Abstract :

This narrative study explores the emerging resistance and optimization of resources in the context of antibiotic stewardship from a home care perspective. Wahat Al Aman, a leading home healthcare services provider in the UAE, recognizes the global concern of antimicrobial resistance (AMR) and its impact on patient care. The organization aims to address increased antibiotic usage and multidrug-resistant organisms through optimized improvement plans. The study investigates the root causes of rising antibiotic utilization within the organization and proposes an Antibiotic Stewardship Program (ASP) to limit consumption. Collaboration with healthcare partners, implementing standard treatment guidelines, monitoring antibiotic resistance, and ensuring compliance are crucial elements of the improvement plan. The study highlights the benefits of cost and time savings, enhanced brand equity, improved regulatory compliance, and increased customer satisfaction resulting from optimized antibiotic prescribing practices.

Organizational Profile:

At Wahat Al Aman, aim to facilitate the recovery process and to promote a positive outlook on health for patients by offering exceptional home healthcare services. Our mission is to establish ourselves as the leading provider of home healthcare services in the UAE, aiming to enhance the lives of every patient under our care. We ensure that our team consists of highly skilled and accredited physicians, therapists, and professional nurses who deliver personalized clinical care tailored to each patient’s specific needs. Our dedicated clinicians go above and beyond to provide comprehensive support, often extending the level of care typically associated with hospitals. Whether it’s assisting patients with chronic conditions like diabetes, providing care to mothers and newborns, aiding in post-operative recovery, supporting families caring for elderly loved ones, or providing temporary assistance during challenging circumstances, our team is committed to meeting the unique requirements of each patient we serve.

Introduction:

The growing problem of antimicrobial resistance (AMR) resulting from the excessive use of antibiotics has become a significant global health concern, including at Wahat Al Aman. As an internationally accredited institution and a prominent leader in home care services in the UAE, we acknowledge the urgency of addressing the increased use of antibiotics and the emergence of multidrug-resistant organisms. This issue has significantly impacted the effectiveness of treating infectious diseases, leading to treatment failures, escalated healthcare expenses, and even the loss of life. At Wahat Al Aman, we are committed to tackling this challenge by implementing optimized improvement plans to combat AMR effectively. The organization has witnessed a substantial rise in the rate of antibiotic usage. The data analysis for the fiscal year 2021-2022 consistently shows that the organization’s antibiotic utilization has consistently exceeded the benchmark. This concerning trend poses a significant threat to patient safety and raises concerns about the quality of care provided.

To find the root cause of the problem, the following steps are taken:

1. The initial decision to prescribe antibiotics after a patient’s discharge is typically made by the assigned treating physician. However, this decision is often influenced by various factors.
2. The understanding of antibiotic treatment by the patient and their family can challenge the decision-making process. Cultural influences and a lack of education about the appropriate use of antibiotics can lead to patients either demanding immediate treatment or using over-the-counter antibiotics purchased from community pharmacies.
3. Clinicians may have misconceptions about antibiotic prophylaxis and delayed treatment. Fearing delayed treatment, they may opt for broad-spectrum antibiotics to cover a wide range of potential pathogens before laboratory results are available. This inappropriate prescribing increases the risk of resistance.
4. The attitude towards managing patient symptoms at home should be considered proactively to avoid delayed referrals, as it can lead to the proliferation of resistant organisms.
5. Overuse of medical supplies, such as personal protective equipment, can become an additional burden for the organization. Improper management of patient symptoms at home can result in unnecessary emergency department visits and potentially hospital admissions.

The solution to the problem was found in the following way:

1. A multidisciplinary team was formed to assess the organisation’s antibiotic prescribing gaps.
2. Data analysis focused on the fiscal year 2021- 2022 to understand the causes of increased antibiotic utilization.
3. Root causes were identified and categorized into five areas, forming the basis for designing an effective improvement plan.
4. An Antibiotic Stewardship Program was implemented, including policies and procedures to limit and reduce antibiotic consumption.
5. Evidence-based treatment guidelines for common infections were established as part of the improvement plan.
6. Agreements were secured with Aster DM Healthcare Pharmacy and ASTER clinics to provide pharmacist and microbiologist support for appropriate antibiotic use and analysis of resistant microorganisms.
7. A process map was created to monitor and track occurrences related to antibiotic use, ensuring compliance.
8. WHONET, software from the Center for Disease Control and Prevention, will be used to create an antibiogram for monitoring antibiotic resistance.
9. The team will continuously monitor and take action based on the improvement plan to prevent antibiotic resistance.

