• To recognise the reasons why medicines-related harm remains an issue
• To refresh your knowledge of the aims of medicines optimisation
• To identify potential strategies that you could use in your area of practice to reduce the risk of medicines-related harm

Key points

• Most adverse drug reactions are due to known side effects, and are predictable, dose-dependent and potentially preventable
• The shift from medicines management to the patient-focused outcomes of medicines optimisation means increased engagement in pharmacotherapeutics for all healthcare professionals, including nurses
• Despite the recommendations aimed at promoting medicines optimisation, medicines-related harm persists among patients
• Potential strategies for reducing medicines-related harm include monitoring patients, structured multidisciplinary working, patient involvement and promoting a nurse-led approach

• Principle 1. Aim to understand the patient’s experience. 
• Principle 2. Evidence based choice of medicines.
• Principle 3. Ensure medicines use is as safe as possible. 
• Principle 4. Make medicines optimisation part of routine practice. 

Key updates include:

• new advice for doctors to stop prescribing controlled drugs without access to patient records, except in emergencies.
• stronger advice on information sharing, making it clear that if a patient refuses consent to share information with other health professionals it may be unsafe to prescribe. 
• alignment with our updated ‘Decision making and consent’ guidance, highlighting the importance of good two-way dialogue between patients and doctors in all settings. 
• updated advice on treating patients based overseas to clarify doctors may need to register in the country where they are based, where the patient is based, and where prescribed medicines are to be dispensed.

Zambia is lower-middle income country but has a very high burden of infectious diseases, including high morbidity and mortality rates from HIV, lower respiratory tract infections, malaria, diarrhoeal diseases and tuberculosis.[3],[4]University Teaching Hospital (UTH) has reported very high AMR rates to a variety of key antimicrobials and while they were aware of antimicrobial stewardship they didn’t proactively engage with it.

WHO has developed an AMS framework with four key components: AMR awareness, appropriate use of antimicrobials, infection prevention and control, and surveillance. Using this framework, our small team from Brighton & Sussex University Trust, UTH and UNZA organised a stakeholders meeting and ‘train the trainers’ event to develop key interventions to improve antimicrobial stewardship at UTH. The three-day event was held in June 2019 in Lusaka and had excellent engagement from doctors, pharmacists and environmental health professionals from UTH plus representatives from Zambian Ministry of Health, THET, Hospital Pharmacist Association of Zambia, University of Zambia and Zambian Medicines Regulatory Authority.

The three-day event was a hive of energy, highlighting the Zambian interest and commitment to AMS and improving outcomes for their people, from grass roots to ministerial level. The main outcomes from the event were:

• To conduct global point prevalence survey (GPPS) for antimicrobial surveillance.
• To develop and implement an antimicrobial specific drug chart which can improve prescribing practices.
• To implement a bare below the elbows (BBE) dress code change to improve infection prevention and control.
• To implement an infection prevention and control and antimicrobial stewardship training programme. 
• To employ an antimicrobial specialist pharmacist to be the guardian of above outcomes.

Data collection was a daunting task for our UTH colleagues, so while in Zambia we volunteered to help with data collection for the GPPS pilot. This was a huge success, highlighting how quick and simple the process could be plus the useful data outputs it enabled. From this, we were able to get first-hand experience in UTH, which was invaluable for future programme development; the hospital is huge and sprawling, with little or no access to computers. Six-bedded bays held 11-beds and outpatient pharmacy requests were often above 700 per day. BBE and infection prevention and control were not present, with staff having to wear long-sleeved white lab coats and hand sanitising stations being woefully lacking. Despite these conditions all staff were committed to patient care and safety, and their enthusiasm for improvement has led to speedy employment of an antimicrobial pharmacist at UTH plus development of UTH antimicrobial guidelines, both of which will improve antimicrobial usage. 

