Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP)

Scottish Antimicrobial Prescribing Group (SAPG)

Dilip NathwaniSIRN, Glasgow June 2008

“The future of humanity and microbes willlikely evolve as ……. episodes of our witsversus their genes”

Jonathan Laderberg Science 2000; 288: 281-93

10080604020

0

S. aureus resistant to methicillin%

1750 1825 1950 2000

10080604020

0

Gram-negative resistance%

1750 1825 1950 2000

Increased Incidence of Sepsis in General

Martin GS et al. N Engl J Med. 2003;348:1546-1554.

Resistance in the press…

InfectionMean Cost

($ US)SD Minimum Maximum

Surgical Site Infection

25546 39875 1783 134602

BI 36441 37078 1822 107156

VAP 9969 2920 7904 12034

UTI 1006 503 650 1361

Attributable costs of HAI Stone et al AJIC 2005; 33(9): 501-509

Socio-economic burden of hospital-acquired infections (HAIs)

Plowman R et al. Public Health Service and the LondonSchool of Hygiene and Tropical Medicine 1999: 12.

Incidence Duration of Stay Overall costs Specific costs

7.8%Acquired one or more HAIs whilst in hospital

11 days GBP 2915 Hospital overheads/ capital charges/ management

33%

2.5 times longer than uninfected

2.8 times more than uninfected

Nursing care 42%

Operations/Consumables 6%

Paramedics/ nurses 4%

Antimicrobials 2%

Others 7%

What is Antimicrobial Stewardship?A marriage of infection control and antimicrobial managementMandatory infection control complianceSelection of antimicrobials from each class of drugs that does the least collateral damageCollateral damage issues include- MRSA- ESBLs- C.difficile- stable derepression- MBLs and other carbapenemases- VREAppropriate de-escalation when culture results are available

Dellit TH et al Clin Infect Dis 2007; 44: 159-177

The Primary Goal of Antimicrobial Stewardship

The primary goal of antimicrobial stewardship is to- Optimize clinical outcomes while minimizing unintended consequences of antimicrobial use

- Unintended consequences include the following: - Toxicity - The selection of pathogenic organisms, such as C.difficile

- The emergence of resistant pathogens

Dellit TH et al Clin Infect Dis 2007; 44: 159-177

Other Aspects of Antimicrobial Stewardship

The appropriate use of antimicrobials is an essential part of patient safetyThe frequency of inappropriate antimicrobial use is often used as a surrogate marker for avoidable impact on antimicrobial resistanceThe combination of antimicrobial stewardship and comprehensive infection control has been shown to limit the emergence and transmission of antimicrobial resistant bacteriaA secondary goal of antimicrobial stewardship- to reduce healthcare cost without adversely impacting the quality of care

Antimicrobial prescribing policy and practice (APP&P) in Scotland:

recommendations for good antimicrobial practice in acute hospitals

Nathwani D. JAC 2006; 57: 1186-1196 (adapted by SACAR Antimicrobial

framework (JAC 2007: 60: Suppl. 1, i87-90)

http://www.Scotland.gov.uk/publications/2005/09/021326 09/26114

20 Key recommendations within 6 domains

APP&PThe core components of the current guidance are:

a. Development of prescribing policies (SACAR provides also generic template for antimicrobial guidelines)

b. Monitoring of compliancec. Structures and responsibilitiesd. Education & Training

e. Audit and performance management.

APP&P KEY DOMAINS FOR RECOMMENDATIONS

Recommendations in the following key areas:Key Area

1. Establish standard structures and lines of responsibility &accountability in NHS Boards across Scotland.

2. Define structures and responsibility for multi-disciplinaryand generic undergraduate and post-graduate trainingrelated to antimicrobial prescribing.

3. Define the minimum dataset requirements and standardprocedures for collecting information related toantimicrobial resistance patterns.

4 Define the minimum dataset requirements and standardprocedures for collecting information related toantimicrobial consumption and quality of prescribing at anorganisational level and/or ward specific level.

