antibiotic guardian leeds workshop 2016

Welcome to the Antibiotic Guardian Leeds Workshop

#antibioticguardian

Introduction

Dr Diane Ashiru-Oredope, Pharmacist Lead, AMR Programme, Public Health England &

Department of Health Expert Advisory Committee on AMR & HCAI (ARHAI)

#antibioticguardian

Strengthening infection prevention

and control practices

Suzanne Calvert – Senior Health Protection Practitioner Yorkshire and the Humber PHE

21st September 2016

Antibiotic Guardian Roadshow: tackling

antimicrobial resistance locally

Introduction

UK Five year Antimicrobial resistance strategy 2013-2018

number of hard-to-treat infections continues to grow…increasingly difficult

to control infection in routine medical care settings …

antibiotic resistance cannot be eradicated, it can be managed to limit the

threat to, and minimise the impact

‘the medicine cabinet is empty for some’

‘Everyone has a responsibility and a role to play in making this happen’

*4

Antibiotic guardian roadshow: Tackling antimicrobial resistance locally

21.9.2016

UK AMR strategy 2013 – 2018

WHO global action plan 2014

European Press release 2016

Tackling drug-resistant infections Globally – O’Neill May 2016

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21.9.2016

European, International resources

Key considerations

6Antibiotic guardian roadshow: Tackling antimicrobial resistance locally

21.9.2016

“ The basics of public health – clean water, good sanitation and

hygiene, infection prevention and control and surveillance –

..critical for reducing the impact of antimicrobial resistance and

infectious disease control’

Infection Prevention and Control needs to be embedded as

a priority for health systems at all levels.

A return to the attitudes pre-antibiotic era,

when infection prevention was a priority, cures were limited.

Top-down priority-setting have a valuable role in bringing this

issue higher up the priority

UK 2016

Government press statement at the close of the G7 summit:

‘global health…the urgent need to tackle antimicrobial resistance’.

‘…the catastrophic consequences if we do not act – 10 million excess deaths a year

by 2050. If we do nothing …. the potential end of modern medicine as we know it’.

Dame Sally Davies, Chief Medical Officer for England – ‘antibiotic apocalypse’

Jane Cummins – Chief Nursing Office - prevent infections and control their spread,

….reduce the need for antibiotics and limit opportunities for antimicrobial resistant

strains to develop.

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21.9.2016

Definitions

Infection is the invasion of body tissues by disease -causing agents,

their multiplication, the reaction of host tissues to these

organisms and the toxins they produce

Prevention action of stopping something from happening or arising

Control the power to influence or direct people's behaviour

a means of limiting or regulating something

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21.9.2016

What do the regulations say?

Outcome 8: CQC`s Essential Standards for Quality and Safety on cleanliness

and infection control

Must… ensure that:

• service users, persons employed, others who may be at risk of exposure to a health care

associated infection

‘are protected against identifiable risks of acquiring such an infection ……..’

assess the risk

appropriate standards of cleanliness and hygiene

*The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

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21.9.2016

Infection prevention - thoughts

Microbes spread from person to person – varying routes

Mobile genes spread between microbial species

Infection control mistakes

Basic infection control precautions are key to preventing spread -

opportunities

Whole health economy involvement

How do we assure ourselves that what should be happening is really

happening?

Should we have more targets?

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IPC Opportunities

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Contact time - opportunities

‘Staffing levels impact upon the ability of nursing and midwifery staff to provide high

quality care’

NHSE: Safer Staffing: A Guide to Care Contact Time

Nov.2014

‘Unnecessary extra workload created by lack of

clear systems and processes for practices and

hospitals to communicate with each other regarding

shared patients…’

Making time in General practice’ 2015

12 Presentation title - edit in Header and Footer

Thoughts contd..

Recurrent factors – learn from others

Improving staff awareness

Cleaning of equipment and the environment

Funding

Infection control team not functioning well

Outbreaks

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21.9.2016

Developing a local approach

Yorkshire & Humber AMR group

HPT AMR leads, FES team, Microbiology services, NHSE

Surveillance –

• Monthly mandatory surveillance data review (MRSA, MSSA & E Coli bacteraemia +

C difficile cases)

• Monthly CPE case review (numbers, epidemiological data, linked cases)

Local Intelligence –

• Review of meetings attended and planned attendance

• Review of escalation required / report for Quality Surveillance Groups

Patient Journey –

• Working together in geographies

• Cross boundary

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Infection Prevention & Control

Patient journey

Local intelligence

15


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Patient

journey

SurveillanceLocal

intelligence

surveillance

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21.9.2016

Infection prevention and control

Is a much better option than the

pre antibiotic era solutions!

Thankyou for Listening

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiK7rTls5zPAhUDfRoKHQ-RAr8QjRwIBw&url=https://www.pinterest.com/pin/115756652896396165/&psig=AFQjCNGdA0SJ8QXGxKJcdvIRURPQq7ghFQ&ust=1474407856576086

Heather EdmondsHead of Medicines optimisation

Leeds North CCG

Show you the range of website and data available

The data they provide

How to use the data locally to influence local decisions and guidance.

