PARTICIPATION:

1. Who can participate in the outpatient Global-PPS?

PATIENTS:

1. What are the inclusion criteria for patients?
2. Can I include only patients with a certain condition, e.g. acute respiratory syndrome?
3. How many patients should we survey?

DEPARTMENTS:

1. Which departments can participate in the survey?
2. Can multiple departments participate in the survey?
3. Do I need to survey all departments each time I participate in the survey?

PARTICIPATION

1. Who can participate in the Global-PPS?

All outpatient healthcare facilities can participate in the outpatient module, including outpatient departments, primary healthcare centres, dental clinics, day surgery wards, community healthcare centres, etc.

If you have a mixed facility or mixed departments, consisting of inpatient beds as well as outpatient beds/consultation rooms, please survey these activities separately in the Global-PPS. I.e., please survey all inpatient beds according to the inpatient module, and all outpatient beds/consultation rooms according to the outpatient module.

Pharmacies cannot participate in the Global-PPS, since our method is focused on prescribing and not dispensing patterns.

PATIENTS

1. What are the inclusion criteria for patients?

All patients seen in consultation for any reason (by appointment or without appointment) during a defined timeslot of the survey. Exclude patients who are admitted as inpatients, who require overnight admission or stay.

Important exception: if you survey emergency or observation departments, please include all patients in the survey, even if they were admitted overnight, as long as they were still present in the department during the defined timeframe of the survey. This exception is made since it is not always clear for emergency and observation departments if the patient will stay, be transferred to another department or sent home.

2. Can I include only patients with a certain condition, e.g. acute respiratory syndrome?

No, you cannot make a selection of patients. It is important that you include all patients, with all diagnoses and symptoms.

We will make sure you can filter based on diagnoses/symptoms in the outpatient extension of the interactive module, once we release this extension.

3. How many patients should we survey?

The number of patients that you should survey is flexible, although we recommend surveying for at least 4 hours, and perhaps a full day or for a few days if you have very few patients that are seen for consultation throughout the day.

This also depends on the aim of your survey: if you want to design targets for antimicrobial stewardship, it is advisable to check if you have collected a sufficient number of patients who receive an antimicrobial prescription (e.g., 30 patients). In this way, it will be easier to see if there is a certain pattern of prescribing. If you have an insufficient number of patients on antimicrobial prescriptions, it might be difficult to distinguish whether this prescription was in line with the normal prescribing behaviour in your setting, or if it was an exception.

If you want to do a very first screening of your healthcare setting to see where the most antimicrobials are prescribed, you may need a smaller number of patients with antimicrobial prescriptions than when you want to effectively design targets for stewardship.

DEPARTMENTS

1. Which departments can participate in the survey?

All outpatient departments, emergency/observation departments, general practitioner practices, dental clinics, day surgery departments, general outpatient clinics, community healthcare centres, etc., can participate.

If you have, for example, departments with both inpatients and outpatients, you can split them up and survey the outpatients in the outpatient module. There is one exception: for emergency and observation wards. These wards have to be surveyed entirely in the outpatient module, and you will have to score the admission status for each patient.

2. Can multiple departments participate in the survey?

Yes, certainly. All outpatient departments, emergency/observation departments, general practitioner practices, dental clinics, day surgery departments, general outpatient clinics, community healthcare centres, etc., can participate.

3. Do I need to survey all departments each time I participate in the survey?

No, we do recommend to survey all departments in your institution the first time you participate, to set a baseline for your entire institution. However, it is possible to survey only a few departments in your hospital. Keep in mind that you should survey all departments of the same specialty type, because we report the numbers by specialty type in the feedback report.

1. How often is the Global-PPS conducted?
2. When is the best day to conduct the survey?
3. When is the best time to conduct the survey?
4. Can data be collected retrospectively?
5. Do all departments need to be surveyed on the same day?
6. How long should the survey period be?
7. Is it possible to participate multiple times within one survey period?

1. How often is the Global-PPS conducted?

Each year, there are three survey periods: January-April, May-August, September-December.