5. Define the key areas for acute hospital policy andrecommendations for audit.

6. Develop and define performance indicators that could beused to assess or gauge performance related toantimicrobial prescribing in hospitals

Document communicated by CMO to all NHS Boards

Establish standard structures and lines of responsibility and accountability in

NHS Scotland across BoardsChief Executives of Boards and Single Delivery Units take overall responsibility for APP&P within acute hospitalsHAI and prescribing should be on NHS boards Local Delivery Plan which has replaced the Local Health Plan and PAF.

Medical DirectorMedical Director Chief ExecutiveChief Executive Infection Control Infection Control ManagerManager

Drugs & Drugs & Therapeutics Therapeutics CommitteeCommittee

Antimicrobial Antimicrobial Management Team (AMT)Management Team (AMT)

SpecialitySpeciality--based Pharmacy leads for based Pharmacy leads for APP&P with responsibility for APP&P with responsibility for antimicrobial prescribingantimicrobial prescribing

Ward Based Clinical Ward Based Clinical PharmacistsPharmacists

Risk Management Risk Management CommitteeCommittee

Clinical Governance Clinical Governance CommitteeCommittee

Infection Control Infection Control CommitteeCommittee

Microbiologist / Microbiologist / Infectious Diseases Infectious Diseases PhysicianPhysician

PRESCRIBERPRESCRIBER

Prescribing support / feedback

Dissemination & feedback

http://www.scotland.gov.uk

5. Define key areas for acute hospital policy and recommendations for auditNational collection of consumption data to evaluate use trends e.g DANMAP

Co-ordination by a “national clinical forum” which will work with key agencies

Facilitate audit of quantity and quality of antimicrobial consumption by use of point prevalence “snapshot”survey

STRAMAGAATESAC

THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL

RESISTANCE ACTION PLAN[ScotMARAP 2007]

SMC- ANTIMICROBIAL PRESCRIBING GROUP

The proposed primary role of the SMC is to convene and service a group to fulfil the aspirations for “a national clinical forum”as expressed in the APP&P. This group would include national stakeholder organisations and would collate the disseminate scientifically rigorous information on antimicrobial resistance trends and antimicrobial use on an ongoing basis to the NHS (primary and secondary care).

Long established, centrally funded by government

Broad membershipCentral function with network to local STRAMA groupsUse of local groups to support implementation of initiativesUse of expert study groups to help interpret studies and data

Broad range of activities

PrescribingResistanceEducationPoint prevalence studiesClinical trials

STRAMA: SWEDISH STRATEGIC PROGRMAME FOR THE RATIONAL USE OFANTIMICROBIAL AGENTS AND SURVEILLANCE OF RESISTANCE

IMPACT OF STRAMA: Lancet ID 2008; 8: 125-32.

1995-2004 OP antibiotic use decrease from 15.7 to 12.6 DDD per 1000 inhabitants per day and from 436 to 410 prescriptions per 1000 inhabitants per year. Children and macrolide use most pronounced decrease Hospital admission rates with quinsy, sinusitis, mastoiditis low or stable Resistance rate in PRP slow increase from 4% to 6%.Other resistance rates lowICU work ongoing from 1999- low rates of resistance so far

ScotMARAP Process & Timelines

ScotMARAP pre-publication review issued to NHS Scotland 7th December 2008

Positive response from NHS Scotland – general sense of support

ScotMARAP business case submitted to SGHD 7th

February 2008

Approved in principal – funding available from 1st April 2008

SGHD announcement of launch of ScotMARAP project by Cabinet Secretary 17th March 2008

SMC is Project Sponsor

Scottish Antimicrobial Prescribing Group (SAPG) to be formed to deliver recommendations within the APP&P and ScotMARAP

Scottish Antimicrobial Prescribing Group chaired by Dilip Nathwani

Partnership working with key stakeholders is imperative for delivery – clearly defined roles, responsibilities and accountabilities

