BACKGROUND:To protect the blood supply, many countries defer higher-risk donors such as men who have had sex with men (MSM) in the last 3 months. However, this may be unnecessarily restrictive and increase non-compliance risks. New Zealand (NZ) has shifted from this approach to individual donor assessment (IDA), but the potential impact is poorly understood. We aimed to estimate the increase in blood donor eligibility and examine the characteristics of newly eligible MSM. METHODS:We used data from SPOTS, a large national cross-sectional online survey of MSM. Items included socio-demographics, blood donation history, views and preferences about blood donation, sexual behaviours and drug use. We described blood donation engagement and estimated the proportion eligible to donate blood under three scenarios (previous NZ policy; UK-style: IDA with chemsex deferral; Canada-style; IDA without chemsex deferral). We then examined the characteristics of potentially newly eligible MSM donors. RESULTS:Of the 3,235 participants, 43.1% had ever donated blood, 82.0% were interested in donating, 86.1% preferred an IDA-style policy, and 80.6% intended to donate, should they become eligible. We estimated 13% were eligible to donate under the previous NZ policy, rising to 37% under a UK-style IDA, and 41% under NZ's new IDA policy. In NZ's new IDA policy, 30% of currently ineligible participants will become eligible. Compared to participants currently eligible, newly eligible MSM were more likely to be aged 30-44 (OR 1.8, 1.4-2.4), tertiary educated (OR 1.4, 1.1-1.8), spend a lot of their free time with gay men (OR 4.3, 3.2-5.9), and identify as gay only (OR 2.5, 1.96-3.2). As expected, a high proportion of newly eligible MSM were in a regular same-sex relationship. CONCLUSIONS:NZ could triple eligible MSM donors with its new IDA policy. Findings from this research are relevant internationally as blood services plan IDA implementation.

BACKGROUND:Pacific region-specific data on the clinical course of COVID-19 are limited. We aimed to describe clinical features and outcomes from Aotearoa New Zealand patients, focusing on Māori and Pacific peoples. METHODS:We conducted a retrospective cohort study among adults (≥16 years) hospitalised due to COVID-19 at 11 hospitals from January to May 2022. We included all Māori and Pacific patients and every second non-Māori, non-Pacific (NMNP) patient using data from chart review and national datasets. RESULTS:Of 2319 patients, 582 (25%) were Māori, 914 (39%) Pacific peoples and 862 NMNP (median age 52, 57 and 63 years respectively). Vaccination coverage (≥2 doses) was 73.4% (n = 437) for Māori, 76.7% (n = 701) for Pacific peoples (n = 701) and 84.8% (n = 731) for NMNP. Among 832 (35.9%) with complications, Māori had a greater risk than NMNP of acute kidney injury (risk ratio (RR) 1.87, P < 0.001), cardiac arrhythmia (RR = 1.60, P = 0.023), shock (RR = 2.64, P = 0.005), myocardial infarction (RR 2.21, P = 0.042), cardiac arrest (RR 2.68, P = 0.046) and acute respiratory distress syndrome (RR = 2.81, P = 0.008). Pacific patients experienced a greater risk than NMNP of acute kidney injury (RR = 2.18, P < 0.001) and pneumonia (RR = 1.32, P = 0.047) and a lower risk of thromboembolism (RR = 0.35, P = 0.004) and myocarditis/pericarditis (RR = 0.23, P = 0.003). During admission, 23 (3.3%) Māori, 36 (3.9%) Pacific and 28 (3.2%) NMNP patients died, with no difference in age-standardised mortality. CONCLUSIONS:The clinical course of patients hospitalised by COVID-19 varied between ethnic groups, likely reflecting differential access to social determinants of health. Healthcare services that respond to this variability are needed to achieve the highest attainable health for all.

Introduction:This is a rare case of Mycobacterium chelonae keratitis following keratorefractive lenticule extraction (KLEX). Case Presentation:A 35-year-old female presented to the emergency eye clinic with 4 days of eye pain and decreased vision following KLEX surgery. She was using topical tobramycin drops four times per day, which was changed to ciprofloxacin drops. Following initial improvement, the eye deteriorated with further stromal infiltrates. A corneal culture identified M. chelonae. The keratitis required extensive topical and systemic medications, repeat scrapes, and an amniotic membrane over several weeks to reach quiescence. Vision deteriorated to hand movements, but an emergency keratoplasty was avoided. Conclusion:This is the third reported case serving to highlight the diagnostic and treatment challenges associated with postoperative keratitis involving nontuberculous mycobacteria.