In the outpatient module, you can participate multiple times per period, if you wish to do so. Data within one survey will be aggregated in the feedback report. However, if you wish to analyse your data at more frequent intervals than these three periods, you can download your data in Excel.

2. When is the best day to conduct the survey?

The best time to conduct a survey is on a day that is representative for your usual practice. Often, this is a weekday, not during the weekend and not on a holiday.

3. When is the best time to conduct the survey?

Please choose a time period that is most representative of your setting. If regular consultation hours are between 8 a.m. and 5 p.m., it would be best to survey in that period.

If patients need to remain after their consultation, for example, to await biomarker test results or advice from an infectious disease specialist, ensure that you follow up with them until their treatment for the survey day is confirmed. Make sure to schedule the survey during a time frame that allows you to reliably follow up with each patient until their final treatment is determined.

For example, if you often have to wait a few hours before the result of a biomarker is obtained when the treatment depends on that result, survey from e.g. 8 a.m. until 12 p.m., and follow-up all patients that were seen during this time, so that you know the results by the end of the day.

Alternatively, if you capture all information in patient files, you can retrospectively survey your institution.

4. Can data be collected retrospectively?

Yes, you can definitely collect data retrospectively, as long as you can retrieve all required information from the patient files, and as long as you survey for a consecutive period of at least 4 hours. It is important that you include all patients seen in your survey window, including patients without an antimicrobial treatment.

Please additionally make sure that all biomarker/POCT/RDT results were available at the time of the prescription. If not, please record ‘Treatment based on [biomarker][POCT/RDT]’ as ‘No’.

5. Do all departments need to be surveyed on the same day?

No, you can survey different departments on different days. But you should survey one entire department on one day.

6. How long should the survey period be?

This depends on how busy your department is. For very busy departments, it might be sufficient to survey for 4 hours. For less busy departments, it might be necessary to survey for one or multiple days, until you reach a sufficient number of patients for the analysis.

The number of patients you should survey is flexible, although we recommend that you survey e.g. at least 30 patients receiving antimicrobial treatments, in order to obtain valid results.

7. Is it possible to participate multiple times within one survey period?

Yes. Unlike the inpatient module, it is possible in the outpatient module to survey multiple times within one survey period. If you want to do so, you can include the unit multiple times within one survey.

Data within one survey will be aggregated in the feedback report. However, if you wish to analyse your data at more frequent intervals than these three periods, you can download your data in Excel.

DATA COLLECTION – GENERAL:

1. What data need to be collected for the survey?
2. How should the data be recorded and submitted?
3. Are there specific forms or templates for data collection?

DATA COLLECTION – PATIENTS:

1. What symptoms should I include?
2. Can I ask the patients for additional information after the patients left the consultation room?
3. When and how should I record admission status?
4. When should I consider a treatment based on a biomarker?
5. What if we do not have any information on previous or ongoing prescriptions?
6. How should I record the dose of an antibiotic with enzyme inhibitor?
7. How should I record fixed-dose combinations of active antimicrobials?
8. How should I report the dose for antimicrobials prescribed a few times per week?
9. How should I record the diagnosis?
10. What diagnosis should I choose for patients with sepsis of known origin, e.g. urosepsis?
11. What if an incorrect diagnosis was made and was only discovered in the audit?
12. When should I classify an infection as Community-Acquired Infection (CAI) and when as Hospital-Associated Infection (HAI)?
13. Can I record multiple diagnoses and indications?
14. How should I encode an antimicrobial prescribed for prophylaxis?
15. How should I record the Reason in Notes?
16. How should I record guideline existence?
17. How should I record guideline compliance?
18. How do I record guideline compliance for combination therapies?

DATA COLLECTION – GENERAL

1. What data need to be collected for the survey?

Essential data to collect are the patients’ age category, sex and presenting symptoms. Data on admission status should be additionally collected for emergency and observation departments.

