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Antimicrobial stewardship

About

What is covered

This interactive flowchart covers systems and processes for effective antimicrobial medicine use, and interventions to change people's behaviour to help reduce antimicrobial resistance and stop the spread of resistant microbes.

Who is it for?

  • Organisations commissioning (for example, clinical commissioning groups or local authorities), providing or supporting the provision of care (for example, national or professional bodies, directors of public health, health and wellbeing boards, healthcare trusts and locum agencies).
  • Organisations and individuals with responsibility for providing information and advice to the public, including local authority public health teams.
  • Health and social care practitioners.
  • Childcare and education providers.
  • Adults, young people and children (including neonates) using antimicrobials or those caring for these groups. This includes people and organisations involved with the prescribing and management of antimicrobials in health and social care settings, including prescribers, primary care and community pharmacy teams.
  • The general public.
The guidance may also be relevant to individual people and organisations delivering non-NHS healthcare services, and to other devolved administrations.
It is anticipated that health and social care providers and commissioners of services will need to work together to ensure that patients benefit from the good practice recommendations in this guidance.

Updates

Updates to this interactive flowchart

24 January 2017 Antimicrobial stewardship: changing risk-related behaviours in the general population (NICE guideline NG63) added.
21 April 2016 Antimicrobial stewardship (NICE quality standard 121) added.
9 February 2016 Tests for rapidly identifying bloodstream bacteria and fungi (LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay) (NICE diagnostics guidance 20) added to clinical assessment.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to clinical assessment.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on effective antimicrobial medicine use and preventing the spread of resistant microbes in an interactive flowchart

What is covered

This interactive flowchart covers systems and processes for effective antimicrobial medicine use, and interventions to change people's behaviour to help reduce antimicrobial resistance and stop the spread of resistant microbes.

Who is it for?

  • Organisations commissioning (for example, clinical commissioning groups or local authorities), providing or supporting the provision of care (for example, national or professional bodies, directors of public health, health and wellbeing boards, healthcare trusts and locum agencies).
  • Organisations and individuals with responsibility for providing information and advice to the public, including local authority public health teams.
  • Health and social care practitioners.
  • Childcare and education providers.
  • Adults, young people and children (including neonates) using antimicrobials or those caring for these groups. This includes people and organisations involved with the prescribing and management of antimicrobials in health and social care settings, including prescribers, primary care and community pharmacy teams.
  • The general public.
The guidance may also be relevant to individual people and organisations delivering non-NHS healthcare services, and to other devolved administrations.
It is anticipated that health and social care providers and commissioners of services will need to work together to ensure that patients benefit from the good practice recommendations in this guidance.

Updates

Updates to this interactive flowchart

24 January 2017 Antimicrobial stewardship: changing risk-related behaviours in the general population (NICE guideline NG63) added.
21 April 2016 Antimicrobial stewardship (NICE quality standard 121) added.
9 February 2016 Tests for rapidly identifying bloodstream bacteria and fungi (LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay) (NICE diagnostics guidance 20) added to clinical assessment.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to clinical assessment.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Antimicrobial stewardship (2016) NICE quality standard 121
Fungitell for antifungal treatment stratification (2017) NICE medtech innovation briefing 118

Quality standards

Antimicrobial stewardship

These quality statements are taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice for antimicrobial stewardship and should be read in full.

Quality statements

Advice on self-limiting conditions

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

People with a self-limiting condition, as assessed by a primary care prescriber, receive advice about self-management and adverse consequences of overusing antimicrobials.

Rationale

People with common colds, sore throat, flu, otitis media and other self-limiting conditions may not know that they are likely to get better without treatment and they may expect to be prescribed an antimicrobial. Primary care prescribers should manage people’s expectations by describing the adverse consequences of using antimicrobials when they are not needed, both for the person and the population as a whole. They should also give advice on what the person can do to help their condition improve (self-management).

