Implementation of a quality improvement strategy to optimise the management of community acquired pneumonia in a rural health setting

In Australia, inappropriate prescribing of antimicrobials is more prevalent in rural and regional areas compared to major metropolitan hospitals.¹ Audits conducted in a Queensland Rural Hospital and Health Service (HHS) identified the prescribing of antimicrobials for respiratory infections, particularly community-acquired pneumonia (CAP) as a potential area for improvement. Key issues included treatment durations exceeding recommended guidelines and high reliance on broad-spectrum agents. 

The Hospital National Antimicrobial Prescribing Survey (NAPS) data shows that in regional and remote facilities, appropriate prescribing of antibiotics for CAP was 73%¹ and the overall appropriateness rate for Australian hospitals was 75%.² 

The HHS, which included four rural hospitals, did not have on-site infectious diseases physicians, clinical microbiologists or antimicrobial stewardship (AMS) pharmacists. However, the HHS is supported by the Queensland Statewide Antimicrobial Stewardship Program (QSAMSP). 

The hospitals collaborated with QSAMSP and nominated on-site champions to deliver an intervention package to support appropriate prescribing of antimicrobials for CAP. An initial retrospective audit was planned to understand trends and identify areas for improvement. The key evaluation measure was the appropriateness of antimicrobial prescribing for baseline and post-implementation phases of the study. 

A retrospective audit was conducted from July 2019 to July 2020, assessing the appropriateness of antibiotic prescribing for CAP at three time points: initial prescription, on transfer to the ward and on discharge. It was found that the overall cumulative appropriateness of antimicrobial prescribing over the three points of care was 35%. This was significantly lower than both the national average for antimicrobial appropriateness and the reported appropriate prescribing rates in rural and remote areas. The audit results demonstrated substantial variability, requiring urgent action for improvement. 

Following the audit, areas identified for improvement included: 

• Optimising treatment duration of antimicrobials 
• Minimising the inappropriate use of broad-spectrum prescriptions 
• Enhancing consumer engagement.

The project team discussed the challenges in prescribing appropriate antibiotics for CAP. Possible contributors included:

• High clinician turnover in rural and remote settings
• Lack of on-site AMS service 
• Clinicians had varying levels of knowledge about the treatment of CAP. 

An intervention package for the management of CAP was developed following review of literature and collaboration with other facilities which had previously developed strategies to improve prescribing of antibiotics in CAP. Interventions included a CAP pathway, duration of therapy guidelines, patient information leaflet, pneumonia flipchart, general CAP fact sheet and clinical education. There was an on-site training during the implementation phase and continued support from AMS champions at each site. AMS champions included clinical pharmacists and senior physicians involved in resource development and implementation. 

The appropriateness of CAP therapy was assessed monthly, with feedback provided to local clinicians. A post-implementation audit revealed the overall appropriateness of antibiotic prescribing improved to 75%, with a decrease in average duration of antibiotic therapy from 8.7 days to 5.5 days. This was in line with the Australian Therapeutic Guidelines.³ Ongoing monitoring to ensure sustained improvements is being conducted using the NAPS audit tool. 

Read about the full project here: http://doi.org/10.1111/ajr.13116