NHS Improvement AMS Workshop London 5th May

Antimicrobial Stewardship

Workshop – Sharing success,

planning ahead and developing AMR

networks

Twitter #AMRWorkshop

Chair Dr Bruce Warner

Deputy Chief Pharmaceutical Officer

NHS England

LONDON 5th May 2016

Workshop objectives

1. Learn about what is new in 2016-17 – AMR CQUIN &

Quality Premium; PHE Fingertips; Behavioural strategies

for AMR

2. Sharing success – learn about what worked well

3. Discuss what this means for your local health economy

4. Start planning local AMR networks – what might these

look like? How to get started

2

UK 5yr AMRS: 7 key areas

for action

3

4

9.30 am Arrival and registration

10 am Chairs Welcome Dr Bruce Warner

Deputy Chief Pharmaceutical Officer

NHS England

10.10 – 10.30 AMR Quality Premium

Sharing success in 2015-16 and planning for 2016-17

Elizabeth Beech

National Project Lead HAI and AMR

NHS Improvement

10.30 – 10.50 AMR CQUIN

An introduction to the NHS England AMR CQUIN 2016-

17

Stuart Brown


NHS Improvement

10.50 – 11.10 AMR CQUIN

So what will this mean for your organisation?

Philip Howard


NHS Improvement

11.10 – 11.30 Table Top Discussion and Panel questions EB, SB, PB

11.30 – 11.50 Refreshments

11.50 – 12.10 How Health Education England are supporting

education for AMR and sepsis

Mohamed Sadak

Clinical Lead and Programme

Manager, Antimicrobial Resistance

and Sepsis.

Health Education England

12.10 – 12.30 Behavioural Matters Dr Tim Chadborn

Behavioural Insights Lead Researcher

Research, Translation and Innovation

Public Health England

12.30 – 12.50 Fingertips AMR Portal Dr Diane Ashiru-Oredope

Pharmacist Lead, AMR Programme


12.50 – 1pm Panel Questions MS, TC, D AO

1 – 1.50 Lunch

5

1 – 1.50 Lunch

1.50 – 3.20 Sharing successful antimicrobial stewardship

1.50 – 2.10 Delivering antimicrobial stewardship in an out of

hours provider organisation

Kym Lowder

Head of Medicines Management,

Integrated Care 24

2.10 – 2.30 Use of point of care diagnostics to improve

antimicrobial stewardship in respiratory tract

infections

Liz Cross

Advanced Nurse Practitioner

Attenborough Surgery

2.30 – 2.50 To Dip or Not To Dip – A patient centred approach

to improve the management of

UTIs in the Care Home environment

Elizabeth Beech on behalf of

NHS Bath and North East Somerset

CCG

2.50 – 3.10 Diabetic feet need antimicrobial stewardship too Naomi Fleming

Antimicrobial Pharmacist

Kettering General Hospital

3.10 – 3.20 Panel Questions

3.20 – 3.30 Refreshment Break

3.30 – 3.40 Using networks to deliver antimicrobial

stewardship

Elizabeth Beech


NHS Improvement

3.40 – 4.00 Table Top discussion and action plans for using

local networks

PH, SB, EB, D AO, MS, LM, BW

4.00 – 4.20 Table Top feedback on action plans

4.20 – 4.30 Summary and close Dr Bruce Warner

Deputy Chief Pharmaceutical

Officer

NHS England

Have a safe journey home

AMR Quality Premium – sharing

success in 2015-16 and planning for

2016-17

Elizabeth Beech

National Project Lead - Healthcare Acquired Infection and

Antimicrobial Resistance

[email protected] @elizbeech

5th May 2016

mailto:[email protected]

THANK YOU – this is what its all about

7

8

Improved antibiotic prescribing in

primary and

secondary care

This is a composite Quality Premium

consisting of three

parts:

Part a) reduction in the number of

antibiotics prescribed in

primary care

Part b) reduction in the proportion of

broad spectrum

antibiotics prescribed in primary care

Part c) secondary care providers

validating their total

antibiotic prescription data

Expectations exceeded!data to Feb 2016

• 2.7 million fewer antibiotics were prescribed

compared to previous 12 months – 7% reduction

• 0.6 million of these were broad spectrum items – a

14% reduction

• Items/STAR-PU value for England reduced by 8%

to 1.098 (median CCG value = 1.091)

• % broad spectrum items value for England reduced

to 9.8% (median CCG value = 10.1%)

• All Trusts, except one, validated data

9

Success in NHS push to reduce avoidable

antibiotic prescribing – NHS England News

23 March 2016

Dr Mike Durkin, NHS National Director of Patient

Safety, said: “Antimicrobial resistance is a major

threat to the delivery of healthcare across the globe,

and these findings clearly show that NHS England’s

incentive programme is an important step in the right

direction. Healthcare staff across the country should

be congratulated for this significant achievement

10

NHS England Antibiotic Quality Premium

monitoring data set – CCG targets met

11

12

13

Reduction in broad spectrum antibiotics items –

all CCGs in England

14

Quality Premium Guidance for 2016/17 -Antimicrobial resistance (AMR) Improving antibiotic prescribing in

primary care

This Quality Premium measure consists of two parts - each worth 50% of the

Quality Premium payment available for this indictor, which is worth 10% of QP

Part a) reduction in the number of antibiotics prescribed in primary care. The

required performance in 2016/17 must either be:

a 4% (or greater) reduction on 2013/14 performance

OR

equal to (or below) the England 2013/14 mean performance of 1.161 items per

STAR-PU

Part b) number of co-amoxiclav, cephalosporins and quinolones as a proportion

of the total number of selected antibiotics prescribed in primary care to either:

- to be equal to or lower than 10%, or

- to reduce by 20% from each CCG’s 2014/15 value

15

Antibiotic prescribing variability by CCG Jan15 – Dec15

16

Antibiotic prescribing variability by GP practice Jan15 – Dec15

17

18

So how do we continue to improve primary care

antibacterial prescribing in 2016-17?

Respiratory tract infections

• Delayed and No antibiotic prescription resources

• Bristol University NIHR funded research tools for use in

children

• Diagnostics – US Agency for Healthcare Research and Quality

• Vaccination

Urinary Tract Infections

• Link with the Think Kidney AKI programme

• Target nursing home residents

Education and Behavioural change

• Engage schools and universities

• Make every contact count – how can nurses help?

Local AMR Plans

19

Reduction in RTI antibiotic prescribing – all CCGs

in England

20

21

Finally

Continuing:

• NHSE Antibiotic quality premium monitoring dashboard

• PrescQIPP AMS Hub

Just arrived:

• PHE Fingertips AMR portal

Looking forward:

• CCG Improvement Assurance Framework (IAF) AMR

indicator

• Sustainability and Transformation Plans – opportunities?

• NICE guidance PHG89: Antimicrobial stewardship - changing

risk-related behaviours in the general population

22

AMR CQUIN 2016/17

Stuart Brown

Project Lead – AMR and HCAI

NHS Improvement

21st April 2016

Plan

• Background

• AMR CQUIN 2016/17– Part A – Reduction in antibiotic consumption per

1,000 admissions

– Part B – Empiric review of antibiotic prescriptions

• FAQ’s

UK Five Year AMR Strategy

Health and Social Care Act 2008

26

Antimicrobial Stewardship – Documents

2015

Part A – Reduction in antibiotic consumption per

1,000 admissions

28

ESPAUR 2014

• First national survey on Antimicrobial Consumption for primary and secondary care

• Information on the use of antibiotics– Primary Care –

NHSBSA database

– Secondary Care –obtained from data held by IMS Health®

ARHAI – Quality measures

Advisory Committee on Antimicrobial Resistance and Hospital Acquired Infections (ARHAI) Recommended Antimicrobial Prescribing Quality

Measures. 2014. https://app.box.com/ARHAI-Minutes-Papers/1/2152374732/18606265032/1

Data Validation – Quality Premium

Part c) secondary care providers with 10%

or more of their activity being

commissioned by the relevant CCG have

validated their total antibiotic prescribing

data as certified by PHE

Reduction in antibiotic consumption per 1,000

admissions

• There are three parts to this indicator

– Reduction of 1% or more in total antibiotic consumption

– Reduction of 1% or more in carbapenem

– Reduction of 1% or more in piperacillin-tazobactam

• Each indicator is worth 0.2% of the CQUIN scheme with an

additional 0.2% for

– Submission of consumption data to PHE for years

2014/15 and 2015/16

• The baseline data set is from 2013/14

33

Example Spreadsheet for upload

34

Example Spreadsheet for upload

35

FAQs Part A

Why has the baseline year been set as 2013/14

As part of the 2015/16 Quality Premium (QP), acute providers were required to submit

antibiotic usage data to Public Health England (PHE) for validation against information held

within IMS. Data provided by acute providers was assumed to be correct and was invaluable

in improving the accuracy of data held within IMS. During the validation exercise data

provided by acute providers was taken as correct and provided an accurate baseline of

antibiotic usage.

Can I use data from 2015/16

As above, the baseline of 2013/14 was chosen as this is the only nationally available data

set to be used for comparison which has been validated

Does the Total antibiotic consumption reduction refer to just those antibiotics that were

submitted as part of the Quality Premium (QP) or all antibiotics including those not included

in the data validation i.e. Aztreonam, Co-trimoxazole etc

The data submitted for the QP represented greater than 90% of antibiotic usage reported by

acute providers. Information on the antibiotics not included as part of the QP will be taken

from IMS to give a total value of antibiotic usage. These values will be available on NHS

England shortly. As soon as they are available, they will be communicated out. Acute

providers will have the opportunity to upload a full antibiotic data set from 2013/14.

36

FAQs Part A

When should antibiotic consumption data for years 2014/15 and 2015/16 be submitted and

how will it be submitted?

Total antibiotic usage data for years 2014/15 and 2015/16 should be submitted by the end of

Q1 (June 2016). A spreadsheet will be made available on the NHS England website, which

can be downloaded and populated with acute provider usage data. Once completed this

spreadsheet should be e-mailed to PHE

How will I submit quarterly data for the year 2016/17

A spreadsheet will be available to download from the NHS England website, similar in design

to last years QP. Once the spreadsheet has been populated it should be e-mailed to PHE

and it would be advised to copy your CCG into this e-mail. PHE and NHS England will

produce a report within 4 weeks to show which acute providers have submitted data.

Where is admission data extracted from?

Admission data has been taken from HSCIC and is available online

(http://www.hscic.gov.uk/)

What if I submitted the wrong data or I have identified an error in the data submitted?

If an error has been identified following submission of data for last year’s QP then it would be

advisable to inform your CCG of the error and data for the year 2013/14. Data for the year

2013/14 can be resubmitted for validation and a new baseline calculated but PHE will require

information on why the original data was incorrect.

