1. No category

Scottish Management of Antimicrobial
Resistance Action Plan (ScotMARAP)
Scottish Antimicrobial Prescribing Group (SAPG)
Dilip Nathwani
SIRN, Glasgow June 2008
“The future of humanity and microbes will
likely evolve as ……. episodes of our wits
versus their genes”
Jonathan Laderberg
Science 2000; 288: 281-93
S. aureus resistant to methicillin
%
100
80
60
40
20
0
Gram-negative resistance
%
100
80
60
40
20
0
1750
1825
1950 2000
1750
1825
1950 2000
Increased Incidence of Sepsis in General
Martin GS et al. N Engl J Med. 2003;348:1546-1554.
Resistance in the press…
Attributable costs of HAI
Stone et al AJIC 2005; 33(9): 501-509
Infection
Mean Cost
($ US)
SD
Minimum
Maximum
Surgical Site 25546
Infection
39875
1783
134602
BI
36441
37078
1822
107156
VAP
9969
2920
7904
12034
UTI
1006
503
650
1361
Socio-economic burden of
hospital-acquired infections (HAIs)
Incidence
7.8%
Acquired one or more
HAIs whilst
in hospital
Duration
of Stay
Overall costs
Specific costs
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%
Plowman R et al. Public Health Service and the London
School of Hygiene and Tropical Medicine 1999: 12.
What is Antimicrobial Stewardship?
z A marriage of infection control and antimicrobial
management
z Mandatory infection control compliance
z Selection of antimicrobials from each class of drugs that
does the least collateral damage
z Collateral damage issues include
- MRSA
- ESBLs
- C.difficile
- stable derepression
- MBLs and other carbapenemases
- VRE
z Appropriate de-escalation when culture results are available
Dellit TH et al Clin Infect Dis 2007; 44: 159-177
The Primary Goal of Antimicrobial
Stewardship
z 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
z The appropriate use of antimicrobials is an essential part
of patient safety
z The frequency of inappropriate antimicrobial use is often
used as a surrogate marker for avoidable impact on
antimicrobial resistance
z The combination of antimicrobial stewardship and
comprehensive infection control has been shown to limit
the emergence and transmission of antimicrobial
resistant bacteria
z A 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
20 Key recommendations within 6 domains
APP&P
z The core components of the current guidance are:
z a. Development of prescribing policies (SACAR
provides also generic template for antimicrobial
guidelines)
z b. Monitoring of compliance
z c. Structures and responsibilities
z d. Education & Training
z 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-disciplinary
and generic undergraduate and post-graduate training
related to antimicrobial prescribing.
3.
Define the minimum dataset requirements and standard
procedures for collecting information related to
antimicrobial resistance patterns.
4
Define the minimum dataset requirements and standard
procedures for collecting information related to
antimicrobial consumption and quality of prescribing at an
organisational level and/or ward specific level.
5.
Define the key areas for acute hospital policy and
recommendations for audit.
6.
Develop and define performance indicators that could be
used to assess or gauge performance related to
antimicrobial prescribing in hospitals
Document communicated by CMO to all NHS Boards
Establish standard structures and lines
of responsibility and accountability in
NHS Scotland across Boards
zChief Executives of Boards and Single
Delivery Units take overall responsibility
for APP&P within acute hospitals
zHAI and prescribing should be on NHS
boards Local Delivery Plan which has
replaced the Local Health Plan and PAF.
Medical Director
Chief Executive
Drugs &
Therapeutics
Committee
Infection Control
Manager
Risk Management
Committee
Antimicrobial
Management Team (AMT)
Clinical Governance
Committee
Dissemination & feedback
Infection Control
Committee
SpecialitySpeciality-based Pharmacy leads for
APP&P with responsibility for
antimicrobial prescribing
Prescribing support / feedback
Ward Based Clinical
Pharmacists
PRESCRIBER
Microbiologist /
Infectious Diseases
Physician
http://www.scotland.gov.uk
5. Define key areas for acute hospital
policy and recommendations for audit
z National collection of consumption data to evaluate use
trends e.g DANMAP
z Co-ordination by a “national clinical forum” which will
work with key agencies
z Facilitate audit of quantity and quality of antimicrobial
consumption by use of point prevalence “snapshot”
survey
z STRAMA
z GAAT
z ESAC
THE SCOTTISH MANAGEMENT
OF ANTIMICROBIAL
RESISTANCE ACTION PLAN
[ScotMARAP 2007]
SMC- ANTIMICROBIAL
PRESCRIBING GROUP
zThe 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).
