Name
Date of Completion
of Audit / 31/05/13
Peer review
feedback available / Yes No
Completion of sections 1 – 5 would indicate a ’5 criterion audit’.
A completed audit cycle would be indicated if sections 1 – 8 had been attempted.
Gentamicin is a commonly used antimicrobial agent however prolonged administration has been shown to cause ototoxicity and nephrotoxicity in patients. In XX, a gentamicin prescribing chart was introduced in August 2012 to prompt prescribers to monitor gentamicin levels and review the need for gentamicin on a daily basis. The chart also prompts prescribers to seek advice from microbiology or infectious disease specialists if the prescription for gentamicin is to continue for longer than 4 days.
As gentamicin related ototoxicity is related to total exposure, repeated prescriptions for gentamicin should be avoided. Currently there is no way of quickly identifying whether or not a patient has been prescribed repeated courses of gentamicin.
This audit looked to examine the prescribing patterns seen on the general surgical wards to clarify whether or not the new prescribing charts have had a positive impact on the duration of gentamicin therapy patients receive. The audit collected data regarding which antibiotics patients were switched to post gentamicin therapy and also which healthcare professional was responsible for stopping gentamicin.
This audit also examined whether or not patients were prescribed repeated courses of gentamicin.
Feedback
A new prescription chart for gentamycin has been introduced and this audit aims to review if the implemtnation has improved the safety around gentamycin prescribing
1. Reason for the AuditExplain why the audit topic was chosen and that as a result of this choice there is the potential for change to be introduced which is relevant to the practice or you as an individual practitioner.
2. Audit Criteria to be MeasuredCriteria are simple, logical statements used to describe a definable and measurable an item of health care eg. Patients with type II diabetes should have a fundoscopy every 12-months. See Audit Guidance for examples of criteria if greater understanding is required. Focusing on one or two criteria makes data collection more manageable and the introduction of small changes to practice less challenging. Where available, evidence should be cited in support of criteria eg. nGMS contract or a clinical guideline. A single criterion is acceptable for Appraisal purposes.
Establish if patients are receiving appropriate duration of gentamicin
Determine which antibiotics patients are switched to post gentamicin therapy
Establish reasons for stopping gentamicin
Establish if patients are receiving repeated courses of gentamicin
Feedback
The criteria chosen are mainly good. I was unclear the importance of establishing which antibiotics patients were switched to? (other than for information) and the information collected on why the gentamycin was stopped was who stopped the gentamycin therapy.
3. Standards SetAll patients (100%) should receive no more than 4 days gentamicin therapy.
Exceptions: On advice of microbiology or an infectious disease specialist.
Feedback
The author had a good undertanding of the standard set. Often setting a standard on 100% is difficult to achieve in clinical practise, however desirable.
I wondered if there was any guidance on repeated exposure to gentamycin and risk and is there a standard of how many times the antibiotic course can be repeated???
An audit standard describes the level of care to be achieved for any particular criterion eg.90% of Patients with type II diabetes should have a fundoscopy every 12-months. Standard levels may be influenced by the target levels contained in the nGMS contract or by discussing and agreeing the desired or ideal level of care with colleagues. State how long you estimate it will take you to reach your chosen standard(s) eg. 3 months.
4. Preparation and PlanningThe need for this audit was identified by the antimicrobial pharmacist on site who wanted to measure the impact of the new prescribing charts. A clinical effectiveness pharmacist was also involved in the audit and acted as a mentor to myself. The surgeons, nursing staff and surgical pharmacists were all informed of the audit and when it would take place.
The audit was to be carried out on the general surgical wards at XX (excluding HDU and ITU). The surgical wards were identified as an area of concern as the new gentamicin prescribing advice is not always adhered to and the surgeons seem less concerned than the medical consultants regarding gentamicin prescribing.
A data collection form was designed and reviewed by the antimicrobial pharmacist and one of the surgeons, the surgeon suggested that we also collect data regarding whether or not patients receive repeated courses of gentamicin therapy.
The data collection form was piloted, no changes were made. The data was then collected over a four week period. All patients prescribed gentamicin (with the exception of those prescribed only one dose for a catheter change or for prophylaxis prior to theatre) were included in the audit.
Feedback
There was good evidence of teamwork and all parties involved in the audit were involved. An pilot audit was conducted which is a useful way of ensuring data collection forms and processes are fit for purpose before actual data collection
Explain briefly who was involved in discussing and planning the audit, how the data were identified, collected, analysed, and disseminated and who gave you assistance at any stage of the project, eg. with a literature review or with collecting or analysing data if this was required.Teamwork is essential to audit and evidence of this should be provided in the report.
5. Data Collection 1A total of 33 patients were identified for inclusion in the audit. Only one of these 33 patients received gentamicin for greater than four days. There did not appear to be a well documented reason for this and it was not discussed with microbiology or infectious diseases.
Figure 1. The total number of days therapy with gentamicin is shown. Only 1 patient exceeded the recommended 4 day course.
Figure 2. The reason why gentamicin therapy was stopped is shown above. The consultants were mainly responsible for stopping gentamicin therapy. It was surprising to find that pharmacist intervention was only responsible for gentamicin being stopped in one patient.
Feedback
The presentation of the results is clear and easy to compare with the criteria and standards set
Initial data collected should be presented using simple descriptive statistics as part of the text, in table format or using graphs (bar charts, pie charts etc.) Remember to quote actual numbers (n) as well as the percentage (%). There is no need to quote irrelevant data (eg. age, gender, or past medical history) if it bears no relation to your chosen audit criteria. Compare and contrast your initial data with the standard(s) you set.
6. Reason for the AuditAlthough the results of this audit did not meet the standard set, it was decided that no intervention was needed. Only one patient exceeded the recommended duration of gentamicin therapy, and although there was no clear reason identified for this it was decided that this was an acceptable result.
Feedback
This is a very good audit evaluating the implimentation of a new process to facilitate improving prescribing of a high risk medicine.
The essence of audit is to change practice in order to improve patient care and services. This section should adequately describe any change(s) that was discussed, agreed and introduced by you. The role of others in this process should also be described. An example of the change introduced should be attached in evidence as an appendix to the report, where this is possible eg. a new or amended protocol or flow chart, or a letter that is sent to a group of patients inviting them in for a review.
7. DATA COLLECTION 2No second data collection was carried out for this audit.
Presentation of data should be as Data One. In this section, compare and contrast the results of the second data collection with data collection one and the standard(s) you originally set. Has your standard been met or surpassed? If not, comment on why you think that is the case.
8. ConclusionsThe results of this audit show that the implementation of the gentamicin prescription chart has led to improved gentamicin prescribing practices within general surgical wards at XX. Although the initial audit standard was not met, 97% compliance was deemed an acceptable result.
There were several limitations to the audit including:
Small sample size
Limited time to carry out data collection
Patients missed over weekend
Patients previous gentamicin courses difficult to identify
Indications/reasons for switching antibiotics not always well documented
In future, we hope to carry out this audit on medical wards and possibly in HDU/ITU settings as these areas were excluded for the purposes of this audit.
Further work is required to design a tool to identify patients who have been prescribed repeat courses of gentamicin as the total exposure to gentamicin is related to side effects such as ototoxicity.
The final section should briefly and simply summarise what the audit achieved, and what were the main learning points gained from this exercise. In doing this, the benefits achieved through the audit should be discussed along with any problems encountered with the process or findings. Some thought should also be given as to whether the audit will be repeated in future and if so when.