What can we learn from point prevalence surveys? Mark Gilchrist Consultant Pharmacist Infectious Diseases

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1 What can we learn from point prevalence surveys? Mark Gilchrist Consultant Pharmacist Infectious Diseases Imperial College Healthcare NHS Trust

2 Outline Placing point prevalence in context Why undertake it? Point Prevalence in action What does it look like How to undertake it Is there a right way Limitations Understanding Point Prevalence value Impact on the ground for learning & change

3 Scenario The microbiology department notice a rise in the numbers of C.difficile cases This issue is raised at your antibiotic stewardship / management committee They ask for a report on antibiotic appropriateness within your hospital What could you include in your report? How would you obtain that data?

4 Antibiotic Stewardship The two objectives of antibiotic stewardship are: To ensure effective treatment for patients with bacterial infection To support professionals and patients to reduce unnecessary use and minimize collateral damage. Davey P, Brown E, Charani E, Fenelon L,Gould IM, Holmes A et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013;(4):CD

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6 Data monitoring Transparency Stewardship infrastructure Monitoring Feedback Visible data Usage Resistance Adverse events Adherence to guidelines

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8 The recommended key roles of the Antimicrobial Stewardship Management Team/Committee are to: Ensure that evidence-based local antimicrobial guidelines are in place and reviewed regularly Ensure regular auditing of the guidelines, antimicrobial stewardship practice and quality assurance measures Formally report a regular review of the organisation s retrospective antibiotic consumption data (especially highlighting the uses of broad-spectrum antibiotics such as cephalosporins, quinolones and carbapenems) Identify actions to address: non-compliance with local guidelines; general antimicrobial stewardship issues; and other prescribing issues.

9 The recommended key roles of the Antimicrobial Stewardship Management Team/Committee are to: Ensure that evidence-based local antimicrobial guidelines are in place and reviewed regularly Ensure regular auditing of the guidelines, antimicrobial stewardship practice and quality assurance measures Formally report a regular review of the organisation s retrospective antibiotic consumption data (especially highlighting the uses of broad-spectrum antibiotics such as cephalosporins, quinolones and carbapenems) Identify actions to address: non-compliance with local guidelines; general antimicrobial stewardship issues; and other prescribing issues.

10 Point Prevalence Definition Measure of the proportion of people in a population who have a disease or condition at a particular time/date It is a snap shot of the disease in time/ date Point prevalence can be described by the formula: Number of existing cases on a specific date Number of people in the population on this date

11 Antibiotic Point Prevalence Question 1 - What are you interested in measuring? Identified any areas of concern? Is there political pressure? General what antibiotics are prescribed in your organisation? Compliance to policy Duration Hospital A Medicine Surgery Intensive Care Paediatrics IV-PO Switch Surgical prophylaxis Ward A Ward A Ward A Ward A Ward B Ward B Ward B Ward B Allergy Status Combinations Ward C Ward C Ward C Ward C List for illustration and not exhaustive

12 Antibiotic Point Prevalence Question 1 - What are you interested in measuring? Specific duration of post operative antibiotics? Compliance to policy Duration Medicine Surgery Hospital A Intensive Care Paediatrics IV-PO Switch Surgical prophylaxis Ward A Ward A Ward A Ward A Ward B Ward B Ward B Ward B Allergy Status Combinations Ward C Ward C Ward C Ward C List for illustration and not exhaustive

13 Antibiotic Point Prevalence Question 2 Can you measure what your interested in Do you have a guideline or policy or recommendation?

14 Antibiotic Point Prevalence Question 3 How much resource do I have available? Who will undertake data collection/ collation of results? Logistics Do you have paper medication charts or electronic prescribing Question 4 How will the results be fed back? Who will see the results? What will the results look like? Do you have a champion to drive change? Clincal + Managerial structures?

15 Point Prevalence In action At a local level Pharmacists collected data once on any inpatient prescribed at least one systemic anti-infective (antibacterial,anti-fungal or anti-viral) on the day of the study providing the drug chart was available. Results are presented for the Trust as a whole and according to individual divisions Trust Infection Board reviews results + discusses with clinical directors, heads of nursing, lead pharmacists Joint action plan developed

16 Point Prevalence In action Restricted to Imperial College Healthcare NHS Trust

17 Restricted to Imperial College Healthcare NHS Trust

18 Landscape of Antibiotic Use

19 Positive influences + areas for improvement Indicator 1: Percentage of anti-infectives in line with policy or infection team approved Indicator 2: Percentage of anti-infectives with a documented indication in the medical notes or drug chart Indicator 3: Percentage of anti-infectives with a documented stop or review date on the drug chart

