PrescQIPP

Go Green IVOST Project: Promoting Metronidazole Tabs Before Jags

NHS Greater Glasgow & Clyde and The Centre for Sustainable Healthcare

Project summary

Promoting intravenous (IV) to oral switch (IVOST) is a fundamental antimicrobial stewardship (AS) initiative providing benefits for patients, staff and the environment including: reduced risk of cannula related infections, medicine costs, nursing workload and carbon footprint. A grassroots quality improvement (QI) initiative highlighting the high oral bioavailability (> 90%) of metronidazole and environmental benefits of IVOST at the Royal Alexandra Hospital resulted in a 45% median reduction in IV administrations. Scale and spread of successful AS initiatives is essential to maximise patient benefits and support attainment of national targets for antimicrobial resistance (AMR) and sustainability.

This project aimed to scale and spread the above QI initiative to all adult acute hospitals in NHSGGC the largest health board in Scotland and measure the impact on AS, drug costs, nursing workload and environmental sustainability.

A QI scale and spread approach was used including: eye catching posters on wards/electronic guideline platform, a 'Think Tabs before Jags’ blog to highlight the initiative widely, electronic prescribing (HEPMA) IVOST prompts displayed when prescribing/administering IV metronidazole, HEPMA targeted prospective audit and feedback of patients prescribed IV metronidazole, multidisciplinary staff champions and Antibiotic-Guardian ‘Gold Star’ awards and ongoing multidisciplinary feedback via update reports and governance committees. Oral and IV metronidazole usage data was calculated at baseline and 40 months ‘post-change’. Measures in terms of reduced IV administrations, drug costs and nursing time saved were calculated. Working in collaboration with the Centre for Sustainable Healthcare plastic waste reduction (giving sets, cannula, gloves and aprons) associated with IVOST was calculated in terms of carbon dioxide equivalent (CO2e) emissions using a hybrid carbon foot-printing methodology and emissions factor databases.

Outcomes included a 33% median reduction in total (IV + oral) metronidazole defined daily doses (DDDs) per 1000 occupied bed days (OBDs), a 46% median reduction in IV metronidazole (DDDs/1000 OBDs) equating to 63,000 fewer IV metronidazole administrations per year, equivalent nursing time released to care 21,000 hours per year, a 37% (£60,000) annual reduction in metronidazole drug cost and annual carbon footprint savings of 93.3 tonnes CO2e.

In conclusion a QI scale and spread approach to promote appropriate metronidazole IVOST across NHSGGC resulted in a sustained change in prescribing behaviour and a significant reduction in total and IV use of metronidazole. This is important in terms of improved AS, patient safety, workforce cost and efficiency and environmental sustainability. Crucially these results support attainment of national targets for tackling AMR and the climate emergency.

Additional supporting information for this project is available in the electronic toolbox.