Consensus based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education

Aim: To provide United Kingdom national consensus on a common set of AMS competencies appropriate for undergraduate healthcare professional education.

The AMS competencies that were developed from this work support the optimal use of antibiotics. These competencies also support the implementation of recommendations in the NICE guideline on antimicrobial stewardship (NG15) and statements 1, 3 and 4 in the NICE quality standard for antimicrobial stewardship (QS121)

Antimicrobial resistant infections cause approximately 700,000 deaths each year globally and this figure is predicted to rise to 10 million, alongside a cumulative cost of $100 trillion, by 2050 if no action is taken. [1] Antimicrobial stewardship (AMS) is defined as 'an organisational or healthcare‑system‑wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness.' [2]

The education of undergraduate healthcare professional students on antimicrobial stewardship (AMS) is a key activity for the containment of antimicrobial resistance. [3] However, UK undergraduate healthcare professional students receive disparate stewardship education, [4] and there is a need to adopt a comprehensive approach with standardised content. [4] A shift toward assessment of quality and outcomes of care has meant that healthcare professional curricular content is now associated with competencies. [5] Competency based education (CBE) recognizes that quality of care is not improved simply by accumulating and disseminating the best available evidence, [6] but instead, with the increasing emphasis on person-centred care, it is necessary for clinicians to respond to patients’ needs in a compassionate, knowledgeable, and coordinated fashion. [7] Although AMS competencies have been developed for United Kingdom (UK) prescribers, [8] specific competencies designed to address the spectrum of AMS activities (such as the administration and supply of antibiotics, and monitoring of patients for effectiveness of treatment and adverse effects), in which those healthcare professionals who do not prescribe are involved, have not been established. Undergraduate education provides an important opportunity to prepare healthcare professionals for these activities. Furthermore, it will become increasingly important to strengthen AMS in undergraduate healthcare professional education as less experienced healthcare professionals are able to access shortened post registration prescribing programmes. [9]

References

1.  HM Government (2019) Tackling antimicrobial resistance 2019-2024 – The UK’s five-year national action plan. Accessed 11 February 2019
2. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE 2018
3. Global action plan on antimicrobial resistance, 2016 http://apps.who.int/iris/bitstream/10665/193736/1/9789241509763_eng.pdf?ua=1
4. Castro-Sánchez, E., Drumright, L.N., Gharbi, M., Farrell, S., Holmes, A.H. Mapping Antimicrobial Stewardship in Undergraduate Medical, Dental, Pharmacy, Nursing and Veterinary Education in the United Kingdom. PLoS ONE 2016,11(2): e0150056. doi:10.1371/journal.pone.0150056 
5. Gruppen, L.D., Mangrulkar, R.S., Kolars, J.C. The promise of competency-based education in the health professions for improving global health. Human Resources for Health 2012,10(1),43.
6. Rathert, C., Wyrwich, M.D., Boren, S.A. Patient-centered care and outcomes: A systematic review of the literature. Medical Care Research and Review 2012, 70(4), 351-379. doi: 10.1177/ 1077558712465774.
7. Gachoud, D., Albert, M., Kuper, A., Stroud, L., Reeves, S. Meanings and perceptions of patient-centredness in social work, nursing and medicine: a comparative study. Journal of Interprofessional Care 2012, 26, 484-490
8. Antimicrobial prescribing and stewardship competencies. London: PHE. 2013 ref 8
9. Standards for prescribing programmes. 2018 https://www.nmc.org.uk/standards/standards-for-post-registration/standards-for-prescribers/standards-for-prescribing-programmes/

SCRIPT is a web-based eLearning programme delivering a portfolio of modules to improve prescribing competency.  The SCRIPT portfolio contains three modules relating to the management of infection for Foundation trainee doctors across England, Wales and Northern Ireland: 1) Principles of prescribing in Infection; 2) Infection in Secondary Care; and 3) Sepsis.  The modules are also available to 14 UK Medical schools to facilitate the delivery of therapeutics teaching and to help students prepare for the national Prescribing Safety Assessment.  Additionally, variants of the modules are available to Paediatric Specialist Trainees, General Practitioners, Nurses, Paramedics and non-medical prescribing Pharmacists, adapted specifically for each audience.

