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

Transcription

1 What are the key challenges in implementing Stewardship the AMS team view Philip Howard Consultant Pharmacist Twitter: AntibioticLeeds

2 Disclosures 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)

3

4

5 New AMS guidance is never ending! 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 (% 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 per 100 admissions

6 UK data from an Interna3onal Survey of Hospital AMS Howard et al (JAC 2015) Conducted in 2012

7 Hours per week for AMS Programme 2% funded from savings 23% dedicated funding (extension of year DoH Hospital Pharmacy Ini3a3ve) AMS pharmacists posts have grown but not WTE (Wickens 2012) Infection Management Group

8 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 Q2 = 49%, Q3 = 58% 61% of red flags required ABs

9 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 Reduce total an3bacterials, piperacillin- tazobactam & carbapenems by 1% per 100 admissions based on 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

10 2016/7 AMR CQUIN: use less or alterna3ves RR8 = - 46 Difference from 2013 to 2014 DDD/100 admissions Total - 0.7% Carbapenem +4% Piperacillin- tazo +7% RR8 = - 1 RR8 = % of hospital AB is OP & ED AB. Same AMS principles of checking indica3on against guidelines s3ll apply & audit of PGDs?

11 NHS Scotland: Use Pip/Taz, carbapenems and carbapenem sparing agents in acute hospitals* (aztreonam, fosfomycin, pivmecillinam, temocillin) but they cost so much more than cheap mero or pip-taz DDDs per 100,000 pop per day * Excludes NHS Highland Year/Qtr Carbapenems Pip-Tazo Carbapenem Sparing Agents

12 NHS Scotland: Use of carbapenems, carbapenem sparing agents and Pip/Taz in Jul-Sep 2015 in acute hospitals by NHS board* DDDs per 100,000 pop per day Carbapenems Carbapenem Sparing Pip-Tazo * Excludes NHS Highland

13 PPS: Compliance With Antibiotic Policy high for meropenem lower for pip-tazo Only 50% have active restricted (protected) AB follow up. (Howard 2015)

14 Chelsea & Westminster restricted AB follow up (Orla Geoghegan Lead AMS Pharmacist Imperial) Micro unaware 73% of 3048 restricted AB FY % deemed inappropriate. 56% stopped within 72h 677 interventions - 91 % were actioned. Avg 45min/day UKCPA PIN Award 2015

15 Reducing total antibiotics 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?

16 Between 2011 and 2014 SSTF surveys: 26%# use of separate AB Rx

17 Do we audit & feedback to improve prescribing? ESPAUR 2014 SSTF: do at least annually. More frequently drives quality improvement LTH audits showed 50% & 81% LTH 59% Only 10% could supply results & outcome (Llewellyn JAC 2015)

18 Dashboard on AMS performance f antibiotic use & prescribing standards for Feb-16 Antimicrobial ABDO ADULT CARDIO- LEEDS TRAUMA ACUTE NEUROS CHAPEL HEAD & URGENT MED CRITICAL RESPIRA CHILDRE CANCER & WOMEN' Prescribing LTH MEDICIN CIENCES ALLERTO NECK CARE SURG CARE TORY N'S (14) CENTRE RELATED S (12) Standards E (18) (34) N (20) (28) (24) (32) (42) (22) (16) (36) 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 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) 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 WOMEN'S CARE (24) (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 users like smiley faces easy to understand

19 Ward health check

20 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

21 Electronic systems for AMS 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) - 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)

22 Summary: To improve antibiotic prescribing in hospitals 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

23 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, 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

24 Challenges of Antimicrobial Stewardship the AMS team Philip Howard Consultant Pharmacist Twitter: AntibioticLeeds