More detailed information should be collected for each patient receiving antimicrobial treatment. This includes information on their specific age and underlying morbidities, as well as treatment-related information, such as:

• the specific antimicrobial agent,
• dose per administration,
• number of doses per day,
• route of administration,
• anatomical site of infection,
• indication of therapy (community- versus hospital-acquired infection or prophylaxis)
• whether the treatment was based on a Point-of-Care test, Rapid Diagnostic Test or biomarker, whether (blood) cultures were taken before the start of the treatment
• whether local guidelines are available for the prescribed treatment.

Denominator data are the number of patients that visited the department in the surveyed timeslot on the day of the PPS.

2. How should the data be recorded and submitted?

There are two methods for data collection: on paper forms before data entry in the web-based application, or directly in the web-based application.

1. Data should be recorded on the Unit forms and Patient forms. Please find all forms under Documentos. Please print these forms in preparation of the survey, and collect all information on these forms. Afterwards, you can enter them in the web application.
2. Alternatively, it is possible to record all data directly into the web-based application.

3. Are there specific forms or templates for data collection?

Yes, the Unit forms and Patient forms. Please find all forms under Documentos. Data entry into the web-based application follows the same logic as these data collection forms.

DATA COLLECTION – PATIENTS

1. What symptoms should I include?

You can include up to 6 symptoms per patient, but it is perfectly fine to record only the most relevant symptoms. The list with symptoms is available in our protocol and data collection forms, available under Documentos.

2. Can I ask the patients for additional information after the patients left the consultation room?

Yes, it is possible to contact them after the consultation. However, for some studies and in some settings, you would need informed consent to do so. Please check whether informed consent is needed before you contact the patient (or before you conduct the PPS).

3. When and how should I record admission status?

Admission status is a question only asked for emergency and observation wards. Please only collect this information if your patient was seen in an emergency or observation ward. Otherwise, you do not need to collect this information.

If your patient was seen in emergency or observation care, you should collect this information for all patients, including those without antimicrobial prescriptions.

Please choose between the following options:

• Already admitted if the patient was admitted in the same institution
• Suspected admission if you strongly suspect the patient will be admitted, but this did not happen yet during the survey period
• Referral to another institution if the patient was referred to another institution
• Inicio if the patient was sent home
• Unknown if it is completely unknown what happened to the patient, e.g. this was not recorded during data collection

4. When should I consider a treatment based on a biomarker?

You should consider a treatment based on a biomarker if the result of the biomarker is available at the time of the prescription on the day of the survey, and if the result solely or complementary to other clinical signs or microbiological tests contributed to the decision to treat with an antimicrobial and/or to the choice of a treatment.

Example:

• If CRP results are used as an indicator for the presence of an infection, and hence supported the decision to start an antimicrobial treatment, you can score this treatment as based on a biomarker, even though the CRP result is not used for the choice of the antimicrobial drug.
• If a biomarker result was obtained the day after the survey, or a few days after the survey, and was used for review and follow-up of the antimicrobial treatment, score the treatment as not based on a biomarker, i.e. treatment based on a biomarker is ‘no’, because this result was not available during the survey.

5. What if we do not have any information on previous or ongoing prescriptions?

At this moment, it is unfortunately not possible to record this information. Please record all new prescriptions, these will likely provide useful information for your facility.

In the future, we are planning to develop an ‘Outpatient institution profile’, where you can add more detailed information for your healthcare setting, such as lack of information on ongoing/previous antimicrobial prescriptions.

6. How should I record the dose of an antibiotic with enzyme inhibitor?

If an antibiotic with enzyme inhibitor was prescribed, such as piperacillin with tazobactam, or amoxicillin-clavulanate, please record only the dose of the antibiotic. Exclude the dose of the enzyme inhibitor. For example:

• 3.375 g piperacillin/tazobactam, of which 3 g is piperacillin. Only these 3 g should be reported.
• 1.2 g amoxicillin/clavulanic acid, of which 1 g is amoxicillin. Only the 1 g should be reported.

For fixed-dose combinations of active antimicrobials (such as co-trimoxazole), please record the dose of both antimicrobials!

7. How should I record fixed-dose combinations of active antimicrobials?

For fixed-dose combinations of active antimicrobials, such as sulfamethoxazole and trimethoprim (co-trimoxazole), please record the dose of both antibiotics. For example:

• 960 mg co-trimoxazole, of which 800 mg is sulfamethoxazole and 160 mg trimethoprim. You should report the 960 mg.