PHE Fingertips portal http://fingertips.phe.org.uk/profile/amr-local-indicators

Open prescribing http://www.openprescribing.net/

Antibiotic quality premium monitoring dashboard https://www.england.nhs.uk/resources/resources-for-ccgs/ccg-out-tool/ccg-ois/anti-dash/

NHSBSA information portal http://www.nhsbsa.nhs.uk/3607.aspx (password required)

PHE Second Generation Surveillance System https://sgss.phe.org.uk/Security/Login (password required)

http://fingertips.phe.org.uk/profile/amr-local-indicators

http://www.openprescribing.net/

https://www.england.nhs.uk/resources/resources-for-ccgs/ccg-out-tool/ccg-ois/anti-dash/

http://www.nhsbsa.nhs.uk/3607.aspx

https://sgss.phe.org.uk/Security/Login

English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report

HCAI Data Capture System https://hcaidcs.phe.org.uk/WebPages/GeneralHomePage.aspx

PrescQIPP - https://www.prescqipp.info/datahub

NHS E Medicines Optimisation dashboard -https://www.england.nhs.uk/ourwork/pe/mo-dash/

https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report

https://hcaidcs.phe.org.uk/WebPages/GeneralHomePage.aspx

https://www.prescqipp.info/datahub

https://www.england.nhs.uk/ourwork/pe/mo-dash/

Antibiotic reports

Antibiotics in uncomplicated UTIs

Minocycline ADQ/1000 patients (KTT11)

Broad-spectrum antibiotics (KTT9)

Co-amoxiclav, cephalosporins & quinolones (KTT9)

CCG comparison Practice comparison

CCG AREA England CCG (%) AREA (%) England (%)

0.28 0.31 0.30 5.95 6.04 8.48

AN

TIB

IOT

ICS

Antibacterial items per STAR PU

Number of prescription items for antibacterial drugs (BNF 5.1) per oral antibacterial (BNF 5.1 sub-set)

ITEM based STAR-PU

Co-amoxiclav, Cephalosporins and Quinolones % items

Number of prescription items for Co-amoxiclav, Cephalosporins and Quinolones as a percentage of

the total number of prescription items for selected antibacterial drugs (sub-set of BNF 5.1)

0.0

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0.3

0.4

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Clinical Commissioning GroupAll CCGs CCGs in West Yorkshire Area

NHS Leeds North CCG England (AVG)

West Yorkshire Area (AVG)

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Clinical Commissioning GroupAll CCGs CCGs in West Yorkshire Area

NHS Leeds North CCG England (AVG)

West Yorkshire Area (AVG)

Any questions?

Tackling AMR: Engaging with

Patients and the Public

Antibiotic Guardian Roadshow

21st September 2016

Aliya Rajah

Professional Training and Public

Engagement Coordinator

Antimicrobial Resistance Programme

Public Health England

[email protected]

Twitter - @AliyaRa5

#AntibioticGuardian

UK 5-year AMR Strategy 2013-18:

Seven key areas for action

PHE

Human health

DH – High Level Steering Group (cross government)

Defra

Animal 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) Chaintarli

42 Tackling AMR: Engaging with Patients and the Public

Antibiotic resistance is poorly communicated and widely

misunderstood by UK public

“the body becomes resistant to antibiotics”

“If my symptoms have gone, I no longer

need to take antibiotics”

“It’s not my problem”

People have a better understanding when

AMR is presented in a way that is relatable

to them

“By getting antibiotics from the doctor, I

haven’t wasted their time”


Every infection prevented

means less antibiotics

are used

AMR



2016 theme: chain of infection

Timeline of English Antibiotic

Awareness campaigns


1999: Andybiotic –

“Don’t wear me out”

• Press and magazines

• GP surgeries –

leaflets and postcards

• GP non-prescription

pads

• 1999, 2000, 2003,

2006

Educating the public: the value of awareness campaigns

Dr Diane Ashiru-Oredope


Sent to all GP surgeries and

independent pharmacies

Developing plans for EAAD 2014• In previous years EAAD plans included creating educational materials

which healthcare professionals could use as part of local awareness

campaigns.

• Developed EAAD in 2014

• campaign that would be available all year round

• awareness raising engagement

• commitment from healthcare professionals and the public

• First year that the lead organisation aimed to directly engage the public

• Campaign developed by PHE in collaboration with all the UK devolved

administrations and also professional organisations

• Planning group is a multi-disciplinary group with public and third-sector

representation from human and animal health sector across the UK


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/

Tackling AMR: Engaging with Patients and the Public Combating AMR (CPC Conference) Dr Diane Ashiru-OredopeAntimicrobial Stewardship Dr Diane Ashiru-OredopeEAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope50 Tackling AMR: Engaging with Patients and the Public

http://antibioticguardian.com/

Video created with TV doctorEducates on antibiotic resistance; suggests three steps that public can

take to help and a call to become an antibiotic guardian. Available for

download


Tackling AMR: Engaging with Patients and the Public Combating AMR (CPC Conference) Dr Diane Ashiru-OredopeAntimicrobial Stewardship Dr Diane Ashiru-OredopeEAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope52 Tackling AMR: Engaging with Patients and the Public

Current website

Public Information should reflect One Health agenda –

VMD, Bella Moss


Tackling AMR: Engaging with Patients and the Public

EAAD & Antibiotic Guardian: children

centres; hospitals; community pharmacies

University College London Hospitals

Awareness and engagement in Hospitals, community pharmacies,

universities, organisations in all UK Countries


Engagement via social media – e.g pictures tweeted with

#AntibioticGuardian


Antibiotic Guardian demographics

31 March 2016:

31, 105 AGs

30 August 2016


AG pledges from across the world

As of 09 May 2016,

there were 31,440

Antibiotic Guardian

pledges; with at least

one pledge from 77

countries across the

world.