Project aim

Upon publication of the antimicrobial stewardship competencies, the SCRIPT team mapped the competencies to their module content to determine if there were any gaps in content taught that needed to be resolved. The aim of this submission is to describe this mapping process so that those involved in the development of curricula for healthcare professionals will be encouraged to review their current AMS teaching and adjust this accordingly.  In addition, healthcare organisations may be encouraged to review the mandatory training they provide for staff on AMS and adapt their content to ensure the competency descriptors are met.

The 54 competency descriptors were assessed independently by two members of the SCRIPT Editorial team to determine if they were covered in the learning content of one or more of the three infection modules, or if they were covered by any other module in the SCRIPT portfolio.  Each competency was scored for each module as either green (outcome covered); amber (outcome partially covered); or red (outcome not covered).  Any descriptors assigned as an amber were checked by a second editor and any disagreement discussed. The Editorial Lead for the SCRIPT team then ran an independent check on the results. A total of 21/54 competencies were scored as green and 9/54 as amber, giving 59.3% (n=31/54) of competencies covered or partially covered by the content in the three modules.  A further 9/54 were covered by modules elsewhere in the SCRIPT portfolio, for example, ‘Explain why it is essential that an accurate diagnosis of an allergy to an antimicrobial is based on history and laboratory tests’ is covered in the Drug Allergy and Anaphylaxis module and ‘Demonstrate an understanding of the rationale and use of perioperative prophylactic antimicrobials to prevent surgical site infection’ in the Perioperative Prescribing module.

Since the SCRIPT modules relate to prescribing and therapeutics, the Editorial team then reviewed all 54 of the outcomes to determine whether they should potentially be included in the module content or whether they were not applicable to the overall aims of the learning portfolio. A total of 6/54 were considered not applicable. Out of the 48 for potential inclusion, 6 were already partially included in the content, but 12 were not included at all.  These 18 were sent to three editors to independently review whether they should be included in one of more of the three infection modules.  A total of 9/19 were considered applicable for inclusion, four of which were partially included in the content already, leaving five to be incorporated into the module content (Table 1).

Table 1: Competency descriptors to be included in SCRIPT eLearning module content

*Competencies partially covered by the eLearning content in one or more of the three infection modules

It is important to note that using the modality of eLearning, competencies such as ‘demonstrate’ and ‘communicate’ cannot be achieved or assessed, however the content relating to these descriptors can certainly be discussed.  For example, Demonstrate an understanding of the roles, responsibilities, and competencies of other health professionals involved in antimicrobial treatment policy decisions, can be approached by discussing the roles and responsibilities of those involved in the process. 

Achieving the missing competencies

For each of the competencies in Table 1, content has been authored by the Editorial team as either case vignettes, activities or text content to ensure each are appropriately covered.  An example has been provided for incorporating ‘delayed prescribing’.

Describe what is meant by delayed prescribing

A case vignette has been added to the Principles of Prescribing in Infection module to discuss when a delayed prescription may be appropriate.  The case also discusses self-management strategies to treat the self-limiting infection (i.e. analgesia/rest/fluids), which touches on a second competency in (see Table 1).

In the context of eLearning, it is important to ensure that information presented to the learner is up-to-date and comprehensive. The AMS competencies provided an opportunity to assess the completeness of our portfolio of content in relation to infection, to ensure that we are achieving agreed standards for undergraduates (and therefore postgraduates).  Like any field of medicine, both the eLearning content and the competencies require regular review to ensure these reflect current practice, the prescribing landscape and any global health concerns.

We would recommend our approach in the review of undergraduate curricular and associated teaching content to determine whether schools or programmes are providing the learning needed to meet the competencies. In addition, healthcare organisations could use the competencies to review the mandatory training they provide on the topic.  Ideally, such reviews should be conducted independently with more than one person and verified by a third to ensure a robust review process.