37

http://www.hscic.gov.uk/

Part B – Empiric review of antibiotic prescriptions

38

Start Smart – Then Focus

39

Part B – Empiric review of antibiotic prescriptions

• Only one part to this element

– Percentage of antibiotics prescriptions reviewed within 72 hours

• Local audit of a minimum of 50 antibiotic prescriptions taken from a

representative sample across sites and wards

• Milestones

– Q1 Perform an antibiotic review for at least 25% of cases in the sample




40

Part B – FAQs

Which areas should be audited to collect the data for Part B?

A selection of wards and areas including Medicine, Surgery, Elderly Care, ICU, Neonates,

Obstetrics and Gynaecology should be included, with an aim to ideally include all areas and

specialities within each quarter. If this is not possible then all areas should be audited within

the year

Should I audit 50 sets of notes, 50 courses or 50 antibiotic prescriptions

Each month 50 antibiotic prescriptions should be audited. This may result in one patient

having two antibiotic prescriptions counted i.e. a patient prescribed IV Cefuroxime and IV

Metronidazole for five days would count as two antibiotic prescriptions.

Who should collect the data for Part B?

Any suitably qualified healthcare professional with experience of data collection e.g. Doctor,

Nurse, Pharmacist, Pharmacy Technician

41

Part B – FAQs

What is an empiric review

As part of good antimicrobial stewardship it would be expected that a review of an antibiotic

should take place within 72 hours of starting. This review will be based on Start Smart then

Focus (https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-

then-focus) and would include documented evidence of either:

• Stop

• IV to PO switch

• Change antibiotic

• Continue

• OPAT

This information can either be documented within the medical notes, on the medication chart

or electronically (if systems exist).

Is there a tool for uploading data for Part B of the CQUIN and how will commissioners know

if the data has been submitted?

PHE are developing a data submission tool for Part B (empiric review). It is recommended

that this form is used for data collection and submission. Following submission of the data to

PHE an e-mail will be sent to you and can be forwarded by you to your CCG as evidence of

data submission. A list of those organisations who have submitted data will be available on

the NHS England website as well as PHE’s AME Fingertips.

Example data sample tool (draft)

42

https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus

43

AMR CQUIN

• Two parts

– 1% reduction in consumption

– Antibiotic review within 72 hours

• Data collection forms will be released shortly and

will be available via NHS England

• Baseline data will be available shortly

44

What are the key challenges in implementing AMR CQUIN?

Philip Howard

Consultant Pharmacist

AMR Project Lead

Twitter: @AntibioticLeeds

[email protected]

#AMRCQUIN


1. Denial / shock

Things I’ve heard already

“I already have a perfect AMS programme in my hospital, and can’t achieve any further improvement …. We reduced our antibiotic consumption by a zillion % and our only vial of pip-tazo and meropenem are kept in the microbiology exhibits cupboard …”

TO

“not more work for the antimicrobial pharmacist without any additional support ……. I might as well give up an apply for one of those new GP prescribing pharmacist posts like the rest of them …. ”

2. Reality check

“I knew something like this was probably coming for months via the grapevine. If only I had heeded the advice to get a plan in place for a once in a lifetime opportunity to improve my AMS programme”

“actually, I know we’re not perfect from my

audit data, and feedback from my colleagues

in the hospital”

“When I chat to people at other hospitals, they’re doing some really innovative things”

3. Where are we now?Difference from 2013 to 2014 DDD/1000 adm (England)

• Total -0.7%

• Carbapenem +4%

• Piperacillin-tazo +7%

40% of hospital AB is OP & ED AB. Same AMS principles of checking indication against guidelines still apply. Audit of PGDs?

RR8 = -46

RR8 = -1

RR8 = -1

4. Feasibility of achieving CQUINs

5. Feasibility (2) – getting ideas

What’s my biggest challenge? Total, carbapenems or pip-tazo or all of them?

What guidelines recommend carbapenems or pip-tazo?

• Are there alternatives? Identify a lead for each to review.

• Does my restricted / protected AB policy really work? LTH

Can I reduce my total consumption?

• Do we over-treat? Is it sepsis driven? LTH+37% IV AB in 2y

• Is our prevalence high to peers? LTH <30%

• Is our day 3 review outcome data good (vs peers)? LTH 70% continue in notes & 85% on Rx

• Do we send appropriate samples before AB? LTH 81%

• Do we act on results within 24 hours? LTH 50%

• Can we use diagnostic tests to delay or avoid starting or stopping antibiotics earlier? CRP in ED, procalcitonin, etc

NHS Scotland: Use of pip-taz, carbapenemsand carbapenem sparing agents in acute hospitals* (aztreonam, fosfomycin, pivmecillinam, temocillin)

* Excludes NHS Highland

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

DD

Ds

pe

r 1

00

,00

0 p

op

pe

r d

ay

Year/Qtr

Carbapenems Pip-Tazo Carbapenem Sparing Agents

“but they cost so much more than cheap mero or pip-taz”

NHS Scotland: Use of carbapenems,carbapenem sparing agents and pip-tazoin Jul-Sep 2015 in acute hospitals by NHS board*

* Excludes NHS Highland

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

DD

Ds

pe

r 1

00

,00

0 p

op

pe

r d

ay

Carbapenems Carbapenem Sparing Pip-Tazo

NHS-Scotland PPS: Compliance With Antibiotic Policy

high for meropenem

lower for pip-tazo

Only 50% have active restricted (protected) AB follow up. (Howard

JAC 2015)

FY 2015/6 Carbapenem sparing vs pip-tazo + carbapenem

Has 2015-6 Sepsis CQUIN ED IV AB use?

Overall 9.3% in rolling 12 mth from April to March (info from Rx-Info Define software)

CEM audit of IV AB in 60 mins: 2011 = 27% (IQR 17-37%) 2013 = 32% (IQR 20-44%)CQUIN Sepsis 2015-6 Q2 = 49%, Q3 = 58%61% of red flags required AbsDay 3 review in 2016-7 CQUIN

Recommended annual AMS audits & feedback to improve prescribing

ESPAUR 2014

LTH audits showed 50% & 81%

Only 10% could supply results & outcome (Llewellyn JAC 2015)

LTH 59% in notes

Summary of antibiotic use & prescribing standards for Feb-16

Antimicrobial

Prescribing

Standards

LTH

ABDO

MED

SURG

(32)

ADULT

CRITICAL

CARE

(42)

ACUTE

MEDICIN

E (18)

CARDIO-

RESPIRA

TORY

(22)

NEUROS

CIENCES

(34)

CHAPEL

ALLERTO

N (20)

CHILDRE

N'S (14)

HEAD &

NECK

(28)

LEEDS

CANCER

CENTRE

(16)

TRAUMA

&

RELATED

(36)

URGENT

CARE

(24)

WOMEN'

S (12)

Indication (as per guideline) on chart 96% 97% 97% 96% 99% 100% 100% 86% 100% 98% 98% n/a 92%

Duration or review date on chart 94% 94% 97% 100% 100% 67% 100% 84% 100% 98% 92% n/a 75%

Follow AB guidelines 99% 97% 100% 99% 100% 100% 100% 100% 100% 98% 98% n/a 100%

Day 3 review completed 76% 66% 89% 81% 58% 71% 100% n/a 100% 89% 46% n/a n/a

All allergy boxes completed fully 92% 94% 97% 90% 90% 92% 100% 99% 100% 92% 80% n/a 100%

Overall performance

Day 3 review outcomes Stop 2% 5% 0% 5% 0% 0% 0% n/a 0% 3% 0% n/a n/a

IVOS 6% 11% 0% 14% 0% 0% 50% n/a 0% 3% 0% n/a n/a

Oral to IV switch (escalate) 1% 0% 0% 2% 0% 0% 0% n/a 0% 0% 0% n/a n/a

Change AB 2% 0% 0% 7% 0% 0% 0% n/a 0% 0% 0% n/a n/a

Continue 89% 84% 100% 72% 100% 100% 50% n/a 100% 95% 100% n/a n/a

LTH

ABDO

MED

SURG

(32)

ADULT

CRITICAL

CARE (42)

ACUTE

MEDICINE

(18)

CARDIO-

RESPIRAT

ORY (22)

NEUROS

CIENCES

(34)

CHAPEL

ALLERTO

N (20)

CHILDRE

N'S (14)

HEAD &

NECK (28)

LEEDS

CANCER

CENTRE

(16)

TRAUMA &

RELATED

(36)

URGENT

CARE (24)

WOMEN'S

(12)

-10% -6% -7% -9% -18% -3% -19% -28% -11% 10% -28% -12% 17%

-5% 2% -3% -1% -21% 23% -52% -26% 17% 9% -20% -3% 22%

6% 4% -5% 14% 9% 11% 19% -8% 0% 11% 3% 12% 6%

1% -2% -9% 13% 5% 7% -19% -8% 26% 4% -5% -4% -1%

IV AB usage

IV AB usage to Feb-16

Total IV - short term (3mth vs last yr)

Broad spectrum IV - short term (3mth vs last yr)

Total IV - long term (12mth vs last yr)

Broad spectrum IV - long term (12mth vs last yr)

Do you know your AMS performance?

• users like smiley faces – easy to understand

Do we actually make a diagnosis?

Bodansky 2012 Clin Med (Lond)

100 consecutive MAU admissions started on antibiotics over 3 days

• Do our guidelines give advice about negative results?

• Driving D3 review with a sticker put in notes by ward nurse

Chelsea & Westminster restricted /

protected AB follow up (Orla Geoghegan)

• Micro unaware 73% of 3048 restricted AB FY20145 • 14% deemed inappropriate. 56% stopped within 72h • 677 interventions - 91 % were actioned. Avg 45min/day

UKCPA PIN Award 2015

E-Whiteboard to highlight IV AB

AB

IV to oral switch – day 3 sticker

Day 3 review of antibioticsMicro results checked Imaging Patient eating? IVOS OPAT New diagnosis:Next review date:

Diagnostic markers to delay or avoid initiation or stopping antibiotics earlier

Health Technology Assessment of procalcitonin (Nov-15)

• 18 studies (36 reports): PCT algorithms were associated with:

• reduced antibiotic duration [WMD –3.19 days, 95% confidence interval (CI) –5.44 to –0.95 days, I2 = 95.2%; four studies],

• hospital stay (WMD –3.85 days, 95% CI –6.78 to –0.92 days, I2 = 75.2%; four studies)

• and trend towards reduced intensive care unit (ICU) stay (WMD –2.03 days, 95% CI –4.19 to 0.13 days, I2 = 81.0%; four studies).

• no differences for adverse clinical outcomes.