BACKGROUND AND OBJECTIVES:As blood donor deferral policies in many countries transition from blanket time-based approaches towards individualized risk-based approaches, blood services need to understand whether and why men who have sex with men (MSM) intend to donate blood. Such knowledge can help blood services develop communication strategies with a population they have historically excluded. We examined why MSM in New Zealand (NZ) intended or not to donate blood. MATERIALS AND METHODS:In a large and diverse NZ online human immunodeficiency virus behavioural surveillance survey (n = 3838), we asked participants: 'In your own words, please tell us why you intend to or don't intend to donate blood in the future?' We interpreted 2363 responses by MSM using reflexive thematic analysis. RESULTS:We constructed four themes to explain why MSM intend to donate blood: (1) helping out by donating blood, (2) donor ineligibility and hesitancy, (3) considerations of individual and collective risk and (4) discrimination, exclusion, frustration and resentment. Our study showed that whether or not MSM in NZ assessed blanket deferral policies as discriminatory, many MSM in NZ were altruistically and civically motivated to donate blood. Some MSM were reluctant to donate because they were resentful or mistrustful of the New Zealand Blood Service (NZBS) or believed that donating blood was inconsistent with their indigenous values. CONCLUSION:Further research is required to enhance communication, improve MSM's understanding of the donation process and residual risks and accommodate the cultural values of prospective indigenous donors.

Objectives: COVID-19 severity prediction scores need further validation due to evolving COVID-19 illness. We evaluated existing COVID-19 risk prediction scores in Aotearoa New Zealand, including for M & amacr;ori and Pacific peoples who have been inequitably affected by COVID-19. Methods: We conducted a multicenter retrospective cohort study in adults hospitalized with COVID-19 from January to May 2022, including all M & amacr;ori and Pacific patients, and every second non-M & amacr;ori, non-Pacific (NMNP) patient to achieve equal analytic power by ethnic grouping. We assessed the accuracy of existing severity scores (4C Mortality, CURB-65, PRIEST, and VACO) to predict death in the hospital or within 28 days. Results: Of 2319 patients, 582 (25.1%) identified as M & amacr;ori, 914 (39.4%) as Pacific, and 862 (37.2%) as NMNP. There were 146 (6.3%, 95% confidence interval 5.4-7.4%) deaths, with a predicted probability of death higher than observed mortality for VACO (10.4%), modified PRIEST (15.1%) and 4C mortality (15.5%) scores, but lower for CURB-65 (4.5%). C-statistics (95% CI) of severity scores were: 4C mortality: M & amacr;ori 0.82 (0.75, 0.88), Pacific 0.87 (0.83, 0.90), NMNP 0.90 (0.86, 0.93); CURB-65: M & amacr;ori 0.83 (0.69, 0.92), Pacific 0.87 (0.82, 0.91), NMNP 0.86 (0.80, 0.91); modified PRIEST: M & amacr;ori 0.85 (0.79, 0.90), Pacific 0.81 (0.76, 0.86), NMNP 0.83 (0.78, 0.87); and VACO: M & amacr;ori 0.79 (0.75, 0.83), Pacific 0.71 (0.58, 0.82), NMNP 0.78 (0.73, 0.83). Conclusions: Following re-calibration, existing risk prediction scores accurately predicted mortality.

Objectives: This multicenter cohort study describes Aotearoa New Zealand children hospitalized during the country's first wave of sustained SARS-CoV-2 transmission, Omicron variant. Methods: Children younger than 16 years, hospitalized for > 6 hours with COVID-19 across New Zealand from January to May 2022 were included. Admissions for all M & amacr;ori and Pacific and every second non-Maori non-Pacific children were selected to support equal explanatory power for ethnic grouping. Attribution of hospital admission, demography, clinical presentation, comorbidity, treatment, and outcome data were collected. Results: Of 444 hospitalizations of children positive for COVID-19, 292 (65.5%) from 290 children were considered admissions attributable to COVID-19. Of these admissions, 126 (43.4%) were aged under 1; 118 (40.7%), 99 (34.1%), and 87 (30.0%) were children of M & amacr;ori, Pacific, and non-Maori non-Pacific ethnicity, respectively. Underlying respiratory disease was the most common comorbidity, present in 22 children (7.6%); 16 children (5.5%) were immunosuppressed. Median length of stay was 1 day (interquartile range 0.0-2.0). Four children received antiviral, 69 (24%) antibacterial, and 24 (8%) supplemental oxygen. Although eight children required intensive care, there were no deaths. Conclusions: Children hospitalized during the first significant wave of SARS-CoV-2 infection in New Zealand presented with a multi-system viral illness and rarely with severe disease.