There were five or

more pledges from

24 countries

including South

Africa, USA, India,

Nigeria, Australia,

several countries in

Europe

Tackling AMR: Engaging with Patients and the Public 58 Tackling AMR: Engaging with Patients and the Public

1) Healthcare Students – seeking Antibiotic Guardian

champions in healthcare schools

2) Young families for children and families

• Developing “Junior Antibiotic Guardian” through the use of digital

badges. This is in collaboration with PHE nursing directorate,

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

3) The Public through Community Pharmacy

New Antibiotic Guardian

Resources for 2016/17


Educating children – e-bug led by PHE

Primary Care Unit (Prof Cliodna McNulty)

Europe wide resource, led by Public Health England

e-Bug has

been

translated

into 22

different

languages,

including

most

European

languages,

Turkish

and Arabic

Free educational resource for classroom and home use and makes learning about micro-

organisms, the spread, prevention and treatment of infection fun and accessible for children and

young adults/students

AMR Public Involvement Forum

• Engage with the public via strategic partners and other voluntary

organisations, PHE colleagues, lay members

• Representation from

• animal health, respiratory conditions, faith organisation, BME organisation,

home hygiene, various Healthwatch

• Raise awareness of the importance of AMR

• Encourage organisations to engage with the public to raise awareness

of AMR, especially during WAAW, IIPW

• Using resources and expertise to produce a public engagement toolkit

to support local Public Health England centres and Health Protection

teams


Local

engagement


Conclusion• Improving professional education, training and public engagement is

one of the seven key areas of the 5 year UK AMR strategy

• England has participated in EAAD activities since 2008, awareness

was increased but no evidence of increased knowledge and behaviour

change

• For the first time, using behaviour change strategies, the Antibiotic

Guardian campaign has shown evidence of moving from increasing

AWARENESS to ENGAGMENT and commitment from healthcare

professionals and the public

• Evaluation of the Antibiotic Guardian campaign highlighted that it is

an effective for increasing knowledge and changing behaviour (self

reported) particularly among members of public


AcknowledgementsBritish Society for Antimicrobial Chemotherapy for the funding the initial website

development in 2014 and continued active support

Pharma Mix for implementing the design and development of AG website of

www.AntibioticGuardian.com

Inkling London www.inklinglondon.com, for providing marketing and

behavioural insights on the pledges during development

Members of the core EAAD-AG planning group are acknowledged for their

contribution in the planning of the AG campaign

Organisations and individuals who have actively participated in the wider

planning and delivery of the campaign are also acknowledged and can be

found listed in the web appendix methods


http://www.antibioticguardian.com/

You are invited to become an Antibiotic Guardian today

(available via mobiles)


Aliya Rajah

Professional Training and Public Engagement Coordinator

Antimicrobial Resistance Programme

Public Health England

[email protected]

Twitter - @AliyaRa5

#AntibioticGuardian


Question and answers from the floor

#antibioticguardian

Lunch and networking

#antibioticguardian

Welcome back

Dr Diane Ashiru-Oredope, Pharmacist Lead, Public Health England

#antibioticguardian

Antimicrobial Stewardship - national

update on CQUIN and QPStuart Brown

Project Lead – AMR and HCAI

NHS Improvement

21st September 2016

Plan

• Background

• AMR CQUIN

• Quality Premium

• It is growing and spreading according to WHO

figures

– 5 of 6 regions show >50% resistance to 3rd gen

cephalosporins & fluoroquinolones in E.coli

– ALL SIX regions have >50% resistance in Kleb

pneumonia to 3rd gen cephalosporins & 2/5 show AMR

to carbapenems

• All antibiotics will be become resistant in time

• Antimicrobial resistance is generally irreversible

• AMR is directly linked to use at national level

• The antibiotic pipeline is dripping at best

Global AMR in 2014

UK Five Year AMR Strategy

Commissioning for Quality

and Innovation (CQUIN)

• CQUIN framework supports improvements

in the quality of hospital services and the

creation of new, improved patterns of care.

• National & local indicators

– 4 or 5 national priorities each year. Worth 2.5%

of income

– 2016-7 Clinical: Sepsis (2nd year), AMR,

Physical health of patient with severe mental

health

Commissioning for Quality and

Innovation (CQUIN) 2016-17

The CQUIN scheme is intended to deliver clinical quality

improvements and drive transformational change. These

will impact on reducing inequalities in access to services,

the experiences of using them and the outcomes

achieved

Part A – Reduction in antibiotic consumption per

1,000 admissions

Part B – Empiric review of antibiotic prescriptions

76

Part A – 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

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




78

AMR-CQUIN – what & why?