Please record fixed-dose combinations as one antimicrobial in Global-PPS! For these combination therapies, add the dose of the first antimicrobial (800 mg) to the dose of the second antimicrobial (160 mg).

Exception: if a physician prescribes two antimicrobials for one diagnosis, but this is not a fixed-dose combination (e.g. amoxicillin and clarithromycin), you should record this as two separate antimicrobials for the same diagnosis, and record for each their own dose.

A few examples of fixed-dose combinations include

• Sulfamethoxazole and trimethoprim
• Artesunate and amodiaquine
• Ampicillin and cloxacillin (“Ampiclox”)
• Rifampicin, isoniazid, pyrazinamide, and ethambutol
• Emtricitabine, tenofovir alafenamide and rilpivirine

8. How should I report the dose for antimicrobials prescribed a few times per week?

If a patient receives an ongoing antimicrobial treatment a few times a week, e.g. 3 times a week (even if the patient does not receive the treatment on the day of the survey itself), you should write down the single unit dose as the actual dose that the patient receives, but change the N doses/day to 0.5 (every other day), 0.43 (twice a week), 0.33 (every 72 hours), 0.29 (twice a week), 0.14 (once a week), etc.

Examples:

• 500 mg every other day: Single Unit Dose = 500 mg. N doses/day = 0.5 (= 1 dose / 2 days)
• 750 mg every 72 hours: Single Unit Dose = 750 mg. N doses/day = 0.33 (= 1 dose / 3 days)
• 2 g every week: Single Unit Dose = 1.2 g. N doses/day = 0.14 (= 1 dose / 7 days)
• 1 g twice a week: Single Unit dose = 1 g. N doses/day = 0.29 (= 1 dose / 3.5 days)

9. How should I record the diagnosis?

Please record the diagnosis as the reason to treat the patient. For the diagnostic code, use the list of diagnostic codes in the Outpatient Patient Forms (Appendix I), which is categorized by anatomical site and which you can find under Documentos.

Choose the most applicable option if the antimicrobial was prescribed for more than one reason. Request additional information from doctors, nurses, or pharmacists if needed. If there is no ‘most applicable option’, you could choose the first identified infection, or you would simply have to make a choice.

10. What diagnosis should I choose for patients with sepsis of known origin, e.g. urosepsis?

If a patient has sepsis with a known origin, such as urosepsis, please choose the appropriate anatomic site for the diagnostic code . Do not choose the code sepsis, since this code is only meant for cases of sepsis where the anatomic site is unknown.

For example: For patients with urosepsis, this would be Pye/Cys (preferably Pye, since this will more likely cause sepsis). For patients with meningitis, please choose CNS.

11. What if an incorrect diagnosis was made and was only discovered in the audit?

If an incorrect diagnosis was made, e.g. due to incorrect interpretation of diagnostic tests, and this was discovered during the audit, please continue in the PPS as if the correct diagnosis was made: consider the given diagnosis at the time of prescription during the survey for the guideline compliance, reason in notes, etc.

If the incorrect diagnosis and consequently the prescription might be harmful in any way for the patient, please inform the prescriber immediately to safeguard patient care. Please record the original (incorrect) diagnosis in the survey, even if this diagnosis and treatment were later changed, since this would have been the practice if the auditor had not informed the prescriber.

12. When should I classify an infection as Community-Acquired Infection (CAI) and when as Hospital-Associated Infection (HAI)?

By definition, if the patient has been discharged from the hospital < 48 hours and has a known hospital infection or a new infection < 48 hours after discharge from hospital, this classifies as a hospital-associated infection. Additionally, if the patient develops an infection >48 hours after admission and is still admitted, it counts as hospital-associated infection.

If the patient develops symptoms >48 hours after discharge, or within the first 48 hours of admission, then it classifies as a community-acquired infection.

Exception: if a patient was re-admitted with a surgical site infection, this is by definition code HAI.

