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Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP)
Scottish Antimicrobial Prescribing Group (SAPG)
Dilip NathwaniSIRN, Glasgow June 2008
“The future of humanity and microbes willlikely evolve as ……. episodes of our witsversus their genes”
Jonathan Laderberg Science 2000; 288: 281-93
10080604020
0
S. aureus resistant to methicillin%
1750 1825 1950 2000
10080604020
0
Gram-negative resistance%
1750 1825 1950 2000
InfectionMean Cost
($ US)SD Minimum Maximum
Surgical Site Infection
25546 39875 1783 134602
BI 36441 37078 1822 107156
VAP 9969 2920 7904 12034
UTI 1006 503 650 1361
Attributable costs of HAI Stone et al AJIC 2005; 33(9): 501-509
Socio-economic burden of hospital-acquired infections (HAIs)
Plowman R et al. Public Health Service and the LondonSchool of Hygiene and Tropical Medicine 1999: 12.
Incidence Duration of Stay Overall costs Specific costs
7.8%Acquired one or more HAIs whilst in hospital
11 days GBP 2915 Hospital overheads/ capital charges/ management
33%
2.5 times longer than uninfected
2.8 times more than uninfected
Nursing care 42%
Operations/Consumables 6%
Paramedics/ nurses 4%
Antimicrobials 2%
Others 7%
What is Antimicrobial Stewardship?A marriage of infection control and antimicrobial managementMandatory infection control complianceSelection of antimicrobials from each class of drugs that does the least collateral damageCollateral damage issues include- MRSA- ESBLs- C.difficile- stable derepression- MBLs and other carbapenemases- VREAppropriate de-escalation when culture results are available
Dellit TH et al Clin Infect Dis 2007; 44: 159-177
The Primary Goal of Antimicrobial Stewardship
The primary goal of antimicrobial stewardship is to- Optimize clinical outcomes while minimizing unintended consequences of antimicrobial use
- Unintended consequences include the following: - Toxicity - The selection of pathogenic organisms, such as C.difficile
- The emergence of resistant pathogens
Dellit TH et al Clin Infect Dis 2007; 44: 159-177
Other Aspects of Antimicrobial Stewardship
The appropriate use of antimicrobials is an essential part of patient safetyThe frequency of inappropriate antimicrobial use is often used as a surrogate marker for avoidable impact on antimicrobial resistanceThe combination of antimicrobial stewardship and comprehensive infection control has been shown to limit the emergence and transmission of antimicrobial resistant bacteriaA secondary goal of antimicrobial stewardship- to reduce healthcare cost without adversely impacting the quality of care
Antimicrobial prescribing policy and practice (APP&P) in Scotland:
recommendations for good antimicrobial practice in acute hospitals
Nathwani D. JAC 2006; 57: 1186-1196 (adapted by SACAR Antimicrobial
framework (JAC 2007: 60: Suppl. 1, i87-90)
http://www.Scotland.gov.uk/publications/2005/09/021326 09/26114
APP&PThe core components of the current guidance are:
a. Development of prescribing policies (SACAR provides also generic template for antimicrobial guidelines)
b. Monitoring of compliancec. Structures and responsibilitiesd. Education & Training
e. Audit and performance management.
APP&P KEY DOMAINS FOR RECOMMENDATIONS
Recommendations in the following key areas:Key Area
1. Establish standard structures and lines of responsibility &accountability in NHS Boards across Scotland.
2. Define structures and responsibility for multi-disciplinaryand generic undergraduate and post-graduate trainingrelated to antimicrobial prescribing.
3. Define the minimum dataset requirements and standardprocedures for collecting information related toantimicrobial resistance patterns.
4 Define the minimum dataset requirements and standardprocedures for collecting information related toantimicrobial consumption and quality of prescribing at anorganisational level and/or ward specific level.
5. Define the key areas for acute hospital policy andrecommendations for audit.
6. Develop and define performance indicators that could beused to assess or gauge performance related toantimicrobial prescribing in hospitals
Document communicated by CMO to all NHS Boards
Establish standard structures and lines of responsibility and accountability in
NHS Scotland across BoardsChief Executives of Boards and Single Delivery Units take overall responsibility for APP&P within acute hospitalsHAI and prescribing should be on NHS boards Local Delivery Plan which has replaced the Local Health Plan and PAF.
