Surveillance of antimicrobials - establishing a national point prevalence system. Maggie Heginbothom Public Health Wales

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1 Surveillance of antimicrobials - establishing a national point prevalence system Maggie Heginbothom Public Health Wales

2 Antimicrobial Stewardship timicrobial-stewardship-start-smart-then-focus

3 Antimicrobial Stewardship Several of the components of best practice can be audited as part of the Trust-wide six-monthly or annual point prevalence studies (PPS). There may be a need to monitor some aspects more frequently. START SMART THEN FOCUS Monitor Feedback GET SMART Make visible data Usage Resistance Adverse events Adherence to guidelines

4 European Society of Antimicrobial Consumption (ESAC)


6 Wales 2012 Antimicrobial PPS In 2012 PPS in Wales: 6951 patients surveyed 69% No AB Rx 31% Prevalence of AB usage Of the 31% receiving AB Rx 51% Treatment of CAI (A) 28% Treatment of HAI (B) 7.6% Surgical prophylaxis (C) 6.9% Medical prophylaxis (D) 2.9% Indication Unknown (U) 2.8% Mixed & Other

7 Prevalence of Antibacterial Usage The prevalence of antibacterial usage has increased from 29% in 2009 to 31% in 2012

8 Number of antibacterial agents Off formulary prescribing often due to lack of guidelines

9 Duration of treatment The proportion of antibacterial prescribed for the treatment of infection for >7days duration ranged from 22% in the community hospitals to 7% in a DGH.

10 Top 10 Antibacterials by Route Antibacterial Proportion Scripts Rank Antibacterial Proportion Scripts PipTazo (P) Piperacillin/Tazo (P) 9.4 Co-amoxiclav (O) Co-amoxiclav (O) 9.3 Co-amoxiclav (P) Co-amoxiclav (P) 7.2 Metronidazole (P) Metronidazole (P) 6.4 Trimethoprim (O) Trimethoprim (O) 5.7 Clarithromycin (O) Amoxicillin (O) 4.2 Metronidazole (O) Clarithromycin (O) 4.2 Amoxicillin (O) Ciprofloxacin (O) 3.9 Cefuroxime (P) Metronidazole (O) 3.9 Flucloxacillin (P) Doxycycline (O) 3.8 Top Ten % Top Ten % In the Wales 2012 PPS, 25% of all antibacterials prescribed were BLI

11 Diagnosis Piperacillin/tazobactam In the Wales 2012 PPS, 49% of all PipTazo usage was for RTI (Pneu & Bron)

12 Treatment of CA-RTI CURB-65 score Mortality risk 0 0.7% 1 3.2% 2 3% 3 17% % 5 57% The 2012 showed an increase in BLI prescriptions - no risk stratification?

13 Diagnosis - Cefuroxime 65% of cefuroxime usage was surgical prophylaxis (37% = Proph SBJ)

14 Duration Surgical Prophylaxis In the Wales 2012 PPS, 42% of surgical prophylaxis was for >24 hours

15 Quality Improvement The Scottish Antimicrobial prescribing Group (SAPG) used ESAC PPS data as the foundation for implementation of a number of measures for improvement in antibiotic prescribing.

16 Prescribing Indicators Establishing a culture of measurement and clinician feedback is an effective stewardship strategy.

17 How does it work in practice? Point Prevalence Surveys are a recognised, established method of auditing antimicrobial usage, compliance to guidelines and best practice. BUT Data validation, processing, analysis, and reporting is a time consuming process requiring much resource... A web-based system is needed!

18 NAS-PPS Online System

19 Features of the System Web Application from Hosted on N3 Server to enable access to all UK centres Easy input of patients from either hard copy forms or electronic entry via IPad or similar. Dashboard for open and closed surveys. Timely reporting at end of survey close. Ability to compare hospitals to trusts / national. Ability to view and compare data by speciality.

20 Requirements for data Any patient identifiable data can only be shared for direct care of the patient with consent Pseudonymised data, that does not have access to the key for reversibility, is shareable without consent Chapter 6 of the review describes in detail the controls necessary: 1. anonymous but with a low residual risk of reidentification In this case the data can be freely published with no explicit patient consent. 2. anonymous but with a high risk of re-identification In this case the data can only be shared with another environment covered by the same contractual arrangements and confirmed data-stewardship arrangements. It is also recommended we obtain patient consent EVEN THOUGH THE DATA IS ANONYMISED. 3. identifiable In this case data can only be shared if there is a legal basis for the processing AND patient consent is required. Caldicott Outline

21 Multiple User Levels BSAC Trust Hospital Ward 4 different levels of user Local responsibility and accountability Each Trust / Hospital / Ward has a designated owner

22 Captured Survey Data Captured Data is owned locally Evaluated and approved at Hospital level Agreed and Published by Trust / Health Board

23 Dashboards

24 Approval - Supervisor Level Data filterable by multiple fields Top line information consistently available to ensure the user knows exactly where they are in the system Display of data that is easy to read Easy to identify outliers, with the ability to single out their record across all of the data set to quickly edit/correct Customised layouts for different types of information collected

25 Real Time Reporting

26 Timeline for development Final Initial development Beta Test Recruiting Post test development Release December 2013 First Quarter 2014 April onwards Late 2014 We are recruiting sites for beta testing now If you are interested please visit us at the BSAC stand!

27 Sir William Thomson, Lord Kelvin ( Mathematician & Physicist) Quotations "To measure is to know. "If you can not measure it, you can not improve it.

28 Thanks to: Billy Malcolm, NHS National Services Scotland Mark Gilchrist, Imperial, London Debbie Lancaster, Dave Russell and Gurpal Virdee Pharma Mix