ANTIMICROBIAL

STEWARDSHIP (AMS)
CLINICAL AND STRUCTURAL AUDIT
IN PRIMARY CARE FACILITIES
9 MAC 2023

Sektor Kualiti & Inovasi Primer

Bahagian Pembangunan Kesihatan Keluarga
 Contents
1. Elements of effective AMS

2. Strategies & Outcome Measurement

3. Clinical AMS Audit + Hands on

4. Structural AMS Audit + Hands on

 Contents
1. Elements of effective AMS

2. Strategies & Outcome Measurement

3. Clinical AMS Audit + Hands on

4. Structural AMS Audit + Hands on

 1. Prescriber

2. Clinical Pharmacist with

ID training
Elements of an
3. Collaborations with other
effective AMS units ie Epidemiologists,
Clinical Microbiology,
programme Infection Control , IT Officer

4. Support from admin

 87%
perceived
very important
national problem

97%
vs
believed widespread
55%
and inappropriate
rated
usage causing
importance
resistance
at own hospitals
vs

60%
restrict use of broad
spectrum antibiotic

Wester CW et al., Arch Intern Med. 2002 Oct 28;162(19):2210-6

https://pubmed.ncbi.nlm.nih.gov/12390064/
 Contents
1. Elements of effective AMS

2. Strategies & Outcome Measurement

3. Clinical AMS Audit + Hands on

4. Structural AMS Audit + Hands on

 2 main core strategies for AMS
1) Prospective audit with intervention and feedback
a. Clinical audit in antibiotic prescription in KK

2) Formulary restriction and pre authorization

These strategies are not mutually exclusive

 Other strategies for AMS
3) Guidelines and Clinical Pathway
4) Education
5) Antimicrobial order forms
6) Streaming / de escalation therapy
7) Dose optimisation
8) Parenteral to oral conversion
9) Profiling in antibiotic prescription
ie Point Prevalence Survey
 Outcome Measurement
Performance with Number of adverse drug
Cost of effects
relation to
Antimicrobial used
guidelines/ clinical
- Define daily dose /
pathway
patient-day Degree of AMR
- Antimicrobial (antibiogram)
acquisition cost per
patient
Clinical Audit Rate of C difficile
scoring infection
 Contents
1. Elements of effective AMS

2. Strategies & Outcome Measurement

3. Clinical AMS Audit + Hands on

4. Structural AMS Audit + Hands on

Clinical Audit for AMS in
Primary Care Facilities
 Introduction
Clinical Audit is a method/tool to evaluate antibiotic prescription's practice
among healthcare providers and antibiotic prescription trend in primary care
clinics.

This can be further used for continuous quality improvement through assessment of
the effectiveness of clinical services based on the guidelines provided (National
Antibiotic Guidelines)
Elements in Clinical Audit
25 elements audited
(18 compulsory)
Audit score
1 - Done
0 - Not done Audit Score percentage
NA - Not applicable
Total Audit Score (numerator)

x 100
Total Full Score (denominator)
 STAGES OF
IMPLEMENTATION
STAGE 1 : PREPARATION
• Annually / as needed basis
- Alert by the pharmacist
- Incidental reporting

• Identify available resources ie audit team

• Refer to guidelines ie National Antibiotic Guidelines

(NAG) and clinical pathways
 STAGE 1 : PREPARATION
• Define criteria:

All antibiotic prescriptions by any particular

healthcare provider in the past 1 month will be
randomly selected with a minimum of 30 records.

*Profiling of individual prescriber can be done using similar audit format with a minimum of 5
randomly selected records (to justify interpretation)
 2013

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170469/pdf/MFP-08-26.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170469/pdf/MFP-08-26.pdf
 2016 2022

https://pubmed.ncbi.nlm.nih.gov/27188538/ https://pubmed.ncbi.nlm.nih.gov/35283676/
 STAGE 2 : MEASURING
LEVEL OF PERFORMANCE
• Data collection maybe from computerized EMR or manual
collection. Data entered in excel format with embedded
formulas for auto calculations. (AMCA-1)

• Audited clinical record will be scored based on criteria of

best practice with score of 80% and above would be
consider as appropriate.
STAGE 2 : MEASURING LEVEL
OF PERFORMANCE
• Analyze the data collected:
- Compare actual performance with the set
standard based on previous year scoring.
- Discuss how well the standards were met.
- If the standards were not met, note the reasons
for this
 STAGE 3 : MAKING
IMPROVEMENTS
• Present the results and discuss them with relevant teams in
the organization.
• The results should be used to develop an action plan,
specifying
- what needs to be done,
- how it will be done,
- who is going to do it and
- by when.
 A
Clinical Audit
Excel Form for
Klinik Kesihatan
 Clinical Audit Excel
Form from KK to PKD

B (AMCA-1)
 Clinical Audit Excel Form

B
from KK to PKD
(AMCA-1)
 Clinical Audit Excel Form from
PKD to JKN

C (AMCA-2)
 Clinical Audit Excel Form from
PKD to JKN

C (AMCA-2)
 Clinical Audit Excel Form
from JKN to BPKK
D (AMCA-3)
 Clinical Audit Excel Form
from JKN to BPKK
D (AMCA-3)
 Summary
1. The antibiotic effectiveness is decreasing due to increasing resistance to current
agents, coupled with a dwindling pipeline for new antibiotics.