Medical DirectorMedical Director Chief ExecutiveChief Executive Infection Control Infection Control ManagerManager
Drugs & Drugs & Therapeutics Therapeutics CommitteeCommittee
Antimicrobial Antimicrobial Management Team (AMT)Management Team (AMT)
SpecialitySpeciality--based Pharmacy leads for based Pharmacy leads for APP&P with responsibility for APP&P with responsibility for antimicrobial prescribingantimicrobial prescribing
Ward Based Clinical Ward Based Clinical PharmacistsPharmacists
Risk Management Risk Management CommitteeCommittee
Clinical Governance Clinical Governance CommitteeCommittee
Infection Control Infection Control CommitteeCommittee
Microbiologist / Microbiologist / Infectious Diseases Infectious Diseases PhysicianPhysician
PRESCRIBERPRESCRIBER
Prescribing support / feedback
Dissemination & feedback
http://www.scotland.gov.uk
5. Define key areas for acute hospital policy and recommendations for auditNational collection of consumption data to evaluate use trends e.g DANMAP
Co-ordination by a “national clinical forum” which will work with key agencies
Facilitate audit of quantity and quality of antimicrobial consumption by use of point prevalence “snapshot”survey
STRAMAGAATESAC
SMC- ANTIMICROBIAL PRESCRIBING GROUP
The proposed 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 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).
Long established, centrally funded by government
Broad membershipCentral function with network to local STRAMA groupsUse of local groups to support implementation of initiativesUse of expert study groups to help interpret studies and data
Broad range of activities
PrescribingResistanceEducationPoint prevalence studiesClinical trials
STRAMA: SWEDISH STRATEGIC PROGRMAME FOR THE RATIONAL USE OFANTIMICROBIAL AGENTS AND SURVEILLANCE OF RESISTANCE
IMPACT OF STRAMA: Lancet ID 2008; 8: 125-32.
1995-2004 OP antibiotic use decrease from 15.7 to 12.6 DDD per 1000 inhabitants per day and from 436 to 410 prescriptions per 1000 inhabitants per year. Children and macrolide use most pronounced decrease Hospital admission rates with quinsy, sinusitis, mastoiditis low or stable Resistance rate in PRP slow increase from 4% to 6%.Other resistance rates lowICU work ongoing from 1999- low rates of resistance so far
ScotMARAP Process & Timelines
ScotMARAP pre-publication review issued to NHS Scotland 7th December 2008
Positive response from NHS Scotland – general sense of support
ScotMARAP business case submitted to SGHD 7th
February 2008
Approved in principal – funding available from 1st April 2008
SGHD announcement of launch of ScotMARAP project by Cabinet Secretary 17th March 2008
SMC is Project Sponsor
Scottish Antimicrobial Prescribing Group (SAPG) to be formed to deliver recommendations within the APP&P and ScotMARAP
Scottish Antimicrobial Prescribing Group chaired by Dilip Nathwani
Partnership working with key stakeholders is imperative for delivery – clearly defined roles, responsibilities and accountabilities
ScotMARAP Project Interfaces
Scottish Medicines Consortium Scottish Antimicrobial rescribingGroup
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 rescribingGroup
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
Project Objective
To improve the quality of prescribing of antimicrobials by front line professionals across all healthcare settings in Scotland through improved systems and processes for collection, collation, analysis, correlation and reporting of antimicrobial utilisation and resistance data and improved education programmes for h ealth care professionals
DECISION MAKING WHEN PRESCRIBING AN ANTIMICROBIAL
HOW CAN WE INFORM THIS PROCESS, INTERVENE AND MEASURE ITS IMPACT
How We Use Antibiotics
1. Adjuvant Rx needed?2. Antibiotics needed?3. Options reviewed
a. On formulary? b. Restricted? c. Will it get job done?
