Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT

Summary

Antibiotic underdosing is a widespread issue in the healthcare system. The use of modern infusion pumps to deliver intravenous (IV) medications has resulted in the practice of flushing IV lines being lost in some specialties. Failure to give full doses of IV antibiotics poses significant risks to individual patients as well as adding to the problem of antimicrobial resistance (AMR).

In this interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT.

A transcript is available below the video.

Content

Transcript

My name is Ruth Dando and I'm the Head of Nursing for theatres, critical care and anaesthetics at Barking Havering and Redbridge University Hospitals NHS Trust (BHRT).

I first became aware of the issue of underdosing of antibiotics just in a casual conversation with  Lynn from B Braun. She happened to mention it—was I aware, did I have an understanding of what happens with the implications of not flushing our lines? Obviously way back in the day when I first started my nursing there was a situation where we administered our antibiotics and all medications through a burette system, so you had the ability to flush your line quite easily. After the infusion had run through you'd top up the chamber with an additional volume of fluid and flush the line. It was our automatic normal practice and it was only after this conversation that I realised that's something that we didn't do anymore and the thought of that was quite astounding.

Why is it important to tackle the issue of antibiotic underdosing?

The key thing as to why we need to do this is from a patient safety perspective, and in the short term getting somebody better quicker from their antibiotics. But also in the long term we've got not just us in our trust, but nationally and globally there's a serious threat from antimicrobial resistance. So if everybody plays their part it comes some small way into making things better for the future.

When we give antibiotics it's really important we give the full dose so that we fight the infection as hard as we can. If we're not giving the full dose [it’s] more likely for the infection to continue and develop some resistance and then we need to give another antibiotic to then try and get on top of the infection to help make the patient better. So all the time that we're not giving the full dose of antibiotics we're increasing our risk of causing more antimicrobial resistance because we're having to use different antibiotics and more antibiotics. As we're all aware the more antibiotics you use the higher the ability for bacteria to develop a resistance against it, so it's about really homing down and trying to reduce our need for antibiotics. So if we give the full dose and all the dose, every time, we're more likely to be able to get on top of our infections quicker, reduce the antimicrobial resistance risks as well as hopefully get our patients better and home to their families quicker.

How does underdosing happen?

With the advent of bringing in infusion pump devices so that we could regulate through a machine how long we delivered our doses over, [it] was very much better for administering all infusions safely, but obviously those devices then did not have the ability to give additional flush and often once the dose had been delivered the infusion line would be taken down and discarded. Hence we then started the practice of underdosing, inadvertently. We thought we were obviously making things safer for our patients and it went unnoticed by many, but now we're aware that this is a practice that has been lost that is really, really essential.

What are the legal implications of antibiotic underdosing?

From a legal perspective nurses are legally obliged to always deliver full medication that is prescribed. Obviously, if we're underdosing our patients then we're not fulfilling our legal obligations—when we were unaware of what we were doing then it was something that was missed but now we are clearly aware we are not delivering full doses of antibiotics, we're not fulfilling our legal requirements and should a patient come to harm and we've underdosed them then it may leave us open to questioning of our practice.

How did you go about implementing the change of practice at your trust?

So recognising that it had to be done I set about having conversations with procurement, supported by B Braun. They also provided me with some information and evidence. So I managed to get what evidence I could around the importance of doing it and presented it at the Procurement Advisory Group and they agreed that it seemed like a good idea to tria. We trialled it in critical care and then we managed to arrange a launch date. It took a little while because unfortunately we were still recovering from Covid and not quite business as usual, but over time with the support of the company we managed to get the practice embedded into ITU. In conjunction with this, to support our change in practice I wrote a standard operating procedure around ensuring that full doses are delivered. I took that to the various groups including the Pharmacy, Quality and Governance and Anaesthetic Critical Care Quality and Governance groups so that everybody had oversight and could input into it. Then it became ratified and improved. We have national guidance that actually stipulates we should be delivering the full dose of medication—NIVAS and the Royal Marsden are examples of these. So we've got national guidance to do it but unfortunately that lost practice wasn't happening, so I wrote my SOP to align with what the national guidance was as well. Now it feels really comfortable that we've got a robust process in terms of adjusting our practice in line with national guidance, as well as doing the right thing for our patients.