ScotMARAP Project Interfaces

SAPG

Scottish Medicines Consortium Scottish Antimicrobial rescribingGroup

Health ProtectionScotland

NHS Education forScotland

NHS Boards Area Drug and Therapeutics Committees

NHS Quality Improvement Scotland

NHS Boards Antimicrobial Management Teams

Clinical GovernanceRisk ManagementInfection Control Team / ManagerPrescribers

Reference DiagnosticServices

NHS Boards Antimicrobial Management Team Sub-Group of Scottish

Antimicrobial Prescribing Group

Scottish Patient Safety Alliance

Information ServicesDivision

Local DiagnosticServices

Scottish Medicines Consortium Scottish Antimicrobial rescribingGroup

Health ProtectionScotland

NHS Education forScotland

NHS Boards Area Drug and Therapeutics Committees

NHS Quality Improvement Scotland

NHS Boards Antimicrobial Management Teams

Clinical GovernanceRisk ManagementInfection Control Team / ManagerPrescribers

Reference DiagnosticServices

NHS Boards Antimicrobial Management Team Sub-Group of Scottish

Antimicrobial Prescribing Group

Scottish Patient Safety Alliance

Information ServicesDivision

Local DiagnosticServices

Project Objective

To improve the quality of prescribing of antimicrobials by front line professionals across all healthcare settings in Scotland through improved systems and processes for collection, collation, analysis, correlation and reporting of antimicrobial utilisation and resistance data and improved education programmes for h ealth care professionals

DECISION MAKING WHEN PRESCRIBING AN ANTIMICROBIAL

HOW CAN WE INFORM THIS PROCESS, INTERVENE AND MEASURE ITS IMPACT

How We Use Antibiotics

1. Adjuvant Rx needed?2. Antibiotics needed?3. Options reviewed

a. On formulary? b. Restricted? c. Will it get job done?

“Scientific” inputsClinical trialsGuidelinesAntimicrobial spectrumLocal susceptibilitiesECONOMIC EVALUATIONS

“Non-scientific” inputsRecent experienceOpinions/behaviour of peersMarketing

Assess Patient

Make Diagnosis

Select Management Plan

SPECIFIC OBJECTIVESTO ESTABLISH A STANDARDISED MECHANISM BY WHICH WE CAN MEASURE AND COMMUNICATE TO FRONTLINE PRESCRIBERS THE CURRENT BASELINE SITUATION RELATED TO ANTIMICROBIAL USE AND RESISTANCEONCE WE HAVE THIS IN PLACE THE INFORMATION WILL SUPPORT THE LOCAL AND NATIONAL MONITORING OF PRESCRIBING AND RESISTANCE TRENDS OVER TIME SO TO INFORM AND CHANGE CLINICAL PRA CTICE IF NECESSARY, WITH THE AIM OF LONG TERM REDUCTION IN INAPPROPRIATE ANTIMICROBIAL USE DE VELOP SPECIFIC OBJECTIVES TO DEFINE CORE EDUCATIONAL AND POLICY INITIATIVES AND FOR THE INFECTION MANAGEMENT WORKSTREAM

PROJECT DELIVERABLESIHI methodology will be used to construct the core outcomes

Deliverable will be have timeframes, accountability, quality assurance and risk assessment

Broad consultation with service and key stakeholders regarding workstreams

ScotMARAP Project Structure

ScotMARAP Project Sponsor

ScotMARAP Project Board

Scottish Antimicrobial Prescribing Group

ScotMARAP Project Manager

ScotMARAP Project Assurance

Antimicrobial Management Team Sub-Group

ScotMARAP Project Support

STREAM 1

Organisation & accountability

Four Parallel Work Streams

Organisation and accountability : implementation of APP&P

Antimicrobial information: surveillance and consumption data as well as qualitative data (Point Prevalence Survey’s)

Antimicrobial education and guidance : Undergraduate and post-graduate medical education, multi-professional learning packages, National guidelines and policy review