Quality measures

Structure
a) Evidence of local arrangements to ensure that people with a self-limiting condition, as assessed by a primary care prescriber, receive advice about self-management and adverse consequences of overusing antimicrobials.
Data source: Local data collection.
b) Evidence of local arrangements to promote self-management of self-limiting conditions and raise awareness of risks associated with overusing antimicrobials.
Data source: Local data collection.
Process
a) Proportion of presentations in primary care assessed as a self-limiting condition with a record stating that advice about self-management was given.
Numerator – the number in the denominator with a record stating that advice about self-management was given.
Denominator – the number of presentations in primary care assessed as a self-limiting condition.
Data source: Local data collection and TARGET Antibiotics toolkit.
b) Proportion of presentations in primary care assessed as a self-limiting condition with a record stating that advice about the adverse consequences of overusing antimicrobials was given.
Numerator – the number in the denominator with a record stating that advice about the adverse consequences of overusing antimicrobials was given.
Denominator – the number of presentations in primary care assessed as a self-limiting condition.
Data source: Local data collection.
Outcome
Antimicrobial prescribing rates in primary care.
Data source: Local data collection.

What the quality statement means for service providers, prescribers and commissioners

Service providers (such as GP practices, health centres, pharmacies, community services) ensure that systems are in place for people with a self-limiting condition to receive advice about self-management and the adverse consequences of overusing antimicrobials.
Prescribers in primary care (such as GPs, nurses and pharmacists) ensure that they provide people with a self-limiting condition with advice on self-management and the adverse consequences of overusing antimicrobials.
Commissioners (clinical commissioning groups, NHS England) ensure that they commission services that provide people with a self-limiting condition with advice on self-management and the adverse consequences of overusing antimicrobials.

What the quality statement means for patients, people using services and carers

People with a condition that is likely to get better on its own (such as cold, flu, earache or tonsillitis) who go to a GP, practice nurse or pharmacist are given advice on what they can do to help their condition improve and why it’s important only to use antimicrobials when they are really needed.

Source guidance

Antimicrobial stewardship (2015) NICE guideline NG15, recommendation 1.1.31

Definitions of terms used in this quality statement

Self-limiting condition
A self-limiting condition is likely to resolve without antimicrobial treatment. Self-limiting conditions include acute otitis media, acute cough, acute bronchitis, acute sore throat, acute pharyngitis, acute tonsillitis, acute rhinosinusitis and the common cold.
[Respiratory tract infections (self-limiting): prescribing antibiotics (2008) NICE guideline CG69 (full guideline) and expert opinion]
Advice for people with self-limiting conditions
Prescribers should discuss with the person and/or their family members or carers (as appropriate):
  • the likely nature of the condition
  • why prescribing an antimicrobial may not be the best option
  • alternative options to prescribing an antimicrobial
  • their views on antimicrobials, taking into account their priorities or concerns about their current illness and whether they want or expect an antimicrobial
  • the benefits and harms of immediate antimicrobial prescribing
  • how long they should expect the symptoms of their self-limiting condition to last
  • what they should do if their condition gets worse (safety netting advice) or if they have problems as a result of treatment
  • what they can do to minimise spreading the infection to others (such as good hand hygiene).
[Antimicrobial stewardship (2015) NICE guideline NG15, recommendation 1.1.31 and expert opinion]

Equality and diversity considerations

Healthcare professionals may need to consider how to advise people who have difficulties understanding the information given to them because of difficulty in understanding English or cognitive impairment.

Back-up (delayed) prescribing

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

Prescribers in primary care can use back-up (delayed) antimicrobial prescribing when there is clinical uncertainty about whether a condition is self-limiting or is likely to deteriorate.

Rationale

When there is clinical uncertainty about whether a condition is self-limiting or is likely to deteriorate, back up prescribing (also known as delayed prescribing) offers healthcare professionals an alternative to immediate antimicrobial prescribing. It encourages self-management as a first step, but allows a person to access antimicrobials without another appointment if their condition gets worse.