Background: Mobile health platforms like smartphone apps that provide clinical guidelines are ubiquitous, yet their long-term impact on guideline adherence remains unclear. In 2016, an antibiotic guidelines app, called SCRIPT, was introduced in Auckland City Hospital, New Zealand, to provide local antibiotic guidelines to clinicians on their smartphones. Objective: We aimed to assess whether the provision of antibiotic guidelines in a smartphone app resulted in sustained changes in antibiotic guideline adherence by prescribers. Methods: We analyzed antibiotic guideline adherence rates during the first 24 hours of hospital admission in adults diagnosed with community-acquired pneumonia using an interrupted time-series study with 3 distinct periods post app implementation (ie, 3, 12, and 24 months). Results: Adherence increased from 23% (46/200) at baseline to 31% (73/237) at 3 months and 34% (69/200) at 12 months, reducing to 31% (62/200) at 24 months post app implementation (P=.07 vs baseline). However, increased adherence was sustained in patients with pulmonary consolidation on x-ray (9/63, 14% at baseline; 23/77, 30% after 3 months; 32/92, 35% after 12 month; and 32/102, 31% after 24 months; P=.04 vs baseline). Conclusions: An antibiotic guidelines app increased overall adherence, but this was not sustained. In patients with pulmonary consolidation, the increased adherence was sustained.

The rate of community antibiotic use is high in Aotearoa New Zealand (NZ) when compared to other nations, and in NZ, as in most other nations, antibiotics are very commonly prescribed for self-limiting upper respiratory tract infections (URTIs). Resources that build knowledge, perceptions and understanding can potentially reduce unnecessary antibiotic consumption. To inform the content of educational resources, we conducted an in-depth qualitative study with 47 participants via 6 focus groups of the knowledge, attitudes, and expectations of whānau Māori and Pacific peoples about antibiotics and URTIs. Focus groups with 47 participants identified four themes: Knowledge that might influence expectations to receive antibiotics for URTIs; Perceptions - the factors that influence when and why to seek medical care for URTI; Expectations - the features of successful medical care for URTI; Solutions - how to build community knowledge about URTI and their treatment and prevention. Knowledge that might reduce expectations to receive antibiotics for URTI included confidence in the use of alternative remedies, knowledge that URTI are usually caused by viruses, and concerns about antibiotic adverse effects. Participants commonly reported that they would confidently accept their doctor’s recommendation that an antibiotic was not necessary for an URTI, provided that a thorough assessment had been performed and that treatment decisions were clearly communicated. These findings suggest that building patients’ knowledge and skills about when antibiotics are necessary, and increasing doctors’ confidence and willingness not to prescribe an antibiotic for patients with an URTI, could significantly reduce inappropriate antibiotic prescribing in NZ.

(See pages xx for the Answer to the Photo Quiz.) A 48-year-old man with living with well-controlled human immunodeficiency virus (HIV) and treated plasmablastic lymphoma presented with 3 weeks of left shin pain and 8 days of right shin and left forearm pain. There was no history of trauma. The pain was described as “sharp” and “prickling” and was exacerbated by movement and weight-bearing. There had been intermittent swelling present over the left shin, but no muscle weakness or associated skin changes. He reported unintentional weight loss of 6 kg over the preceding 6 months; he had no fevers or night sweats. He was receiving antiretroviral treatment with tenofovir disoproxil, emtricitabine, and dolutegravir. Regular testing demonstrated undetectable HIV viral loads for the previous 2 years. Plasmablastic lymphoma was treated in 2016 with R-CHOP-B chemotherapy, and follow-up positron emission tomography–computed tomography (CT) imaging confirmed remission. During the lymphoma treatment, he was diagnosed with primary syphilis via direct fluorescent antibody staining from a penile ulcer, which showed multiple fluorescing treponemes. He was treated with 2 weeks of doxycycline due to a history of developing a rash following prior treatment with penicillin. Following this treatment, the rapid plasma reagin (RPR) was stable at 1:2. Physical examination revealed a trace of edema in the left lower leg and tenderness over the left anterior tibia. Plain X-rays of the left leg showed no fracture or focal osseous lesion. He had normocytic anemia (hemoglobin 97 g/L) with normal neutrophil and lymphocyte counts; 6 months prior, his full blood count was normal (hemoglobin 132 g/L). C-reactive protein was elevated at 23 mg/L; HIV viral load was undetectable and CD4 count was 666 (34%) cells/mm3; lactic acid dehydrogenase was normal. Magnetic resonance imaging and CT (Figures 1, 2) showed a left tibial lesion. There was an area of permeative change within the cortex of the mid-shaft of the tibia with a rim of surrounding enhancing soft tissue extending from the proximal diametaphyseal region to approximately 4.5 cm proximal to the ankle joint (Figures 1, 2). He underwent a radiologically guided biopsy of the tibial lesion. The immunohistochemical stain is shown in Figure 3. What is your diagnosis?