All inpatient areas across the trust have now just gone live with delivering the full dose of antibiotics so we're embedding the practice. It'll take probably a little while and we've got an audit and are going to monitor our compliance and make sure it's happening, and there's ongoing support. We had a two week period where the team from B Braun was present in the trust every day and they were available for training. We have done presentations on Teams for huddles and team meetings. I've spoken at the pharmacy group and PDNs [practice development nurses] had a Presentation—so key people that we needed to support this work were given additional presentations so that everybody was aware. So by the time we came to launch it, people had heard a lot about it. We also were able to share things on our local workplace platform so lots of different posts were going up there. [We were] just spreading the word as much as we could.

How did you get frontline staff on board with the new practice?

Once you explain to people why we need to do this, because it's so logical and sensible, they think, “Absolutely yes this is what we need to do!” An additional element from a nursing perspective is that when you instil the saline flush and flush the line, you have then got a line that you can use for other administrations, so that's time saving as well for a nurse, in the fact that you don't have a to reprime a line every time you give a drug. So it's about getting them to see the benefits for them and what how it's going to help them in their work. It's not like an additional task or an additional chore for them, it's just something it's really important to remember: flush the line and then actually you've got a line that's clear and flushed ready to go. It's a relatively simple change in practice— there's no new additional skills that nurses need to deliver this, it's simply instilling an additional amount of fluid into an already attached giving set, so in terms of training, etc, it's not been a big issue. It's just about embedding that
as our normal way of working and, like I say, we're still very early on in our change of practice. I think if six months down the line we're showing that our compliance could be better then I think that would be concerning, but like I say it's about continuing to deliver the message, support the teams on the floor and hopefully see those benefits as we move along.

What positive impact have you seen so far?

So we're seeing improvements hopefully in patient outcomes in the fact that they get better quicker and hopefully don't deteriorate from their infections. We're looking to hopefully improve our ability to switch from intravenous antibiotic treatments to oral—there's a key piece [of work] around moving somebody as early as possible from intravenous antibiotic administration to oral administration, and that again has huge implications in terms of nursing time. Also in terms of what's nice for a patient to receive—a tablet's nicer than having a drip. In terms of looking at costs around drug medication, intravenous antibiotics are more expensive than oral antibiotics so we could be saving a lot of money on drugs, and also from an antimicrobial resistance perspective, delivering oral antibiotics as opposed to intravenous is much more preferable to help reduce that.

In terms of getting sufficient data and evidence of changes in patient outcomes, obviously it's far too early for us to be able to assess that but since starting on this journey with BHRUHT, it's kind of grown and snowballed from what it was initially going to be. We're going to give all the antibiotics and hopefully help people recover from infections quicker, but we've also seen through our changing practice that we're hopefully going to reduce our amount of giving sets being used, because previous practice was one dose one giving set. But now it's flushed, the line is free to be used for other subsequent doses. So we're looking to hopefully reduce our use of giving sets—that's going to reduce costs but also [give] savings from a sustainability perspective. I've linked in with our sustainability team around looking at the change in practice and the improvements we're going to have around the reduction and we're looking at seeing how we can build that into a sustainability project as well.

How can patients, families and carers get involved in helping to tackle underdosing?

I think it's really important that patients and their carers are aware that when an intravenous medication is delivered to them, it's really important that the nurse flushes that line. So if a patient is aware of that, they can check in with the nurse when they've finished administering that the line has been flushed. Obviously, it's early days in changing the practice here but it would be lovely to get patients and carers involved in supporting our ability to remember to do that. A kindly reminder from our patients will really help us to to get this practice 
right.

Related reading

• How antibiotic underdosing affected my mum’s end of life care: An interview with Ashleigh Hughes
• Short-term intermittent IV antibiotics – Understanding the issue of under delivery
• Understanding the importance of accurate antibiotic administration through an IV administration set (drip): A patient’s guide
• Antibiotic underdosing and disposal in NHS organisations across Great Britain (20 November 2023)

About the Author

Ruth has been nursing for forty years, with 36 of these spent in critical care. She has had the privilege to have worked in a variety of critical care units in and around London and has enjoyed the experience and opportunities that she has encountered over the years. Ruth has a strong focus on developing processes and practices that underpin patient safety and promote care delivery to attain the best patient outcomes and experiences. Staff wellbeing is also a high priority for Ruth, as patient care is co-dependent on the caring and committed high-functioning nursing teams that she works with.