microguide app, pop up uni, 1pm, 3 september 2015

MicroGuide App: decision-support Accelerating development and adoption of innovation through partnership

David Meehan, Deputy CEO, Wessex Academic Health Science Network

Kieran Hand, Consultant Pharmacist Anti-infectives, University Hospital Southampton NHS Foundation Trust

Eamus Halpin, Design Mentor, Horizon Strategic Partners Limited

What are AHSNs ?

The 15

AHSN

regions

What do AHSNs do and How? Every AHSN shares a focus on:

– Promoting economic growth – Diffusing innovation – Improving patient safety – Optimising medicine use – Improving quality and reducing variation – Putting research into practice

In addition AHSN priorities and programmes reflects the diversity of the

challenges of improving health and wealth in each region.

AHSNs different and distinct • Everything we do is driven by two imperatives: improving health and generating economic growth in

our regions.

• We are partnership bodies -we are the only place where the whole of a regional health economy comes together voluntari ly to improve the health of local communities.

• We have a remit from NHS England to occupy a unique space outside of the usual NHS service contract and performance management structures. This enables us to foster collaborative solutions. We use our local knowledge and harness the influence of our partners to drive change on the ground and integrate research into health improvement.

• We are as interested in seeing healthcare businesses thrive and grow, creating jobs and bringing in investment to the UK, as we are in seeing the healthcare system improve.

What do AHSNs do and How? • AHSNs connect academics, NHS, researchers and industry in order to

accelerate the process of innovation and facilitate the adoption and spread of innovative ideas and technologies across large populations.

• We are catalysts and facilitators of change across whole health and social care economies, with a clear focus on improving outcomes for patients.

• We open doors and create a more conducive environment for relevant industries to work more effectively with the NHS and other parts of the UK healthcare sector.

A Systematic Approach to Adoption and Spread

• Spot - identify the innovations that can give greatest impact or align with

our work

• Seed - get the first few places or settings to use or apply the innovation,

evaluating if needed

• Spread - ‘duplivate’ to next settings or areas with support,

then get much wider adoption

Innovation and Wealth Creation Accelerator Funds

2013/14 2014/15

Applications 59 72

Successful 17 13

WAHSN Investment £301k £333k

Stakeholders’

in kind contribution

£398k £558k

Making Oakley and Overton Partnership a Dementia Friendly General Practice

• Dr Nicola Decker- Dementia Champion

• Memory Screening increase from 1 to 144 patients

and diagnosis increased by 20% in first 6 months

• Power of Attorney and resuscitation status in place

• Patient and Carer experience significantly improved

• Spread to 25 + GP practices

Bournemouth University Orthopaedic Research Institute

Prof. Rob Middleton – Consultant Orthopaedic Surgeon

Tom Wainwright – Clinical Researcher & Visiting Fellow

1000 Additional Trials

£4m Investment

Innovation and Wealth Creation Accelerator Fund

The Wessex Faecal Microbiota Bank – Dr Robert Porter,

Portsmouth Hospitals NHS Trust

An innovative pilot service to create a frozen faecal microbiota store

and provide Faecal Microbiota Transplantation (FMT)

to treat recurrent Clostridium Difficile,

SAVING LIVES AND REDUCING COSTS.

MicroGuide App

Antibiotic Prescribing Decision Support

Kieran Hand, Consultant Pharmacist Anti-infectives,

University Hospital Southampton NHS Foundation Trust

U.S. CDC “Threat Report”: Sept 2013

The problem with antibiotic prescribing… • Under treatment

– A 2010 systematic review of 70 prospective studies of the effect of initial antibiotic treatment on all-cause mortality among adult inpatients with sepsis reported that 46.5% of patients were given inappropriate initial therapy (pathogen non-susceptible) and this was associated with an adjusted odds ratio for fatal outcome of 1.6 fold (95% confidence interval 1.37-1.86). [Paul M et al, AAC 2010]

• Over treatment – The 2011 ECDC point prevalence survey of healthcare-associated infection (HCAI), recruiting 59% of NHS

acute trusts in England, reported that one-third of patients prescribed antibiotics intended for treatment of HCAI did not meet the case definition for HCAI. [HPA 2012]

• Misuse of broad-spectrum agents – The period between 2004 and 2009 saw a 50% increase in the prescribing of the carbapenem class of

antibiotics English hospitals, representing the most broad spectrum antibiotics currently available. [Ashiru-Oredope D et al, JAC 2012] These trends have continued.

