Prescribers, infection specialist, pharmacy and nursing teams are responsible for ensuring timely intravenous-to-oral switch (IVOS) of antibiotics (UK Health and Security Agency (UKHSA), 2023).
National antimicrobial stewardship (AMS) competencies for nursing practice say nurses should be able to describe why it’s important to switch patients from intravenous (IV) to oral antibiotics in a timely manner and how this should be done (Courtenay, 2020). This is important because timely IVOS benefits our patients, our NHS, our planet and nurses too.
“A proactive approach to IVOS benefits our patients, our NHS, our planet and nurses too”
For patients, timely IVOS interventions can reduce the likelihood of hospital-acquired bacteraemia, line infections and phlebitis and support earlier patient discharge from hospital.
Oral antibiotics are also better for the planet as they have a lower carbon footprint and produce less plastic waste compared with the packaging and personal protective equipment used to administer IV antibiotics. Treatment with oral antibiotics is also more cost-effective and supports national targets to reduce use of broad-spectrum IV antibiotics.
For nurses, IVOS reduces our risk of making an error when preparing and giving IV antibiotics. A recent time-in-motion study from University Hospitals Birmingham NHS Foundation Trust also suggests it can also free up nursing time to care (Jenkins, 2023).
The study looked at savings in nursing time after switching from to IV to oral administration of medicines; applying the findings to the antibiotic flucloxacillin administered four times a day suggests IV administration takes one and a half hours of nursing time compared with around five minutes to give the medicine orally.
However, despite these benefits, another study of 400 hospital nurses found that while timely IVOS was regarded by nurses as a nursing role, implementation into clinical practice was low (Sakaguchi et al, 2022).
In 2022, the UKHSA published national antimicrobial criteria for ensuring timely IVOS, which were multidisciplinary and included nurses in their coproduction (UKHSA, 2023).
At Nottingham University Hospitals NHS Trust, these national criteria have been developed into a local IVOS assessment tool to assist nurses in prompting for IVOS.
The tool asks nurses to assess whether the patient has an infection that typically requires a longer course of IV antibiotics, whether the clinical signs and symptoms of infection are improving, whether infection markers are falling and whether the patient is able and happy to take oral medication, which could be in liquid form.
Nurses at the trust were introduced to this tool between November 2022 and March 2023 using a problem-based learning approach and patient case study. Nurses’ views were then gathered via a questionnaire to see whether prompting for IVOS was seen as a nursing role and gauge nurses’ confidence in using the local IVOS prompt tool, its suitability for nursing clinical practice and nurse engagement and training needs.
Nurses were asked to provide anonymous feedback on a series of statements using a five-point Likert score. The questionnaire was completed by 98 nurses and showed (average Likert score in brackets) that IVOS was recognised as a nursing role (4.2) and that generally nurses felt confident using the IVOS tool during the training activity (4.1) and would use it on the ward to assess their patients (4.2). However, optional free-text feedback highlighted concerns that this was “another tool to complete when there are already many”. Therefore, the AMS team decided to place the IVOS tool in the clinic room where IV antibiotics were prepared, where it would act as a reference aid rather than an assessment tool requiring formal completion.
As formal IVOS assessment using national antimicrobial criteria is new, it will also be supported with trust-wide communication and inter-professional frontline staff training and engagement activities.
Through collaborative working as an AMS team, there will be a prompt on the IV administration guide to remind nurses to assess patients for IVOS. A smart list on the electronic prescribing system for use by prescribers, pharmacists and nurses, will also highlight which patients are currently on IV antibiotics.
These measures, along with nurses using the IVOS tool as a reference aid on the ward, will help us implement IVOS assessments into nursing clinical practice, so benefiting patients, nurses, the NHS and the planet.
Sue Bowler is antimicrobial stewardship nurse specialist, Nottingham University Hospitals NHS Trust; Diane Ashiru-Oredope is lead pharmacist, Healthcare-associated Infections and Antimicrobial Resistance Division, UK Health Security Agency and honorary chair and professor Pharmaceutical Public Health School of Pharmacy, University of Nottingham
Acknowledgment
We acknowledge Annette Clarkson for her support in gathering the questionnaire feedback and reviewing the abstract and content of the poster and Kieran Hand, Naomi Fleming and Alisha Lakha for their pre submission review of the article.
References
Courtenay M (2020) Introduction. In: Courtenay M, Castro-Sánchez E (eds) Antimicrobial Stewardship for Nursing Practice. CABI.
Jenkins A (2023) IV to oral switch: a novel viewpoint. Journal of Antimicrobial Chemotherapy; 78: 10, 2603-2604.
Sakaguchi M et al (2022) The roles of bedside nurses in Japan in antimicrobial stewardship. American Journal of Infection Control; 51: 1, 48-55.
UK Health Security Agency (2023) Guidance: National antimicrobial intravenous-to-oral switch (IVOS) criteria for early switch. gov.uk, 1 February (accessed 31 October 2023)