Title of Audit
The use of gentamicin on general surgical wards
Name
Date of Completion
of Audit
Peer review
feedback available
31/05/13
Yes
No
Completion of sections 1 – 5 would indicate a ’5 criterion audit’.
A completed audit cycle would be indicated if sections 1 – 8 had been attempted.
1. REASON FOR THE AUDIT
Explain why the audit topic was chosen and that as a result of this choice there is the potential for
change to be introduced which is relevant to the practice or you as an individual practitioner.
Gentamicin is a commonly used antimicrobial agent however prolonged administration has been
shown to cause ototoxicity and nephrotoxicity in patients. In XX, a gentamicin prescribing chart was
introduced in August 2012 to prompt prescribers to monitor gentamicin levels and review the need for
gentamicin on a daily basis. The chart also prompts prescribers to seek advice from microbiology or
infectious disease specialists if the prescription for gentamicin is to continue for longer than 4 days.
As gentamicin related ototoxicity is related to total exposure, repeated prescriptions for gentamicin should
be avoided. Currently there is no way of quickly identifying whether or not a patient has been prescribed
repeated courses of gentamicin.
This audit looked to examine the prescribing patterns seen on the general surgical wards to clarify
whether or not the new prescribing charts have had a positive impact on the duration of gentamicin
therapy patients receive. The audit collected data regarding which antibiotics patients were switched to
post gentamicin therapy and also which healthcare professional was responsible for stopping gentamicin.
This audit also examined whether or not patients were prescribed repeated courses of gentamicin.
Feedback
A new prescription chart for gentamycin has been introduced and this audit aims to review if the
implemtnation has improved the safety around gentamycin prescribing
2. AUDIT CRITERIA TO BE MEASURED
Criteria are simple, logical statements used to describe a definable and measurable an item of health
care eg. Patients with type II diabetes should have a fundoscopy every 12-months. See Audit
Guidance for examples of criteria if greater understanding is required. Focusing on one or two criteria
makes data collection more manageable and the introduction of small changes to practice less
challenging. Where available, evidence should be cited in support of criteria eg. nGMS contract or a
clinical guideline. A single criterion is acceptable for Appraisal purposes.
Establish if patients are receiving appropriate duration of gentamicin
Determine which antibiotics patients are switched to post gentamicin therapy
Establish reasons for stopping gentamicin
Establish if patients are receiving repeated courses of gentamicin
Feedback
The criteria chosen are mainly good. I was unclear the importance of establishing which
antibiotics patients were switched to? (other than for information) and the information
collected on why the gentamycin was stopped was who stopped the gentamycin therapy.
3. STANDARDS SET
An audit standard describes the level of care to be achieved for any particular criterion eg. 90% of Patients with
type II diabetes should have a fundoscopy every 12-months. Standard levels may be influenced by the target
levels contained in the nGMS contract or by discussing and agreeing the desired or ideal level of care with
colleagues. State how long you estimate it will take you to reach your chosen standard(s) eg. 3 months.
All patients (100%) should receive no more than 4 days gentamicin therapy.
Exceptions: On advice of microbiology or an infectious disease specialist.
Feedback
The author had a good undertanding of the standard set. Often setting a standard on 100% is difficult
to achieve in clinical practise, however desirable.
I wondered if there was any guidance on repeated exposure to gentamycin and risk and is
there a standard of how many times the antibiotic course can be repeated???
4. PREPARATION AND PLANNING
Explain briefly who was involved in discussing and planning the audit, how the data were identified,
collected, analysed, and disseminated and who gave you assistance at any stage of the project, eg.
with a literature review or with collecting or analysing data if this was required. Teamwork is essential
to audit and evidence of this should be provided in the report.
The need for this audit was identified by the antimicrobial pharmacist on site who wanted to
measure the impact of the new prescribing charts. A clinical effectiveness pharmacist was also
involved in the audit and acted as a mentor to myself. The surgeons, nursing staff and surgical
pharmacists were all informed of the audit and when it would take place.
The audit was to be carried out on the general surgical wards at XX (excluding HDU and ITU). The
surgical wards were identified as an area of concern as the new gentamicin prescribing advice is not
always adhered to and the surgeons seem less concerned than the medical consultants regarding
gentamicin prescribing.
A data collection form was designed and reviewed by the antimicrobial pharmacist and one of the
surgeons, the surgeon suggested that we also collect data regarding whether or not patients receive
repeated courses of gentamicin therapy.
The data collection form was piloted, no changes were made. The data was then collected over a
four week period. All patients prescribed gentamicin (with the exception of those prescribed only
one dose for a catheter change or for prophylaxis prior to theatre) were included in the audit.