For maintaining and replicating the improvements, the following steps are taken:

1. Implement an Antibiotic Stewardship Program (ASP) to improve antibiotic prescription and use.
2. Secure a signed Memorandum of Agreement with referral links for effective collaboration.
3. Develop and implement standard treatment guidelines for common infections, starting with low-generation antibiotics.
4. Maintain an Antibiogram to monitor antibiotic resistance.
5. Carefully assess and detail the plan to ensure success in antibiotic prescribing and overall quality of care.
6. Follow a simple and organized set of steps within the organization to enhance intervention outcomes.

The implementation of the project followed the guidelines of the BAXTER Tubing Misconnections Self-Assessment for Healthcare Facilities. Top-level management actively participated in the project process, from the initial definition phase to the control phase. The project team comprised professionals from various disciplines, including doctors, nurses, technicians, clinical pharmacists, and the quality team, ensuring a multidisciplinary approach to address tubing misconnections effectively. Tubes and catheters play a crucial role in delivering essential healthcare services daily. Critically ill patients often have multiple tubes and catheters connected to them, serving various purposes such as medication administration, food intake, and intravenous therapy. In a recent incident at our hospital, a nurse came close to misconnecting the tubes, but fortunately, a senior nurse intervened and prevented a potential crisis. The problem was promptly identified and effectively managed by our vigilant team. To find out the nature of the problem, the following measures were taken:

1. The project followed the DMAIC methodology, consisting of the Define,Measure, Analyze, Improve, and Control phases.
2. A descriptive study examined the potential for misconnection among tubes and catheters in the hospital.
3. Forty-six commonly used tubes were categorized, and 2070 possibilities of connections/misconnections were identified.
4. Each connection possibility was assigned a risk priority number, calculated based on the ease of connection and potential harm.
5. A risk priority number of 25 indicated a high-risk misconnection that could result in patient death.
6. Sixty-three connections were classified as high-risk based on their assigned risk priority numbers.
7. A fishbone analysis was performed to identify the challenges contributing to the high-risk connections.
8. Challenges included multiple tubes for patients, similar device designs, lack of tube reconciliation adherence, untrained staff, and involvement of patient attendees in handling tubes.
9. The similar design of devices was identified as the most significant challenge and contributor to the misconnection problem.

An action plan was implemented to address the design flaw contributing to misconnections. Firstly, Leur Slip IV and Blood sets, prone to misconnections, were eliminated. Instead, alternative sets that minimized the risk of misconnections were adopted. Additionally, black piston syringes were explicitly introduced for tracheostomy procedures, ensuring clear differentiation and reducing the chances of incorrect connections. Colour-coded labels were assigned to different tubes and catheters to enhance clarity. For example, arterial tubes were designated with a red code, while venous tubes were labelled in blue. This visual distinction aided in easily differentiating and identifying the tubes during medical procedures. A colour-coding system was initially implemented in the cardiac Intensive Care Unit (ICU) to assess its effectiveness as part of a pilot initiative.

Outcome:

1. Cost savings achieved through reduced consumption of medical supplies and decreased cash payment for unapproved antibiotics.
2. Time savings due to resource optimization, allowing for better allocation of staff and resources to other patients.
3. Enhanced brand equity as a leading healthcare institution through the implementation of an internationally recognized Antibiotic Stewardship Program.
4. Improved compliance with regulatory board audits resulting from the enhanced process of antibiotic utilization.
5. Increased customer satisfaction as a result of improved antibiotic prescribing practices.

Conclusion

Implementing an Antibiotic Stewardship Program (ASP) and other improvement measures at Wahat Al Aman demonstrates the organization’s commitment to addressing the challenges of antibiotic resistance. By identifying the root causes of increased antibiotic utilization and designing effective strategies, the organization aims to optimize resources, improve patient outcomes, and ensure high-quality care. Through collaborative partnerships, evidence-based treatment guidelines, and continuous monitoring, the organization strives to lead in antibiotic stewardship and set a benchmark for home healthcare services. The results of this initiative include cost and time savings, enhanced brand equity, regulatory compliance, and improved customer satisfaction, reinforcing the organization’s commitment to delivering exceptional care while combating antibiotic resistance.