Antibiotic prescribing and antimicrobial stewardship in primary care
Aims & Objectives
- To improve the quality of antibiotic prescribing and awareness of antimicrobial stewardship amongst clinicians
- For clinicians to develop a strategy to reduce inappropriate prescribing of antibiotics, including a delayed/ back-up prescription, or no prescribing strategy
- To demonstrate local implementation of NICE guidance
- To improve accessibility to educational resources for antibiotic prescribing
- To raise awareness of the wider national and international issues surrounding the misuse of antibiotics
Antibiotic prescribing and antimicrobial prescribing has been a key focus for CCGs and GP practices following the Chief Medical Officer’s 2011 highlighting the dangers of continuing to prescribe antibiotics at current rates, and subsequent publications including the UK Five Year Antimicrobial Resistance Strategy.
Practices in the North East and Cumbria, have some of the highest antibiotic prescribing levels in England and so it was recognised that, in line with all CCGs nationally, a number of interventions, including clinician education, were required to tackle the issue on a regional basis.
An education programme of face to face workshop sessions for clinicians, based around the recommendations in NICE CG69 took place in a number of localities prior to development of the elearning package. The face to face education sessions were generally well attended, but needed to be planned well ahead in order to ensure clinician attendance. As well as potential travel costs, possible locum clinician cover costs, there were also venue costs to consider.
An e-learning package was developed in order to reach a wider audience, and also to allow clinicians to work at their own pace, and explore issues in more detail if needed. Clinicians were encouraged to share their learning from the package with colleagues in clinical meetings to facilitate further discussion.
Across the North East & Cumbria there are over 600 GP practices, and an e-learning package seemed a much more sensible way of engaging and educating across such a large area.
The content of the package was peer reviewed by local secondary trust antimicrobial stewardship teams for accessibility, ease of use and relevance of content. The package has evolved slightly due to the on-line feedback facility. There were many benefits to promoting this particular guideline. Principally not many clinicians were aware of this guideline; it came out in 2008 – almost 8 years ago – but is still hugely relevant. The principles of stratifying patients into easily identifiable groups in order to consider your prescribing strategy proved to be enormously useful to clinicians. Clinicians who completed the package were able to print a certificate of completion.
Initially, the programme was developed as a face to face educational workshop, using a slide set, and “voting cards” to assist with the case studies, i.e. different card colours for the 3 different prescribing strategies (immediate, delayed, or no prescription).
Working with IT colleagues the information from the face to face workshops was translated into an interactive e learning package. This was much more user friendly than purely sharing presentation slides as clinicians can work at their own speed and explore related issues. Our IT department was essential to ensuring the package looked good and was easy to use by building a very intuitive pathway for clinicians to navigate.
The face-to-face education sessions were still available to groups of clinicians or CCGs for group protected learning sessions, and reference was made to the e-learning package for further dissemination.
The elearning was well received by clinicians, though there was some reticence from some clinicians who were possibly not too familiar with the concept of computer based training. Some CCGs used focused on antibiotic stewardship as part of their GP engagement schemes and encouraged clinicians to complete the e learning. Some practices completed the e learning in a practice clinical session.
No costs were incurred in the development of the e learning package as it was all completed in-house by NECS.
Results and evaluation
The greatest improvement of putting this clinical guideline into practice in the form of an e-learning package was that we could reach far more clinicians than face to face education sessions. The knock on effect is productivity savings in terms of clinician time and travel costs. The material got clinicians talking to each other in practice in terms of how they currently manage patients attending with respiratory tract infections.
The material also re-ignited debates around delayed antibiotic strategies, and no-antibiotic strategies, and led to the promotion of a “non-antibiotic” prescription, or self-care leaflet for use in practice. The package was developed in conjunction with our IT department and we are able to monitor use of the e learning amongst clinicians.
To date the e learning has been completed by over 570 primary care clinicians over the North East & Cumbria and has coincided with a reduction in total antibiotic prescribing and level of broad spectrum antibiotic prescribing in line with national Quality Premium targets.
All CCGs across the North East & Cumbria are currently meeting their NHS England antibiotic “3c” QP target, and all but two CCGs are currently showing a decrease in their total volume antibiotic QP target indicator.
Key learning points
The challenge of promoting prudent antibiotic prescribing and stewardship in primary care is one all CCGs should be engaged in and promoting.
Educating clinicians and offering resources and opportunities in order to assist clinicians is key to starting to bring about change in antibiotic prescribing. Getting clinicians to talk about antibiotic prescribing and challenge each other is vital.
Promotion of the strategies in the NICE clinical guideline 69 is essential to get clinicians thinking differently about antibiotic prescribing.
This case study is also featured on the NICE website which can be viewed by clicking here.