Open access Quality improvement report BMJ Open Qual: first published as 10.1136/bmjoq-2021-001474 on 3 August 2021. Downloaded from Quality improvement initiative approach to decrease the unindicated usage of antibiotics in a neonatal intensive care unit of a tertiary care teaching hospital in Hyderabad, India Kalyan Chakravarthy Konda , Himabindu Singh, Alimelu Madireddy, Megha Mala Rao Poodari To cite: Konda KC, Singh H, ABSTRACT unit (NICU) of department of neonatology, Madireddy A, et al. Quality Antimicrobial resistance is an emerging global problem Niloufer Hospital. It was found that 61% of improvement initiative approach concerned with patient safety. It is even more challenging to decrease the unindicated neonates were receiving unnecessary or inap- in developing countries like India. Antibiotic stewardship usage of antibiotics in a propriate antibiotics in terms of choice of neonatal intensive care unit initiative is the best arrow in the quiver to prevent and drug, dosage or duration. A quality improve- of a tertiary care teaching control this antimicrobial resistance. We observed 61% of ment (QI) initiative was designed to address the neonates admitted to neonatal intensive care unit of hospital in Hyderabad, this problem and reduce the incidence of India. Niloufer hospital, Hyderabad, India were receiving improper BMJ Open Quality unindicated usage of antibiotics by 50% in the 2021;10:e001474. doi:10.1136/ antibiotics with respect to choice of drug or dosage or bmjoq-2021-001474 duration. Subsequently, an antibiotic stewardship team next 10 weeks among the neonates admitted was formed to address the antibiotic misuse. Team to the inborn NICU. The purpose of this report is to describe how the team handled Received 2 March 2021 consisted of neonatology faculty, residents, staff nurses, copyright. Accepted 29 May 2021 infection control nurses and microbiologist. We identified the challenging issue of unindicated antibi- problems related to staff awareness, policy issues like otic use by adopting a simple and doable QI lack of display of the antibiotic policy and lack of antibiotic initiative. lock, process issues like low rate of documentation of indication for initiation or escalation of antibiotic and a lack of dynamic review plan regarding continuation or BACKGROUND http://bmjopenquality.bmj.com/ de- escalation. We used the Plan- Do- Study- Act cycles Antimicrobial resistance is an emerging global to test and adapt solutions to these problems. Within 10 problem concerned with patient safety. It is weeks of starting our quality improvement (QI) project, even more challenging in developing coun- the proportion of unindicated antibiotic usage decreased tries like India.1 There is a surge in the infec- from 61% to 27%. Timely de- escalation of antibiotic is tions caused by antibiotic resistant bacteria, a neglected intervention in neonates, and yielded the but huge limitation with respect to the pipe- maximum result in our study. We conclude that QI projects line of new classes of antibiotics.2 3 The emer- are simple, doable yet powerful effective tools to address the burning problems like antibiotic misuse. This result gence of antibiotic resistance is related to was very satisfying and encouraging boosting our team’s the exposure to the antimicrobials. A meta- faith in the effectiveness of QI approach. analysis by Costelleco et al showed a good link between the antimicrobial resistance and on September 23, 2021 by guest. Protected prescription of antibiotics in primary care. PROBLEM The likelihood of growing a drug resistant © Author(s) (or their Niloufer hospital is a part of Osmania Medical organism from an individual is associated employer(s)) 2021. Re- use College in Hyderabad. It is an exclusively with the number and duration of antibiotic permitted under CC BY-NC. No women and child tertiary care government courses prescribed in the recent past.4 The commercial re- use. See rights and permissions. Published by hospital. It is the highest referral centre for infections caused by these resistant organ- BMJ. the entire Telangana state. The department isms are associated with higher morbidity and Department of Neonatology, of neonatology here is a large unit catering to mortality, increased hospital duration and 5 Niloufer Hospital, Osmania around 350 neonates (inborn and outborn) healthcare burden. Medical College, Hyderabad, at any given point of time. Therefore, we need a multifaceted approach Telangana, India In November 2019, baseline data were with a dedicated individual commitment to Correspondence to collected to assess the magnitude of unindi- curb the problem of antibiotic resistance. Himabindu Singh; cated prescription of antibiotics, in the Antibiotic stewardship initiative is the best dr. himabindusingh@ gmail. com babies admitted to neonatal intensive care arrow in the quiver to prevent and control Konda KC, et al. BMJ Open Quality 2021;10:e001474. doi:10.1136/bmjoq-2021-001474 1 Open access BMJ Open Qual: first published as 10.1136/bmjoq-2021-001474 on 3 August 2021. Downloaded from antimicrobial resistance. The main