Requires 1% (DDD per admission) vs 2013-4

baseline for:

• Total (IP & OP): +6% over 4 years nationally

• Carbapenems: +36% & KPC outbreaks

• Piperacillin-tazo: +55% & K.pneum-R +36%

E.coli +31%

• 90%+ documentation of empiric antibiotics review

by day 3 (Q1 25%, Q2 50%, Q3 75%, Q4 90%): Only 10% of

Trusts could provide data though mandatory

Hospitals AMS Teams to use ££ to improve IT, staffing,

fund more expensive antibiotics or tests.

Leadership

Can we (AMS team) achieve this on our

own?

• 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?

• 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

Start Smart – Then Focus

82

Progress So Far (as of August 2016)

• Part A – Antibiotic consumption per 1,000 admissions

– 115 of 155 Trusts have submitted consumption data for 2014/15

and 2015/16

– A number of Trusts (n=86) have also submitted data for 2013/14

– 105 Trusts have submitted data for Q1 2016/17

• Part B Empiric review of antibiotic prescriptions

– 119 of 155 Trusts have submitted data via the PHE AMS online

submission tool

– Preliminary data indicates that 80.84% of prescriptions have

evidence of review within 72 hours (range 22-100%).

• All data submitted will be available on AMR Fingertips

October 2016

Quality Premium

2015/16 and 2016/17

Improved antibiotic prescribing in

primary and secondary care

The ‘quality premium’ is intended to reward

clinical commissioning groups (CCGs)

for improvements in the quality of the

services that they commission and for

associated improvements in health

outcomes and reductions in inequalities in

access and in health outcomes

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

NHS England Antibiotic Quality

Premium Dashboard

NHS England Antibiotic Quality Premium

Dashboard 2015-16

Antimicrobial resistance (AMR) Improving

antibiotic prescribing in primary care

Quality Premium Guidance for 2016/17

The two parts of the quality premium have specific thresholds as follows:

• 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

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

Antimicrobial resistance (AMR)

Improving antibiotic prescribing in

primary care Quality Premium Guidance for 2016/17

Current Performance

93

Future Work

• Joining Sepsis and AMR work

• Continue to reduce inappropriate antibiotic use

• Reductions in Gram negative bacteraemias

Philip HOWARDConsultant Antimicrobial Pharmacist,

LTHT AMS Co-lead NHS Improvement AMR project Lead (part-time)

[email protected]@AntibioticLeeds @ LTHTAntibiotic

Antimicrobial Resistance CQUIN

mailto:[email protected]

1800 in-patient beds over 3 sitesSecondary care population of Leeds 900k & tertiary care to 2.5m for northern Yorkshire & Humber St James’s: Acute Medicine, CF, ID, Cancer (surgery & tx), Transplant, ED LGI: Reg trauma, Neuro, Cardio-vascular, Paeds + CF, EDChapel Allerton: Elective ortho, rehab, rheum /dermatology

Leeds Teaching Hospitals approach

• AMR-CQUIN requires a 1% per admission against 2013-4 baseline for:

• total (IP & OP), carbapenems and pip-tazo

• 90%+ documentation of empiric antibiotics by day 3 by Q4 (Q1 =25%+, Q2 = 50%+ and Q3 = 75%+)

• LTHT target is 1% total (already 9% lower than FY20134), 1% carbapenem (8% lower than FY1314)and 16% pip-tazo (based on growth since FY1314).

• Day 3 – could do better. Was 72% from monthly PPS• Worth £1m OR £250k per element

AMR-CQUIN

• Reasonably mature AMS programme ~7 years

• lean! (1.3wte/2000beds for micro & pharmacy). Monthly reports.• Antimicrobial treatment & prophylaxis guidelines are mainstay of ASP.

• >16k hits per month (no App), 100+ guidelines (diagnosis & tx)• Monthly mini PPS since 2008:

• >90% for indication & duration

• Since Jul-15: guideline compliance >90%, D3 review outcome ~70%. • Benchmark consumption using Rx-info Define:

• higher CDI risk antibiotics; < peers (DDD/1000 beds), avg for total AB and slightly higher for IV antibiotics

• Trust AMS audit programme: monthly mini PPS (pharmacy) & annual specialty audit.

Where we were

LTHT feasibility of achieving CQUINs

Antibacterial usage was growing after our early AMS years gain – less focus?

Getting ideasWhat’s my biggest challenge? Total, carbapenems or pip-tazo?

What guidelines recommend pip-tazo (or carbapenems)?

• Are there alternatives? Identify a lead for each to review. LTHT: HAP, cIAI, CVC, CF, CA-urosepsis >65yr diagnosis, sepsis (?no PsA), SBP?,

• 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% Q1 63%

• Do we act on results within 24 hours? LTH 50% Q1 83%

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

Can we (AMS team) achieve this on our own?• 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?• They came asking for a monthly update – income

stream. • Supplied activity data• AMSG developed an action plan for Trust

Leadership

Which CSU has the biggest share & growth of target antibiotics?