STRAMA: SWEDISH STRATEGIC PROGRMAME FOR THE RATIONAL USE OF
ANTIMICROBIAL AGENTS AND SURVEILLANCE OF RESISTANCE
Long established,
centrally funded by
government
z Broad membership
z Central function with
network to local
STRAMA groups
z Use of local groups to
support implementation
of initiatives
z Use of expert study
groups to help interpret
studies and data
Broad range of activities
z
z
z
z
Prescribing
Resistance
Education
Point prevalence
studies
z Clinical trials
IMPACT OF STRAMA:
Lancet ID 2008; 8: 125-32.
z 1995-2004
z 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.
z Children and macrolide use most
pronounced decrease
z Hospital admission rates with
quinsy, sinusitis, mastoiditis low or
stable
z Resistance rate in PRP slow
increase from 4% to 6%.Other
resistance rates low
z ICU work ongoing from 1999- low
rates of resistance so far
ScotMARAP
Process & Timelines
z ScotMARAP pre-publication review issued to NHS
Scotland 7th December 2008
z Positive response from NHS Scotland – general sense
of support
z ScotMARAP business case submitted to SGHD 7th
February 2008
z Approved in principal – funding available from 1st April
2008
z SGHD announcement of launch of ScotMARAP project
by Cabinet Secretary 17th March 2008
ScotMARAP Project Interfaces
z SMC is Project Sponsor
z Scottish Antimicrobial Prescribing Group (SAPG) to be
formed to deliver recommendations within the APP&P
and ScotMARAP
z Scottish Antimicrobial Prescribing Group chaired by
Dilip Nathwani
z Partnership working with key stakeholders is imperative
for delivery – clearly defined roles, responsibilities and
accountabilities
SAPG
Health Protection
Scotland
Information Services
Division
Scottish Medicines Consortium
Scottish Antimicrobial rescribingGroup
NHS Education for
Scotland
NHS Quality
Improvement Scotland
Scottish Patient
Safety Alliance
Reference
Local
Diagnostic Diagnostic
Services
Services
NHS Boards Area Drug and
Therapeutics Committees
NHS Boards Antimicrobial Management
Team Sub-Group of Scottish
Antimicrobial Prescribing Group
NHS Boards Antimicrobial
Management Teams
Clinical Governance
Risk Management
Infection Control Team /
Manager
Prescribers
Project Objective
zTo 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” inputs
z Clinical trials
z Guidelines
z Antimicrobial spectrum
z Local susceptibilities
z ECONOMIC
EVALUATIONS
Assess Patient
Make Diagnosis
Select Management Plan
“Non-scientific” inputs
z Recent experience
z Opinions/behaviour of
peers
z Marketing
SPECIFIC OBJECTIVES
z TO ESTABLISH A STANDARDISED MECHANISM BY WHICH WE
CAN MEASURE AND COMMUNICATE TO FRONTLINE
PRESCRIBERS THE CURRENT BASELINE SITUATION
RELATED TO ANTIMICROBIAL USE AND RESISTANCE
z ONCE 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
z DE VELOP SPECIFIC OBJECTIVES TO DEFINE CORE
EDUCATIONAL AND POLICY INITIATIVES AND FOR THE
INFECTION MANAGEMENT WORKSTREAM
PROJECT DELIVERABLES
zIHI methodology will be used to construct
the core outcomes
zDeliverable will be have timeframes,
accountability, quality assurance and risk
assessment
zBroad consultation with service and key
stakeholders regarding workstreams
ScotMARAP Project
Structure
ScotMARAP
Project Sponsor
ScotMARAP
Project
Manager
ScotMARAP
Project
Support
ScotMARAP
Project Board
Scottish Antimicrobial
Prescribing Group
Antimicrobial Management
Team Sub-Group
ScotMARAP
Project
Assurance
STREAM 1
Organisation & accountability
Four Parallel Work Streams
z Organisation and accountability : implementation
of APP&P
z Antimicrobial information: surveillance and
consumption data as well as qualitative data
(Point Prevalence Survey’s)
z Antimicrobial education and guidance :
Undergraduate and post-graduate medical
education, multi-professional learning packages,
National guidelines and policy review
z Infection management : quality indicators, care
bundles
¾ 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
Overview of Information from NHS Boards
Antimicrobial Training for Healthcare Professionals
• 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
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
STREAM 2
ANTIMICROBIAL
RESISTANCE SURVEILLANCE
AND CONSUMPTION
Alert Antibiotics
Ansari et al, JAC 52 (5):842-848, 2003.
