Dilip Nathwani Ninewells Hospital & Medical School Dundee, Scotland DD1 9SY
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Transcript of Dilip Nathwani Ninewells Hospital & Medical School Dundee, Scotland DD1 9SY
Dilip NathwaniNinewells Hospital & Medical School
Dundee, Scotland DD1 9SY
SCOTTISH ANTIMICROBIAL PRESCRIBING
GROUP (SAPG) AMT NETWORK
MEETING STIRLING 2008
SAPG AMT CLINICAL NETWORK
Antimicrobial Prescribing Facts
~ 1/3 of all hospitalised inpatients at any given time receive antibiotics
~ up to 1/3 to ½ are inappropriate ~ up to 30% of all surgical prophylaxis is
inappropriate Antimicrobials account for upwards of 30% of
hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets.
Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, increased litigation and reduce quality of life
Managing risk of empiric or prophylactic therapy & adopting
change“Many clinicians regard the right to prescribe antibiotics
freely (unrestricted) as a basic human right”
“The desire of the clinicians to achieve the most optimal outcome for the patient needs to be balanced against the risk of inappropriate antibiotics to the patient presently & in the future, the ecology and other patients
“The organisation needs to risk manage this conflict and help with solutions “
THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL
RESISTANCE ACTION PLAN[ScotMARAP 2007]
ScotMARAP Output
SAPG: A 3 year programme of work launched on the 17th of March 2008
Total funding of £1.2 million and allocation split between key stakeholders
SMC asked to convene, host and service national clinical forum – SAPG
SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG)
The primary role of the SMC is to convene and service a group to fulfil the aspirations for “a national clinical forum” as expressed in the APP&P. This group (SAPG) would include national stakeholder organisations and would collate the disseminate scientifically rigorous information on antimicrobial resistance trends and antimicrobial use on an ongoing basis to the NHS (primary and secondary care).
Aim
A National Framework for Antimicrobial stewardship
Improve the quality of antimicrobial prescribing and infection management
Scottish Medicines Consortium Scottish Antimicrobial rescribing Group
Health ProtectionScotland
NHS Education forScotland
NHS Boards Area Drug and Therapeutics Committees
NHS Quality Improvement Scotland
NHS Boards Antimicrobial Management Teams
Clinical GovernanceRisk ManagementInfection Control Team /
ManagerPrescribers
Reference DiagnosticServices
NHS Boards Antimicrobial Management Team Sub- Group of Scottish
Antimicrobial Prescribing Group
Scottish Patient Safety Alliance
Information ServicesDivision
Local DiagnosticServices
Scottish Medicines Consortium Scottish Antimicrobial rescribing Group
Health ProtectionScotland
NHS Education forScotland
NHS Boards Area Drug and Therapeutics Committees
NHS Quality Improvement Scotland
NHS Boards Antimicrobial Management Teams
Clinical GovernanceRisk ManagementInfection Control Team /
ManagerPrescribers
Reference DiagnosticServices
NHS Boards Antimicrobial Management Team Sub- Group of Scottish
Antimicrobial Prescribing Group
Scottish Patient Safety Alliance
Information ServicesDivision
Local DiagnosticServices
THE STAKEHOLDERS
CEL 30(2008)8TH July
As an immediate intervention to reduce the risk form C.difficle,we accept SAPG’s recommendation that all boards should immediately establish an AMT which covers primary and secondary care prescribing.
“AMT’s work closely strategically and operationally with ICT’s and ICM”- SAPG
Antimicrobial management team
Multi-disciplinary team ResourcedSupported Multi-faceted
interventions (consistently more effective then single interventions)
Active team at the coalface
Supported by hospital leadership
Core InterventionsFormulary +
restrictions (expert approval)
Audit and feedback (information) of antimicrobial use and resistance patterns and unintended consequences
CEL 30(2008)8TH July
Recognition of the key role of the antimicrobial pharmacist: central additional funding for £40,000 for each mainland board and £20k for Island boards for 3 years (2011).