Introduction Children have a high consumption of antimicrobials that require complicated decision-making by prescribers. Despite this, antimicrobial stewardship (AMS) interventions are often not translated into paediatric medicine. Script is a smartphone application (app) launched in Auckland, New Zealand to support decision-making for antimicrobial prescribers. The aim was to improve adherence to existing local clinical guidelines for both adult and paediatric infections. Methods Inpatient and emergency department antimicrobial prescriptions were prospectively collected and evaluated for guideline adherence. Baseline prescribing data were collected and compared with prescribing at 4 months and 1 year after the app was launched. Prescriptions were graded as 'appropriate' or 'inappropriate' by investigators. Grading was done blinded to timing of the prescription relative to the intervention. Results Following the launch of the Script app, guideline adherence significantly increased from 241 of 348 (69%) antimicrobial prescriptions graded as appropriate during the baseline period to 301 of 359 (83%) after 4 months (p<0.0001). This improvement from baseline was sustained at 1 year with 263 of 323 (81%) adherence (p<0.001). At 1 year, this improvement could be demonstrated separately for medical, surgical and emergency department prescriptions. Conclusion There was a significant and sustained improvement in adherence to paediatric antimicrobial guidelines following the introduction of a prescribing support app. The need to seek guidance for antimicrobial doses due to the age-based and weight-based calculations in paediatrics may mean that AMS interventions such as decision support and prescribing tools are particularly well suited to paediatric prescribing.

(1) Background. Intravenous (IV) to oral switch (IVOS) of antibiotics can reduce the length of hospitalisation, risk of IV catheter complications, and hospital costs. Pharmacists can play an instrumental role in implementing an IVOS initiative. The aim of this study is to evaluate the impact of pharmacist-led IVOS of metronidazole. (2) Method. This was an observational study conducted in a New Zealand hospital. During a 3-month intervention period, pharmacists identified patients receiving IV metronidazole; then initiated an IVOS for patients who met the criteria. The comparator groups were patients who were not switched by pharmacists in the post-intervention (post-IVOS) group, or patients treated with either IV or oral metronidazole prior to the intervention (pre-IVOS). Primary outcome measures were switch rate and duration of IV metronidazole treatment. Secondary outcome measures were readmission and/or repeat surgery within 90 days of discharge and the length of hospital stay. (3) Results. In total, 203 patients were included: 100 in the pre-IVOS and 103 in the post-IVOS groups. Pharmacists switched 63/93 (67.7%) of eligible patients to oral metronidazole in the post-IVOS period. Only 9/89 (10.1%) of IVOS eligible patients were switched in the pre-IVOS group. In the post-IVOS group, the mean duration of IV metronidazole treatment in patients switched by pharmacists was shorter than in those who were not switched by pharmacists (2.5 ± 2.8 days vs. 4.8 ± 5.9 days, p = 0.012). No significant difference was found in readmission or repeat surgery within 90 days of discharge for patients switched by pharmacists versus patients who were not switched by pharmacists. (4) Conclusion. Our data have demonstrated successful implementation of the hospital-approved pharmacist-led IVOS service.