CardioResp (Carbapenems

Oncology (PipTaz)

Oncology (Carbapenem)

AcuteMed - PipTazCR

ACC

Onc (total)

AMSNS

UCTRS

UC

AMNS

AM

GOOD

Room for improvement

Rx-info developed scatter plots based on this so bought Refine £6k

CSUs with biggest growth per admission & share of target ABs

Antibiotic CSU Share (% of all CSUs)

Growth (DDD/adm) FY1516 vs FY1314

Piperacillin-tazo Oncology 27% 30%

Acute Med 15% 24%

Adult Critical Care 15% 11%

Cardio-Resp 13% 12%

Abdo Med Surgery 9% 20%

Neurosciences 7% 60%

Urgent care 5% 45%

Carbapenems Cardio-resp 44% 21%

Oncology 18% 12%

Total Oncology 14% 16%

Acute Medicine 8% 14%

Tighten up our protected (restricted) antibiotics

• Already had a system that used micro / ID authorisation codes PLUS order forms. Eg PPH2109A02

• Replaced with pharmacist writing code on order form and copied onto JAC “patient notes”

• Band 3 pharmacy business support runs a SQL report on “restricted antibiotics” & checks telepath for missing codes

• Email micro / ID where codes are missing or expired to follow up

• Now much improved = less carbapenems

Date Drug Name Time Pack Size Packs Dose

Units

Value Cost Centre Iss

Type

User Patient Name Hosp No Indication Note

Status

When note added Note added by

POSACONAZOLE 100 mg Gastro-

Resistant Tablets

15/09/2016 POSACONAZOLE 100 mg Gastro-

Resistant Tablets

14:25 96 Tablet

Pack

1 0 £2,865.42 J***** R.M. DR

(PAEDIATRIC

HAEMATOLOGY)

ONEST

OP

EPS01 4113656

TIGECYCLINE 50 mg Dry Powder

for Infusion

15/09/2016 TIGECYCLINE 50 mg Dry Powder for

Infusion

21:42 10 Dry

Powder for

Infusion Pack

0 2 £77.54 ALD******** M.A. MR

(HEPATOLOGY)

INP AL04 3919168

Antimicrobial stewardship extractRestricted antimicrobials - date range: 15-Sep-2016 to 16-Sep-2016

Auth Code

Business case to fund initiatives

Summary of funding received for AMR-CQUIN from Aug-16 Amount

Procalcitonin £ 55,462

Day 3 review data collection (AMR 50 pts /mth and Sepsis 30/mth) Band 6 nurse Penicillin allergy testing £ 10,000 AMR-CQUIN Antibiotic Guardian campaign £ 5,000 Alternative antibiotics £ 150,000 Refine software £ 6,000

Must be invoiced each month

One side of A4 justifying need for funding – spent £6k

• Updating guidelines where piperacillin-tazo recommended as 1st line

• Hospital acquired pneumonia – little Pseudomonas (Amox + Temo)

• Severe sepsis thro ED – only 2/68 cases have Pseudomonas

• Uncomplicated intra-abdo infections = only 4 day course (NEJM)

• Urosepsis in >80yr – new guideline BUT aztreonam shortage• Improve culture taking (currently 73-81% BC where required)• Acting on C&S results more quickly (currently 50-83% in 24hr)• Improving review of empiric antibiotic within 1st 3 days (STOP, de-

escalate, IVOS, change AB, OPAT) – currently 61-82% continue IV

• IVOS (LOS, ££, Nursing time, phlebitis, patients prefer it, less C.diff as usually narrower spectrum / shorter)

• Targeted use of procalcitonin in ITU ( LOS by 1.8 days) & medical admissions (AB by 3.8 days & LOS by 3 days)

What is AMSG (IAPG) doing to reduce pip-tazo use?

Ward HCAI / AMS health check

May-16 Day 3 audit results(Womens, Children on old Rx, UC no AB, Head &

Neck – no D3 reviews)

Update e-Whiteboard to highlight IV AB – for nursing safety huddle & Dr Board Rounds

AB

Change to IV or PO in orange circle

Day 3 review tool• Combination of our IVOS and Dundee

(Pulcini) D3 review

• Trial in Acute Medicine and AbdoMedicine & Surgery of small sticker

• Nurse puts sticker in medical notes on day 3 for ward round

• Didn’t make much difference, so version 2 being designed

Complete daily review of antibiotics.

IV to oral switch – day 3 sticker over D5-7?

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

• Got protocols for ED & AMU from Winchester & Sepsis from Central Manchester.

• Got agreement for pathology and a great cost ~£6/test

• Micro / clinician leads amending protocols for starting in Oct-16 (respiratory season)

• CASPUR (Cost effectiveness and Antibiotic Stewardship of serum Procalcitonin UK Report)

• prospectively 1-2 months or ~ 70-100 patients.