“Scientific” inputsClinical trialsGuidelinesAntimicrobial spectrumLocal susceptibilitiesECONOMIC EVALUATIONS
“Non-scientific” inputsRecent experienceOpinions/behaviour of peersMarketing
Assess Patient
Make Diagnosis
Select Management Plan
SPECIFIC OBJECTIVESTO ESTABLISH A STANDARDISED MECHANISM BY WHICH WE CAN MEASURE AND COMMUNICATE TO FRONTLINE PRESCRIBERS THE CURRENT BASELINE SITUATION RELATED TO ANTIMICROBIAL USE AND RESISTANCEONCE WE HAVE THIS IN PLACE THE INFORMATION WILL SUPPORT THE LOCAL AND NATIONAL MONITORING OF PRESCRIBING AND RESISTANCE TRENDS OVER TIME SO TO INFORM AND CHANGE CLINICAL PRA CTICE IF NECESSARY, WITH THE AIM OF LONG TERM REDUCTION IN INAPPROPRIATE ANTIMICROBIAL USE DE VELOP SPECIFIC OBJECTIVES TO DEFINE CORE EDUCATIONAL AND POLICY INITIATIVES AND FOR THE INFECTION MANAGEMENT WORKSTREAM
PROJECT DELIVERABLESIHI methodology will be used to construct the core outcomes
Deliverable will be have timeframes, accountability, quality assurance and risk assessment
Broad consultation with service and key stakeholders regarding workstreams
ScotMARAP Project Structure
ScotMARAP Project Sponsor
ScotMARAP Project Board
Scottish Antimicrobial Prescribing Group
ScotMARAP Project Manager
ScotMARAP Project Assurance
Antimicrobial Management Team Sub-Group
ScotMARAP Project Support
Four Parallel Work Streams
Organisation and accountability : implementation of APP&P
Antimicrobial information: surveillance and consumption data as well as qualitative data (Point Prevalence Survey’s)
Antimicrobial education and guidance : Undergraduate and post-graduate medical education, multi-professional learning packages, National guidelines and policy review
Infection management : quality indicators, care bundles
Each work-stream will have a Lead and will manage this project
Overview of Information from NHS Boards Antimicrobial Formularies / Guidelines
• 10 NHS Boards – formularies cover primary & secondary care
• 1 NHS Board – formulary covers secondary care only
• 3 NHS Boards – use formularies from other NHS Boards
• Guidelines generally included in or linked to formularies
Overview of Information from NHS Boards Routine information on
antimicrobials• 4 NHS Boards – routine information provided to
healthcare profession
• 10 NHS Boards – no routine information provided to healthcare professionals
• 3 NHS Boards – routine information provided to the public
• 11 NHS Boards – no routine information provided to the public
Overview of Information from NHS Boards Reporting antimicrobial use in DDDs
• 3 NHS Boards – routine reporting in primary & secondary care
• 2 NHS Boards – routine reporting in primary care
• 3 NHS Boards – ad hoc reporting
• 6 NHS Boards – no reporting
• 14 NHS Boards – training for doctors
• 5 NHS Boards – training for other healthcare professionals (e.g. nurses, pharmacists)
• Training varies widely, mainly focused on secondary care and FY1 / FY2 doctors
Overview of Information from NHS Boards Antimicrobial Training for Healthcare Professionals
Overview of Information from NHS Boards Audit / point prevalence studies
• 2 NHS Boards – routine in primary care
• 2 NHS Boards – routine in secondary care
• 3 NHS Boards – ad hoc
• 7 NHS Boards – no audit / point prevalence studies
0
5
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0 12 24 36 48Months
Use
DDD/1
00 b
ed-d
ays
Alert AntibioticsAnsari et al, JAC 52 (5):842-848, 2003.
•First implemented August 2001
•By 2004 clear evidence that use was going back up
•Re-launched February 2006 with quarterly feedback via clinical groups
•Pharmacy initiated consults to support early switch from April 2006
COMPETENCY FRAMEWORK FOR ANTIBIOTICS
COMPETENCY – FOR EACH COMPETENCY STATE WHETHER YOU WISH FOR IT TO BE CATEGORISED AS APPLICATION OR AWARENESS
APPLICATION- skills that the prescriber should apply regularly in their work and be able to carry out with minimal supervisionAWARENESS- skills that the prescriber would not be expected to have acquired but sufficiently aware to seek help
COMPETENCY HEADINGS1. CONSIDER DIAGNOSIS 1.1-1.32. ASSESS SEVERITY 2.1-2.33. INITIATE INVESTIGATIONS 3.1-3.24.CONSIDER INFECTION CONTROL AND PUBLIC HEALTH 4.15.INITIATE AND REVIEW ANTIMICROBIAL PRESCRIBING 5.1-5.56. CONSIDER OTHER ASPECTS OF MANAGEMENT 6.1
http://pause-online.org.uk/
PRUDENT ANTIBIOTIC USER (PAUSE WEBSITE)
SUPPORTED BY BSAC, ESGAP, ESCMID
Postgraduate training in infection management for junior
doctors in Scotland
o Doctors on line Training (DOTS) Programme National Antibiotic Prescribing Project
(SNAPP) is funded by National Education Scotland.