• not clear that PCT testing is the main cause of these reductions, or reproducible in UK hospitals

• may be cost-saving for adults with sepsis in an ICU setting and adults and children with possible bacterial infection in EDs.

www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0005/156911/FullReport-hta19960.pdf

http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0005/156911/FullReport-hta19960.pdf

NICE diagnostics guidance [DG18] on Procalcitonin testing

“procalcitonin tests …. show promise but there is currently insufficient evidence to recommend their routine adoption in the NHS. Further research on procalcitonin tests is recommended for guiding decisions to:

• stop antibiotic treatment in people with confirmed or highly suspected sepsis in ITU or

• start and stop antibiotic treatment in people with suspected bacterial infection presenting to the emergency department.

Centres currently using procalcitonin tests to guide these decisions are encouraged to participate in research and data collection

Talk to your hospital Director of Quality if you consider this a antibiotic sparing strategy. Some hospitals target patients.

Completion of a NICE non-conformity statement

Electronic systems for AMS

• Hosp e-Rx is poor (9%17%, but 50% in progress) + indn + durn ~34% built in (2012 Global AMS survey UK data)

• Data warehousing (2% in UK) - links pathology & pharmacy systems to patient admin system

• Can use data warehousing without e-Rxing if issue antibiotics to patients– Bug – no drug. Drug – no bug. – Reporting systems of use & resistance– Increases productivity by 50% of AMS staff (USA – Theradoc)– Big savings on antibiotics & improved outcomes (USA)

• Use CQUIN money to get better AMS tools• National specification for e-prescribing to improve AMS

(ESPAUR subgroup)

5. Feasibility (3) – investment

1. Carbapenem or pip-tazo sparing AB will cost more. How much?

• LTH: already use 24% carb sparing (vs 8% mean). New costs from £5-£12/day to £80-100, but generic linezolid will save me £400k/yr). Est £150-200k

2. Do we have antimicrobial consumption monitoring systems in place?

• LTH: poor but use Rx-Info Define to benchmark nationally. £6k for Refine (inward looking)

3. Do we need extra staff to collect / share data or AMS rounds?

• LTH: IT support for data sharing. Extra staff for collection , audit and education. £50k

Ward HCAI / AMS health check

New evidence for AMS Teams

Schuts (LID 2015) metanalysis: strong evidence

• mortality: empirical guideline adherence, de-escalation based on C&S, bedside consultation for S.aureus bacteraemia)

• IV to oral switch = LOS + ££, cure

• TDM: nephrotoxicity

• restricted antibiotics: use (but non-restricted) + AMR

Taconelli (ECCMID 2016) – metanalysis of AMS on AMR

• AMR G+ve -43% (MRSA -49%), G-ve -28% (CRE -48%)

5. Feasibility (4) - leadership

Can we (AMS team) achieve this on our own?

• LTH: need to join sepsis & AMR CQUINs (start smart then focus) into a single quality improvement programme.

How will I keep the hospital senior leaders updated on progress?

• LTH: ask! They will be asking you for a monthly update – income stream

Summary: To meet the AMR and Sepsis CQUINs

• Design systems to force better prescribing eg day 3 review for de-escalation AND IV to oral switch

• Review guidelines containing piperacillin-tazobactam and meropenem. Ensure they are followed through audit & feedback

• Quality improvement, not annual audit of AMS

• Merge sepsis and AMR CQUIN – start smart then focus

• Protected (restricted) antibiotic systems need to work

• Monitor & benchmark antibiotic usage

• Regular but varied communication on progress

• Local education & training at ward level

• Strong and effective multidisciplinary leadership (champions) at all levels

Thank you to lots of people

• Leeds THT: Jon Sandoe, Abimbola Olusoga, Damian Mawer, Jason Dunne, Cheryl Mitchell, Mark Wilcox

• NHS England: Elizabeth Beech, Stuart Brown, Matthew Fogarty, Lauren Mosley, Mike Durkin, Celia Ingham-Clarke

• PHE: Diane Ashiru-Oredope, Susan Hopkins, Cliodna McNulty, Duncan Selby

• NHS Scotland: William Malcolm, Jacqui Sneddon, Alison Coburn, Dilip Nathwani, Andrew Seaton, Susan Paton

• UKCPA PIN: Orla Geoghegan, Mark Gilchrist, Tejal Vegha

• ESCMID ESGAP: Celine Pulcini, Stephan Harbarth

• ISC: Gabriel Levy Hara, Ian Gould

Table Top Discussion and Panel Questions

Refreshments

How HEE is supporting education for AMR and

sepsisMohamed Sadak, Clinical Lead and Programme Manager

www.hee.nhs.ukwww.hee.nhs.uk

What does HEE do?

Health Education England (HEE) exists to support the delivery of excellent healthcare and health improvement to the patients and

public of England by ensuring that the workforce of today and tomorrow has the

right numbers, skills, values and behaviours, at the right time and in the right place.


The Mandate identifies a number of priorities for the future, as well

as providing an opportunity to recognise the progress made in

meeting objectives set in previous mandates.

Work with PHE to ensure that the competence and principles of

prescribing antimicrobials, as set out by the NPC and the ARHAI

advisory group are embedded in professional curricula.

Work with universities, commissioners and employers to ensure

workforce capability, capacity and planning mitigates the risk of

antimicrobial resistance as set out in the UK AMR strategy.

Take steps to ensure that training is also available so that

healthcare staff are competent in the recognition of, and response

to, acute illness such as sepsis as a key factor in preventable

mortality.

HEE Mandate 2015/16


Work streams

AMR

• Introductory e-learning module.

• AMPS competence HEI survey into curricula.

• AMR animation.

• AMPS competence embedding by professional bodies.

Sepsis

• Educational video on paediatric sepsis.

• Educational resources for primary care.

• Scoping work on current training.

• GP spotlight project.

• Partnership with UKST.


Introductory e-learning module

http://www.e-lfh.org.uk/programmes/antimicrobial-resistance/

http://www.e-lfh.org.uk/programmes/antimicrobial-resistance/


The Antimicrobial Prescribing and Stewardship (AMPS) Competences, (ARHAI & PHE, 2013).

45 universities and 100 course responses (17 Medical, 13 Pharmacy, 22 Independent Prescribing, 5

Dental , 24 Nursing, 13 Midwifery and 7 Allied Health Professional courses).

86 courses (86%) confirmed they were aware of these AMPS competencies.

Embedding AMPS competence

into HEIs curricula. COMPETENCY Dent Pharm Med Midw Nurs Ind

Pres

AHP

1: Infection Prevention and Control. 100% 98% 99% 85% 86% 72% 94.2%

2: Antimicrobial resistance and antimicrobials 97% 100% 99% 59% 56% 75% 41%

3: Prescribing antimicrobials. 88% 81% 96% 41% 29% 90% 30%

4: Antimicrobial Stewardship. 73% 77% 91% 51% 42% 77% 25%

5: Monitoring and learning 50% 48% 63% 23% 16% 68% 14%

Total average 82% 81% 90% 52% 46% 76% 40.8%


AMR animation

https://youtu.be/oMnU6g2djm4

https://youtu.be/oMnU6g2djm4


Royal College of General Practitioners (RCGP).

The UK Sepsis Trust (UKST).

Public Health England (PHE).

Royal College of Paediatrics and Child Health

(RCPCH).

Royal College of Emergency Medicine (RCEM).

Royal College of Obstetricians and

Gynaecologists (RCOG).

Royal College of Surgeons (RCS).

Royal College of Nursing (RCN).

Royal College of Medicine (RCM).

College of Paramedics (CP).

Royal Pharmaceutical Society (RPS).

Royal College of Physicians (RCP).

Academic Health Science Networks (AHSN).

A Patient Representative.

HEE sepsis working group


Short awareness video to help the healthcare

community recognise the signs of sepsis in children and

direct them to appropriate learning materials involving:

Jason & Clara Watkins (Lost their daughter Maude to sepsis on

New Year’s Day, 2011).

Dr Nelly Ninis (Consultant Paediatrician, Imperial College

Healthcare, NHS Foundation Trust).

Dr Tim Fooks (Clinical Lead, Children and Young People, South

East Coast Strategic Clinical Networks).

Advisors:

Dr Sanjay Patel (Paediatric infectious diseases and immunology

consultant at Southampton Children’s Hospital).

Dr Hilary Cass (Consultant in paediatric neurodisability at the

Evelina Children’s Hospital, former President of the RCPCH and HEE’s

senior national clinical lead for children and young people’s health).

https://vimeo.com/165134226

Educational video on paediatric

sepsis: THINK SEPSIS.



E-learning package on the identification

and management of sepsis in primary

care.

Lead authors are 3 GPs;

Dr Simon Stockley, the RCGP’s sepsis lead.

Dr James Larcombe.

Dr Alison Tavare.

The target audience for the modules will be

GPs, but our intention is to make them

available across primary care,.

Sessions:1. Introduction on sepsis.

2. Adult sepsis.

3. Childhood sepsis.

4. Complex safety issues.

5. Care homes and the frail elderly.

Educational resources for

primary care: THINK SEPSIS.


Scoping the provision of learning materials available to support the recognition and

management of sepsis in different sectors of practice and across different healthcare

groups.

Our aim is to be able to promote existing good practice, identify gaps in the materials

currently available and make recommendations for the commissioning of new materials to

cover these gaps.

The organisations we have contacted as part of this work include:

All acute hospital trusts in England via the Directors of Medical Education and pharmacists via the

United Kingdom Clinical Pharmacy Association (UKCPA) Infection Management Group and Critical Care

Group.

Primary Care Pharmacists via the Primary and Community Care Pharmacy Network, Primary Care

Pharmacists Association and Primary Care Advisors Group.

All ambulance trusts in England via the Association of Ambulance Chief Executives Group / College of

Paramedics (x 13).

All Health Education England Local Teams (x 13).

All Academic Health Science Networks in England (x 13).

Royal Colleges

Scoping work


UKST:

“Sepsis Savvy” microteaching sessions for parents and lay people in order to help

raise awareness.

E-learning module on sepsis recognition in care homes (led by NWC AHSN).

RCGP:

RCGP Clinical Lead for sepsis.

Coordinate and focus General Practice efforts to improve the outcomes from sepsis,

particularly to collaborate with colleagues across all health systems to reduce deaths

from sepsis in England.

Develop and deliver 4 regional workshops across England delivered through RCGP

Enterprises/Faculties.

Work with UKST and RCGP


Julie Screaton (Director, London and South East, Health Education England).

Ged Byrne (Director of Education and Quality, Health Education North).

Alan Ryan ( National Programme Director, e-LfH).

Andrew Frankel (Postgraduate Medical Dean, Health Education South London).

