title: Design of antimicrobial stewardship care bundles on the high dependency unit.
abstract: BACKGROUND
  Antimicrobial guidelines aim to optimise treatment and minimise development of resistance. Care bundles support the implementation of local guidelines.
  
  
  OBJECTIVE
  Pharmacist identification of where in the prescribing, monitoring and documentation process, the quality of antimicrobial management in a High Dependency Unit of a large teaching hospital could be improved and design of antimicrobial care bundles for initiation and de-escalation of therapy to standardise care and improve practice.
  
  
  METHODS
  This study was conducted in a 10-bed, mixed medical-surgical HDU in a large Scottish (UK) teaching hospital.
  
  
  METHODS
  Quality indicators (n = 30) were agreed through multidisciplinary team review with reference to the evidence base, national strategy and local policy. Adherence to these quality indicators was measured before and after the pharmacist's contributions. Areas of non-adherence to quality indicators were used to design the care bundles.
  
  
  METHODS
  Adherence to the quality indicators before and after the pharmacist's action. Categorisation of pharmaceutical care issues ('check', 'change in drug therapy' and 'change in drug therapy process') were quantified.
  
  
  RESULTS
  From 134 prescriptions, the pharmacist undertook 1,447 actions to ensure adherence to the 30 indicators. Adherence was very good (85.3 % CI 83.5, 87.1), but would have been unsatisfactory (53.5 % CI 50.9, 56.1) without the pharmacist's action (p < 0.001). Change in drug therapy process or change in drug therapy initiated by the pharmacist accounted for 31.9 % (CI 29.5, 34.3) of adherence. Non-adherence was related to documentation of past allergic reactions, bacteriological specimen results, indication and length of course of treatment (both at initiation and de-escalation). Care bundles were designed to target areas of non-adherence to local guidelines.
  
  
  CONCLUSIONS
  The pharmacist made a significant contribution to improving adherence to evidence based antimicrobial prescribing quality indicators agreed by the multidisciplinary team. Prompts have been identified from the pharmaceutical care process and applied in the design of two antimicrobial care bundles proposed to support adherence with antimicrobial prescribing policies and guidelines.
authors.affiliation: NHS Lothian Pharmacy Service, Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, Scotland, UK. alison.coll@luht.scot.nhs.uk
authors.forename: Alison
authors.initials: A
authors.lastname: Coll
authors.forename: Moira
authors.initials: M
authors.lastname: Kinnear
authors.forename: Anne
authors.initials: A
authors.lastname: Kinnear
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D002983:Clinical Competence; D016303:Clinical Pharmacy Information Systems; D003428:Cross Infection / Q000517:prevention & control*; D011307:Drug Prescriptions; D004363:Drug Utilization; D017723:Drug Utilization Review; D005260:Female; D019983:Guideline Adherence; D006742:Hospital Bed Capacity; D006784:Hospitals, Teaching; D006801:Humans; D017053:Infection Control / Q000379:methods* / Q000592:standards; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000592:standards; D010348:Patient Care Team; D010595:Pharmacists / Q000592:standards; D010607:Pharmacy Service, Hospital / Q000592:standards; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D024382:Professional Role; D016730:Program Development; D015397:Program Evaluation; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000592:standards; D019984:Quality Indicators, Health Care / Q000592:standards; D012606:Scotland; D055815:Young Adult
chemical_list: D000890:Anti-Infective Agents