Feedback
There was good evidence of teamwork and all parties involved in the audit were involved. An pilot
audit was conducted which is a useful way of ensuring data collection forms and processes are fit
for purpose before actual data collection
5. DATA COLLECTION 1
Initial data collected should be presented using simple descriptive statistics as part of the text, in table format or
using graphs (bar charts, pie charts etc.) Remember to quote actual numbers (n) as well as the percentage (%).
There is no need to quote irrelevant data (eg. age, gender, or past medical history) if it bears no relation to your
chosen audit criteria. Compare and contrast your initial data with the standard(s) you set.
A total of 33 patients were identified for inclusion in the audit. Only one of these 33 patients
received gentamicin for greater than four days. There did not appear to be a well documented
reason for this and it was not discussed with microbiology or infectious diseases.
Figure 1. The total number of days therapy with gentamicin is shown. Only 1 patient
exceeded the recommended 4 day course.
Figure 2. The reason why gentamicin therapy was stopped is shown above. The consultants
were mainly responsible for stopping gentamicin therapy. It was surprising to find that
pharmacist intervention was only responsible for gentamicin being stopped in one patient.
Feedback
The presentation of the results is clear and easy to compare with the criteria and standards set
Oral Antibiotic
Number of patients (%)
Co-amoxiclav
14 (42%)
Ciprofloxacin
7 (21%)
Clindamycin
1 (3%)
Amoxicillin plus
metronidazole
2 (6%)
Metronidazole plus
ciprofloxacin
1 (3%)
Figure 3. A total of 25 (76%) of patients were switched to an alternative oral antibiotic as
detailed above.
IV antibiotic
Number of patients (%)
Amoxicillin plus
metronidazole
2 (6%)
Tazocin
1 (3%) (micro advice)
Co-amoxiclav
2 (6%)
Clindamycin plus tazocin
1 (3%) (micro advice)
Figure 4. A total of 6 (18%) of patients were switched to an alternative IV antibiotic as detailed
above.
Two (6%) of patients were switched to alternative IV plus oral therapy. One patient was
switched to IV vancomycin, IV metronidazole and oral ciprofloxacin on micro advice for
suprapubic abcess.
One patient switched to IV flucloxacillin plus oral rifampicin on micro advice for gram positive
cocci in blood cultures.
Patients medical notes were examined to investigate previous treatment with gentamicin (from
August 2012). Only one patient was found to have received repeat gentamicin courses having
already had 2 this year (March 2013 and April 2013).
Criteria
Audit
Standard
Exceptions
Result
Total duration
of gentamicin
therapy
< 4 days
100%
Microbiology
advice/
Infectious
disease advice
97%
Figure 5. The audit standard was not met as 1 patient received greater than a 4 day course of
gentamicin therapy without any documented discussion with microbiology advice or an
infectious disease consultant.
The presentation of the results is clear and easy to compare with the criteria and standards set
6. REASON FOR THE AUDIT
The essence of audit is to change practice in order to improve patient care and services. This section should
adequately describe any change(s) that was discussed, agreed and introduced by you. The role of others in this
process should also be described. An example of the change introduced should be attached in evidence as an
appendix to the report, where this is possible eg. a new or amended protocol or flow chart, or a letter that is sent
to a group of patients inviting them in for a review.
Although the results of this audit did not meet the standard set, it was decided that no
intervention was needed. Only one patient exceeded the recommended duration of gentamicin
therapy, and although there was no clear reason identified for this it was decided that this was
an acceptable result.
Feedback
This is a very good audit evaluating the implimentation of a new process to facilitate
improving prescribing of a high risk medicine.
7. DATA COLLECTION 2
Presentation of data should be as Data One. In this section, compare and contrast the results of the second data
collection with data collection one and the standard(s) you originally set. Has your standard been met or
surpassed? If not, comment on why you think that is the case.
No second data collection was carried out for this audit.
8. CONCLUSIONS
The final section should briefly and simply summarise what the audit achieved, and what were the main learning
points gained from this exercise. In doing this, the benefits achieved through the audit should be discussed along
with any problems encountered with the process or findings. Some thought should also be given as to whether
the audit will be repeated in future and if so when.
The results of this audit show that the implementation of the gentamicin prescription chart has
led to improved gentamicin prescribing practices within general surgical wards at XX.
Although the initial audit standard was not met, 97% compliance was deemed an acceptable
result.
There were several limitations to the audit including:
 Small sample size
 Limited time to carry out data collection
 Patients missed over weekend
 Patients previous gentamicin courses difficult to identify
 Indications/reasons for switching antibiotics not always well documented
In future, we hope to carry out this audit on medical wards and possibly in HDU/ITU settings
as these areas were excluded for the purposes of this audit.
Further work is required to design a tool to identify patients who have been prescribed repeat
courses of gentamicin as the total exposure to gentamicin is related to side effects such as
ototoxicity.