Infection management : quality indicators, care bundles

Each work-stream will have a Lead and will manage this project

Overview of Information from NHS Boards Antimicrobial Formularies / Guidelines

• 10 NHS Boards – formularies cover primary & secondary care

• 1 NHS Board – formulary covers secondary care only

• 3 NHS Boards – use formularies from other NHS Boards

• Guidelines generally included in or linked to formularies

Overview of Information from NHS Boards Routine information on

antimicrobials• 4 NHS Boards – routine information provided to

healthcare profession

• 10 NHS Boards – no routine information provided to healthcare professionals

• 3 NHS Boards – routine information provided to the public

• 11 NHS Boards – no routine information provided to the public

Overview of Information from NHS Boards Reporting antimicrobial use in DDDs

• 3 NHS Boards – routine reporting in primary & secondary care

• 2 NHS Boards – routine reporting in primary care

• 3 NHS Boards – ad hoc reporting

• 6 NHS Boards – no reporting

• 14 NHS Boards – training for doctors

• 5 NHS Boards – training for other healthcare professionals (e.g. nurses, pharmacists)

• Training varies widely, mainly focused on secondary care and FY1 / FY2 doctors

Overview of Information from NHS Boards Antimicrobial Training for Healthcare Professionals

Overview of Information from NHS Boards Audit / point prevalence studies

• 2 NHS Boards – routine in primary care

• 2 NHS Boards – routine in secondary care

• 3 NHS Boards – ad hoc

• 7 NHS Boards – no audit / point prevalence studies

STREAM 2

ANTIMICROBIAL RESISTANCE SURVEILLANCE

AND CONSUMPTION

0

5

10

0 12 24 36 48Months

Use

DDD/1

00 b

ed-d

ays

Alert AntibioticsAnsari et al, JAC 52 (5):842-848, 2003.

•First implemented August 2001

•By 2004 clear evidence that use was going back up

•Re-launched February 2006 with quarterly feedback via clinical groups

•Pharmacy initiated consults to support early switch from April 2006

STREAM 3

ANRIMICROBIAL EDUCATION & GUIDANCE

COMPETENCY FRAMEWORK FOR ANTIBIOTICS

COMPETENCY – FOR EACH COMPETENCY STATE WHETHER YOU WISH FOR IT TO BE CATEGORISED AS APPLICATION OR AWARENESS

APPLICATION- skills that the prescriber should apply regularly in their work and be able to carry out with minimal supervisionAWARENESS- skills that the prescriber would not be expected to have acquired but sufficiently aware to seek help

COMPETENCY HEADINGS1. CONSIDER DIAGNOSIS 1.1-1.32. ASSESS SEVERITY 2.1-2.33. INITIATE INVESTIGATIONS 3.1-3.24.CONSIDER INFECTION CONTROL AND PUBLIC HEALTH 4.15.INITIATE AND REVIEW ANTIMICROBIAL PRESCRIBING 5.1-5.56. CONSIDER OTHER ASPECTS OF MANAGEMENT 6.1

http://pause-online.org.uk/

PRUDENT ANTIBIOTIC USER (PAUSE WEBSITE)

SUPPORTED BY BSAC, ESGAP, ESCMID

Postgraduate training in infection management for junior

doctors in Scotland

o Doctors on line Training (DOTS) Programme National Antibiotic Prescribing Project

(SNAPP) is funded by National Education Scotland.

o E-learning tool. Mandatory like Infection Control Programme

o Aimed at on line training for doctors in training at foundation level ; link between DOTS (https://www.nhsdots.org/nhsdots/dotsx/login.asp) and NES HAI portal (http://www.elib.scot.nhs.uk/portal//hai/Pages/index.a spx)

STREAM 4

INFECTION MANAGEMENT

INFECTION MANAGMENT

SURGICAL PROPHYLAXIS INDICATORS

SNAP-CAP

C.difficle interventions- restriction of key antibiotics, bundles including antibiotic “review bundle”Others e.g care home prescribing

PRESCRIBING QUALITY INDICATORS

Surgical orthopaedic (arthroplasty) prophylaxis (single v 3 doses; prophylaxis < 24h) – data routinely collected from mandatory surveillance surgical site infection in Orthopaedic surgery.New SIGN guideline for limb arthroplasty 3-4 antibiotics in 24 hours. Previously single antibiotic.