Group A Streptococcus (GAS) is a major human pathogen responsible for superficial infections through to life-threatening invasive disease and the autoimmune sequelae acute rheumatic fever (ARF). Despite a significant global economic and health burden, there is no licensed vaccine available to prevent GAS disease. Several pre clinical vaccines that target conserved GAS antigens are in development. Assays that measure antigen-specific antibodies are essential for vaccine research. The aim of this study was to develop a multiplex beadbased immunoassay that can detect and quantify antibody responses to multiple GAS antigen targets in small volume blood samples. This builds on our existing triplex assay comprised of antigens used in clinical serology for the diagnosis of ARF (SLO, DNase B and SpnA). Five additional conserved putative GAS vaccine antigens (Spy0843, SCPA, SpyCEP, SpyAD and the Group A carbohydrate), were coupled to spectrally unique beads to form an 8-plex antigen panel. After optimisation of the assay protocol, standard curves were generated, and assessments of assay specificity, precision and reproducibility were conducted. A broad range of antibody (IgG) titres were able to be quickly and accurately quantified from a single serum dilution. Assay utility was assessed using a panel of 62 clinical samples including serum from adults with GAS bacteraemia and children with ARF. Circulating IgG to all eight antigens was elevated in patients with GAS disease (n = 23) compared to age-matched controls (n = 39) (P < 0.05). The feasibility of using dried blood samples to quantify antigen-specific IgG was also demonstrated. In summary, a robust and reproducible 8-plex assay has been developed that simultaneously quantifies IgG antibodies to GAS vaccine and diagnostic antigens.

Antimicrobial resistance (AMR) is a threat to public health. Addressing unnecessary antibiotic use provides an opportunity to reduce antibiotic consumption and to slow AMR. Understanding people’s beliefs is important for informing antimicrobial stewardship (AMS) initiatives. Within New Zealand, health inequities exist between Māori and non-Māori; however, no research has examined Māori beliefs about antibiotics and AMR. The aim of this study was to explore the experiences related to antibiotic use of Māori in New Zealand. In-depth, semi-structured interviews were conducted with 30 Māori adults recruited from primary care to explore the experiences, perceptions and beliefs that Māori have about antibiotics, and about AMR. Overall, 30 Māori adults (23% male; age range from 20 to 77 years) participated. Three themes emerged: systemic-, social-, and individual-related factors. From these themes, seven subthemes explained the factors that influenced antibiotic use and their perceptions of AMR in Māori: general practitioner (GP) times and ratios, effect of colonisation, lack of knowledge and information, access and poverty barriers, relationship with health professionals, illness perceptions, treatment beliefs and Whaakaro (thoughts), and beliefs pertaining to natural (rongoā) and Western medicine. Participants identified potential solutions to improve antibiotic use such as cultural support and involving Te Ao Māori; recognising these can inform future AMS initiatives.

AIM As New Zealand transitions towards endemic SARS-CoV-2, understanding patient factors predicting severity, as well as hospital resourcing requirements will be essential for future planning. METHODS We retrospectively enrolled patients hospitalised with COVID-19 from 26 February to 5 October 2020 as part of the COVID-19 HospitalisEd Patient SeverIty Observational Study NZ (COHESION). Data on demographics, clinical course and outcomes were collected and analysed as a descriptive case series. RESULTS Eighty-four patients were identified across eight district health boards. Forty-one (49%) were male. The median age was 58 years [IQR: 41.7-70.3 years]. By ethnicity, hospitalisations included 38 NZ European (45%), 19 Pasifika (23%), 13 Māori (15%), 12 Asian (14%) and 2 Other (2%). Pre-existing co-morbidities included hypertension (26/82, 32%), obesity (16/66, 24%) and diabetes (18/81, 22%). The median length of stay was four days [IQR: 2-15 days]. Twelve patients (12/83, 14%) were admitted to an intensive care unit or high dependency unit (ICU/HDU). Ten (10/83, 12%) patients died in hospital of whom seven (70%) were not admitted to ICU/HDU; the median age at death was 83 years. CONCLUSION Despite initially low case numbers in New Zealand during 2020, hospitalisation with COVID-19 was associated with a high mortality and hospital resource requirements.