One of our first priorities has been infection prevention and control implementation by utilising neighbouring Ndola Teaching Hospital's experience to conduct more ‘train the trainers’ sessions on handwashing technique, alcohol gel production and use, and BBE requirements. Uniquely we have organised this at hospital level (rather than external workshops) as we have found a larger and more diverse cadre of hospital staff are then able to attend (including nurses, porters and cleaning staff) and minimises patient care disruption and enables a whole hospital approach plus doesn’t require unobtainable technology. These trainers will now disseminate this information among their colleagues and an audit of implementation and practice is planned.

Our second drive is implementation of the antimicrobial drug chart with GPPS to determine if the additional chart is effective in improving antimicrobial use. 

All these initiatives require training to ensure staff are aware of the importance of the initiative and its intended outcomes. We are also now exploring ways to make antimicrobial stewardship training mandated during staff induction. Once this baseline knowledge is established, we can continue to develop more complex training to develop skills and knowledge further and support clinical excellence.

We have overcome many challenges to produce these outputs. The distance, lack of conference calling ability and rolling electricity shortages could make communication difficult, but we have employed weekly Zoom calls plus Trello online storage, which require smartphones only, to overcome these issues and this has been very successful and kept us to deadlines. Additionally, we have aimed for the Brighton & Sussex University Trust role to be supportive rather than directive to ensure that projects are owned and used by UTH colleagues and so more sustainable. We have tried to ensure that all tools are culturally appropriate and so more likely to be engaged with, such as newly developed infection prevention and control posters that have UTH staff promoting the initiative. During the workshop we noted Zambian staff enjoyed learning through games and case studies and so (in collaboration with Focus games) we have developed a Sepsis; Zambia board game and are now developing case studies using the new UTH antimicrobial guidelines.

A reciprocal visit for UTH staff to experience life in the NHS was also arranged; this has included attendance on ward rounds, shadowing of staff, education observations (in Trust and at local university) and the UKCPA conference. Our feedback sessions have highlighted that there are more commonalities between our hospitals than differences; while the diseases and drugs may be different we are all working in resource tight settings trying to do the best for our patients. A repeating feedback theme though was that there was a more cohesive multi-disciplinary approach to antimicrobial stewardship at Brighton & Sussex University Trust and UTH would like to emulate this; we hope this has been started by involving doctors in the visit, mentoring of antimicrobial stewardship pharmacist and inclusive antimicrobial stewardship / infection prevention and control training and chart development. Future suggestions included undergraduate MDT training and pharmacy induction for medics.

As expected, this project has allowed me to fulfil humanitarian aspects that I wanted to achieve. Unexpectedly, I have also seen a development in my problem-solving skills, teaching methods (especially when there is scant technology available), negotiation and leadership skills, which I can then apply to my daily job back in the NHS. Importantly this opportunity has enabled me to really feel like I am given back to the (global) community and provide immense job satisfaction in an area of important global challenge; I encourage anyone with an interest to become involved.

References:

1. World Health Organisation. 2016. https://www.who.int/bulletin/volumes/94/9/16-020916/en/ [Accessed 10/11/19].
2. World Health Organisation. Antimicrobial Resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance [Accessed 10/11/19].
3. Institute for Health Metrics and Evaluation. GBD Compare. Zambia. https://vizhub.healthdata.org/gbd-compare/ [Accessed 10/11/19].
4. World Health Organisation. Zambia: WHO Statistical Profile. https://www.who.int/gho/countries/zmb.pdf [Accessed 10/11/19].

• an e-learning module on Anti microbial resistance (AMR)
• shared learning articles from other trusts
• a video explaining what AMR is
• a range of blogs
• leaflets and infographics
• quizzes.

• Seven health literacy tools for pharmacy:

1. Pharmacy Health Literacy Assessment Tool & User's Guide.
2. Training Program for Pharmacy Staff on Communication.
3. Guide on How To Create a Pill Card.
4. Telephone Reminder Tool To Help Refill Medicines On Time.
5. Explicit and Standardized Prescription Medicine Instructions.
6. How to Conduct a Postdischarge Followup Phone Call
7. Health literacy tools to improve communication for providers of medication therapy management

• Curricular modules for pharmacy faculty.
• Resources for pharmacists interested in understanding more about health literacy.
• Health literacy tools to improve communication for providers of medication therapy management.