Quality measures

Structure
Evidence of local arrangements to ensure that prescribers in primary care can use back-up (delayed) antimicrobial prescribing if there is uncertainty about whether a condition is self-limiting or is likely to deteriorate.
Data source: Local data collection.
Process
a) Proportion of prescriptions for antimicrobials issued as a back-up (delayed) prescription.
Numerator – the number in the denominator issued as a back-up (delayed) prescription.
Denominator – the number of prescriptions for antimicrobials issued.
Data source: Local data collection.
b) Proportion of people issued a back-up (delayed) prescription for antimicrobials who are advised when to use the prescription.
Numerator – the number in the denominator who are told when to use the prescription.
Denominator – the number of people issued a back-up (delayed) prescription for antimicrobials.
Data source: Local data collection and TARGET Antibiotics toolkit.
Outcome
a) Back-up (delayed) prescriptions for antimicrobials that are dispensed.
Data source: Local data collection.
b) Antimicrobial prescribing rates in primary care.
Data source: Local data collection.

What the quality statement means for service providers, prescribers, and commissioners

Service providers (such as GP practices, health centres, pharmacies) ensure that systems are in place to allow back-up (delayed) antimicrobial prescribing if there is uncertainty about whether a condition is self-limiting or is likely to deteriorate.
Prescribers in primary care (such as GPs, nurses, pharmacists) can use back-up (delayed) antimicrobial prescribing if there is uncertainty about whether a condition is self-limiting or is likely to deteriorate.
Commissioners (clinical commissioning groups, NHS England) allow and monitor the use of back-up (delayed) antimicrobial prescribing when there is uncertainty about whether a condition is self-limiting or is likely to deteriorate.

What the quality statement means for patients, people using services and carers

People with conditions that may need antimicrobial treatment, but may get better without treatment, are told that they can have a prescription for an antimicrobial but they should only use it if their condition gets worse. This is known as a back-up or delayed prescription. They are given clear advice about when they should use the prescription.

Source guidance

Antimicrobial stewardship (2015) NICE guideline NG15, recommendation 1.1.34

Definitions of terms used in this quality statement

Back-up (delayed) prescribing
A back-up (delayed) prescription is a prescription (which can be post-dated) given to a patient or carer, with the assumption that it will not be dispensed immediately, but in a few days if symptoms worsen.
When using back-up (delayed) antibiotic prescribing, patients should be offered:
  • reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects (for example, diarrhoea, vomiting and rash)
  • advice about using the back-up (delayed) prescription if symptoms get significantly worse
  • advice about how long they should expect their symptoms to last
  • advice about re-consulting if symptoms get significantly worse despite using the back-up (delayed) prescription.
A back-up (delayed) prescription with instructions about use can either be given to the patient or left at an agreed location (for example, the local pharmacy) to be collected at a later date.
[Respiratory tract infections (self-limiting): prescribing antibiotics (2008) NICE guideline CG69, recommendation 1.1.6 and expert opinion]

Equality and diversity considerations

Prescribers may need to consider how to advise people who have difficulties in understanding the information given to them because of difficulty in understanding English or cognitive impairment.

Recording information

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

People prescribed an antimicrobial have the clinical indication, dose and duration of treatment documented in their clinical record.

Rationale

Recording in patients’ records the clinical indication (that is, the results of clinical assessment, symptoms and diagnosis) for an antimicrobial, and the prescribed dose and duration of treatment, allows better management during follow-up of care and transfer of care to another setting. It also supports monitoring of prescribing practice and identification of appropriate and inappropriate prescribing in all settings.