Examples:

• If a patient comes in for consultation with an infection, and has not been admitted/discharged for >48 hours before their consultation, then this infection counts as a community-acquired infection.
• If a patient comes in for consultation with an infection but was discharged the day before, it counts as a hospital-associated infection.
• All early-onset sepsis (i.e. at age <48 hours) is classified as community acquired (CAI) according to the protocol.
• If a patient comes in for consultation with a suspected infection and was on dialysis, chemotherapy or was a recipient of OPAT in the past month, you should still classify this as CAI, since the patient was not admitted for any of these therapies. Outpatient related infections are not defined in the Global-PPS, therefore, to keep it simple, please record this as CAI.
• If a patient comes back 4 days after (inpatient or outpatient) surgery with a surgical site infection, this is classified as HAI1.

13. Can I record multiple diagnoses and indications?

No, you can only score one reason to treat. You cannot score multiple diagnoses and indications. If your prescription was based on multiple diagnoses and indications, please choose the most relevant one.

14. How should I encode an antimicrobial prescribed for prophylaxis?

Please choose for the Diagnostic code the prophylaxis option for the most appropriate anatomic site. When the prophylaxis is for general use, not targeting a specific organ or site, please choose Medical Prophylaxis in General (MP-GEN).

After choosing the appropriate diagnostic code, select ‘Indications’ to record whether it concerns a Medical or Surgical Prophylaxis. For Surgical Prophylaxis, additionally choose between a single dose Surgical Prophylaxis (SP1), one day Surgical Prophylaxis (SP2), or >1 day Surgical Prophylaxis (SP3).

Examples:

• Please choose Prophylaxis for Respiratory pathogens (Proph RESP) if e.g. azithromycin is prescribed as prophylaxis for exacerbations of COPD. Since this is not prescribed as surgical prophylaxis, please choose Medical Prophylaxis as Indication.
• Please choose Prophylaxis for Gastro-Intestinal pathogens (Proph GI) if e.g. amoxicillin clavulanate is prescribed as prophylaxis for elective abdominal surgery. Please choose Surgical Prophylaxis as Indication.

15. How should I record the Reason in Notes?

Reason in Notes captures information on whether the reason for prescribing an antimicrobial  is documented in the notes (medical, nursing, or other files) at the start of the treatment. It must be clearly written down so anyone (e.g. replacing clinician or other staff member) can easily understand the rationale when consulting the medical or nursing files. 

Example:

• Even if all staff are aware that e.g. amoxicillin-clavulanate (Augmentin) is prescribed for pneumonia in a certain patient, but this is not recorded in the patient’s files, you should score ‘no’ for Reason in Notes.
• If the reason is very briefly but clearly described somewhere in the patient’s files, please score ‘yes’ for Reason in Notes.
• If the prescriber did not record it, but e.g. the nurse or pharmacist recorded the reason for prescription, then the reason is still visible in the patient’s files, which is the aim of this variable. In this case, score ‘yes’ for Reason in Notes.
• If a surgery report includes a section listing all administered medications, you can mark ‘yes’ for Reason in Notes if an antimicrobial is present, even if it is not explicitly labelled as surgical prophylaxis. It is reasonable to assume that the antibiotic was given for this purpose, given its context within perioperative care.

16. How should I record guideline existence?

The local guidelines considered in the Global-PPS are any institution guidelines, national guidelines, WHO guidelines, or e.g. the WHILE App or any book that is used in the institutions.

Please choose between the following options: Yes, No, Unknown, No information. No information is chosen when the diagnosis is completely unknown. Unknown is chosen when it is truly not known whether guidelines exist for the diagnosis, but please first check with the prescriber, or any physician, nurse or pharmacist within the institution to see whether there are any guidelines available.

17. How should I record guideline compliance?

If guidelines exist, you will need to assess whether the drug, dose, duration and route of administration was according to these local guidelines.

You can consider a prescription as guideline complaint when the prescription is for example adapted to the antibiogram, according to the weight or renal function of your patient, and/or following the advice of an infectious disease specialist who is the expert in the institution.