goals of antibiotic was supported by infectious disease control team of the stewardship are to enhance efficacy, decrease adverse hospital. The team set an aim of reducing the unindi- effects and unintended consequences of antimicrobial cated usage of antibiotics in the inborn NICU by 50% use and limit the spread of antimicrobial resistance. from a baseline in 10 weeks duration. We then used process flow diagrams and fishbone diagrams (figure 1) to identify factors contributing to problem. These anal- BASELINE MEASUREMENT yses identified a number of challenges that could poten- Unindicated prescription of antibiotics was the outcome tially contribute to antibiotic misuse, including lack of measure and was defined as inappropriate drug choice, awareness among the healthcare professional regarding dosage or duration as per the hospital antibiotic policy. the antibiotic policy of the unit and the importance of The case records of all the babies admitted to inborn antibiotic stewardship, rotation of residents in the unit, NICU unit of Niloufer hospital were reviewed to note the limitation of human- resource, time constraints. The team unindicated antibiotic usage magnitude. Data collection used the Plan- Do- Study- Act (PDSA) cycles to test and was done by a staff nurse and it was verified by a resident adapt possible solutions to these contributing factors. doctor over a period of 4 weeks retrospectively. A total of 200 babies were analysed for obtaining the baseline data. The data captured included, whether the choice of anti- STRATEGY biotic was in accordance with the antibiotic policy of the The following PDSA cycles were executed one after the hospital, was the correct dose prescribed, was the indi- other to implement the desired change ideas. Each PDSA cation for initiation of antibiotic documented, was there was conducted over a 2-week duration. Unindicated any review plan regarding continuation or de- escalation prescription of antibiotics was the outcome measure used of the prescribed medicine. Data were reviewed by the QI and was defined as inappropriate drug choice, dosage team on a weekly basis. or duration as per the hospital antibiotic policy. Various process measures used were proportion of neonates DESIGN receiving antibiotic with a clear indication for initiation In November 2019, team identified that 61% of neonates documented (10 audits/week), proportion of neonates admitted to the inborn NICU received unnecessary or receiving antibiotic with review plan regarding contin- inappropriate antibiotics. Staff in the NICU decided uation or de- escalation of the prescribed medicine (10 copyright. to use the WHO Point-of- Care QI Model to solve this audits/week). problem.6 We formed a team consisting of consultants PDSA cycle 1—The existing antibiotic policy was revised and resident trainees (from neonatology and paediatric based on the last 6 months culture sensitivity data. The departments) and nurses posted in NICU. The team newly framed antibiotic policy was displayed in the unit as was led by the neonatologist in charge of the NICU and a reminder for the healthcare professionals. The soft copy http://bmjopenquality.bmj.com/ on September 23, 2021 by guest. Protected Figure 1 Fish bone analysis to identify contributing factors. 2 Konda KC, et al. BMJ Open Quality 2021;10:e001474. doi:10.1136/bmjoq-2021-001474 Open access BMJ Open Qual: first published as 10.1136/bmjoq-2021-001474 on 3 August 2021. Downloaded from of the policy along with the dose of the drugs was also sent PDSA cycle 4—In order to discourage the unnecessary to phones of all the staff through ‘Whatsapp’ interface, so and improper usage of high end antibiotics, we imple- it would be always available in their pocket for quick and mented a lock model. A resident was allowed to start a immediate review while prescribing the drugs. The ratio- first line antibiotic by himself, but required an approval nale of this intervention is being a teaching hospital with of a faculty to consider a second-line drug and opinion of many residents and rotating faculty, there is a constant two consultants for prescribing a third-line drug. When a need to remind and reinforce the antibiotic policy and third- line drug was prescribed, the hospital microbiologist other protocols for uniformity of practice. This interven- was also informed with a justification for initiation. This tion was adopted and it led to a decrease in proportion of lock model was tested in 26 neonates. As many non-septic unindicated usage of antibiotics by 5%. conditions like Patent ductus arteriosus or apnoea of PDSA cycle 2—We intended to create awareness among prematurity also mimic sepsis in neonates, inexperienced the healthcare professional regarding the importance residents may be deceived and tempted to unnecessarily and the necessity of antibiotic stewardship practice. A escalate antibiotics. Hence, consulting a higher authority total of six meetings were conducted in week duration for escalation of antibiotic was intended to decrease the by our QI team and all the staff were asked to attend antibiotic misuse.