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Background:Prolonged or inappropriate antibiotic therapy increases the risk of health-care-associated infections and the development of resistance to antibiotics, and lengthens hospital admissions. There are clear guidelines on antimicrobial stewardship which state that antibiotics should be reviewed between 48 and 72 hours from commencement (National Institute of Health and Care Excellence, 2015). Despite these guidelines this review was often not documented as having been carried out on the authors' inpatient wards.Methods:A quality improvement project was undertaken with the aim of improving the percentage completion of the 48-hour antimicrobial review box section of the inpatient drug charts to over 90% across two 30-bed acute respiratory wards within 7 weeks. The primary outcome measures were percentage completion of 48-hour antibiotic review and number of days on intravenous antibiotics. The quality improvement programme took place over 7 weeks and included seven interventions designed to improve completion of the 48-hour review.Results:During the study, the percentage completion of 48-hour review rose from a baseline median of 68% to 100% and was accompanied by a reduction in the number of days on intravenous antibiotics from a baseline median of 2.25 days to 1.5 days.Conclusions:This simple quality improvement project led to a greatly improved review of antimicrobial therapy which was associated with significantly reduced time on intravenous antibiotics. The quality improvement methodology could easily be adapted for other inpatient medical wards.

Introduction and ObjectivesEffective antimicrobial stewardship aims to reduce healthcare associated infections such as hospital-acquired pneumonia, prevent misuse and overuse of antibiotics, minimise the development of resistance1and shorten hospital stay. The need for antibiotics should be reviewed at 48 hours of starting antibiotic is the focus part of the “start smart then focus” approach.2The aim of our QIP was to improve the percentage completion of the 48 hour antimicrobial review box section of our newly designed inpatient drug charts to over 90% across two 30-bed acute respiratory wards within 7 weeks.Methods30 sequential antibiotic prescriptions were examined twice weekly for a 7 week period (QI Period 10/01/2017–24/02/2017). The Outcome measures were: i) 48 hour box ticked ii) Days on IV-antibiotics. Process measures were iii) Signature recorded iv) Date of 48 hour review. The Balancing measures were: v) Indication and vi) Duration of antibiotic recorded. 14 measurement cycles with 7 PDSA interventions took place.ResultsDuring the QI period, 334/420 (79%) of 48 hour Antimicrobial Review boxes were ticked. Commonly ticked options were; Continue Antibiotics (n=230), IV to PO (n=88) and Stop (n=15). Commonest treatment indications were: Community acquired pneumonia (28%) and lower respiratory tract infection (22%). We achieved and sustained 100% completion of our 48 hour review with an associated reduction of IV antibiotic use by mean of 1.1 days (figure 1). 48 hour signature recorded on the drug chart increased from 37% to 100%. Balancing measures remained unaffected during QI period.ConclusionsThe PDSA Interventions with greatest impact were 1) Educational talk by consultant and 2) Pharmacy engagement to highlight non-completion. The QI methodology can be replicated to other respiratory wards to improve antimicrobial stewardship. Appropriate de-escalation may reduce unnecessary use of IV antibiotics.References. NICE: Antimicrobial stewardship: Systems and processes for effective antimicrobial medicine use. NICE guideline [NG15]Published August, 2015. https://www.nice.org.uk/guidance/ng15. Antimicrobial stewardship: Start smart–then focus. Public Health EnglandUpdated 25th March, 2015. https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus[Figure]

Introduction and AimSepsis and pneumonia commonly present together, however the preferred clinical scoring system to use is unclear. NEWS (National Early Warning Score) and SIRS (Systemic Inflammatory Response Syndrome) and SOFA(Sequential Organ Failure Assessment) scores can be used to evaluate patients admitted with sepsis. Due to complexity of SOFA scoring, qSOFA has been proposed for routine practice.1We compared sepsis scores in patients with community acquired pneumonia related sepsis (CAP sepsis) and compared this to sepsis from other causes (non-CAP sepsis). We also evaluated how sepsis scoring systems compared with the CURB-65 score to predict mortality and ICU admission in CAP sepsis.MethodsMedical records were audited between 01/09/2016–20/03/2017 at Barking Havering and Redbridge University Hospitals NHS Trust. Adult patients were included if ICD-10 codes on discharge/death were Sepsis A40/A41. Physiological and blood parameters were collected at time of trigger from medical/electronic records. All plain chest x-rays (CXR) and CT-chest scans were reviewed independently by two respiratory registrars to confirm consolidation. We calculated the positive predictive value (PPV) and negative predictive value(NPV) of each sepsis scoring system against two outcome measures; i)ICU Admission <24 hours ii)mortality(death) at 30 days.Outcomes/ResultsWe identified 114 cases of sepsis. Median age-78 years. Male:female ratio 56:58. We found 22/114 (19%) of patients had a diagnosis of CAP sepsis with CXR/CT-chest confirming consolidation <48 hours from admission. Scores for CAP sepsis (n=22) triggered more often than non-CAP sepsis(n=92) for NEWS ≥4 (77% vs 54%,p=0.05), SOFA ≥2 (86% vs 54%,p<0.01). For CAP sepsis and non-CAP sepsis, the PPV and NPV for each sepsis score including CURB-65 were calculated for <24 hour ICU admission and 30 day mortality (Table 1). In patients with CAP sepsis, scores for NEWS/SIRS/SOFA had a high PPV for ICU admission and mortality. CURB-65 ≥3 had a low PPV but higher NPV.Abstract P120 Table 1Triggering of sepsis scoring systems and CURB-65 scores for predicting ICU admission within 24 hours and 30 day mortality in patients with community acquired pneumonia related sepsis and non-community acquired pneumonia related sepsisSepsis Scoring SystemCAP sepsis(n=22)non-CAP sepsis(n=92)Total cases triggered n (%)Admission to ICU<24 hoursMortality<30 daysTotal cases triggered n (%)Admission to ICU<24 hoursMortality<30 daysPPVNPVPPVNPVPPVNPVPPVNPVNEWS≥417 (77.2%)100.0%33.3%91.6%40.0%50 (54.3%)57.1%45.8%65.3%49.5%SIRS≥218 (81.8%)100.0%26.6%91.6%30.0%66 (71.7%)100.0%30.5%80.7%30.7%SOFA≥219 (86.3%)100.0%20.0%100.0%30.0%50 (54.3%)85.7%48.2%76.9%55.4%qSOFA≥27 (31.8%)57.1%80.0%41.6%80.0%15 (16.3%)28.5%84.7%34.6%90.7%CURB 65≥216 (72.7%)85.7%33.3%83.3%40.0%CURB 65 was not used for non-CAP sepsisCURB 65≥37 (31.8%)28.5%66.6%41.6%80.0%ConclusionPatients with CAP sepsis triggered more often with NEWS ≥4 and SOFA≥2 compared to non-CAP sepsis. Our data suggests that NEWS ≥4,SIRS≥2,SOFA≥2 or CURB-65≥2 may be used as initial screening for CAP sepsis. However, all had low NPV for ICU admission and 30 day mortality. Further studies are needed to evaluate the best scoring system to assess clinical severity for CAP sepsis and avoid unnecessary duplication.ReferenceSinger Met al. Third International Consensus Definitions for Sepsis and Septic Shock: JAMA2016;315(8):801–810.