use their expertise to combat the issue from every angle. Bacteria’s are getting smarter; the solution needs to be smartest for combat.And so the antimicrobial stewardship programme (ASP) was formulated with the passionate team of the intensivist, physicians, pediatricians, microbiologist, and clinical pharmacists. Post prescriptive audit of all prescriptions with reserved antimicrobials was conducted during daily ASP meetings to ensure patients received the right antibiotic for the right indication at the right dose,frequency and duration.The ASP team gradually increased in size with an intention to reduce the size of hospital bacterias.
Soon we realized that ego is a bad word but clinical ego is worse. Who can tell the prescribing doctor to be appropriate? But the team got some teeth and did that. Appropriate use was applauded with positive feedback and engagement was initiated with inappropriate use. Sweetly worded recommendation was filed in the patient’s file and were discussed with the providers too. However,the team realized that working with bacterias is better. Many “God’s gift to mankind” would ask ‘On what basis can you recommend changes in our treatment?”. The team, worked hard with passion and grace and persevered to become change agents. Intent was not to do harm with over and under prescription. Strategies changed and many mid-course corrections were brought in viz new and simple forms, stand up huddle meetings, team meetings, post it recommendations and bed side rounding with treating clinicians. Reviewof practices and consistency in follow up helped. Outcome sharing brought a concept of data driven decision making for best outcomes. Compliance of seniors improved and they became role models. They soon started monitoring the junior colleagues thus bringing ripple effect. Impact of “Hit hard and Hit fast” for targeted therapy brought in huge dividends. Adherence to good prescription practices improved, patients stay was reduced, mortality became better, harm because of inappropriate antibiotics reduced. Attributable mortality on Antimicrobial Resistance improved, with morbidity and patient experience improved. High bills are huge “No No” and this judicious practice lead to cost benefit of 1.2 CR (INR).
Success was shared and very soon other healthcare institutions started following this quality improvement initiative. The State government's also adopted the state action plan for fighting AMR which would definitely lead to improved practices and good outcomes.
'The bugs are in for a tough battle' he chuckled while he sat down for yet another fruitful meeting with his purpose driven ASP team.
The success of the ASP program did not come overnight. It was through constant and untiring efforts from the team.
Lessons Learned
- Team work is key in success of any intervention.
- Effective interdepartmental communication is essential for sharing expertise on the best treatment options for patients
- Continuous surveillance is essential and that PDSA tool for Continuous Quality Improvement helps improving the process.
- Data driven decision making should lead to change culture and adopt good, evidence based practices