New problem: Rx of very broad-spectrums driving resistance

Further 31% increase from 2010 to 2013

Why do these problems exist? Complexity

16

Other diseases Infectious diseases

Diagnosis – Is bacterial infection present? Diagnosis

Bacteria species causing infection unknown

Antibiotics not active against all bacteria

Treatment regimen Treatment regimen

Variable local antibiotic resistance

Patient factors Patient factors

The problem with education… • A survey of doctors in Johns Hopkins Medical Institutions in 2004 reported that 90% wanted more

education about antibiotics with only 21% of doctors feeling very confident they were using antibiotics optimally. [Srinivasan A, Arch Intern Med 2004]

• A more recent survey of junior doctors in a Scottish hospital suggested that 75% (47/63) were confident to choose the correct antibiotic but only 36% felt confident to plan the duration of treatment. [Pulcini C, Clin Microbiol Infect 2011]

– The availability of guidelines was found to be the intervention rated most highly by junior doctors to improve antibiotic prescribing.

• Research carried out in two university hospitals in Paris used brief case studies to explore physician knowledge of antibiotic prescribing and 86% of the 206 physicians who participated felt they had insufficient knowledge. [Lucet JC, J Antimicrob Chemother 2011]

• A 2012 survey of 317 (61%) fourth year medical students from three US medical schools reported that 90% said they would like more education on the appropriate use of antibiotics and only one third perceived their preparedness to be adequate in some of the fundamental principles of antibiotic use. [Abbo LM, Clin Infect Dis 2013]

From maps to Apps 2008 2011 2013

Survey of guideline users in UHS Published at Federation of Infection Societies 2013 (n=49)

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Initiatives to improve guideline adherence at UHS: relative importance

Highest importance

High importance

Moderate importance

Some importance

no importance

Evidence of success of decision-support • Sintchenko V et al 2005

– Handheld decision support system RCT – Reduced length of stay on ICU from 7.15 to 6.22 days – Reduced carbapenem prescribing by 7%

• Paul M et al 2006 – Desktop decision support system cluster RCT – Effective initial treatment improved from 64% to 73% (p=0.033) – 30-day mortality improvement trend from 11.9% to 9.7% (p=0.72)

• Thursky K et al 2006 – Desktop decision support system time series analysis – Carbapenem prescribing reduced by 25%

MicroGuide Decision-Support wins 2014 Award in

the Infection Prevention Category: funding for

software development (£50k)

MicroGuide Decision-Support secures

funding for clinical algorithm

development (£25k)

Innovation and Wealth Creation Accelerator Fund 2014/15

Decision support concept • Evidence of infection

• Likely pathogens

• Local/national antibiotic resistance data

• Clinical evidence of treatment efficacy & safety

• Risk of mortality (severity)

• Risk of antibiotic resistance

• Risk of Clostridium difficile

• Penicillin allergy

Acute exacerbation of COPD: Evidence of infection

• Patients reporting a change in the colour of spontaneously expectorated sputum samples over the past 72 h from uncoloured to yellow-green should

receive antibiotic treatment. [Soler N, Eur Respir J 2012]

• Uncomplicated patients* who do not report changes in sputum colour may

be managed without antibiotics.

• *not pneumonia / immunocompromised / ICU / NIV / CHF / neoplasm /

recent hospitalisation

In vitro antibiotic susceptibility: local data Gram +ve Gram +ve Gram –ve Gram –ve Gram –ve Atypicals

1 2 3 4 5 6

Drug\Organism S. pneumoniae Staph. aureus (MSSA only)

H. influenzae Moraxella catarrhalis

Pseudomonas aeruginosa

Chlamydophila Mycoplasma

Prevalence in COPD (Sethi S & Murphy TF 2008)

10-15% Unlikely to be a pathogen

20-30% 10-15% 5-10% 5-7%

a Benzylpenicillin 99% R - - R R

b Amoxicillin

100% R 74%

1% R R

c Co-amoxiclav

100% 100% 93% 99% R R

d Pip-taz

100%

100% 93% 99% 95% R

e Doxycycline

86% 85% 99% 100% R +++

f Co-trimoxazole 86% +++ ++ +++ R -

g Chloramphenicol 100% 98% 99% 100% R ++

h Clarithromycin 80% 72% 99% 100% R +++

i Moxifloxacin +++ +++ 97% 99% + +++

j Ciprofloxacin ++ 88% 97% 99% 77% +++

k Teicoplanin 99% 99.5% R R R R

l Ceftazidime ++ ++ +++ +++ 92% R

Clinical trial efficacy: quinolones vs

macrolides [Siempos I 2007]

Treatment success in clinically evaluable patients with acute bacterial exacerbations of chronic bronchitis in randomised controlled trials.