Choose between: Yes, No, Not assessable, Unknown. Not assessable can be chosen when guidelines exist, but do not describe the guideline for e.g. route of administration, even though they do describe the guideline for drug and dosing.

Please consult the prescriber or other prescribers in your institution for the guideline compliance assessment. It might be the case that the written guideline is not followed, but that the prescription was adapted based on the antibiogram/consult of ID specialist/etc.

18. How do I record guideline compliance for combination therapies?

Guideline compliance must be recorded per antimicrobial prescription: if one patient receives multiple antimicrobials, please assess for each prescription whether it is according to the local guidelines.

If multiple antimicrobials are prescribed for one diagnosis, but the guidelines recommend monotherapy, then please score one of these antimicrobials as guideline-compliant (if the guidelines do recommend monotherapy with this antimicrobial), and score the other antimicrobials as non-compliant.

In the feedback report, we analyze guideline compliance at patient- & diagnosis-level:

• If all antimicrobials are compliant for one diagnosis = treatment is guideline-compliant
• If one antimicrobial is non-compliant but other antimicrobials are compliant for one diagnosis = treatment is not guideline-compliant

1. Where can I enter data?
2. How long does it take to enter data?
3. Can I edit patient information after I data entry, to correct mistakes or update e.g. admission status?
4. Which results do I obtain?
5. How do I obtain the results? 

1. Where can I enter data?

Data can be entered within our web application. Please find more detailed instructions in the user manuals in the application. To begin, ensure you’re logged in and have registered your institution. After that, select the appropriate survey period for which you collected data. Then, follow these steps for data entry:: (1) create your departments under ‘Departments’, (2) create a new unit under ‘Surveys’ > ‘Outpatient module’, (3) add new patients under ‘Surveys’ > ‘Outpatient module’ in the appropriate unit.

2. How long does it take to enter data?

This depends on the availability of your data. If you have already collected all data on paper forms, it takes approximately 1-2 minutes to enter the data for a patient with an antimicrobial prescription, and (less than) a minute to enter the data for patients without an antimicrobial prescription.

If you want to enter the data directly in the web-based tool without collecting it first on paper, the time it takes to enter your data depends on whether you have to ask the patient all required information, if you have to look the information up from the patient file, and how organized and accurate your patient files are.

It can take ±3-8 minutes to enter the data of each patient with an antimicrobial prescription, again depending on how long it takes to ask the patient or to look up their file in the system of your institution. It usually takes 1-2 minutes to enter patients without antimicrobial prescriptions, since only a few questions are asked.

3. Can I edit patient information after I data entry, to correct mistakes or update e.g. admission status?

Yes, you can edit patient information at any time before the survey is closed.

If you collect patient information on paper forms, ensure that you write the survey number automatically assigned to each patient in the web-based application once their information is entered. This allows you to trace which patient corresponds to the data in the web application. Since the web application does not allow entering an institution identifier, it’s essential to record the assigned survey number on the paper form. If you have finalized your unit or finalized the survey and you still want to make edits or correct data, you can re-open the survey and re-open the unit before making any edits.

If the survey is closed, you can contact us at global-pps@uantwerpen.be with the question to re-open the survey.

4. Which results do I obtain?

You can obtain the results in different ways: an Excel export, and feedback slides.

The Excel file contains your raw data. In this file, each row is one antimicrobial prescription. Some variables will be automatically added, such as ATC-codes, AWaRe classification and DDDs. You can download this within the Global-PPS application.

You obtain the feedback report in a PDF-file, where all data are pre-analysed. You can download this feedback report after finalizing your units and survey.

5. How do I obtain the results?

You can download all results from within our web application:

• Excel report: go to ‘Surveys’ > ‘Export’ and it will be automatically downloaded. If you wish to export your results for a different survey, first go to ‘Surveys’ > ‘Subscribe’ and select the appropriate survey under ‘Action’. Then download the export for this survey.
• One-point feedback report: Go to ‘Surveys’ > ‘Outpatient module’ and finalize your units and your survey if you have not yet done this. Then, a new button will appear: ‘Generate feedback’. After clicking this, your feedback report will be sent to you by email.