Public Board of Directors papers 27.01.22

cleaning schedules are in place

3. Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance Key lines of enquiry Evidence Gaps in assurance Mitigating actions Systems and process are in place to ensure that: Arrangements for antimicrobial stewardship are maintained

The Antimicrobial policy is available on the trust intranet and referred to for clinician, pharmacy and Non-medical prescribing teaching. Amendments to the policy are disseminated via email from the Director of Pharmacy / Consultant Microbiologist. See Antimicrobial Policy. In addition to the trust policy, up to date antibiotic guidance is accessible via Microguide available on the intranet and an app available for download onto staff individual mobile devices. Microguide has been maintained throughout the pandemic. A monthly antimicrobial prevalence audit is undertaken by ward pharmacists. This was paused during March 2020 and the first half of April 2020 due to reducing pharmacy footfall on the wards. However, data was still gathered at the end of April 2020, resulting in a total time of reduced audit data of ~ 6 weeks. See antimicrobial prescribing standards audit and MEG antimicrobial report as supporting evidence. See RAG Status of Antimicrobial Prescribing (April 2018 – October 2021) and MEG Antibiotic Point Prevalence Audit (June 1, 2021 - January 17, 2022). The red for duration documented within the audit is a long term issue that will be improved by electronic prescribing.

Antimicrobial ward rounds paused at the end of February 2020 to reduce footfall and restarted 17/7/20.

Microbiology and antimicrobial pharmacy team remained available for remote advice throughout. Microbiologist attends weekly medical handover to discuss cases, themes and feedback regarding antimicrobials practice. As prescriptions are reviewed regularly, this mitigates any significant risk.

Duration isn’t always documented at time of prescribing. This can be an issue specific for neutropenic sepsis where the situation is unknown at time of prescribing.

C1501: Infection prevention and control board assurance framework (24 December 2021 Version 1.8) – January 2022

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