Favours quinolone Favours macrolide

Levo 750 od 3d Azithro 500/250 od 5d

Levo 500 od 7d

Levo 500 od 10d

Gemi 320 od 5d

Moxi 400 od 5-10d

Moxi 400 od 5d

Moxi 400 od 5d

Azithro 500/250 od 5d

Clari 500 bd 10d

Clari 500 bd 7d

Clari 500 bd 10d

Azithro 500/250 4d

Clari 500 bd 7d

Severity assessment [Archibald R et al, 2012]

• CAUDA-70

• One point each for:

– Confusion

– Acidosis (pH <7.35; first ABG

post-admission)

– Urea >7mmol/L

– Dyspnoea (MRC score ≥4)

– Albumin <35g/L

– Age >70y

• Predicted in-hospital mortality

– Score 0 = 0%

– Score 1 = 1%

– Score 2 = 2%

– Score 3 = 6%

– Score 4 = 20%

– Score 5 = 53%

– Score 6 = 100%

• Severe = score of 3 or higher

(mortality 14%)

Risk assessment (resistance) Risk factors for Pseudomonas aeruginosa isolated from sputum on hospital admission [Garcia-Vidal C et al, 2009, n=188 patients]:

• Evidence of bronchiectasis as co-morbidity [local consensus]

• Previous isolation of Pseudomonas aeruginosa from sputum or bronchial

lavage (n=31; 61% had P. aeruginosa on admission)

• Systemic steroid treatment (n=17; 41% had P. aeruginosa on admission)

New sputum purulence?

YES (Patient reports change in the colour of

spontaneously expectorated sputum samples over the past 72 h from uncoloured

to yellow-green )

UNCERTAIN (Purulent sputum at baseline or difficulty

identifying an increase in purulence)

NO (Uncomplicated patient* who does not

report changes in sputum colour )

Bacterial infection unlikely. Antibiotics not indicated.

SIRS? (2 or more criteria):

• Temperature >38.3°C or <36°C • Heart rate > 90/min • Respiratory rate > 20/min • White cells >12 or <4 x 109/L

NO YES Severe sepsis? YES

NO Follow severe sepsis treatment guideline

Any convincing radiological evidence

of pneumonia?

Any convincing radiological evidence

of pneumonia? YES YES Follow CAP guideline

NO NO

Acute exacerbation of Chronic Obstructive Pulmonary Disease: algorithm 1

Go to algorithm 2 Go to algorithm 3

Penicillin allergy?

Severe Mild / non-severe None

Patient risk for C. difficile Patient risk for C. difficile


Sputum purulence = yes/uncertain; SIRS = no; pneumonia = no

• Check for previous culture and susceptibility results before selecting treatment

• If recent (<3 months) antibiotic exposure, use alternative class of antibiotic

Choose from:

• Doxycycline (1st line) • Co-trimoxazole • Azithromycin

• Moxifloxacin (2nd line) (not if

cardiac disease due to QT-prolongation)



Choose from:

• Doxycycline (1st line) • Co-trimoxazole



Choose from:

• Doxycycline (1st line) • Co-trimoxazole • Azithromycin

• Co-amoxiclav (2nd line)



Choose from:

• Doxycycline (1st line) • Co-trimoxazole

High risk Low risk High risk Low risk


Sputum purulence = yes/uncertain; SIRS = yes; severe sepsis = no; pneumonia = no

Risk of colonisation/infection with Pseudomonas aeruginosa? Any of:

• Previous isolation of Pseudomonas aeruginosa from sputum or bronchial lavage

• Systemic corticosteroid treatment (ongoing prior to admission)

• Evidence of bronchiectasis as co-morbidity

YES Note: Frequently colonising

flora but if suspected pathogen, then continue:

NO

Penicillin allergy?


Choose from: • Chloramphenicol (1st

line) • Co-amoxiclav • Ceftriaxone

• Moxifloxacin (2nd line)

(not if cardiac disease due to QT-prolongation)

Choose from: • Chloramphenicol (1st

line) • Ceftriaxone



Choose from: • Chloramphenicol



Penicillin allergy?


Choose from: • Piperacillin-tazobactam

(1st line) • Ceftazidime high-dose

Review MC&S after 48h to confirm susceptibility

• Ceftazidime high-dose

Review MC&S after 48h to confirm susceptibility

Contact microbiology urgently

• Chloramphenicol • Chloramphenicol • Chloramphenicol Contact microbiology

urgently Contact microbiology

urgently Contact microbiology

urgently

Patient risk for C. difficile Patient risk for C. difficile Patient risk for C. difficile Patient risk for C. difficile Patient risk for C. difficile Patient risk for C. difficile