SAPG (not in CEL) keen on developing clinical networks for AMT’s to provide support for smaller boards, share good practice and do joint planning. Launch of AMT clinical network in STIRLING 18TH November 2008.
4 WORKSTREAMS
1. INFORMATION MANAGEMENT (HPS AND ISD)
2. EDUCATION (NES)3.ORGANISATION AND ACCOUNTABILITY
(NQIS)4.INFECTION MANAGEMENT
(SPA,NQIS,NES,HPS-ISD,Professional Organisations)All the work-streams work in parallel but with vertical
integration Workstream work underpinned by an AMT Clinical
Network
MEASURES OF IMPROVEMENT: SECONDARY AND PRIMARY
CARE Consumption of antibiotics (total and
class)Surveillance of resistance Quality of prescribing through PPS
(targeted)HEAT indicator/sHAI standards
INDICATOR/S: HOSPITAL AND EMPRIC THERAPY
Indicator: >90% compliance with empiric antibiotic treatment policy in acute medical and surgical receiving/admission units
Measure : 1. the working diagnosis/reason for prescribing the antibiotic was documented in the medical notes
2. The choice (? Route/dose) was consistent with the empiric treatment policy
How ? 5 random charts of patients receiving antibiotic daily
one day a week reviewed by team and compliance charted
EFFECTS OF PERIOPERATIVE PROPHYLAXIS ON NOSOCOMIAL C. DIFFICILE COLONIZATION A Prospective Study
122 patients underlying clean non-GI surgery (herniorraphy, splenectomy, ortho reconstruction…) 3% positive C. difficile culture preoperatively Postoperative positive, by prophylactic regimen:
Cephalosporin 23%
Cefoxitin
1%14%25%
Cefazolin 11441425%14%3%
%
Cefotetan 525% Ceftriaxone 25%
Cefoperazone 44%
Mezlocillin 3%
Privitero et al, AAC 35:208,1991
The Surgical Infection Prevention (SIP) and Surgical Care improvement Project (SCIP): National Initiatives to imporve the
Outcomes of Patients Having SurgeryCID 2006; 42: 322-30.
3 INDICATORS FOR SSI
Antibiotics administered within 60mins
Antibiotic selectionAntibiotic stopped
within 24h
Quality IndicatorsNational Surgical Infection Prevention
ProjectQuality Indicator #3
Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time
Numerator statement: no. of patients who prophylactic antibiotics were discontinued within 24h of surgery end time (48h for cardiac surgery)
Denominator statement: All selected surgical patients with no evidence of prior infection
Impact of Prolonged Antibiotic Prophylaxis
2,641 CABG patientsGrp 1 - < 48 hours of antibioticsGrp 2 - > 48 hours of antibiotics
SSI RatesGrp 1 - 8.7% (131/1502)Grp 2 - 8.8 % (100/1139)
Antibiotic resistant pathogen - Grp 2Odds Ratio 1.6 (95% CI: 1.1-2.6)
Harbarth S, et al. Circulation. 2000.
How do we communicate what we would like NHS Boards to do & also hear from them what they would like us to do?
SAPG Communication
Road show about SAPG programme
Developing an SAPG website within SMC website to communicate and share information, recommendations and good practice
Inform the development and monitoring of national antibiotic prescribing indicators
Setting up of extra-nets: SNAP-CAP, CDAD, ? Surgical prophylaxis
Regular AMT network in Stirling: 3/3/09; 2/6/09 & 29/9/09
SAPG
Chair (DN)Project Manager (JS)Project administratorPharmaceutical
advisor (BM)AMR (CW)QIS (PC) Work-stream leads
(AS, MB-AE, LG, JW)
Steering Group (SMC, AMT, Dental, Vet, Medical School, Patient Group Representative, CEO, MD, Industry, ID, Microbiology, SIRN, Pharmacy, General Practice, Nursing, Patient Safety Alliance, SGHD
Co-opted experts in work-streams