East of Matata

Eastern BOP Stunning but Low income; in the Red Zone

Brief audits while prescribing Benzathine Penicillin, “Bicillin” for Acute Rheumatic Fever (ARF ) secondary prevention;

a practical quality improvement tool for Rheumatic fever/Rheumatic Heart Disease areas without registers.

John Malcolm MRCP, FRACP, DTMH, DCH, PGCertPH, Paediatrician, Bay of Plenty District Health Board, Whakatane NZ.Contact; john.malcolm@bopdhb.govt.nz for expanded abstract, references and discussion; Korero mai koa!

Audits trigger rapid responses to ARF & Rheumatic Heart needs

Learnt from Acute Rh fever diagnosis

Analgesia helps IM adherence!

ARF/RHD Register essentials

More patients get Benzathine Penicillin IM cardio protection from

District Nursing Service (DNS) and more heart follow-up

Clinical follow-up for those with Rheumatic Hearts is improvable

Age at Rh fever diagnosis

Learning from rural town, Opotiki 2012 audit of 12 children & their 12 ARF presentations.

Q ...● WhogotARF&Why?

● WhatmadediagnosingARFsohard?

● WhoisonIMpenicillin-whoisnot?

● Whatelseishappeningmedicallyandsocially?

● Howmanygrandparentsareparenting?

A ...● KidswithgroupAstrepsorethroatsnotprescribed10days

Penicillin or had Rx short course Penicillin 5 day; n=2 (adherence is best on once daily Amoxil)

● MonoarticularArthritis,firstexcludesepticarthritis AND acute Rh fever. The cost of delayed diagnosis includes rheumatic heart disease n=1.

● ArthritisinMaorikidsthinkARF;admitforrapidwork-up (not Outpatients). Diagnosis delay, 2 year before Echocardiograph&heartsurgery,n=1.

● EarlyNSAIDmasksdiagnosis;Rxparacetamolorcodeinefirst;n=3.

● ARFpresentswithRHD,someheartfailure; some ARF=subclinical. n=2.

● Psychosocialreasonswhychildren don’t say “sore throat”; some shy, some putup/shut up, some not articulate, boys intellectual disability n=2.

● Familiesfacemultiple challenges; shifted townsbefore diagnosis; n=3.

District Nursing aim; effective analgesia to help adherence for IM Benzathine

Penicillin for secondary ARF prevention.● 2011 - Benchmark Buzzy Bee + Lignocaine CMDHB

NicholsonrefRussell,Nicholson,NaiduJPCH2014,50,2,112-8.

● 2013-BOPDNSIntroducegatetheorytoolRxBuzzyBee. PaediatricclinicfeedbacktoDNSsomepainscores.● 2014 - BOP DN Service plan individual analgesia from PreinjectionEMLA,ICE,BuzzyBeePLUS.● Somewith0.25ml2%LignocainewithIMBenzathine.● Someday2musclepain;Ice,ParacetamolorNSAID.

What would a Register ARF RHD control programme look like?

RecommendedElements,NationalHeartFoundatoinNZguidelines2006

● Computerbased,regionalcommitment.● Localevidencebasedguidlines.● Partnershipclinicians,publichealth.● SupporttheneedsofthosewithARFRHD.● Assessandmonitorburdenofdisease.● EducatehealthworkersARF,RHD,whanau.● Follow-upsystem;dedicatedclinicsthatensureongoingcare

delivered; esp high risk.

2007 goal to improve effective secondary prevention of recurrent Acute Rheumatic fever

● RuraltownARF3patientsonIMand6oralpenicillin.

● EfficacyIM95%;oralPenicillin65%;Frankish1984.

● Prevalencefromclinic>9/8000population.

● =112/100,000totalpopulation;2007-8

Opotiki ARF RHD 2014Transitioning with Paediatric overlap to adult cardiology

● 10/12ARFinitialdiagnosiswaswithpaediatricservice.

● Secondsurgeryasadolescent,afteraperiodonoralPenicillinn=1● 12/13localsonBenzathinePenicillin

(17yroldonoralsnewaorticandmitralmildincompetence).

● Allmoderate,severeandpost-operativeRHDseecardiologist.

● Clinicalfollow-ups=NHFNZguide6-24months.

● 5AdultCardiology,2PaediatricCardiology,9PaediatricFU.

● Transitioned3,Transitioning2PardiatrictoAdultCardiology (noadultphysicianfollow-upclinics).

Benchmark; NHF NZ & Starship Cardiology Rheumatic Heart Echo & Clinical Follow-up

www.nhf.org.nz2006Carditisp16,echosp9-21,routinereviewp43

Kawerau ARF RHD Audit of Secondary Prevention & Clinical Follow-up

Dr Rebecca Garland Paed SHO and John Malcolm 2011

● 3/9suboptimalsecondaryBenzathinePenicillinandclinical follow-up.

● Adolescents/youngadults;allmoderatetosevereRHD.

● Suggestfollow-upguidestogeneralpractice.

● Generalpracticesupportexamine,Cardiologysafetynet.

● Educationopportunities,practiceanddistrictnurses,EasternBayPHAcommunityhealthworkers.

ARF;Yearssincelastphysician/paediatricianexamWhakatane audit 2010; 3/16 outside NHF 2006 guide● 3yrModerate-severeaorticincompetenceBenchmark 1-2yr

followup.● 3yrOnemildmitralandaorticincompetenceA1.● 4yrA1MIMstenosislowpumpfunctionBenchmark 1-2yr followup.● 4yrModerateA1Benchmark 1-2yr followup.● 7yrNoRHD.● 5yrMildmitralincompetence.● 9yrNormalexamandechoexitexamination.● 10yrMildAorticincompetencestable.

Years of clinical follow-up achieved; some get District Nurse penicillin but no medical review n=29

Audit 2007 for DNS Whakatane Opotiki Rh fever patients

Youngest 2 years (In recent years 1:6 in 20s)WhakataneOpotikiDNS2008

Severity RHD Description, De�nition (Echo or clinical grade)

First follow -up including echo

Subsequent followup NHF and Eastern BOPDHB

Mild or nil RHD Echo onlyif new murmurs

Clinical(most bene�t from frequent initial/education 3/12ly �rst yr JM)

Echo

Moderate Echo in 6-12 months

Clinical

cho

Severe Close supervision until stable

Clinical

Echocardiogram

Quality improvement rampGodfreyNelsonBattenden2005Dartmouth