Quality measures

Structure
Evidence of local arrangements and processes to ensure that all prescribers document the clinical indication, dose and duration of treatment in patients’ records when prescribing an antimicrobial.
Data source: Local data collection.
Process
Proportion of prescriptions for antimicrobials with the clinical indication, dose and duration of treatment documented.
Numerator – the number in the denominator with the clinical indication, dose and duration of treatment documented.
Denominator – the number of prescriptions for antimicrobials.
Data source: Local data collection, Start smart then focus tools and TARGET Antibiotics toolkit.
Outcome
Antimicrobial prescribing rates.
Data source: Local data collection.

What the quality statement means for service providers, prescribers, and commissioners

Service providers (such as hospitals, walk-in centres, GP practices, health centres, dental care providers, pharmacies, community services) monitor standards of record-keeping to check that clinical indication, dose and duration of treatment are documented when antimicrobials are prescribed.
Prescribers document in patients’ clinical records the clinical indication, dose and duration of treatment when they prescribe antimicrobials.
Commissioners (clinical commissioning groups, NHS England) ensure that services monitor standards of record-keeping to check that clinical indication, dose and duration of treatment are documented when antimicrobials are prescribed.

What the quality statement means for patients, people using services and carers

People who are prescribed an antimicrobial have the reason recorded in their medical record, as well as how long they should take the antimicrobial and the dose.

Source guidance

Antimicrobial stewardship (2015) NICE guideline NG15, recommendations 1.1.26 and 1.1.32

Microbiological samples

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

People in hospital who are prescribed an antimicrobial have a microbiological sample taken and their treatment reviewed when the results are available.

Rationale

Analysing microbiological samples allows more targeted and effective prescribing of narrow spectrum antimicrobials or stopping antimicrobials if they are not necessary or effective. In hospital, microbiological samples should be taken before antimicrobials are prescribed. In some situations, it may be necessary to start antimicrobial treatment immediately (for example, in people with severe sepsis or life-threatening infections) but the treatment should be reviewed when the microbiological results are available.

Quality measures

Structure
Evidence of local arrangements and processes to ensure that people in hospital who are prescribed an antimicrobial have a microbiological sample taken and their treatment reviewed when the results are available.
Data source: Local data collection, Start smart then focus toolkit and TARGET Antibiotics toolkit.
Process
a) Proportion of prescriptions for antimicrobials issued to people admitted to hospital with a record of a microbiological sample being taken.
Numerator – the number in the denominator with a record of a microbiological sample being taken.
Denominator – the number of prescriptions for antimicrobials issued to people admitted to hospital.
Data source: Local data collection.
b) Proportion of prescriptions for antimicrobials issued to people admitted to hospital and reviewed when microbiological results become available.
Numerator – the number in the denominator reviewed when the microbiological results become available.
Denominator – the number of prescriptions for antimicrobials issued to people admitted to hospital with a record of a microbiological sample being taken.
Data source: Local data collection.
Outcome
a) Altered or withdrawn prescriptions for antimicrobials following microbiological results showing lack of effectiveness of initial antimicrobial treatment.
Data source: Local data collection.
b) Antimicrobial prescribing rates in hospitals.
Data source: Local data collection.
c) Length of hospital stay.
Data source: Local data collection.

What the quality statement means for service providers, prescribers, and commissioners

Service providers (hospitals) ensure that systems are in place for people in hospital to have a microbiological sample taken before they are prescribed an antimicrobial, and have the treatment reviewed when the microbiological results are available.
Prescribers in hospitals ensure that microbiological samples are taken before they prescribe antimicrobials and that they review the treatment when the microbiological results are available.
Commissioners (clinical commissioning groups, NHS England) ensure that they commission services that take microbiological samples from people in hospital before they are prescribed antimicrobials, and that review the treatment when the microbiological results are available.

What the quality statement means for patients, people using services and carers

People who are in hospital have a sample taken before they are prescribed an antimicrobial to find out what is causing the infection. They may be given an antimicrobial immediately, but once the test results come back the prescription is checked to make sure that the antimicrobial is the right one and will work against the infection.