Janet Flint (Programme Lead, Public Heath National Programmes, Health Education

England).

Diane Ashiru-Oredope (Seconded to HEE March 2015 – September 2015).

Rachel Alder (Fellow in Medical Education, Health Education South London).

Antonio De Gregorio (Programme Coordinator – National Programmes, Antimicrobial

Resistance and Sepsis, Health Education England).

The HEE team.


Thank you for listening.

Questions / Thoughts /

Comments?Visit: www.e-lfh.org.uk/programmes/sepsis

&

https://www.hee.nhs.uk/our-work/hospitals-primary-

community-care/prevention-public-health-

wellbeing/antimicrobial-sepsis-awareness

Contact: [email protected]

http://www.e-lfh.org.uk/programmes/sepsis

https://www.hee.nhs.uk/our-work/hospitals-primary-community-care/prevention-public-health-wellbeing/antimicrobial-sepsis-awareness


Antimicrobial Stewardship Workshop

AMR: a behavioural challenge

Dr Tim Chadborn & Anna Sallis CPsychol


Leeds 21 April 2016

Aims:

1. Illustrate innovative behavioural approaches to AMR

2. Summarise key behavioural/social issues and

opportunities related to AMR

3. Share key examples of innovative behavioural

intervention

Wicked problems for behaviour change

90

Limitations of Traditional

Behaviour Change Theories• The Health Belief Model – Becker (1974) Importance of beliefs, perceived benefits &

barriers to action, self-efficacy, stimulus/ cue to action. Limitations; focused on

conscious decision making and ignores habits.

• Social Learning Theory – Bandura (1977) Importance of social environment,

modelling and self efficacy

• Theory of Reasoned Action Ajzen & Fishbien (1980)/ / Theory of Planned

Behaviour – Ajzen (1985) Limitation; assumption people act in a rational way at all

times, not all behaviour is planned.

• Stages of Change Model / Transtheoretical Model – Prochaska and DiClemente

(1997) Assumption behaviour change occurs in a linear fashion, progression through a

series of stages.

Key limitations:

• Effectiveness of predicting behaviour change

• Intention-behaviour gap

• Not addressing automatic motivation, habits and impulsive behaviour.

91 3 Public Heath England - Behavioural Insights

Behavioural challenges in dispensing

92

Causes

• Failure to check

• Lack of concentration

• Poor handwriting

• Design of dispensary

• Busy workplace / distractions

• Stress

• Staff shortages

• Lack of clinical knowledge

• Medicines with similar names

• Medicines with similar packaging

Recommendations

• Verification

• Take breaks

• Check – involve two people

• Clutter free / organised dispensing

• Minimise disruptions

• Limit workload

• Maintain appropriate staffing

• Limit roles to competent staff

• Alert staff

• Alert staff

3 Public Heath England - Behavioural Insights

Leyla Hannbeck et al. www.npa.co.uk // James et al. IJPP 2009

Are these appropriate to change the

behaviour?

http://www.npa.co.uk/

Characterising interventions using a

comprehensive model of behaviour change

Identify gaps /

opportunities

Deliver current

interventions

smarter

Michie et al (2011)

Behavioural analyses

Literature

Antibiotic prescribing:

literature review and behavioural analysis

Structured search using Ovid Medline® to 18 November 2013.

95

629 down to 197. 529 down to 54.

What do we know

(or think) might

contribute to AMR?

What do we know

(or think) might

improve stewardship?

BMJ Editorial

Behaviour occurs as interaction between:

Michie et al. (2011)

Identified behavioural drivers of antibiotic prescribing

Behaviour pathways

Key findings from behavioural analysis –

focus on prescribing in primary care

96

Feel unwell with self-limiting

infection

Visit GP

Inappropriately prescribed antibiotics

Recovery

Inappropriate attribution of recovery to antibiotics

Reinforcement of health seeking

behaviour

Intervention

opportunities

GP prescribes

antibiotics to

patients as norm

with insufficient

professional or

personal

consequence

Patient is satisfied

– linked to GP

performance pay

Some possible solutions:

• Address GP concerns of

consequences of not

prescribing

• Improve GP belief in the

consequences of

overprescribing

• Enhance GP perceived

capability regarding the

impact of their personal

behaviour on AMR

• Make consequences of

AMR more immediate,

visible, salient and

personally relevant

• Increase credibility of

pharmacy advice

Consequences of

AMR are unclear to

the public

Do not realise that

antibiotics will not

improve their symptoms

for viral or self-resolving

infections

Societal benefits but few

immediate personal benefits

- lack of incentive to change

current behaviour

Intervention design and implementation

COM-B – dual process model

98

Michie et al (2011)

Cane et al (2012)

Behaviour

Capability

Psychological

Physical

Motivation

Reflective

Automatic

Opportunity

Social

Physical

Skills, strength, stamina

Knowledge, skills, memory

Attitudes, beliefs, intentions

Emotions, impulses, habits

Norms, cues, acceptability

Time, resources, cues

Behavioural Insights Intervention

12 Lancet. 2016 Apr 23;387(10029):1743-1752.

Randomised Control Trial -

reducing antibiotic prescribing

through behavioural science

1581 GP practices in top 20% by

prescribing rates randomised to:

1. Education materials for patients

2. Social norms feedback letter

from the Chief Medical Officer

3. Combination of the two

4. No intervention (control)

2 x 2 factorial design determines

independent effects of the two

interventions

Published in Lancet in Feb 2016

“The great majority

(80%) of practices in

[NHS Area team]

prescribe fewer AB

per head than yours”

Reduction in antibiotics dispensed among practices

sent the letter compared to controls - at low cost

2014 2015

Reduction of 3·3% in top 20% - equates to 0.83% across all GPs

Estimated 73,406 fewer antibiotic items dispensed

Cost of £4,335 - saving £92,356 in just prescription costs

13

Graph shows the effect of letter only as no reduction from educational materials

Letter reduced prescriptions

Letter

intervention

Letter reduced prescriptions in control group

Other key references

101

JAMA 2016; 315 (6): 562-570

NICE Medicines and Prescribing Centre – Neal Maskrey / Jonathan

Underhill

Evidence-informed decision making

https://vimeo.com/115958879 & https://vimeo.com/115958880

MeReC Bulletin Vol.22 No.01 August 2011 - Making decisions better



In summary

We won’t tackle AMR if we don’t

change behaviour

Focus on behavioural issues and opportunities – incl. system and

context – considering practicality/sustainability/opportunity costs

Immediate focus on what works, rather than basic understanding

(but aware of and considering wider evidence developments)

Few influences of AMR do not involve behaviour. Behavioural and

social science cut across areas of action in the UK AMR Strategy(start from behaviour we want to change – not ‘we want to do ……….’)

Need to apply evidence-based frameworks for behaviour change

103

Implementation of national AMS toolkits in England Dr

Diane Ashiru-Oredope

Become an Antibiotic Guardian today

(available via mobiles)

104

Thank you - questions

Antimicrobial Stewardship:

tools for local action

NHS Improvement and PHE

Antimicrobial Stewardship Workshop

21 April 16

Dr Diane Ashiru-Oredope

Pharmacist Lead;

Antimicrobial Resistance Programme


Twitter - @DrDianeAshiru #AntibioticGuardian

OutlineFingertips – tool for local action

Implementation of national antimicrobial stewardship interventions in national

toolkits

• Systems and processes

• Toolkits

• Education and training

• Engaging with patients and the public

Tools available for local action

• Fingertips

• Data submission for CQUIN

106Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr


UK 5-year AMR Strategy 2013-18:

Seven key areas for action

PHEHuman health

DH – High Level Steering Group (cross government)

DefraAnimal health

DH

1. Improving infection prevention and control

2. Optimising prescribing practice

3. Improving professional education, training

and public engagement

4. Better access to and use of surveillance

data

• Improving the evidence

base through research

• Developing new drugs,

vaccines and other

diagnostics and treatments

• Strengthening UK and

international collaboration

Impact of EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope & Ms Katerina (Aikaterini) ChaintarliEAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope

Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr

Diane Ashiru-Oredope107

108

Antimicrobial Stewardship Tools NHSI_PHE

#AMSWorkshop Dr Diane Ashiru-Oredope

Complete NICE AMS baseline assessment



Antimicrobial stewardship : NICE quality standard

(Was due for publication : 20 April 2016) - postponed

What tools are available:



Antimicrobial stewardship toolkits: PHE in collaboration with

several professionals and professional organisations



Treating your infection

Never share antibiotics and always return any unused antibiotics to a pharmacy for safe disposal

Leaflet developed in collaboration with these professional societies.

TARGET LEAFLET – GP, OOH, Community Pharmacy

TREATING YOUR INFECTION LEAFLET: GPs; Out of Hours practice; Community Pharmacy• A leaflet for health professionals working in primary care to use when provide

advice to patients. The leaflet provides practical advice on how to treat symptoms of common self limiting infections and warning signs for serious illness.

Developed by Public Health England 112



AMR Education and Training



% Acute

Trusts

(n=100)

%CCG

s

(n=82)

Has a written Antimicrobial Education and Training Strategy 24 1

Competency assessments carried out for prescriber 17 *

Competency assessments are mandatory 20 *

Teaching on induction for all nurses 27 6

Teaching on induction for all pharmacists 69 6

Teaching on induction for non-medical prescribers 18 7

Mandatory e-learning for senior doctors (registrar and higher) 17 4

Mandatory e-learning for junior doctors 24 4

Antimicrobial prescribing and stewardship training is left to

individual trainers to decide* 33

E-Learning for Healthcare (HEE)


Diane Ashiru-OredopeAMR; WLMHT Physical Health Conference Dr Diane Ashiru-Oredope

Free for all with

NHS email address

115

Open access for ALL

Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

Specialists in primary and secondary care

Primary Care

Prescribing advisors/medicine

management pharmacists in 66% of

CCGs

Specialist antimicrobial pharmacist

in 5%

Quality leads and nursing clinical leads

in 6%,

GP clinical leads in 2%.

Specialist antimicrobial pharmacists

spent 4-7 times longer on these

duties than non-specialists such as

prescribing advisor/medicine

management pharmacists, quality

leads, nursing clinical leads or GP

clinical leads

Secondary Care

90% of responding Trusts had a

specialist antimicrobial pharmacist

at band 8a and above in post.