o E-learning tool. Mandatory like Infection Control Programme
o Aimed at on line training for doctors in training at foundation level ; link between DOTS (https://www.nhsdots.org/nhsdots/dotsx/login.asp) and NES HAI portal (http://www.elib.scot.nhs.uk/portal//hai/Pages/index.a spx)
INFECTION MANAGMENT
SURGICAL PROPHYLAXIS INDICATORS
SNAP-CAP
C.difficle interventions- restriction of key antibiotics, bundles including antibiotic “review bundle”Others e.g care home prescribing
PRESCRIBING QUALITY INDICATORS
Surgical orthopaedic (arthroplasty) prophylaxis (single v 3 doses; prophylaxis < 24h) – data routinely collected from mandatory surveillance surgical site infection in Orthopaedic surgery.New SIGN guideline for limb arthroplasty 3-4 antibiotics in 24 hours. Previously single antibiotic.
RESPIRATORY QUINOLONE PRESCRIBING-MONTHLY DATA ON QUALITY OF USE PRESENTED AS RED, GREEN OR AMBER TO EACH WARD
ALERT ANTIBIOTICS
PRI and NW Single Dose Antibiotic Prophylaxis in Hip Procedures w37.1 and w 38.1 Jan 2006 - Jun 2007
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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act Plan
Study Do
Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement
Guide: A Practical Approach to Enhancing Organisational Performance.
San Francisco: Jossey‐Bass, 1996
Outcome Aims
Mortality: 15% reductionAdverse Events: 30% reductionVentilator Associated Pneumonia: 0 or 300 days betweenCentral Line Bloodstream Infection: 0 or 300 days betweenBlood Sugars w/in Range (ITU/HDU): 80% or > w/in rangeMRSA Bloodstream Infection: 30% reductionCrash Calls: 30% reductionHarm from Anti-coagulation: 50% reduction in ADEsSurgical Site Infections: 50% reduction
All processes at 95%
InterventionsCritical Care
E.g: ventilator acquired pneumonia bundleWard
E.g.: Outreach teamsMedicines management
E.g.: Medicines reconciliationTheatres
E.g.: Surgical pauseLeadership
E.g.: Safety walkarounds
What Is A Bundle?A structured way of improving the processes of care and patient outcomesA small, straightforward set of practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.The changes in a bundle are NOT new; they are well established best practices, but they are often not performed uniformly, making treatment unreliable, at times idiosyncratic.A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/WhatIsaBundle.htm
THE ANTIBIOTIC CARE BUNDLEAT INITIATION: DOCUMENT CLINICAL RATIONALE FOR
ANTIBIOTICAPPROPRIATE SPECIMENS FOR LABORATORYANTIBIOTIC SELECTED ACCORDING TO LOCAL POLICY AND RISK GROUPCONSIDER REMOVAL OF FOREIGN MATERIAL AND SURGICAL INTERVENTION
CONTINUATION: DAILY CONSIDERATION OF DE-ESCALATION, IV-ORAL SWITCH OR STOPTDM AS REQUIRE BY POLICY
Cooke FJ, Holmes A. IJAA 2007; 25-29.
Day 3 Antibiotic Plan: Clinical Diagnosis, Laboratory Results, Duration, Route
Pulcini et al, JAC, 2008
Day 3 Antibiotic Plan: Clinical Diagnosis, Laboratory Results, Duration, Route
Pulcini et al, JAC, in press
Completion of day-3 antibiotic plan
New Year
Christmas
Change FY1s
Stickers
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CONCLUSIONSSAPG IS NOW IN OPERATION WITH 4 KEY WORKSTREAMSOTHER AREAS CAN BE DEVELOPEDWE NEED YOUR ENGAGEMENTWE NEED YOUR SUPPORT WE NEED TO SHOW IMPROVEMENT IN PROCESS AND AMOUNT OF ANTIMICROBIAL USE AND ? OUTCOMESWE NEED TO IMPROVE SYSTEMS OF CARE
THANK [email protected]