What are the key challenges in implementing Stewardship the AMS team view

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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 [email protected]

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• Speaker or consultancy fees, educational grants for conferences or research from:

• Astellas, AstraZeneca, BBraun, Danone, Eumedica, Gilead, GSK, MSD, Novartis, Pfizer, Sanofi

• Royal Pharmaceutical Society spokesman on antimicrobials

• UKCPA Trustee & Pharmacy Infection Network committee

• BSAC Council

• ESCMID Guidelines & Policies Group Committee

• DH Start Smart then Focus development group

• RCGP TARGET guidance group

• WHO AMR Strategy Task Group (for FIP)

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• Update to the 2008 Health & Social Care Act IPC Code of Practice to

include AMS – criterion 3: ensure AB use optimises outcomes &  risk of adverse events and AMR.

• NHS-England patient safety alert on AMS

• NICE guidelines (2) on AMS: systems and processes & changing risk-related behaviours in the general population (draft)

• Update of Hospital AMS guidelines – Start Smart then Focus

• Quality premium for general practice to reduce total by 1% and broad spectrum antimicrobial 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; draft NICE sepsis, new global sepsis definitions

• BUT AMR keeps increasing, esp Klebsiella to pip-tazo

• Hospital AB use 6%, carbapenem 36% & pip-tazo  55% from 2011-14 per 100 admissions

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UK data from an International

Survey of Hospital AMS – Howard et al (JAC 2015)

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Infection Management Group

• 2% funded from savings

• 23% dedicated funding

(extension of 2003 3 year DoH

Hospital Pharmacy Initiative)

AMS pharmacists posts have

grown but not WTE

(Wickens 2012)

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Has Sepsis CQUIN



ED IV AB use?

Overall 4.8%  in rolling 12 mth from March to February (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 ABs

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New 2016/7 CQUINs: Sepsis & AMR

Biggest AMS implementation challenge or opportunity?

• Both 0.25% of tariff income eg £1b turnover = £2.5m

• _{Sepsis: ED & In Patients and Day 3 review}

– Expanded to include in-patients this year plus day 3 review.

– % who met criteria for sepsis screening who were screened (both)

– % with severe sepsis, Red Flag Sepsis or septic shock and had IV AB within appropriate time period

• 60 min of arrival at ED, 60 min of recognition for newly admitted

or 90 min of existing in-patient 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 antibacterials, piperacillin-tazobactam & carbapenems by ≥1% per 100 admissions based on 2013-4 baseline.

– Evidence of day 3 review (and outcome) of 50 patients per month. Thresholds: Q1 = 25%+, Q2 = 50%+, Q3 = 75%+, Q4 = 90%+

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2016/7 AMR CQUIN: use less or alternatives

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 indication against guidelines still apply & audit of PGDs?

RR8 = -46

RR8 = -1

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NHS Scotland: Use Pip/Taz, carbapenems

and 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 DDDs p er 10 0,0 00 p o p per d ay Year/Qtr

Carbapenems Pip-Tazo Carbapenem Sparing Agents

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NHS Scotland: Use of carbapenems,

carbapenem sparing agents and Pip/Taz

in 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 DDDs p er 10 0,0 00 p o p per d ay Carbapenems Carbapenem Sparing Pip-Tazo

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PPS: Compliance With Antibiotic Policy

high for meropenem lower for pip-tazo

Only 50% have active restricted (protected) AB follow up. (Howard 2015)

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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

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Avoid starting or finish earlier

• NICE diagnostics guidance [DG18] on

Procalcitonin

testing for

diagnosing and monitoring sepsis

.

• _{“high levels can show that a person has a serious}

bacterial infection. … and the results can help doctors

to diagnose bacterial infection and decide about

starting or stopping antibiotic treatment.

• _{“not enough evidence to recommend that these tests}

are used in the NHS.” “.. further research and data

collection (needed) to show the impact “

• _{Do potential benefits mean PCT could be used but}

collect data to show the impact to meet the CQUIN?

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Between 2011 and 2014 SSTF surveys:

26%



use of separate AB Rx

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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)

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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 L L L L L L J L J L L J L

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 K J J K K L J J K L J J L 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)

Dashboard on AMS performance

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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

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• Hosp e-Rx is poor (9%



17%, but 50% in progress) + ind

n

+ dur

n

_{~34% built in}

_{(2012 Global AMS survey UK data)}

• Data warehousing

(2% in UK)

-

l

inks 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)

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• AMR & Sepsis CQUINs are our biggest opportunity

• Design systems to force better prescribing

• Consensus based, easy to access guidelines (including diagnosis and investigations)

• Quality improvement, not annual audit

• Local antibiotic champions (hierarchy) & multidisciplinary

• Merge IPC & AMS teams

• Monitor & benchmark antibiotic usage

• Regular but varied communication

• Local education & training at ward level

Summary: To improve antibiotic

prescribing in hospitals

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• 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