• [email protected]

Procalcitonin

Communications campaign

• Base around Antibiotic Guardian campaign

• Link to Leeds Citywide AMS campaign• So far – screensavers, spoke to key

groups (CDs, HoN), monthly AMS report for CSUs, pharmacy newsletters

• To come – stands, Start of the Week (for procalcitonin launch), Grand Round debate on 16th Nov 2016, all IPC Link Nurse events

@LTHTAntibiotics

• Review diagnosis as new information arrives• Bodansky 2012: only 55% of 100 consecutive MAU admissions had

clear infection diagnosis at discharge

• Review all IV AB daily: benefit & harm• Check for results daily on ward / board round• Culture of challenge “do they really or still need

antibiotics?” rather than “just 1 more day”• Review need for catheters regularly (prevent HCAIs)• Become an Antibiotic Guardian• Any other ideas?

What can doctors do to help?

• Review all patients on IV Abs at safety huddle

• Drive IV to oral switch.

• Eating & on IV AB = IVOS or OPAT review• Charts by beds on ward rounds• Avoid missed doses• Become an Antibiotic Guardian• Other ideas?

What can nursing do to help?

• Check AB prescribing vs guidelines• Check/update IV AB column on eWhiteboard• Check pts on IV AB daily• Drive IV to oral switch & OPAT

• Thoughts on protocol for IVOS? Common in USA• Check micro results• Follow up “protected” antibiotics• Become an Antibiotic Guardian• Other ideas?

What can pharmacy do to help?

ChallengesAztreonam shortage• Biggest user in UK (9178 DDD/1000

beds vs 1034 avg)

• Restricted to 5 pts/day (27%)

• Restricting to CF mainly• Alternatives: IV cipro except pip-

tazo for >65yr upper UTI.• Impact on pip-taz = 4.6%DDD/adm

• Micro reluctant to use gentamicin as AKI risk

Lack of AMS staff - vacancies

Summary of antibiotic use & prescribing standards for Aug-16

AB usage per admission to

YTD FY1617 vs FY1314 (AMR-

CQUIN period) - target -1%

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)

Total AB (IP+OP) -11% 0% -37% 8% -11% -16% -53% -34% 2% 43% -17% -47% -18%

Carbapenem -16% -25% -48% -19% 9% 0% -56% -51% 895% 64% -61% -24% -85%

Pipercillin-Tazobactam 13% 13% -27% 16% 31% 48% -59% -24% 225% 52% 22% -9% -94%

Day 3 review (target 90%+) 63% 23% 92% 73% 93% n/a 100% n/a 60% 53% 71% 0% n/a

AMR-CQUIN performance

Other AB usage per

admission to YTD FY1617 vs

FY1314 (AMR-CQUIN period)

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)

IV AB 6% 16% -28% 30% 17% -27% -29% -16% 30% 30% 5% 16% 15%

4C AB (cef/FQ/clind/CoAmox) -9% 0% -14% 5% -16% 5% -63% -22% 38% 42% -29% -44% -1%

Higher risk Cdiff (4C+Carb+PipTaz) -8% 0% -32% 6% -7% 9% -63% -25% 45% 46% -27% -43% -3%

Antimicrobial Prescribing

StandardsLTH

ABDO

MED

SURG

ADULT

CRITICAL

CARE

ACUTE

MEDICINE

CARDIO-

RESPIRAT

ORY

CENTRE

FOR

NEUROS

CIENCES

CHAPEL

ALLERTO

N

CHILDRE

N'S

HEAD &

NECK

LEEDS

CANCER

CENTRE

TRAUMA &

RELATED

SERVICES

URGENT

CAREWOMEN'S

Overall AB Rx Std 83% 74% 96% 86% 85% 82% 95% 95% 71% 75% 84% 64% 97%

No on Abs 372 49 15 61 52 16 12 41 8 62 48 2 6

No of Abs Rxd 471 56 25 71 90 16 13 65 8 65 54 2 6

No on Abs % 31% 28% 32% 29% 33% 16% 20% 34% 44% 50% 37% 9% 16%

% with indication 96% 96% 100% 99% 99% 88% 100% 94% 75% 97% 94% 100% 83%

% Abs with duration or review 93% 82% 96% 92% 94% 100% 100% 95% 88% 95% 93% 100% 67%

Following guidelines 97% 95% 96% 99% 98% 81% 100% 100% 100% 98% 98% 100% 100%

% D3 review completed 63% 55% 67% 49% 74% 67% #DIV/0! #DIV/0! #DIV/0! 83% 50% #DIV/0! #DIV/0!

% allergy completed 97% 95% 100% 95% 95% 100% 100% 98% 100% 99% 91% 100% 100%

% daily review codes completed 78% 68% 80% 80% 86% 75% 100% 100% 88% 75% 43% 100% 100%

% MRSA screening boxes completed 58% 60% 94% 29% 43% 78% 100% 100% 28% 23% 55% 61% 100%% of Abs IV 59% 59% 96% 42% 52% 50% 77% 66% 38% 63% 69% 0% 50%

% of IV Abs given for >48hr 62% 55% 75% 50% 70% 75% 70% 67% 33% 54% 68% #DIV/0! 0%

Day 3 r/v STOP 5% 6% 0% 6% 0% 0% no Abs n/a not done 0% 20% no D3 no D3

Day 3 r/v IVOS 5% 0% 0% 0% 14% 0% no Abs n/a not done 3% 15% no D3 no D3

Day 3 oral to IV switch 0% 0% 0% 0% 0% 0% no Abs n/a not done 0% 0% no D3 no D3

Day 3 r/v change AB 2% 18% 0% 0% 0% 0% no Abs n/a not done 0% 0% no D3 no D3

Day 3 r/v CONT 88% 76% 100% 94% 86% 100% no Abs n/a not done 97% 65% no D3 no D3

Do you know your AMS performance?