Pharmacist Grade % Acute

Trust

(n=100)

Pharmacy technician - band

5 or higher

2

Pharmacist - band 7 9

Pharmacist - band 8a 59

Pharmacist - band 8b 17

Pharmacist - band 8c 2

Consultant Pharmacist (≥8c) 5

None 4

No answer provided 2

Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

117Antimicrobial Stewardship #AMSworkshop

Dr Diane Ashiru-Oredope

See Posters

Information for local action• With access to PHEs Fingertips

portal, data for stakeholders

regularly in a timely fashion

• Fingertips can be used information

for action in each of key areas

• antimicrobial stewardship

• antimicrobial prescribing

• antimicrobial resistance

• infection prevention and control

• healthcare associated infections



Antibiotic Guardians per 100,000 population by CCGs

PHE Fingertips Web Portal

(http://fingertips.phe.org.uk/)



PHE Fingertips Web Portal



Published: 5 April 2016

Questions?

Email: [email protected]




Domain Quality Indicators

AMR • % of E. coli from blood tested for susceptibility to carbapenems

• Gram-negative BSIs and resistance to key antibiotics

Prescribing • Community prescribing (CCG)

HCAI • Mandatory bacteraemia surveillance data

• Mandatory CDI surveillance data

• Mandatory SSI surveillance data

IPC • ERIC data on single rooms/single rooms with ensuite (by Trust);

• PLACE cleanliness scores

• Healthcare worker influenza vaccination

AMS • Antibiotic Guardians per 100,000 population per year (CCG)

• SSTF review and action plans (by Trust);

122 AMR Local Indicator122 Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

AMR Local Indicator

Domains Click these to change between domains, note that indicators will only display if there is an indicator

for the Area type chosen

All indicators that are available for Acute Trusts and CCGs are available in the

“All Trust” and “All CCGs” domains.

123Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

AMR Local Indicator

Area type This dropdown allows you to switch between GP Practice, CCG and Acute Trust indicators


AMR Local Indicator

Area Use this to select the individual GP practice, CCG or Acute Trust you would like to view all data for


AMR Local Indicator

Area

grouped by

This dropdown will determine how the data is aggregated, sub-regions are the default for this

profile


AMR Local Indicator

Sub-region This dropdown will determine which sub-region the system will display data for


Benchmark The default for this is England, in some cases a benchmark against sub-region values will be

allowed.



AMR Local Indicator

View tabs These offer alternative ways of displaying the data, further detail in the later slides


AMR Local Indicator

Some indicators display a coloured background on their values. This is to denote a

comparison to the benchmark value.

A legend is provided by the system at the top.


AMR Local Indicator

In the overview mode, you view multiple indicators within a domain simultaneously.

This will only display the indicators for the chosen area type and the appropriate sub-

region and national value.


In this view you can change between sub-regions. The grey left and right arrows allow

you to scroll between all the CCGs/ Trusts within the selected region.



AMR Local Indicator

Scatterplots to be drawn between different health indicators. Indicators are chosen from

the drop down menu

You can highlight individual GP, CCG, Trusts

AMR Local Indicator

Treat with caution due to concerns over time release of data from different indicators

and potential misuse due to not fully appreciating caveats of individual indicators.

Trendlines will only display if R2 > 0.15


The mapping function gives a strong visual

representation of the indicator as well as

regional fluctuations.

The system does not currently have the

facilities to map at trust or GP level.

The scale can be altered to be matched

against the benchmark, by quartiles,

quintiles on a continuous scale.

AMR Local Indicator

Able to monitor the trend of an indicator over time.

Can be done along with or independently from a benchmark against a chosen area or

areas within a single area-grouping

View a single indicator or all indicators within the same domain and area type

simultaneously.

AMR Local Indicator

Additionally, users can view a single area or multiple areas within a region

simultaneously.

The data can be viewed for just the selected sub-region or at a national level.

Data can be sorted by Area, Count or Value.

95% CI are presented if the data is sample of the total population



AMR Local Indicator

Multiple indicators can be viewed at once within a single domain. Users are able to see

where their chosen area falls among the range of all values for that indicator.


AMR Local Indicator

Users are able to see the highest and lowest values recorded for any indicator as well as

the value for their chosen area.

Further information on the interpretation of a high or low value can be found in the

definitions tab.

141 AMR Local Indicator

Within the definitions you will find the full explanation of each indicator, where the data is

sourced from and how the indicator was produced.

Information on how this data should be interpreted and any data caveats for the indicator

will be listed here.

141 Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

This tab allows you to download the data

as an excel file.

Note the timescale of the data if you are

looking to download the data regularly.

This slide is for All Trust data

AMR Local Indicator

All Acute Trust indicators displayed together


This slide is for all CCG data

All CCG indicators displayed together.



This slide is for National GP Profile Page

AMR Local Indicator

For an individual General practice you can see the trend data across the

indicators.


You can also create a scatter plot with any other indicator on the GP profile,

identifying outliers with particular patient groups.



Future AMR local indicators

147

Domain Quality Indicators

AMR •Number of AMRHAI confirmed CPE by Trust

•Trimethoprim resistance in community urine samples by CCG

Prescribing • Nitrofurantoin: trimethoprim ratio, by GPs and CCGs

HCAI • Surgical Site Infection Surveillance datasets

• Other GN-BSI by CCG (and in future Trusts)

• HCAI mortality data

• Number of Blood cultures sets and Clostridium difficile tests

IPC • Healthcare worker Flu vaccination

AMS • Start Smart Then Focus Audits, by Trusts



Antimicrobial Stewardship Surveillance:

CQUIN - data collection form and

submission tool



AMS Surveillance tool piloted



Participants stated whether they collected the following information

and provided the percentage of patients who met these criteria



% Trusts that collected these data (n=28)

Mean percentage of patients achieving this indicator

Range of the proportion of patients meeting this indicator

Indication documented on drug chart (inc severity where appropriate)

89.29 83 27-100%

Stop or review date documented

92.86 73 30-99%

Antibiotic courses reviewed with formal documentation at 48-72 hours after initiation of therapy

35.71 71 10-96%

Compliant with local guidelines (dose, frequency, duration) or reason for variance

78.57 84 30-98.5%

C&S samples taken before starting antibiotics

14.29 58 10-88%

Antimicrobial allergy documented

60.71 93 30-100%

Tool adapted to focus on CQUIN data

submission







National Point Prevalence Survey 2016Voluntary participation

England’s fifth point prevalence survey (PPS) on HCAI and second national

survey on antimicrobial consumption and prescribing quality indicators.

At a national level the PPS will act to improve knowledge and understanding of

antimicrobial resistance (AMR), HCAI and AMU – a key aim of the cross-

government UK 5 year AMR strategy

At a hospital level the data generated could be utilised to demonstrate

compliance with criteria one and three of Code of practice.

Letters sent to Chief Pharmacists and DIPCs of all acute Trusts.

Please consider including this in your 2016/17 IPC and antimicrobial

stewardship work plan and nominate two surveillance leads

(suggestion: lead IPC nurse and antimicrobial pharmacist) and email

names to [email protected] by April 1 2016.



Engaging with

patients & the

public

Educating the public

Moving from awareness to engagement:

Antibiotic Guardian calls on everyone in UK to become

Antibiotic Guardians – Behaviour change – ‘if-then’ approach

pledge system: http://antibioticguardian.com/


Diane Ashiru-OredopeCombating AMR (CPC Conference) Dr Diane Ashiru-OredopeAntimicrobial Stewardship Dr Diane Ashiru-Oredope

EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope156 AMR; WLMHT Physical Health Conference Dr Diane Ashiru-Oredope156 Antimicrobial Stewardship Tools NHSI_PHE #AMSWorkshop Dr Diane Ashiru-Oredope

http://antibioticguardian.com/

Evaluation summary

• Good response of an overall representative sample

• Increased self-reported knowledge and changed self reported behaviour

particularly with those with prior AMR awareness

• Increased commitment to tackling AMR by both HCPs and members of the

public

• Less successful in engaging general public most likely due to modes of

promotion

• Majority thought the campaign was well promoted


Diane Ashiru-Oredope157 Overview of AMR in England & AMR campaigns: Dr Diane Ashiru-Oredope

In Press

157

EAAD and World Antibiotic Awareness Week

16 – 22 November 2016

307 organisations registered their

antibiotic awareness activities with

PHE, 69% were NHS organisations and

13% were universities.

During WAAW, 6510 individuals became

Antibiotic Guardians.

Of AGs who registered during WAAW, 49%

were healthcare professionals, 31%

were members of the public and 20%

were students or educators.



Antibiotic Guardians per 100,000 population by CCGs &

registered orgnisations

PLANS FOR EAAD/AG 2016/17• Healthcare Students

• Young families: suggestions included promotion through council-run

nurseries, building on the success of “Listen to your Gut” campaign

materials. Encouraging local authorities to promote Antibiotic Guardian

alongside flu vaccination campaign.

Plans are currently underway to develop a “Junior Antibiotic Guardian” through

the use of digital badges. This is in collaboration with PHE nursing

directorate, eBug and Makewaves (https://www.makewav.es/).

The Public through Community Pharmacy

NOTE: THERE WOULD STILL BE MATERIALS AVAILABLE FOR

ENGAGING WITH OTHER PLEDGE GROUPS



Developed by Public Health England

National Awards 12 May 2016, Birmingham

Categories include:Staff engagement: How have staff promoted Antibiotic Guardian and stewardship within their organisation?

Community: How has your organisation worked within the community to highlight Antibiotic Guardian?

Prescribing: How has your organisation tackled prescription and prescribing antibiotics effectively?

Innovation: Tell us how you have demonstrated innovation to address Antimicrobial Resistance?

Antibiotic Stewardship: How have you improved or measured antibiotic usage in your area or community?

AMS Research: How have you demonstrated development of research to support

Antimicrobial Stewardship?

79 entries. Shortlist on www.antibioticguardian.com



http://www.antibioticguardian.com/

Questions for delegates:

Feedback on Fingertips presentation

Are IPC and AMS teams working together? If not, how can we do this?

How can we make better use of existing networks?

Is there emphasis on education on AMR and AMS in addition to IPC which is

currently part of most Trusts mandatory training in addition to the statutory

training?





Distribution of Antibiotic Guardians between

13 October 2015 - 31 March 2016, n=16,173.



How Antibiotic Guardians reporting hearing

of the campaign, asked as part of sign up



Panel Questions

Lunch

Formerly South East Health

Antimicrobial Stewardship in an Out of

Hours Provider

Kym Lowder Head of Medicines

Management and NICE Medicines & Prescribing

Associate

Service Variations: Q4 12.13

0

1

2

3

4

5

6

7

8

9

10

% Items Ceph & Quin of all Antibiotics

Nat Average

IC24 Service Variations 2015

OOHs Challenges

• Patient expectations• Primary Care access• Relationships• Access to patient records• Transient Workforce (600 clinicians/month)• Shift patterns• Benchmarking & Numbers• Data issues• Worzel Gummidge Effect• No carrots• Demands on unscheduled care• Activity & Service development• Increased care out of hospital

OOHs Advantages

• No hiding place.....

