• Alison Coll, Moira Kinnear, and Anne Kinnear.
• NHS Lothian Pharmacy Service, Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, Scotland, UK. alison.coll@luht.scot.nhs.uk
• Int J Clin Pharm. 2012 Dec 1;34(6):845-54.

BackgroundAntimicrobial guidelines aim to optimise treatment and minimise development of resistance. Care bundles support the implementation of local guidelines.ObjectivePharmacist identification of where in the prescribing, monitoring and documentation process, the quality of antimicrobial management in a High Dependency Unit of a large teaching hospital could be improved and design of antimicrobial care bundles for initiation and de-escalation of therapy to standardise care and improve practice.SettingThis study was conducted in a 10-bed, mixed medical-surgical HDU in a large Scottish (UK) teaching hospital.MethodsQuality indicators (n = 30) were agreed through multidisciplinary team review with reference to the evidence base, national strategy and local policy. Adherence to these quality indicators was measured before and after the pharmacist's contributions. Areas of non-adherence to quality indicators were used to design the care bundles.Main Outcome MeasureAdherence to the quality indicators before and after the pharmacist's action. Categorisation of pharmaceutical care issues ('check', 'change in drug therapy' and 'change in drug therapy process') were quantified.ResultsFrom 134 prescriptions, the pharmacist undertook 1,447 actions to ensure adherence to the 30 indicators. Adherence was very good (85.3 % CI 83.5, 87.1), but would have been unsatisfactory (53.5 % CI 50.9, 56.1) without the pharmacist's action (p < 0.001). Change in drug therapy process or change in drug therapy initiated by the pharmacist accounted for 31.9 % (CI 29.5, 34.3) of adherence. Non-adherence was related to documentation of past allergic reactions, bacteriological specimen results, indication and length of course of treatment (both at initiation and de-escalation). Care bundles were designed to target areas of non-adherence to local guidelines.ConclusionThe pharmacist made a significant contribution to improving adherence to evidence based antimicrobial prescribing quality indicators agreed by the multidisciplinary team. Prompts have been identified from the pharmaceutical care process and applied in the design of two antimicrobial care bundles proposed to support adherence with antimicrobial prescribing policies and guidelines.

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