• users like smiley faces – easy to understand

• Total: FY1516 vs FY1314: -9% (DDD/Adm) To Aug-16: -11%• Carbapenems: FY1516 vs FY1314: -8% (DDD/Adm) To Aug-16: -16%• Pip-tazo: FY1516 vs FY1314: +16% (DDD/Adm). +5% (+2% azt shortage) to

Jul-16 but +13% to Aug-16: (+8% accounting for aztreonam shortage)

• Day 3 review: Q1 69% (from PPS), Q2 so far 62% (from PPS)

Performance so far

AMR-CQUIN Summary position to Aug-16

• On target : Total -11%, Carbapenem -16%, Day 3 review 69% Q1• Off target: Pip-tazo +13% (as Apr-Aug FY1314 vs FY1617)

Summary of AMR-CQUIN to Aug-16

DDD/1000 adm (except ACC /

Thea = DDD)Growth FY1516 vs FY1314

CSU Total Carbapenem Pip-TazoPerforman

ceTotal Carbapenem Pip-Tazo

Performan

ceTotal Carbapenem Pip-Tazo

Performan

ce

24 Urgent Care CSU -15% 36% 45% -47% -24% -9% -52% -55% -21%

22 Cardio-Respiratory CSU -26% 22% 17% -11% 9% 31% -25% 26% 20%

32 Abdominal Med-Surg CSU 9% -27% 21% 0% -25% 13% -1% -33% 8%

18 Acute Medicine CSU 15% -19% 27% 8% -19% 16% 9% -25% 10%

16 Leeds Cancer Centre 16% 15% 30% 43% 64% 52% 37% 34% 44%

14 Childrens CSU -21% -39% -22% -34% -51% -24% -32% -47% -22%

36 Trauma & Related CSU -2% -51% 12% -17% -61% 22% -15% -67% 7%

28 Head & Neck CSU -11% -50% 69% 2% 895% 225% -11% 96% 275%

12 Womens CSU -15% -43% -68% -18% -85% -94% -22% -50% -93%

20 CAH CSU -49% -76% -35% -53% -56% -59% -55% -49% -74%

44 Theatres & Anaesthetics CSU* 4% -5% 22% 23% -76% 46% 19% -62% 60%

34 Neurosciences CSU 2% 9% 60% -16% 0% 48% -10% -26% 39%

42 Adult Critical Care* -15% -41% -5% -37% -48% -27% -35% -43% -25%

Total -9% -8% 16% -11% -16% 13% -15% -16% 7%

Growth YTD FY1617 vs YTD FY1314 Growth YTD 1617 vs Avg FY1314

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

• Jon Sandoe, Abimbola Olusoga, Damian Mawer, Jason Dunne, Cheryl Mitchell, Mark Wilcox, Kelly Atack,

• Colin Richman – Rx-Info for developing new reports so quickly

Philip HOWARDConsultant Antimicrobial Pharmacist,

LTHT AMS Co-lead NHS Improvement AMR project Lead (part-time)

[email protected]@AntibioticLeeds @ LTHTantibiotic

AMR CQUIN – any questions?

mailto:[email protected]

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%)

Tackling AMR locally – workshop session

#antibioticguardian

Working with South Asian communities

BILAL YAKUB PATELMEDICINES MANAGEMENT PHARMACIST

North Kirklees • Population 190,244

• Growing South Asian population

– Batley and Dewsbury - 38% of those aged under 18 are now South Asian

• Health issues exacerbated by a lack of understanding

Antimicrobial Prescribing

• Antibacterial prescribing rates in North Kirklees have traditionally been much higher than the England average

• GP practices in Dewsbury and Batley in particular have struggled to make any impact on reducing antimicrobial prescribing rates

• GPs working in these areas report difficulties in managing the demand for antibiotics from the South Asian population

APPROACH

MOSQUE PRESENTATION

OTHER AREAS OF WORK

• Push for all clinicians and surgery staff to sign up to be Antibiotic Guardians

• Educational videos and leaflets in surgeries

• Delayed antibiotic prescription templates being used

• Other useful resources for clinicians, surgery staff and patients to use

RESULTS: Total Antimicrobials

ADU’s per 1000 Star PUs

LEARNING POINTS• Engage with the community

• Build relationships and find champions

• A health message from within mosques has a high acceptance rate amongst users and they enjoy/appreciate the interaction

• The South-Asian communities are looking for education on issues surrounding health.

• Success in one mosque opens many doors

WHAT NEXT?

ANY QUESTIONS?

The role of community pharmacists in delivering the 5 year AMR strategy.