20 Positive influences + areas for improvement Indicator 1: Percentage of anti-infectives in line with policy or infection team approved Indicator 2: Percentage of anti-infectives with a documented indication in the medical notes or drug chart Indicator 3: Percentage of anti-infectives with a documented stop or review date on the drug chart

21 Positive influences + areas for improvement Indicator 1: Percentage of anti-infectives in line with policy or infection team approved Indicator 2: Percentage of anti-infectives with a documented indication in the medical notes or drug chart Indicator 3: Percentage of anti-infectives with a documented stop or review date on the drug chart

22 Point Prevalence In action Welsh perspective The prevalence of antibacterial usage has increased from 29% in 2009 to 31% in 2012 Maggie Heginbothom,Cardiff, UK

23 Point Prevalence In action Welsh perspective 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. Maggie Heginbothom,Cardiff, UK

24 Point Prevalence In action Welsh perspective 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 Maggie Heginbothom,Cardiff, UK

25 Point Prevalence In action Welsh perspective In the Wales 2012 PPS, 49% of all PipTazo usage was for RTI (Pneu & Bron) Maggie Heginbothom,Cardiff, UK

26 Point Prevalence In action Scottish perspective

27 Point Prevalence In action Scottish perspective Acute Hospitals 2011 Treatment of infection (n=4494) Respiratory infection (31.2%), SSTI (18.0%), UTI (13.8%) and GI (13.5%) Amoxicillin (15.6%), co-amoxiclav (10.0%), metronidazole (9.0%) Surgical prophylaxis (n=482) Orthopaedic (34.4%), GI tract (22.2%), obstetrics and gynaecology surgery (16.4%) Gentamicin (26.6%), co-amoxiclav (15.8%), flucloxacillin (15.1%) Medical prophylaxis (n=431) General medical prophylaxis (29.0%), UTI (20.6%), respiratory infection (16.2%) Co-trimoxazole (11.8%), trimethoprim (9.7%), ciprofloxacin (7.4%) Data from Health Protection Scotland/ Jacqui Sneddon, Glasgow, UK

28 Point Prevalence In action Scottish perspective Prescribing Indicators- Surgical Prophylaxis Hospital type Local SP Policy Number assessed Compliance (%) SP duration one day SP duration > 1 day Acute (n=482) Comparison with 2009 PPS Compliance with policy = 81.1% (all AM in combined volunteer hospitals where compliance could be assessed) SP 1 day = 19.7% SP > 1 day = 30.3% Data from Health Protection Scotland/ Jacqui Sneddon, Glasgow, UK

29 Point Prevalence In action European Perspective

30 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!

31 NAS-PPS Online System

32 Dashboards

33 Real Time Reporting

34 PPS in action Speciality Ward Ward Ward Ward Ward Ward

35 PPS in action Organisational Medicine Surgery Speciality Intensive Care Paediatrics Ward Ward Ward Ward Ward Ward Transplant

36 PPS in action National Hospital A Organisational Hospital B Hospital C Hospital D Medicine Surgery Intensive Care Paediatrics Transplant Speciality Ward Ward Ward Ward Ward Ward

37 Learning from PPS Baseline Allows interventions to be developed Benchmarking Monitor Development of indicators Creates a learning environement Improve Influence behaviour

38 Examples of PPS Interventions Anti-infective stickers Antimicrobial Management Code BHR Hospitals Used with permission from Dr Diane Ashiru-Oredope - Barking Havering and Redbridge University Hospitals NHS Trust Antimicrobial Stewardship Group June 2011

39 Examples of PPS Interventions Anti-infective stickers Dedicated antimicrobial medication charts Mid Essex Hospital Services NHS Trust Used with permission from Dr Louise Teare and Dr Diane Ashiru-Oredope.

40 Examples of PPS Interventions Anti-infective stickers Dedicated antimicrobial medication charts Restricted list of antibiotics Educational tools Bundles of care

41 Learning from PPS Baseline Monitor Awareness Education Agreement Engagement Logistics Improve Feedback CLINICAL MANAGERIAL ORGANISATION PATIENTS

42 Baseline Monitor Improve Awareness Feedback Education Agreement Engagement Logistics CLINICAL MANAGERIAL ORGANISATION PATIENTS In terms of the overall Antibiotic Stewardship Agenda. Point prevalence Delivers both audit & quality improvement Method of surveillance and epidemiology

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

44 Acknowledgements Jacqui Sneddon Maggie Heginbothom Imperial Pharmacy Team Alison Holmes BSAC Tracey Guise

45 What can we learn from point prevalence surveys? Mark Gilchrist Consultant Pharmacist Infectious Diseases Imperial College Healthcare NHS Trust