RESPIRATORY QUINOLONE PRESCRIBING-MONTHLY DATA ON QUALITY OF USE PRESENTED AS RED, GREEN OR AMBER TO EACH WARD

ALERT ANTIBIOTICS

PRI and NW Single Dose Antibiotic Prophylaxis in Hip Procedures w37.1 and w 38.1 Jan 2006 - Jun 2007

0

10

20

30

40

50

60

70

80

90

100

Jan-06 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan-07 Feb Mar Apr May Jun

Month

%

PRI

NW

Model for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

Act Plan

Study Do

Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement 

Guide: A Practical Approach to Enhancing Organisational Performance. 

San Francisco: Jossey‐Bass, 1996

What?

Scottish Patient Safety Programme

Outcome Aims

Mortality: 15% reductionAdverse Events: 30% reductionVentilator Associated Pneumonia: 0 or 300 days betweenCentral Line Bloodstream Infection: 0 or 300 days betweenBlood Sugars w/in Range (ITU/HDU): 80% or > w/in rangeMRSA Bloodstream Infection: 30% reductionCrash Calls: 30% reductionHarm from Anti-coagulation: 50% reduction in ADEsSurgical Site Infections: 50% reduction

All processes at 95%

InterventionsCritical Care

E.g: ventilator acquired pneumonia bundleWard

E.g.: Outreach teamsMedicines management

E.g.: Medicines reconciliationTheatres

E.g.: Surgical pauseLeadership

E.g.: Safety walkarounds

What Is A Bundle?A structured way of improving the processes of care and patient outcomesA small, straightforward set of practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.The changes in a bundle are NOT new; they are well established best practices, but they are often not performed uniformly, making treatment unreliable, at times idiosyncratic.A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.

http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/WhatIsaBundle.htm

THE ANTIBIOTIC CARE BUNDLEAT INITIATION: DOCUMENT CLINICAL RATIONALE FOR

ANTIBIOTICAPPROPRIATE SPECIMENS FOR LABORATORYANTIBIOTIC SELECTED ACCORDING TO LOCAL POLICY AND RISK GROUPCONSIDER REMOVAL OF FOREIGN MATERIAL AND SURGICAL INTERVENTION

CONTINUATION: DAILY CONSIDERATION OF DE-ESCALATION, IV-ORAL SWITCH OR STOPTDM AS REQUIRE BY POLICY

Cooke FJ, Holmes A. IJAA 2007; 25-29.

Day 3 Antibiotic Plan: Clinical Diagnosis, Laboratory Results, Duration, Route

Pulcini et al, JAC, 2008

Day 3 Antibiotic Plan: Clinical Diagnosis, Laboratory Results, Duration, Route

Pulcini et al, JAC, in press

Completion of day-3 antibiotic plan

New Year

Christmas

Change FY1s

Stickers

New SpR & FY1s

0%10%20%30%40%50%60%70%80%90%

100%

09th

July

14th

Aug

28th

Aug

12th

Sep

25th

Sep

10th

Oct

23rd

Oct

6th

Nov

27th

Nov

11th

Dec

27th

Dec

15th

Jan

29th

Jan

Dates

Per

cent

age

CAP Bundle Compliance

CAP Antibiotics During First 4hrs

CONCLUSIONSSAPG IS NOW IN OPERATION WITH 4 KEY WORKSTREAMSOTHER AREAS CAN BE DEVELOPEDWE NEED YOUR ENGAGEMENTWE NEED YOUR SUPPORT WE NEED TO SHOW IMPROVEMENT IN PROCESS AND AMOUNT OF ANTIMICROBIAL USE AND ? OUTCOMESWE NEED TO IMPROVE SYSTEMS OF CARE

THANK YOUDILIP.NATHWANI@NHS.NET