• Customised software

• Information updates

• Timely information

• Stock management

Generic Service Actions

• Removal of Cephalexin from OOH formulary (c. 2010) – no stock available for supply OOHs

• Antibiotic guidelines based on HPA

• Locality guidelines

• Quinolone stock minimal

• Newsletter reminders

• Locality Comparisons

• Highlighting NICE guidance e.g. CG69

• RCGP audit toolkit – focus on antibiotic use

Updated actions

• NICE AMS Guidelines

• Baseline assessment and action plan

• Use of QP data/MO KTT as benchmarks

• Participation in health economy AMS groups

• Regular data analysis and feedback

Locality Specific Actions

• Run report for Prescribing Patterns for Quinolones and Cephalosporins

• Identify GPs with “higher” than average prescribing rates

• Ascertain whether outliers are NMPs/local GPs/agency/IC24 salaried

• Place information message re key antibiotic messages on intranet

• Ensure antibiotic guidelines are easily accessible to staff

• Write to all prescribing outliers, individually, highlighting key antibiotic messages

• Raise with AMDs and Nurse Manager re salaried staff performance

• Sample calls/Review prescribing practice if rates remain high

• Include Co-amoxiclav in reporting and analysis

Apr-Jun12 (Apr-Jun 15) Cephalexin Ciprofloxacin

Total FP10 Prescriptions 478 (98) 204 (92)

Number of individual

clinicians who have

prescribed specified drug

in time frame

105 (59) 84 (48)

Number of individual

clinicians categorised as

‘high’ prescribers

17 (16%)

4 (7%)

4 (5%)

5 (10%)

% of prescriptions

accounted for by ‘high’

prescribers

52% 25%

No. High Prescribers: Local

GPs

13 4

No. High Prescribers:

Agency Locums

1 0

No. High Prescribers:

NMPs

3 0

NOOH

West Kent• 17 (6/66) ‘high’ Prescribers (Av 90 (130)

clinicians/month)

• 3 GPs requested feedback and info

• GP1: 8.8% (17% inc Co-amox) reduced to 5.97%

• GP2: 7.7% reduced to 3.85%

• GP3: 15.5% reduced to 5.79% BUT Co-amoxiclav 16.8% to 20.5%.

• WK OOH Av 6.92% reduces to 5.34% inc FP10recs

• New ‘offenders’

0

2

4

6

8

10

12

WK CCG DGS CCG WK OOH WK OOH (2)

C&Q Percentages Q1 2013

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Corby Daventry Kettering Northamptonshire Wellingborough Nene CCG Average

% Cephs & Quins Prescribed NOOH Q1 -Q4 2012/13

To Summarise

• OOHs is a complex environment

• Data doesn’t tell the whole story

• Peer review can work

• Individualised approaches

• Happy to work with commissioners particularly if IC24 is an outlier

• Co-amoxiclav!

• Constant Review

• Now have NICE NG15 & MO KTT to support the work

Liz Cross, Advanced Nurse PractitionerAttenborough Surgery Hertfordshire

Winner of NHS Innovation Challenge Prize (acorn category) 2015/16

C-reactive protein (CRP) is a major acute-phase plasma protein displaying rapid andpronounced rise of its serum concentration inresponse to infection or tissue injury

CRP levels are typically highest in patientswith a bacterial infection

A Simple CRP blood test (finger prick) takes just 4 mins

Standard of care in many European countries9,10,11

Nearly 80% of antibiotic prescribing is in PrimaryCare 4

Over half of antibiotics prescribed in Primary Careare for respiratory tract infections (RTI)5

There is strong evidence that primary care CRPtesting for RTI reduces antibiotic prescribing andenables patient education and the consultationdiscussion.6 Especially:

.

(i) where there is a high degree of diagnostic uncertainty(ii) for patients who are very worried and/or demanding antibiotics(iii) to differentiate the seriously ill from the non-seriously ill.

Community-acquired pneumonia

Consider a point-of-care C-reactive protein test for patientspresenting with lower respiratory tract infection in primarycare if it is not clear after clinical assessment whetherantibiotics should be prescribed.

Use the results of the C-reactive protein test to guide antibioticprescribing as follows: Do not routinely offer antibiotic therapy if the C-reactive protein concentration is

less than 20 mg/litre.

Consider a delayed antibiotic prescription (a prescription for use at a later date ifsymptoms worsen) if the C-reactive protein concentration is between 20 mg/litreand 100 mg/litre.

Offer antibiotic therapy if the C-reactive protein concentration is greater than 100mg/litre

• ‘Use of C-reactive protein point-of-care tests as an adjunct to clinical examination likely reduces antibiotic use in primary care patients with acute (lower as well as upper) respiratory infections without affecting patient recovery rates or the duration of illness. ‘

• Economic evaluations show cost-effectiveness of POC CRP over existing RTI management in primary care.16

• Results from a recent UK 3 year decision analytic model of CRP testing in the pathway for managing antibiotic prescribing in primary care for respiratory tract, showed that a GP plus CRP test and practice nurse plus CRP test model cost less and resulted in more quality of life years gained (QALYs) than current practice.17

• Cost savings come as a result of reduced re-attendance rates to primary care and out of hours as well as reduced antibiotic prescriptions

Our story……..

To reduce the antibiotic prescribing rates for uncomplicated LRTIs in line with NICE guidelines in a GP based ANP minor illness clinic.

The secondary objective was the conduct a cost and workflow analysis to support a larger scale roll out to 10 sites.

Over a 3 month period, patients presenting to an ANP clinic were offered POC CRP testing under the following conditions

◦ 18-65 years old, the patient had a suspected LRTI of duration <3 weeks or the patient requested abx for an acute cough

◦ Exclusion criteria- pregnant, immunocompromised, terminally ill, intubated in the past year, acute pneumonia requiring hospital admission, under follow up for COPD.

Figure 1. NICE recommendations for use of CRP point of care testing in patients presenting with a lower respiratory tract infection

Adult presents in primary care with symptoms of LRTI

Clinical assessment & diagnosis

Pneumonia not diagnosed or not clear if antibiotic should be prescribed

CRP rapid test

< 20mg/L

Do not routinely offer antibiotic therapy

20-100 mg/L

Consider a delayed antibiotic prescription

>100 mg/L

Offer antibiotic therapy

Pneumonia diagnosed

See NICE pathway

70%

25%

5%

<20 mg/L 21-99 mg/L >100 mg/L

CRP level(mg/l)

nImmediate antibioticsprescribed

Delayedantibiotics prescribed

No antibioticsprescribed

<20 47 0 (0%) 3 (6%) 44 (94%)

21-99 17 3 (18%) 3 (18%) 11 (65%)

>100 3 3 (100%) 0 (0%) 0 (0%)

No antibiotics prescribed

Delayed antibiotics prescribed

Immediate antibioticsprescribed

Unscheduledfollow up

within 28 days

2014/15No CRP testing

(n=106)51% 18% 31% 28%

2015/16CRP testing

(n=67)84% 9% 8% 13%

Reduction of 23%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Winter

2014/15

Winter

2015/16

No antibiotics

prescribed

Unscheduled follow

up within 28 days

Reduction in re-attendance of >50% when antibiotics not

prescribed

70% of patients presented with a suspected LRTI had a CRP <20mg/L

31% of patients were prescribed antibiotics on their initial presentation during winter 2014/15, compared with 8% the following year when POC CRP testing was implemented – reduction of 23%

Unscheduled follow up within 28 days for patients who were not prescribed antibiotics reduced by >50%

POC CRP testing was easy to incorporate into the consultation and didn’t increase the work load of the clinic

Patients were more accepting and reassured when they weren’t prescribed antibiotics as demonstrated by reduced presentation rates

Implementing POC CRP testing helps responsible prescribing, reducing unnecessary prescriptions

The reduction in re-attendance rates infers a level of patient satisfaction and represents significant cost savings to GPs and wider urgent care services.

Cost savings are made due to reduced antibiotic prescriptions and re-attendance rates

POC CRP testing does not increase work load in clinic

• Encourages appropriate antibiotic prescribing

• Facilitates patient education and self- management

• Responsible prescribing helps to slow down the spread of antimicrobial resistance

• Results in saving to the NHS and society from fewer prescriptions and antimicrobial resistance related costs

Wide spread adoption in the UK

Funding models and increasing access

Other applications within the NHS, pharmacies, OOH, urgent care

1. UK Five Year Antimicrobial Resistance Strategy 2013 to 2018. Department of Health. 2013

2. STTP

3. O’Neill review

4. Public Health England ESPAUR Report 2015

5. Royal College of General Practitioners, Public Health England and The Antimicrobial Stewardship in Primary Care (ASPIC). TARGET Antibiotic toolkit. http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx

6. Andreeva E, Melbye H. Usefulness of C-reactive protein testing in acute cough/respiratory tract infection: an open cluster–randomized clinical trial with C-reactive protein testing in the intervention group. BMC family practice 2014;15:80

7. Verlee L, Verheij TJ, Hopstaken RM, Prins JM, Salome PL, Bindels PJ. Summary of NHG practice guideline 'Acute cough'. Nederlands tijdschrift voor geneeskunde2012;156:A4188.

8. Little, P. et al. (2013). Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet 382(9899):117-82.

9. Bjerrum et al. (2011) Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme. BMC Family Practice 2011, 12:5215.

10. Huang Y, et al., (2013) Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies. The British Journal of General 63(616):787-94.

11. Jochen W L Cals, Christopher C Butler, Rogier M Hopstaken, Kerenza Hood, Geert-Jan Dinant. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ 2009;338:b1374

12. ECDC Report 2014 http://www.ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/esac-net-database/Pages/Antimicrobial-consumption-rates-by-country.aspx

13. ‘Limit antibiotic use to combat drug resistance, GPs told.’ General Practitioner July 2013

14. Aabenhus R, Jensen JU, Jørgensen KJ, Hróbjartsson A, Bjerrum L.Biomarkers are point of care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care. Cochrane Database Syst Rev. 2014 Nov 6;11:CD010130

15. Cooke J. Butler C. Hopstaken R. Dryden M. McNulty C. Hurding S. Moore M. Livermore D. Narrative Review of Primary care point-of-care testing (POCT) and antibacterial use in respiratory tract infection (RTI). BMJ Open Respiratory Research 2015; Accepted for publication.

16. Oppong R, et al., (2013) Cost-effectiveness of point-of-care C-reactive protein testing to inform antibiotic prescribing decisions. British Journal of General Practice, July 2013.

17. Hunter, R., (2015) Cost-effectiveness of point-of-care C-reactive protein tests for respiratory tract infection in primary care in England. Advances in Therapy, 32(1):69-85.

