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

philip.howard2@nhs.net

•  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!

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

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

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

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  

Ward health check

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

philip.howard2@nhs.net