A Collegiate Approach to: Surgical Stewardship The Surgical Antimicrobial Stewardship Sustainability Initiative (SASSI)

The Therapeutic Guidelines recommend that following adequate source control, antimicrobial therapy can continue for a further duration of 4 to 7 days for intra-abdominal infections, depending on clinical response.¹ Despite these recommendations, the antimicrobial stewardship (AMS) team at Concord Hospital identified that their surgical patients were often prescribed prolonged courses of broad-spectrum antimicrobials. The AMS Clinical Care Standard states that antimicrobial therapy should be regularly reviewed for ongoing need, appropriate antimicrobial spectrum of activity, dose, frequency and route of administration. Benchmarking found antibiotic plans for these surgical patients often missed the key indicators. 

Concord Hospital participates in the National Antimicrobial Prescribing Survey (NAPS) annually. The results from the latest NAPS were used to establish the extent of the issue and inform strategies to address the high volume of inappropriate antimicrobial use in surgical patients.

Evaluation of the prescribing data found only 60% of antimicrobial prescriptions for colorectal patients were appropriate and just 71.4% of these prescriptions were appropriate for vascular patients. Overall appropriateness was below the overall national principal referral hospital average of 72.9%.

The AMS team explored the underlying drivers for the high rate of inappropriate antimicrobial prescribing in surgical specialties. Through discussions, it was found that: 

• Due to the structure of surgical teams, junior ward-based doctors were the point of first contact and lacked authorisation to make substantial changes to antimicrobial choices
• Limited understanding of surgical procedural resulted in antibiotic de-escalation choices being delayed, undocumented antibiotic durations or review dates, and inter-team conflict
• There was a perception among surgical teams that AMS teams under-appreciate surgical complexities, and antimicrobial prescribing recommendations are based on inadequate parameters and understanding of surgical procedures.

The AMS team initiated weekly collaborative meetings attended by a range of staff, including senior surgical staff from the Vascular, Colorectal and Upper Gastrointestinal (GI) Surgery teams. Discussion focused on the surgical context including recent procedures, relevant microbiology, and devising an antibiotic plan.

The meetings were facilitated by electronic prescribing and an innovative locally developed tool called the Cerner LiveAMS Monitoring Page (AMS mPage). The tool provides a live, direct feed from eMeds into a summary dashboard, enabling identification of all patients on antibiotic therapy. It integrates key information, including microbiology results, medication orders (such as indication, duration, prior antibiotic use and known drug allergies). The tool allowed the AMS and surgical teams to make real-time changes to prescriptions directly from the meeting room. 

The project has achieved:

• Improved rates of appropriate antimicrobial prescribing from 68% appropriateness to 85% to 100% appropriate in the last five years (2019 – 2023) for the surgical specialties 
• Improved patient outcomes
• Increased scope of AMS service.

Other outcomes included: 

• Increased rapport between the surgical department and the AMS team – the meetings are championed by the heads of surgical departments
• Greater collaboration with other surgical departments – the initiative has been extended to include Plastic Surgery and the Breast and Endocrine Surgery units.