What are the key challenges in implementing Stewardship ... · What are the key challenges in...
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www.england.nhs.uk/ourwork/patientsafety/amr
What are the key challenges in implementing
Stewardship – the AMS team view
Philip Howard
Consultant Pharmacist Twitter: AntibioticLeeds
• Speaker or consultancy fees, educa3onal grants for conferences or research from:
• Astellas, AstraZeneca, BBraun, Danone, Eumedica, Gilead, GSK, MSD, Novar3s, Pfizer, Sanofi
• Royal Pharmaceu3cal Society spokesman on an3microbials
• UKCPA Trustee & Pharmacy Infec3on Network commiNee
• BSAC Council
• ESCMID Guidelines & Policies Group CommiNee
• DH Start Smart then Focus development group
• RCGP TARGET guidance group
• WHO AMR Strategy Task Group (for FIP)
Disclosures
• Update to the 2008 Health & Social Care Act IPC Code of Prac3ce to include AMS – criterion 3: ensure AB use op3mises outcomes & ↓ risk of adverse events and AMR.
• NHS-‐England pa3ent safety alert on AMS • NICE guidelines (2) on AMS: systems and processes & changing risk-‐related behaviours in the general popula3on (dra\)
• Update of Hospital AMS guidelines – Start Smart then Focus • Quality premium for general prac3ce to reduce total by 1% and broad spectrum an3microbial prescribing by 10% or to median of 11.3%
• NHS-‐England CQUIN on Sepsis 2015-‐6 (% red flags and AB within 1 hr) • NCEPOD Sepsis report; dra\ NICE sepsis, new global sepsis defini3ons
• BUT AMR keeps increasing, esp Klebsiella to pip-‐tazo • Hospital AB use #6%, carbapenem #36% & pip-‐tazo # 55% from 2011-‐14 per 100 admissions
New AMS guidance is never ending!
Infection Management Group
• 2% funded from savings • 23% dedicated funding (extension of 2003 3 year DoH Hospital Pharmacy Ini3a3ve) AMS pharmacists posts have grown but not WTE (Wickens 2012)
Hours per week for AMS Programme
Has Sepsis CQUIN # ED IV AB use?
Overall 4.8% # in rolling 12 mth from March to February (info from Rx-‐Info Define so\ware)
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 ABs
New 2016/7 CQUINs: Sepsis & AMR Biggest AMS implementa3on challenge or opportunity?
• Both 0.25% of tariff income eg £1b turnover = £2.5m • Sepsis: ED & In Pa3ents and Day 3 review
– Expanded to include in-‐pa3ents this year plus day 3 review. – % who met criteria for sepsis screening who were screened (both) – % with severe sepsis, Red Flag Sepsis or sep3c shock and had IV AB
within appropriate 3me period • 60 min of arrival at ED, 60 min of recogni3on for newly admiNed or 90 min of exis3ng in-‐pa3ent to start or change Abs
– empiric AB review within 3 days (30 pts/mth of ED & IP = 60pts/mth) • NHS-‐England CQUIN on AMR 2016-‐7
– Reduce total an3bacterials, piperacillin-‐tazobactam & carbapenems by ≥1% per 100 admissions based on 2013-‐4 baseline.
– Evidence of day 3 review (and outcome) of 50 pa3ents per month. Thresholds: Q1 = 25%+, Q2 = 50%+, Q3 = 75%+, Q4 = 90%+
– Submission of consump3on data to PHE for 2014/5, 2015/6 & 2016/7
2016/7 AMR CQUIN: use less or alterna3ves Difference from 2013 to 2014 DDD/100 admissions • Total -‐0.7% • Carbapenem +4% • Piperacillin-‐tazo +7%
40% of hospital AB is OP & ED AB. Same AMS principles of checking indica3on against guidelines s3ll apply & audit of PGDs?
