Over the winter months, thousands of people across New Zealand will present to primary care with sore ears and throats, nasal and sinus congestion, coughs
and colds.* Many of these symptoms are caused by viral infections and antibiotic treatment is not appropriate. In some cases there may be bacterial
infection present but the infection will be self-limiting and the adverse effects of antibiotics may outweigh potential benefits.
While in most cases antibiotics are not required for winter illnesses, there will always be people who do need antibiotics. The challenge
is in identifying these situations. In general, antibiotic treatment for winter illnesses should be considered in people who have a known or
likely bacterial infection and are at increased risk of developing systemic complications; this includes those who are systemically very unwell,
young infants, frail elderly people or those who have co-morbidities such as immune suppression, diabetes or significant heart, lung, renal,
liver or neuromuscular disease. People with a history of hospitalisations and children of premature birth are also often at increased risk.
People with some specific infections generally require antibiotics, e.g. pneumonia, pertussis, or acute otitis media or sore throat in some patient groups.
For the majority of people with upper respiratory tract infections symptomatic treatment will offer better outcomes than antibiotics,
which will not be indicated in most cases. Providing patients or caregivers with clear information about when antibiotics are appropriate,
supportive treatments and the expected duration of symptoms can help reduce unnecessary antibiotic use over the winter period.
Refer to the bpacnz antibiotics guide for indications for antibiotic treatment for common winter illnesses:
* For the purposes of this audit, this group of symptoms will be referred to as “winter illnesses”,
but it is acknowledged that these illnesses occur at any time of the year.
This audit identifies patients who present with winter illnesses (see above) and documents their management so that clinicians can
reflect on their practice with the overall aim being to reduce inappropriate prescription of antibiotics.
Recommended audit standards
Ideally, antibiotics for winter illnesses should be prescribed for people with a known or likely bacterial infection and for those who are at
increased risk of developing systemic complications. There are also other specific conditions and clinical circumstances where antibiotics are
usually required, e.g. all people with pneumonia or pertussis and some people with sore throat, acute otitis media or sinus symptoms.
For people presenting with symptoms consistent with a common winter illness the clinical notes should reflect the likely diagnosis and
document what treatment was offered and why. For most people with winter illnesses supportive treatment options such as paracetamol,
decongestants, adequate fluid intake and rest will provide the best symptomatic relief.
Identifying eligible patients
All patients who present within the winter months with a diagnosis of a winter illness are eligible for this audit.
Searching for eligible patients electronically through your PMS will not easily work for this audit given that multiple search terms
would be required. Therefore the simplest way to identify eligible patients is to keep a tally of those who present with a winter illness
as you go through your consulting sessions over a week or two, until sufficient numbers of patients have been seen. Exclude patients who
were referred to hospital for treatment at the initial consultation.
The number of eligible patients will vary according to your practice demographic and the circulating winter illnesses at the
time of the audit. A sample size of 20–30 patients is sufficient for the purposes of this audit.
Review of treatment
For each patient who presents with a winter illness, review their notes and record the following information:
- The likely diagnosis
- Whether an antibiotic was indicated, based on a likely diagnosis of a bacterial infection and the patients individual clinical circumstances
- What treatment was provided: if advice on symptomatic treatment only was given (no antibiotic), an antibiotic was
prescribed or a “back-pocket” prescription was given. Also record if the patient returned for a follow-up visit and if
so what action was then required, e.g. different diagnosis, prescription for antibiotic, referral
Criteria for a positive outcome
A positive result is if:
- An antibiotic was not indicated and advice on symptomatic treatment only was given
- An antibiotic was indicated and prescribed or a “back pocket” prescription given
For each patient presenting with a winter illness, record if a diagnosis was made, whether an antibiotic was clinically justified and what treatment was provided.
For example, if a patient presented with symptoms consistent with a viral winter illness, and there were no other complicating factors,
then an antibiotic is not indicated and if an antibiotic was not prescribed, this is a positive result. If a patient presented with otitis media
and they had complicating factors, e.g. aged under six months, then an antibiotic is indicated, and if an antibiotic was prescribed, this is also a positive result.
The purpose of collecting data on follow-up consultations is for reflection on practice: did the diagnosis change? Is an antibiotic now indicated?
The first step to improving medical practice is to identify the criteria where gaps exist between
expected and actual performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s)?
- Change it to an aim
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- Identifying barriers can provide a basis for change
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with
them in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed
to bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as
performance and behaviour
Monitoring change and progress
It is important to review the action plan developed previously at regular intervals. It may be
helpful to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following the completion of the first cycle, it is recommended that the doctor completes the first part of the
of Medical Practice summary sheet (Appendix 1).
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order
to quantify progress on closing the gaps in performance.
It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle
should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices
complete the remainder of the Audit
of Medical Practice summary sheet.
Claiming credits for Continuing Professional Development (CPD)
This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement – CQI) for allocation of CPD
credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits
in accordance with the current CPD programme.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
Record your completion of the audit on the CPD Online Dashboard, under the Audit of Medical Practice section.
From the drop down menu select “Approved practice/PHO audit” and record the audit name.
General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.
As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).