18. National Institute of Health and Care Excellence. Pneumonia: diagnosis and management of community-and hospital-acquired pneumonia in adults; published as CG191; 2014.

http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx

http://www.ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/esac-net-database/Pages/Antimicrobial-consumption-rates-by-country.aspx

To Dip or Not To Dip – a patient centred approach to improve the management of UTIs in the Care Home environment

Sharing success AMS Workshop Leeds & London 2016

Elizabeth BeechPharmacist - NHS Bath and North East Somerset CCGNational Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS [email protected] @elizbeech



• This is an evidence based systematic approach to improve the diagnosis and management of UTIs in residents in all 23 Nursing Homes in Bath and North East Somerset - Residential homes were not included

• It was delivered by the CCG care home pharmacist service working during 2015-16, aligned to the existing GP enhanced nursing home service, and funded by the CCG as a quality improvement project in 2014 - <£10K

• Why did we do this? Local clinical audit in 2013 identified residents were frequently prescribed antibiotics (19 - 48% of residents per care home) based on use of urine dip sticking

Scatter plot of both National Antibiotic QIPP indicators, Q2 Jul-Sep 2013-14, for all GP practices in England, with practices in NHS Bath and North East Somerset identified.

To Dip or Not To Dip – early resultsplease do not publish as submitted to RPS2016

Early evaluation shows

• 56% reduction in the proportion of residents who had an antibiotic for a UTI 143 / 690 residents had at least one antibiotic for a UTI in 6 month period Jul-Dec 2015 after implementation

• 67% reduction in the number of antibiotic prescriptions – 153 fewer in 8 NH with pre and post data

• 82% reduction in the number of residents prescribed antibiotic prophylaxis 13 / 690 residents had antibiotic prophylaxis in 6 month period Jul-Dec 2015 after implementation

• Unplanned hospital admissions for UTI, urosepsis and AKI reduced in NH population following implementation

To Dip or Not To Dip - the what we did

• Clever commissioning – CCG incentivised nursing homes using a shadow CQUIN

• The care home pharmacist team – already existed, so extra funding was obtained to allow them to develop & deliver the intervention

• Documentation and education – used SIGN 88 guidance to structure documentation for UTI diagnosis, and implemented within an educational bundle in every nursing home delivered by the pharmacist

• Communicated with everybody – but could have done this better

• Monitoring – for unintended harm resulting in urosepsis

• Evaluation – pre and post audit occurred and a census

Older patients (>65) with suspected UTI (urinary tract infection)

Guidance for Care Home staff

Complete 1) to 4) and patient details and fax to GP. Original to patient notes.

DO NOT PERFORM URINE DIPSTICK – No longer recommended in pts >65 years

CLEAR URINE – UTI highly unlikely

Consider MSU if possible if ≥ 2 signs of infection (especially dysuria, Temp>38⁰C or new

incontinence)

2) Patients who can communicate symptoms: Y / N 3) All Patients: 4) Catheter

Sign/Symptom Tick if

presentTemperature above 38.3⁰C or below 36⁰C or

shaking chills (rlgors)in last 24 hours

Heart Rate >90 beats/min

Respiratory rate >20 breaths/min

Blood glucose >7.7 mmol/L in absence of

diabetes

Diabetic?

Y / N

Bloods taken?

WCC >12/µL or < 4/µL

WCC:

CRP:

New onset or worsening confusion or

agitation

1) Signs of any other infection source? Y / N If Y circle any NEW symptoms which apply:

Cough Shortness of breath Sputum production Nausea/vomiting Diarrhoea Abdominal pain Red/warm/swollen area of

skin

Patient:……………………………………………………………

DOB:……………………………………………………………….

Nursing Home:………………………………………….…….

Date:…………………………… Carer:……………….…..

NEW ONSET

Sign/Sympto

m

What does this mean? Tick if

presen

tDysuria Pain on urinating

Urgency Need to pass urine urgently/new

incontinence

Frequency Need to urinate more often than usual

Suprapubic

tenderness

Pain in lower tummy/above pubic area

Haematuria Blood in urine

Polyuria Passing bigger volumes of urine than

usual

Loin pain Lower back pain

5) GP Management Decision - circle all which apply: Prescribing guidance at http://www.bcapformulary.nhs.uk/5-

infections• Review in 24 hours• Mid Stream Urine specimen (MSU) – if possible if ≥ 2 signs of infection (especially dysuria, Temp>38⁰C or new incontinence) or failed

treatment• Uncomplicated lower UTI• Pyelonephritis Antibiotic prescribed:

………………………………………………………………………….......

• Other …………………………………………………………………………………………………………………………………… Signed: …………………………………….…Date: ………………………..

Yes / No

If YES:Reason for catheter:

Temp / Perm

Date changed:

26/1/20151/2Healthier, Stronger, Together

http://www.bcapformulary.nhs.uk/5-infections

Public Health England – guidance for diagnosis April 2011 https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis

URINE CULTURE IN WOMEN AND MEN > 65 YEARS

Do not send urine for culture in asymptomatic elderly with positive dipsticks

Only send urine for culture if two or more signs of infection, especially dysuria, fever > 38 o or new incontinence.4,5C

Do not treat asymptomatic bacteriuria in the elderly as it is very common.1B+

Treating does not reduce mortality or prevent symptomatic episodes, but increases side effects & antibiotic resistance.2,3,B+

URINE CULTURE IN WOMEN AND MEN WITH CATHETERS

Do not treat asymptomatic bacteriuria in those with indwelling catheters, as bacteriuria is very common and antibiotics increase side effects and antibiotic resistance.1B+

Treatment does not reduce mortality or prevent symptomatic episodes, but increase side effects & antibiotic resistance.2,3,B+

Only send urine for culture in catheterised7B- if features of systemic infection.1,5,6C However, always: Exclude other sources of infection.1C

Check that the catheter drains correctly and is not blocked.

Consider need for continued catheterisation. If the catheter has been in place for more than 7 days,

consider changing it before/when starting antibiotic treatment.1,6C, 8B+

Do not give antibiotic prophylaxis for catheter changes unless history of symptomatic UTIs due to catheter change. 9,10B+

Public Heath England – treatment guidance October 2014 https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care

http://www.sign.ac.uk/guidelines/fulltext/88/index.html

References: Nina, S et al (2014). Investigation of suspected urinary tract infection in older people. BMJ 349.TARGET toolkit for training on UTI’s from RCGP Autumn 2014 http://www.rcgp.org.uk/courses-and-events/online-learning/ole/urinary-tract-infections.aspx26/1/2015 Mandy Slatter/Elizabeth Beech, BANES CCG. Contact

[email protected] 2/2

https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis

http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1279888711402

https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care

http://www.sign.ac.uk/guidelines/fulltext/88/index.html

http://www.rcgp.org.uk/courses-and-events/online-learning/ole/urinary-tract-infections.aspx


To Dip or Not To Dip - what we do next

• Commissioning – the CCG will fund continuation of the model, and will adopt a similar approach for the AKI programme

• The care home pharmacist team – has extended to cover residential homes so we will now audit UTI management here now

• Documentation and education – need to review and improve use of the documentation and continue a rolling education bundle

• Communicated with everybody – but could have done this better and now need to share the results locally and nationally

• Monitoring – retrospective audit in all nursing homes every 6 months to produce a run chart for CCG care home quality dashboard

• Evaluation – need to continue to improve antimicrobial stewardship and documentation lots still to do

Antibiotic prescribing for UTI in all Nursing Homes over 6 month period post implementation

66

81

24

23

8 2

Antibiotic choice as a proportion of 204 antibiotic prescriptions for UTI in 143/690 residents in 22 nursing homes - after implementing use of

Sign 88 diagnostic criteria 6 months Jul-Dec 2015

Nitrofurantoin

Trimethoprim

Cefalexin

Co-amoxiclav

Ciprofloxacin

Amoxicillin

To Dip or Not To Dip – a patient centred approach to improve the management of UTIs in the Care Home environment - Key messages for CCG reporting to NHSE

• Use of an evidence based algorithm to diagnosis UTI in nursing home residents does improves care

• 56% reduction in the number of residents prescribed antibiotics for a UTI based on a urine dip stick test

• 82% reduction in the number of residents prescribed antibiotics prophylactically

• 67% reduction in the number of antibiotic prescriptions

• Improved appropriate management of UTI

• Reduction in unplanned admissions for UTI, urosepsis and AKI

• Reduced calls to GP practices for inappropriately diagnosed UTI

• Include hydration messages within the educational content


Published as an Innovation poster at RPS2015Shared the concept with many CCGs, some are adopting/adaptingSubmitted to RPS2016

Elizabeth BeechPharmacist - NHS Bath and North East Somerset CCGNational Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS [email protected] @elizbeech


Diabetic feet need antimicrobial stewardship too

Naomi Fleming: Antimicrobial Pharmacist

What is Antimicrobial Stewardship?

The selection of the most appropriate antimicrobial treatment, optimization of drug dosage and duration of

therapy needed to cure infection, improve patient safety through reducing risk of toxicity and adverse

effects and control of resistant strains

Ultimate goal is improved patient care and healthcare outcomes

The term ’antibiotic

stewardship’ is used to capture the twin aims of ensuring

effective treatment of patients with infection and minimizing collateral

damage from antimicrobial use (Allerberger 2009; Davey

2010; Dellit 2007; MacDougall 2005).

Health and Social Care Act:Code of PracticeCriterion 3:

Ensure appropriate antimicrobial use to optimise patient

outcomes and to reduce the risk of adverse events and

antimicrobial resistance

3.1 Systems should be in place to manage and monitor the use of

antimicrobials to ensure inappropriate and harmful use is minimised and

patients with severe infections such as sepsis are treated promptly with the

correct antibiotic. These systems draw on national and local guidelines,

monitoring and audit tools such as NICE guidelines, guidance on patient group

directions, the TARGET toolkit in primary care and Start Smart then Focus in

secondary care (SSTF).

Diabetes and InfectionInfection occurs with greater frequency and severity in

diabetic patients.

People with Diabetes twice as likely to be hospitalised due to infection.

Increased risk due to reduced immune response, neutrophils, inflammatory mediators, leucocytes.

◦ Reduction in neutrophil activity, neutrophils play an essential role in host inflammatory response.

◦ Decreased responses to inflammatory mediators eg histamine and bradykinin◦ Increased leucocyte apoptosis◦ Reduced oxidative activity of neutrophils

Decreased availability of insulin partly responsible and insulin treatment can improve functional neutrophil activity.

Hyperglycaemia partly responsible

High glucose in tissues and body secretions provides ideal environment for bacteria to survive

Background diabetic foot•Diabetes is one of the most common chronic diseases in UK, prevalence is increasing, with predictions of 5 million by 2025.