Use DDD/100 bed-days
10
5
0
0
12
24
Months
36
48
•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
STREAM 3
ANRIMICROBIAL
EDUCATION & GUIDANCE
COMPETENCY FRAMEWORK
FOR ANTIBIOTICS
z COMPETENCY – FOR EACH COMPETENCY
STATE WHETHER YOU WISH FOR IT TO BE
CATEGORISED AS APPLICATION OR
AWARENESS
z APPLICATION- skills that the prescriber should
apply regularly in their work and be able to carry
out with minimal supervision
z AWARENESS- skills that the prescriber would
not be expected to have acquired but sufficiently
aware to seek help
COMPETENCY HEADINGS
z1. CONSIDER DIAGNOSIS 1.1-1.3
z2. ASSESS SEVERITY 2.1-2.3
z3. INITIATE INVESTIGATIONS 3.1-3.2
z4.CONSIDER INFECTION CONTROL
AND PUBLIC HEALTH 4.1
z5.INITIATE AND REVIEW
ANTIMICROBIAL PRESCRIBING 5.1-5.5
z6. 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)
STREAM 4
INFECTION MANAGEMENT
INFECTION MANAGMENT
zSURGICAL PROPHYLAXIS INDICATORS
zSNAP-CAP
zC.difficle interventions- restriction of key
antibiotics, bundles including antibiotic
“review bundle”
zOthers e.g care home prescribing
PRESCRIBING QUALITY
INDICATORS
z 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.
z RESPIRATORY QUINOLONE PRESCRIBINGMONTHLY DATA ON QUALITY OF USE PRESENTED
AS RED, GREEN OR AMBER TO EACH WARD
z ALERT ANTIBIOTICS
PRI and NW Single Dose Antibiotic Prophylaxis in Hip Procedures w37.1 and w 38.1 Jan 2006 - Jun 2007
100
90
80
70
60
%
PRI
NW
50
40
30
20
10
0
Jan-06
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Month
Nov
Dec
Jan-07
Feb
Mar
Apr
May
Jun
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
Study
Plan
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
What?
Scottish Patient Safety
Programme
Outcome Aims
z
z
z
z
z
z
z
z
z
Mortality: 15% reduction
Adverse Events: 30% reduction
Ventilator Associated Pneumonia: 0 or 300 days between
Central Line Bloodstream Infection: 0 or 300 days between
Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range
MRSA Bloodstream Infection: 30% reduction
Crash Calls: 30% reduction
Harm from Anti-coagulation: 50% reduction in ADEs
Surgical Site Infections: 50% reduction
All processes at 95%
Interventions
z Critical Care
z E.g: ventilator acquired pneumonia bundle
z Ward
z E.g.: Outreach teams
z Medicines management
z E.g.: Medicines reconciliation
z Theatres
z E.g.: Surgical pause
z Leadership
z E.g.: Safety walkarounds
What Is A Bundle?
z A structured way of improving the processes of care and
patient outcomes
z A small, straightforward set of practices — generally
three to five — that, when performed collectively and
reliably, have been proven to improve patient outcomes.
z 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.
z 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 BUNDLE
AT INITIATION: DOCUMENT CLINICAL RATIONALE FOR
ANTIBIOTIC
z APPROPRIATE SPECIMENS FOR LABORATORY
z ANTIBIOTIC SELECTED ACCORDING TO LOCAL
POLICY AND RISK GROUP
z CONSIDER REMOVAL OF FOREIGN MATERIAL AND
SURGICAL INTERVENTION
CONTINUATION:
™ DAILY CONSIDERATION OF DE-ESCALATION, IVORAL SWITCH OR STOP
™ TDM 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
Completion of day-3 antibiotic plan
100%
New SpR & FY1s
70%
60%
50%
Christmas
Stickers
New Year
Change FY1s
40%
30%
Dates
Pulcini et al, JAC, in press
an
29
th
J
an
th
J
15
th
De
c
27
th
De
c
11
th
No
v
27
No
v
6th
ct
rd
O
23
th
Oc
t
10
th
Se
p
25
th
Se
p
12
th
Au
g
28
th
Au
g
14
th
J
uly
20%
10%
0%
09
Percentage
90%
80%
CAP
Bundle Compliance
CAP
Antibiotics During First 4hrs
CONCLUSIONS
z SAPG IS NOW IN OPERATION WITH 4 KEY
WORKSTREAMS
z OTHER AREAS CAN BE DEVELOPED
z WE NEED YOUR ENGAGEMENT
z WE NEED YOUR SUPPORT
z WE NEED TO SHOW IMPROVEMENT IN
PROCESS AND AMOUNT OF ANTIMICROBIAL
USE AND ? OUTCOMES
z WE NEED TO IMPROVE SYSTEMS OF CARE
THANK YOU
[email protected]