Source guidance

Antimicrobial stewardship (2015) NICE guideline NG15, recommendations 1.1.27 and 1.1.29

Data collection and feedback

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.

Quality statement

Individuals and teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber, team, organisation and commissioner level.

Rationale

Monitoring and reviewing prescribing data enables individuals and teams responsible for antimicrobial stewardship to check adherence to local formularies, provide feedback, recognise good practice and to challenge inappropriate prescribing. It also allows peer review, and identifying training needs and areas for quality improvement.

Quality measures

Structure
a) Evidence of local arrangements to deliver an antimicrobial stewardship programme.
Data source: Local data collection.
b) Evidence of local arrangements and processes to ensure that individuals and teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber, team, organisation and commissioner level.
Data source: Local data collection.
Process
a) Proportion of prescribers who receive feedback on their antimicrobial prescribing practice.
Numerator – the number in the denominator who receive feedback on their antimicrobial prescribing practice.
Denominator – the number of prescribers.
Data source: Local data collection.
b) Proportion of teams within an organisation that receive feedback on their antimicrobial prescribing practice.
Numerator – the number in the denominator that receive feedback on their antimicrobial prescribing practice.
Denominator – the number of teams prescribing antimicrobials within an organisation.
Data source: Local data collection.
c) Proportion of organisations within a specified commissioning area that receive feedback on their antimicrobial prescribing practice.
Numerator – the number in the denominator that receive feedback on their antimicrobial prescribing practice.
Denominator – the number of organisations prescribing antimicrobials within a specified commissioning area.
Outcome
Antimicrobial prescribing rates.

What the quality statement means for service providers, prescribers, and commissioners

Service providers (such as hospitals, GP practices, walk-in centres, dental practices, pharmacies, community health services) ensure that systems are in place for individuals and teams responsible for antimicrobial stewardship within the service to monitor data and provide feedback on prescribing at prescriber, team, organisation and commissioner level. The frequency and specific content of the feedback should be agreed locally between commissioners and service providers.
Prescribers receive feedback on their individual antimicrobial prescribing practice and the antimicrobial prescribing practice of their team, organisation and commissioning group from individuals and teams responsible for antimicrobial stewardship within the organisation.
Commissioners (clinical commissioning groups, NHS England) ensure that they commission services that have individuals and teams responsible for antimicrobial stewardship who monitor data and provide feedback on antimicrobial prescribing practice at prescriber, team, organisation and commissioner level. The frequency and specific content of the feedback should be agreed locally between commissioners and service providers.

What the quality statement means for patients, people using services and carers

People receive care from healthcare professionals whose prescribing of antimicrobials is monitored to make sure that it is safe and appropriate.

Source guidance

Antimicrobial stewardship (2015) NICE guideline NG15, recommendations 1.1.1 and 1.1.3

Definitions of terms used in this quality statement

Antimicrobial stewardship
The term ‘antimicrobial stewardship’ is defined as an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness.
[Antimicrobial stewardship (2015) NICE guideline NG15]

Electronic prescribing systems: developmental

This quality statement is taken from the antimicrobial stewardship quality standard. The quality standard defines clinical best practice in antimicrobial stewardship and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

Prescribers in secondary and dental care use electronic prescribing systems that link indication with the antimicrobial prescription.

Rationale

Although most GP practices already use electronic prescribing systems, many secondary care services (inpatient and outpatient) and dental care settings don’t have access to this technology. Linking the indication with the antimicrobial prescription using electronic prescribing supports antimicrobial stewardship by highlighting inappropriate prescribing, and monitoring individual prescribing practice.