•Life expectancy shortened by up to 15years, 75% die of macrovascular complications.

•The risk of foot problems is increased, due to either diabetic neuropathy or peripheral arterial disease (PAD) or both.

• Diabetes most common cause of non-traumatic limb amputation, 80% are linked with diabetic foot ulcers and the majority of these with infection.

•Mortality rates are high, with up to 70% of people dying within 5years of having an amputation and around 50% dying within 5years of developing a diabetic foot ulcer.

•Foot problems with diabetes significant financial impact on NHS ~£650million pa (£1in every £150) spent on foot ulcers/ amputations each year

•Variation in practice in preventing and managing diabetic foot problems, amputation rates still vary up to fourfold in the UK.

•This variation in practice results from a range of factors including availability of healthcare professionals for the MDT with expertise in the management of diabetic foot problems. Antimicrobial stewardship input into the MDT may improve this.

Treatment of diabetic foot ulcers:Off-loading to alleviate mechanical load on the ulcers eg: heel protectors, appropriate mattress, scotch cast boots and potentially complete non-weight bearing status

Assessment for limb ischaemia. Patients with clinically significant limb ischaemia should be assessed by a vascular surgeon depending on severity.

Antibiotics will be required if there are symptoms of infection, they should be used to treat infection, not to heal the wound which usually takes longer.

Optimisation of glycaemic control is crucial in the ulcer healing process. Ensure that the patient is not in DKA or Hyperosmolar Hyperglycamic State (HHS previously referred to as HONK). Consideration of changing oral treatment to SC or IV insulin if appropriate.

IDSA guidelines diagnosing infection:•Clinicians should evaluate a diabetic patient presenting with a foot wound at 3 levels: the patient as a whole, the affected foot or limb, and the infected wound.

•Infection generally includes classic signs of inflammation (redness, warmth, swelling, tenderness, or pain) or purulent secretions.

•Secondary signs (eg, nonpurulent secretions, friable or discolored granulation tissue, undermining of wound edges, foul odour).

•Factors that increase the risk for infection include a wound for which the probe-to-bone (PTB) test is positive; an ulceration present for >30 days; a history of recurrent foot ulcers; a traumatic foot wound; the presence of peripheral vascular disease in the affected limb; a previous lower extremity amputation; loss of protective sensation; the presence of renal insufficiency; or a history of walking barefoot

•Clinicians should use a validated classification system, eg PEDIS developed by (IWGDF) or IDSA.

•Clinicians should diagnose infection based on the presence of at least 2 classic symptoms or signs of inflammation (erythema, warmth, tenderness, pain, or induration) or purulent secretions. They should then document and classify the severity of the infection based on its extent and depth and the presence of any systemic findings of infection.

Challenges of Diagnosing Diabetic Foot Infection

•Open wounds are always colonised, therefore growth of microorganisms from swabs alone is not diagnostic.

•Classical clinical manifestations of erythema, warmth, swelling, and pain can either be mimicked by or diminished by peripheral neuropathy and vascular disease.

•Patients with a neuropathic or neuroischaemic feet often have little or no pain leading to a delayed presentation and diagnosis.

•Inflammatory markers such as CRP and WCC may not reflect the severity of the infection.

•Patients may present with an ‘asymptomatic’ limb or life-threatening infection with the only clue being deterioration in glycaemic control.

•Foot architecture

Investigations (NICE NG 19)1.6.1 If a diabetic foot infection is suspected and a wound is present, send a soft tissue or bone sample from the base of the debrided wound for microbiological examination. If this cannot be obtained, take a deep swab because it may provide useful information on the choice of antibiotic treatment.

1.6.2 Consider an X-ray of the person's affected foot (or feet) to determine the extent of the diabetic foot problem.

1.6.3 Think about osteomyelitis if the person with diabetes has a local infection, a deep foot wound or a chronic foot wound.

1.6.4 Be aware that osteomyelitis may be present in a person with diabetes despite normal inflammatory markers, X-rays or probe-to-bone testing.

1.6.5 If osteomyelitis is suspected in a person with

diabetes but is not confirmed by initial X-ray,

consider an MRI to confirm the diagnosis.

Treatment (NICE NG 19)1.6.6 All hospital, primary care and community settings should have antibiotic guidelines covering the care pathway for managing diabetic foot infections that take into account local patterns of resistance.

1.6.7 Do not offer antibiotics to prevent diabetic foot infections.

1.6.8 Start antibiotic treatment for suspected diabetic foot infection as soon as possible. Take cultures and samples before, or as close as possible to, the start of antibiotic treatment.

1.6.9 Choose the antibiotic treatment based on the severity of the diabetic foot infection, the care setting, and the person's preferences, clinical situation and medical history and, if more than one regimen is appropriate, select the regimen with the lowest acquisition cost.

1.6.10 Decide the targeted antibiotic regimen for diabetic foot infections based on the clinical response to antibiotics and the results of the microbiological examination.

1.6.11 Do not offer tigecycline to treat diabetic foot infections unless other antibiotics are not suitable.

Which antibiotic?1.6.12 For mild diabetic foot infections, initially offer oral antibiotics with activity against gram-positive organisms.

1.6.13 Do not use prolonged antibiotic treatment (more than 14days) for the treatment of mild soft tissue diabetic foot infections.

1.6.14 For moderate and severe diabetic foot infections, initially offer antibiotics with activity against gram-positive and gram-negative organisms, including anaerobic bacteria, as follows:

Moderate infections: base the route of administration on the clinical situation and the choice of antibiotic.

Severe infections: start with intravenous antibiotics and then reassess, based on the clinical situation.

1.6.15 Offer prolonged antibiotic treatment (usually 6weeks) to people with diabetes and osteomyelitis, according to local protocols.

Likely pathogensMild infection in an antibiotic naïve person is likely to be caused by Staphylococcus aureus or beta-haemolytic streptococci.

Moderate and severe infections in antibiotic naïve patients are likely to be caused by Staphylococcus aureus or beta-haemolytic streptococci, obligate anerobes are often associated with limb ischaemia, gangrene, necrosis or wound odour.

People with chronic infections, who are not antibiotic naïve may have polymicrobial infections including aerobic gram-negative bacilli, enterobacteriaceae.

Organisms that are usually colonisers but may cause infection include coagulase negative Staphylococcus and Pseudomonas aeruginosa, these may also need treatment if empirical therapy is failing following discussion with microbiology and the diabetes foot team.

Severe infections should always be treated in hospital.

Renal function, antibiotic allergies and Clostridium difficile risk should be assessed when deciding on antibiotic choices for further treatment.

Appropriate Prescribing

Input of antimicrobial pharmacist to MDT:

•Timely antibiotic review

•Interpretation of microbiology results

•Recommendations of antibiotics for specific organisms

•Recommendations with specific patient factors

•Advice to patients

•Restrictions

•Referrals and liaison

•Follow up

•Service development

Final messages:

AMS in DFI complex and needs an understanding of both

DFI is not SSTI

Correct management can save limbs and lives

Get involved

Thank you for listening

[email protected]

Panel Questions

Refreshments

How local networks are enabling antimicrobial stewardship activity in the South West

Elizabeth Beech 8th March 2016 Pharmacist - NHS Bath and North East Somerset CCGNational Project Lead Healthcare Acquired Infection and Antimicrobial Resistance - NHS [email protected] @elizbeech


Five core features of effective networks

1. common purpose

2. cooperative structure

3. critical mass

4. collective intelligence

5. community building

CCG footprints aligned within the West of England Academic Health Science Network

SWAG – South West Antimicrobial Pharmacist

network

• Membership is hospital antimicrobial pharmacists

• Share clinical audit, education & best practice, professional support

• Collaborate on delivery of the 2016-17 AMR CQUIN

• Link with other networks –microbiologist network

• SWAG network provides a reliable communication cascade system

• Example: working together to develop a methodology for 48 hour review as part of SSTF

BGSW Bath and North East Somerset, Gloucestershire, Swindon, Wiltshire

Clostridium difficile Infection Commissioner Group

• Membership is NHS England quality lead, CCG quality leads & pharmacists, and PHE field and epidemiology staff

• Strategic and operational content to support NHS CDI objectives, and 2015-16 AMR Quality Premium

• Share intelligence – IPC, AMR and AMS data and practice

• Enhanced surveillance of Community Attributed CDI led by PHE, to drive improved management of CDI

BGSW Antimicrobial Stewardship Network

• NHS England led (building on CDI network) - membership open to all organizations including councils and PHE, and all healthcare professionals

• Established to support delivery of the 2015-16 AMR Quality Premium

• Shares intelligence and successful practice fast; including sharing educational resources and expertise

• Example: EAAD 2016 planning

Bristol, South Gloucestershire, North Somerset, Bath and North East Somerset Antimicrobial Stewardship Network

• Membership is CCG and provider organization pharmacists, and links to BGSW network by overlap

• Established to support delivery of the 2015-16 AMR Quality Premium

• Shares intelligence – AMS audit data and practice

• Example: sharing community IV antimicrobial service activity, AMS audit data

Bath and North East Somerset Health Strategic Healthcare Infection Prevention

and Control Collaborative

• Originally established to support HAI & IPC agenda - now evolved to include AMR and stewardship

• Led by the CCG, multi organizational, multi disciplinary, acute provider hosted 8 weekly

• Operational and strategic, shares intelligence and expertise

• Example: whole health community dataset for all cases of CDI; improving transfer of information across care boundaries; learning from norovirus to improve preparedness

Bath and North East Somerset AMR Group

• Set up under Health and Well Being Board, reporting to Health Protection Board

• Chaired By CCG Clinical Chair• Membership will represent the

whole community, including patient representation

• Strategic role to support delivery of National AMR strategy and PHE local AMR plans

• Example: Public engagement with, and education about, resistant infections – prevention and appropriate use of antimicrobials

Five core features of effective networks

1. common purpose

2. cooperative structure

3. critical mass

4. collective intelligence

5. community building

What will you lead?

• What networks already exist in your local health economy?

• What pharmacy involvement looks like?

• How can you improve effectiveness?

• What will you take away today?

• Your pledge to……

Table Top Discussion on action plans for using local networks

Table Top feedback on action plans

Summary and Close

Dr Bruce WarnerDeputy Chief Pharmaceutical Officer

NHS England

Key take home messages

• Improving antimicrobial Stewardship is essential to

reduce the rate at which resistant infections

develop

• And to provide patients with effective and safe care

now, and in the future

• Last years AMR Quality Premium exceeded what

was required – please help do the same with the

2016-17 AMR incentives, particularly the CQUIN

• Collaboration and sharing is essential to do this

effectively

• Thank you for coming and do complete the

evaluation and feedback form

244

Health & Medicine

NHS Improvement AMS Workshop London 5th May