LOW

LOW

HIGH LOW HIGH LOW HIGH LOW HIGH LOW HIGH LOW HIGH

Treatment regimen permutations

Decision Detail Answer choices Permutations

1 Evidence of infection: Sputum purulence 3 1x

2 Severity: Inflammatory response (SIRS) 2 2x

3 Severity: Severe sepsis 2 1x

4 Severity: Pneumonia 2 1x

5 Risk of resistance: Pseudomonas risk 2 2x

6 Penicillin allergy 3 3x

7 Clostridium difficile risk 2 2x

Total 16 24

‘Tailoring’ choices

Decision support system

Acute exacerbation of COPD

Sputum purulence

O No O Don’t know

O Yes

SIRS O No O Yes

Severe sepsis O No O Yes

Pneumonia O No O Yes

Pseudomonas risk

O No O Yes

Penicillin allergy

O None

O Mild O Severe

C. difficile risk

O Low O High

Continue

Decision support system


Sputum purulence

O No O Don’t know

Yes

SIRS O No Yes

Severe sepsis

No O Yes

Pneumonia No Yes

Pseudomonas risk

No O Yes

Penicillin allergy

O None

Mild O Severe

C. difficile risk

Low

O High

Continue


You selected: • Yes: evidence of bacterial

infection • Yes: inflammatory response

• No: severe sepsis • No: pneumonia

• No: Pseudomonas risk • Yes: mild penicillin allergy

• Yes: low risk of C. difficile

Recommended treatment regimen

Choose from: • Chloramphenicol 12.5mg/kg IV

6-hourly (1st line) • Ceftriaxone 1g IV once-daily

• Moxifloxacin 400mg IV once-

daily (2nd line) (not if cardiac disease due to QT-prolongation)

Back

MicroGuide - Vital Statistics • Nearly 100,000 app users (42,000 in the UK

alone)

• 72 subscribing Medical Organisations (over 50 NHS Acute NHS Trusts)

• Top 3 downloaded Medical app on iTunes/Google Play

• Guidance created in England, NI, Scotland, Wales, Rep of Ireland, New Zealand, Cambodia and US

• Over 250 Pharmacists creating, editing and publishing content

MicroGuide App Eamus Halpin - Design Mentor, Horizon

Strategic Partners Limited

Content Management

Apps

Web Viewer

We have now gathered over 4 million guidance touch points within our framework (Research output to follow soon)

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App - Adult

App - Adult

Rank Count Condition

1 1378 Pneumonia: moderate/ severe (CURB65=2-5) community-acquired

2 1196 Systemic sepsis of UNKNOWN source

3 1031 Pneumonia: with SEPSIS / severe SEPSIS community-acquired

4 909 Healthcare-associated pneumonia: moderate/severe

5 909 Pneumonia : non-severe (CURB65= 0-1) community-acquired

6 747 Healthcare-associated pneumonia: mild

7 611 Cellulitis, lower limb

8 446 UTI, lower, non-severe (not-pregnant)

9 333 COPD: infective exacerbation

10 323 Intra-abdominal infection: lower-risk

11 257 Ebola

12 255 Community-acquired pneumonia: prior treatment with amoxicillin (within 2 weeks) or moderate/ severe (CURB65=2-5)

13 248 Community-acquired pneumonia: with SEPSIS / SEVERE SEPSIS (regardless of CURB65 score)

14 227 Cellulitis, lower or upper limb

15 214 Community-acquired pneumonia : non-severe (CURB65= 0-1)

16 214 UTI, suspected / probable + functional decline (older person)

17 204 Cholecystitis / ascending cholangitis

18 148 LRTI (suspected) + functional decline (older person)

19 124 bacterial keratitis

20 122 Healthcare-associated pneumonia or aspiration: moderate/severe

21 104 What's new in this Version?

22 97 Post operative treatment after complex adnexal procedures

23 92 Epidural or intraspinal abscess / discitis / vertebral osteomyelitis, post-surgical/trauma or potentially epidural-catheter associated

Daily usage patterns of both the app and the web viewer

have been phenomenal

Typically, with thousands of touch

points, clinicians still only access circa 20% of

their guidance

We have studies and overview research created by Trusts…

“…we have been monitoring Antibiotic

Prescribing Compliance since 2009 with a target of 90% which we have NEVER

hit. Since we launched the App ( MicroGuide™) we hit 90% in February

and 90.7% in March” Antimicrobial Pharmacist UK Acute

Hospital Trust

“ the use of MicroGuide™ has supported a

sustained reduction in the prescribing of high risk broad spectrum antibiotics from 40% to 28%”

University Hospitals Southampton Foundation Trust

The introduction of MicroGuide™ has “increased

awareness of antimicrobial stewardship” and “encouraged clinicians to challenge/question

inappropriate prescribing by others”. Survey at UCLH 2014

MicroGuide officially became a Medical Device, and designated with the CE Mark, in May 2015

Developmental path • Any type of guidance can now be created and published through the same

platform – 30 different types already exist, from Pain to Oncology

• Design iteration has already begun for the Decision Support Module

• When completed DSM will be capable of being applied to any form of

clinical guidance

• Initial testing and early adopter deployment is expected by the end of Spring

2016

Thank you

Questions & Answers