Dr Gill Hawksworth

Visiting Fellow University of Huddersfield

Student project 2015

An Evaluation of Antimicrobial Stewardship in Community Pharmacy

• Hancock L, Mellor C, Hawksworth G. University of Huddersfield. Huddersfield.Howard P. Leeds teaching hospitals NHS trust . Leeds.

• Results- It was found 92 (92%) members of the public selected that they would be comfortable allowing their indication on prescriptions for antibiotics, and 83 (83%) selected that they would be comfortable with pharmacy access to medical records.

• Conclusions-This study suggests that increased awareness is necessary of the resources available to pharmacists, regarding antibiotic resistance initiatives and monitoring of antimicrobial prescribing. Also, an improvement is required, concerning patient education by community pharmacists. Finally, the public should be appropriately educated, regarding patient confidentiality, and the benefits of pharmacy access to patient information.

Presented as poster at FIS 2015 Glasgow and published in FIELDS U of Huddersfield 2015.

Student project-2016

Three streams of research:-• The role of community pharmacists in delivering the

5-year antimicrobial resistance strategy- linking to the current work programme of the NHS England antimicrobial strategy to shape the national strategy.Clifford E, Devine S, Mills J, Yazdani B, Hawksworth G. University of Huddersfield . Huddersfield Howard P. Leeds teaching hospitals NHS trust. Leeds

• Patient’s views of community pharmacists delivering the 5-year antimicrobial resistance strategy .

• Younger generation views-community pharmacists delivering the 5-year antimicrobial resistance strategy.

Methodology

• Ethical approval obtained

• Questionnaires sent to community pharmacists in Calderdale and Kirklees.

• Questionnaires requested from patients collecting prescriptions for antibiotics at consenting community pharmacies.

• World Antibiotic Awareness Week 16-22 November 2015 – all pharmacy students (yr1-4) U of Huddersfield did a pledge eg 3rd students instructed on handwashing before making their pledge. Antibiotic Public health campaign held in University main atrium –students from all courses invited to complete questionnaire.

The role of community pharmacists in delivering the 5-year antimicrobial resistance strategy .

Important results of interest-

During patient counselling , 32 (64%) explained the dose, 31 (62%) explained about completing the course and 26 (52%) explained about the avoidance of sharing antibiotics with friends and family. Only 17 (34%) of pharmacists rate themselves as good antimicrobial stewards but when asked about further services, 37 (74%) pharmacists would consider point of care testing and 45 (90%) pharmacists would consider an expansion of a vaccination programme with 38 pharmacists stating that there needs to be more of an emphasis on hand washing.

Conclusion -This study suggests community pharmacists need more training in local antibiotic prescribing to deliver the 5-year antimicrobial strategy. Potential practice improvements could be made by the inclusion of the indication on an antibiotic prescription and a checklist including allergies of patients, counselling (dose, complete the course, left-overs and common side effects) as well as general hygiene and self-help guides for patients. The study also suggests that diagnostic services are something community pharmacists would develop which may show further implementation of the 5-year antimicrobial strategy.

Patient’s views of community pharmacists delivering the 5-year antimicrobial resistance strategy .Important results of interest:-

One hundred (83%) of patients would be comfortable having their indication written on their prescription but when asked about personal conditions (HIV, chlamydia etc.), 18 (18%) changed their mind. Ninety one patients (75%) said they knew what antimicrobial resistance was, but confirmed their knowledge was obtained via the media although 81 patients (67%) said that they didn’t trust the media.Patients were aware of the NHS self help guide with 92 patients (76%) in favour .

Conclusions

This study highlights the potential of development of practice around specific counselling points on antibiotics from community pharmacists to improve adherence to the 5-year antimicrobial strategy plan so patients obtain relevant information and resources from trusted sources such as the community pharmacist or GP. Further interventions such as the indication on antibiotic prescriptions at the patient’s discretion would help improve antibiotic monitoring and counselling.

Younger generation views-community pharmacists delivering the 5-year antimicrobial resistance strategy.

Important results of interest:-

From 90 questionnaires, 54.4% (n=49) students missed and/or stopped before the antibiotic course ended, 72.2% (n=65) correctly identified antibiotics solely effective against bacterial infections .For cold/flu symptoms only 66.7% (n=67) students saw a pharmacist before GP but 61.1% (n=55) support the cause of infection on their prescription, however 21 of these would feel uncomfortable for personal conditions such as chlamydia, HIV and thrush. Handwashing was important for 70.9% (n=61) who used good hand washing technique.

Conclusion :-

Students’ knowledge on antimicrobial resistance needs improving, many students were not taking their antibiotics correctly. Community pharmacists could increasing compliance of antibiotic use with further counselling, signposting to informative websites, and provision of leaflets on hand washing technique .However many students are unwilling to see a pharmacist before a GP.

Publications and future work

Posters accepted:-

• FIS 2016 Edinburgh 2016

• UKCPA Manchester-November 2016

Ongoing AMR research at University of Huddersfield 2017.

We acknowledge ongoing support from Phil Howard.

Concluding comments

Dr Diane Ashiru-Oredope, Pharmacist Lead, Public Health England

#antibioticguardian

antibiotic guardian leeds workshop 2016

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