RR8 = -‐46
RR8 = -‐1
RR8 = -‐1
NHS Scotland: Use Pip/Taz, carbapenems and carbapenem sparing agents in acute hospitals* (aztreonam, fosfomycin, pivmecillinam, temocillin)
* Excludes NHS Highland
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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/Taz in Jul-Sep 2015 in acute hospitals by NHS board*
* Excludes NHS Highland
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Carbapenems
Carbapenem Sparing
Pip-Tazo
PPS: Compliance With Antibiotic Policy high for meropenem lower for pip-tazo
Only 50% have active restricted (protected) AB follow up. (Howard 2015)
Chelsea & Westminster restricted AB follow up (Orla Geoghegan – Lead AMS Pharmacist Imperial)
• 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
Avoid star3ng or finish earlier • NICE diagnos3cs guidance [DG18] on Procalcitonin tes3ng for diagnosing and monitoring sepsis.
• “high levels can show that a person has a serious bacterial infec3on. … and the results can help doctors to diagnose bacterial infec3on and decide about star3ng or stopping an3bio3c treatment.
• “not enough evidence to recommend that these tests are used in the NHS.” “.. further research and data collec3on (needed) to show the impact “
• Do poten3al benefits mean PCT could be used but collect data to show the impact to meet the CQUIN?
Reducing total antibiotics
Do we audit & feedback to improve prescribing?
ESPAUR 2014 SSTF: do at least annually. More frequently drives quality improvement
LTH audits showed 50% & 81%
Only 10% could supply results & outcome (Llewellyn JAC 2015)
LTH 59%
Summary of antibiotic use & prescribing standards for Feb-16
Antimicrobial Prescribing
StandardsLTH
ABDO MED
SURG (32)
ADULT CRITICAL
CARE (42)
ACUTE MEDICIN
E (18)
CARDIO-RESPIRA
TORY (22)
NEUROSCIENCES
(34)
CHAPEL ALLERTO
N (20)
CHILDREN'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 L L L L L L J L J L L J LDay 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
LTHABDO MED SURG (32)
ADULT CRITICAL CARE (42)
ACUTE MEDICINE
(18)
CARDIO-RESPIRATORY (22)
NEUROSCIENCES
(34)
CHAPEL ALLERTO
N (20)
CHILDREN'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 K J J K K L J J K L J J L
IV AB usage to Feb-16Total 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)
Dashboard on AMS performance
• users like smiley faces – easy to understand
Do we actually make a diagnosis?
Bodansky 2012 Clin Med (Lond)
100 consecu3ve MAU admissions started on an3bio3cs over 3 days
• Do our guidelines give advice about nega3ve results?
• Driving D3 review with a s3cker put in notes by ward nurse
• 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 pa3ent admin system
• Can use data warehousing without e-‐Rxing if issue an3bio3cs to pa3ents
• Bug – no drug. Drug – no bug. • Repor3ng systems of use & resistance • Increases produc3vity by 50% of AMS staff (USA – Theradoc) • Big savings on an3bio3cs & improved outcomes (USA)
• Use CQUIN money to get beNer AMS tools • Na3onal specifica3on for e-‐prescribing to improve AMS (ESPAUR subgroup)
Electronic systems for AMS
• AMR & Sepsis CQUINs are our biggest opportunity • Design systems to force beNer prescribing • Consensus based, easy to access guidelines (including diagnosis and inves3ga3ons)
• Quality improvement, not annual audit • Local an3bio3c champions (hierarchy) & mul3disciplinary • Merge IPC & AMS teams • Monitor & benchmark an3bio3c usage • Regular but varied communica3on • Local educa3on & training at ward level
Summary: To improve antibiotic prescribing in hospitals
• Leeds THT: Jon Sandoe, Abimbola Olusoga, Damian Mawer, Jason Dunne, Cheryl Mitchell, Mark Wilcox
• NHS England: Elizabeth Beech, Stuart Brown, MaNhew 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
Thank you to lots of people
www.england.nhs.uk/ourwork/patientsafety/amr
Challenges of Antimicrobial
Stewardship – the AMS team
Philip Howard
Consultant Pharmacist Twitter: AntibioticLeeds