Quality measures

Structure
Evidence of local arrangements to ensure that prescribers of antimicrobials in secondary care and dental care settings have access to electronic prescribing systems that link indication with the antimicrobial prescription.
Data source: Local data collection.
Process
a) Proportion of secondary care services using electronic prescribing systems that link the indication with the antimicrobial prescription.
Numerator – the number in the denominator using electronic prescribing systems that link the indication with the antimicrobial prescription.
Denominator – the number of secondary care services.
Data source: Local data collection.
b) Proportion of dental practices using electronic prescribing systems that link the indication with the antimicrobial prescription.
Numerator – the number in the denominator using electronic prescribing systems that link the indication with the antimicrobial prescription.
Denominator – the number of dental practices.
Data source: Local data collection.
Outcome
Antimicrobial prescribing rates.

What the quality statement means for service providers, prescribers, and commissioners

Service providers (such as hospitals and dental practices) ensure that prescribers of antimicrobials have access to electronic prescribing systems that link indication with the antimicrobial prescription.
Prescribers use electronic prescribing systems that link indication with the antimicrobial prescription.
Commissioners (clinical commissioning groups, NHS England) ensure that they commission services with electronic prescribing systems that link indication with the antimicrobial prescription.

What the quality statement means for patients, people using services and carers

People receive care from healthcare services that have electronic systems for prescribing. These systems support prescribing of antimicrobials according to diagnosis as well as local and national guidance on antimicrobial use.

Source guidance

Antimicrobial stewardship (2015) NICE guideline NG15, recommendation 1.1.32

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

loss of effectiveness of any anti-infective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines
an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness
any anti-infective therapy (antiviral, antifungal, antibacterial and antiparasitic medicines) and any formulation (oral, parenteral and topical agents)
all anti-infective therapies (antiviral, antifungal, antibacterial and antiparasitic medicines) and all formulations (oral, parenteral and topical agents)
a preparation applied to the hands to reduce the number of viable microorganisms. This guidance refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol)
preparations applied to the hands to reduce the number of viable microorganisms. This guidance refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol)
the wider care team, including but not limited to, case managers, care coordinators, GPs, hospital doctors, microbiologists, pharmacists, nurses and social workers
'inappropriate antimicrobial demand' refers to people asking for antimicrobials for conditions against which they are ineffective (for example antibiotics to treat a viral infection such as a cold) or for self-limiting infections that will resolve on their own, with no long-term harm to the person's health. 'Inappropriate antimicrobial use' refers to the way in which people may misuse antimicrobials that they have been prescribed or supplied with, and which may result in the antimicrobials becoming ineffective in treating infections. This is because the bacteria, virus, fungus or parasite they are designed to treat may become resistant to the antimicrobial. Examples of inappropriate use include not taking or using the antimicrobials as prescribed and sharing them with others
for example, a drug and therapeutics committee, area prescribing committee or local formulary decision-making group
services that can advise people whether they have a self-limiting infection that they can safely manage themselves or whether their infection needs medical attention. Examples include community pharmacies, practice nurses, 111, other locally developed advice and helplines, and emergency and out-of-hours primary care services
includes all commissioners (clinical commissioning groups and local authorities) and providers (hospitals, GPs, out-of-hours services, dentists and social enterprises) of health or social care services, unless specified otherwise. Occasionally, in order to make a recommendation more specific to the intended care setting, the setting is specified; for example the recommendation will state 'hospital'
evidence-based materials that have been developed through a research-based approach with the target audience, wherever possible. They may be in a variety of formats, including posters, leaflets, digital and online resources
advising people what to do if their condition deteriorates or does not improve within a certain time, or if they develop adverse effects as a result of the treatment
approaches a person can use to look after themselves in a healthy way; for example, drinking plenty of fluids and getting sufficient rest when you have a cold
an infection that resolves on its own and has no long-term harmful effect on a person's health (assuming that they are not immunosuppressed). Examples include colds, flu, oral thrush, winter vomiting bug
infections that resolve on their own and have no long-term harmful effect on a person's health (assuming that they are not immunosuppressed). Examples include colds, flu, oral thrush, winter vomiting bug

Paths in this pathway

Pathway created: August 2015 Last updated: August 2017

© NICE 2017

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