Background The Dundee classification of cellulitis severity, previously shown to predict disease outcomes, provides an opportunity to improve the management of patients with cellulitis. Methods We developed and implemented a pathway to guide the management of adults with cellulitis based on their Dundee severity class, and measured its effect on patient outcomes. We compared the outcomes in patients admitted to Auckland City Hospital (ACH) between July 2014 and July 2015 (the baseline cohort) with those in patients admitted between June 2017 and June 2018 (the intervention cohort). Results The median length of stay was shorter in the intervention cohort (0.7 days, interquartile range (IQR) 0.1 to 3.0 days) than in the baseline cohort (1.8 days, IQR 0.1 to 4.4 days; P < .001). The 30-day mortality rate declined from 1.8% (19/1092) in the baseline cohort to 0.7% (10/1362; P = .02) in the intervention cohort. The 30-day cellulitis readmission rate increased from 6% in the baseline cohort to 11% (P < .001) in the intervention cohort. Adherence to the ACH cellulitis antibiotic guideline improved from 38% to 48% (P < .01) and was independently associated with reduced length of stay. Conclusions The implementation of the Auckland cellulitis pathway, readily generalizable to other settings, improved the outcomes in patients with cellulitis, and resulted in an annual saving of approximately 1000 bed days.

PURPOSE Many family practitioners prescribe antibiotics for patients with upper respiratory tract infections (URTIs) to meet patients’ expectations. We evaluated the impact of providing brief tablet-based information about antibiotic treatment of URTIs on patients’ expectations for antibiotics and on family practitioners’ antibiotic-prescribing behavior. METHODS We performed a 3-arm randomized controlled trial among patients presenting with URTIs at 2 urban family practices in Auckland, New Zealand, during winter 2018. Participants were randomly allocated to view a presentation about the futility of antibiotic treatment of URTIs, the adverse effects associated with antibiotics, or the benefits of healthy diet and exercise (active control), immediately before their consultation. Before and after viewing the presentations, participants used a Likert scale to rate the strength of their belief that antibiotics are effective for treating URTIs and of their desire to be prescribed an antibiotic. Patients reported whether an antibiotic had been prescribed, and pharmacy dispensing records were reviewed to determine whether an antibiotic was dispensed. RESULTS Participants who viewed either the futility or the adverse effects presentation had greater reductions in their expectations to receive antibiotics than the control group. The mean reduction (95% CI) was 1.1 (0.8-1.3) for the futility group, 0.7 (0.4-0.9) for the adverse effects group, and 0.1 (0-0.3) for the control group (Cohen d = 0.7; P <.001). There was no significant difference among the 3 groups with regard to antibiotic prescribing (P = .84) or dispensing (P = .43). CONCLUSIONS A brief tablet-based waiting room intervention significantly reduced participants’ expectations about receiving antibiotics for URTI immediately before their family practitioner consultation. The intervention did not influence family practitioner prescribing behavior, however.

Within 30 years, the global number of deaths from AMR-associated infections is predicted to increase from ~700,000 to ~10 million people annually, if we do not act now.1 The Aotearoa New Zealand (NZ) response to the current COVID-19 pandemic has been lauded internationally-found-ed in science, responsive to expert advice, implemented with clear leadership and communication, and subject to ongoing critical evaluation and improvement. AMR-associated infections and related care (eg, time off work or school to travel to hospital for treatment) will disproportionately impact the most socioeconomically disadvantaged among us, those living in rural or remote settings, and Maori and Pacific populations who shoulder a greater infection and AMR burden and have increased reliance on antimicrobial therapy.6'7 One of the biggest drivers for AMR is antimicrobial use, which is high in human health in NZ compared with many developed countries.8'9 Most of our antimicrobial use (95%) is in the community9 and up to 50% may be inappropriate.2 The NZ community antibacterial consumption rate increased 49% between 2006 and 2014;in 2013, it exceeded that of 22 out of 29 European countries.8 A subsequent modest 14% decrease occurred across 2015 to 2018, mainly due to reductions in under 5 year olds,10 which is pleasing as antimicrobial use in childhood may create reservoirs of resistant pathogens impacting communities cross-generationally. In 2013, the Health Quality and Safety Commission (HQSC) published a scoping report that offered insight into what was needed to progress AMS in NZ.14 Key recommendations were to establish: * National leadership and coordination of AMS activities * National antimicrobial prescribing guidelines * Quality improvement tools and measures In the near decade that has followed this report, none of these recommendations have been achieved. The NCAMS should provide access to (and support use of) quality improvement tools (eg, auditing systems for between facility benchmarking), develop initiatives to improve antimicrobial use (including those involving consumers), monitor performance against quality markers, and establish clinical care standards with the oversight of NAMSEG.