2. AMS should extend the effectiveness of currently available antibiotics

3. Prospective Clinical Audit with intervention and feedback of antibiotic

prescription in KK is one of main core strategies in AMS that can lead to reduction
in overall antibiotics use (especially inappropriate prescriptions).
 Contents
1. Elements of effective AMS

2. Strategies & Outcome Measurement

3. Clinical AMS Audit + Hands on

4. Structural AMS Audit + Hands on

Structural Audit for AMS
in Primary Care Facilities
 Introduction
Structural Audit is a method/tool to evaluate the main
elements and progress of AMS activities in primary care
facilities.

Done via Cross Audit by another AMS team

using AMSA-1.
Elements in Structural Audit
4 components
4 components
(3 (3 elements
elements each)
each)
• Commitment
• Commitment
Action
• Tracking & Reporting
• Education & Expertise Audit Score percentage (%)

Total Audit Score

x 100
100
 Elements in Structural Audit

1. COMMITMENT

Does your facility demonstrate dedication to and accountability for

optimizing antibiotic prescribing and patient safety related to antibiotics?

Has dedicated AMS team, appointment letter & AMS plan of action?
Incorporates AMS agenda in clinic management meeting?
Communicates with patient about antibiotic indications?
 A
Structural Audit
Excel Form from
KK to PKD
(AMSA-1)
 Elements in Structural Audit

2. ACTION
Has your facility implemented at least one policy or practice to improve
antibiotic prescribing?

Availability of treatment guidelines and clinical pathways?

Formulary restriction based on category of prescriber and local setting?
Implementation of AMS clinical audit?
Structural Audit Excel
Form from KK to PKD
(AMSA-1)
A
 Elements in Structural Audit

3. TRACKING & REPORTING

Does your facility monitor at least one aspect of antibiotic prescribing?

Track and report antibiotic utilization using Daily Defined Dose (DDD) & WHO
target achieved?
Implementation of antibiotic Point Prevalence Survey (PPS)?
Assess and share performance on AMS surveillance and audit?
Structural Audit Excel
Form from KK to PKD
(AMSA-1) A
 Elements in Structural Audit

4. EDUCATION & EXPERTISE

Does your facility provide resources to clinicians and patients on evidence-
based antibiotic prescribing?

Continuous Medical Education (CME)?

Prescribing aids: educational aids for prescribers
(e.g. information technology support, weight-based dosing etc)?
Public awareness-raising tools (poster/pamphlet)?
 A
Structural Audit
Excel Form from
KK to PKD
(AMSA-1)
 Structural Audit Excel Form
from PKD to JKN

B (AMSA-2)
 Structural Audit Excel Form
from JKN to KKM

C (AMSA-3)
 SUMMARY
CLINICAL AUDIT STRUCTURAL AUDIT
• To evaluate antibiotic prescription's practice among • To evaluate the main elements and progress of
healthcare providers & antibiotic prescription trend AMS activities

• Auditor : FMS / Senior MO • Auditor : Other AMS team (Cross Audit)

• 25 elements (18 compulsory elements)
Audit Score
1 - Done
0 - Not done
NA - Not applicable
• Audit in KK : May - 29th June 2023
AMCA-1 (KK to PKD) : By 30th June 2023
AMCA-2 (PKD to JKN) : By 31st July 2023
AMCA-3 (JKN to BPKK) : 30th November 2023
• 4 components (3 elements each; 12 in total)
- Commitment
- Action
- Tracking & Reporting
- Education & Expertise
• Audit in KK : Aug - 29th Sept 2023
AMSA-1 (KK to PKD) : By 30th Sept 2023
AMSA-2 (PKD to JKN) : By 31st Oct 2023
AMSA-3 (JKN to BPKK) : 30th November 2023

Skor Preskripsi Wajar Skor Audit Struktur

TARGET TARGET
> 80% > 80%
kualitiprimer_bpkk@moh.gov.my

drnorainimy@moh.gov.my
03 - 88832158

anuarhakim@moh.gov.my
03 - 88832120

nor.hazirah@moh.gov.my
03 - 88832153