SUMMARY REPORT Quality and Safety Committee ABM University Health Board Meeting On 20 TH OCTOBER 2016 Subject Prepared by Approved & Presented by Purpose Big Fight Campaign AGENDA ITEM: 2.2 Debra Woolley Specialist Antimicrobial Prescribing Adviser and Janice Price Infection Control and Prevention Nurse Judith Vincent Clinical Director Pharmacy and Medicines Management The purpose of this report is it to update the committee on the Big Fight Campaign, a project funded by the Welsh Government, which formally commenced in January 2016 Corporate Objectives Healthier Communities Excellent Patient Outcomes & Experiences Sustainable & Accessible Service Strong Partnerships Decision Approval Information Other A fully Engaged & Skilled Workforce x Effective Governance X X X X X X Executive Summary The Big Fight Campaign aims to improve patient outcomes and minimise the potential risks for increasing antibiotic resistance and Clostridum difficile (C. difficile) infection through the development and implementation of a multidisciplinary programme, applying the principles of prudent healthcare to progress Antimicrobial Stewardship in Primary Care. This paper highlights: That ABM has amongst the highest antibiotic use and C.difficle rates in Wales A range of interventions taking place in primary care Outcome measures Promising early data demonstrating reductions in antibiotic prescribing and variation Targeted activity aimed at reducing the incidence of C.difficle Key Recommendations The Quality and Safety Committee are asked to note The dedicated campaign approach to antimicrobial stewardship, which aims to support cultural change through engagement with key stakeholders, drive forward improvements which embed changes into everyday life The progress to date in delivery of the key outcome measures for the campaign The Conference on the 9 th November antimicrobials Stewardship A partnership to tackle Antimicrobial Resistance. Next Steps Quarterly reports to Welsh Government are required. A progress report to be provided in six months time to the Quality and Safety Committee
MAIN REPORT Quality and Safety ABM University Health Board Meeting On 20 TH OCTOBER 2016 AGENDA ITEM: 2.2 Subject Prepared by Approved & Presented by Big Fight Campaign Debra Woolley Specialist Antimicrobial Prescribing Adviser and Janice Price Infection Control and Prevention Nurse Judith Vincent Clinical Director Pharmacy and Medicines Management 1. Purpose The purpose of this report is it to share the progress and early outcomes from the Big Fight Campaign, a project funded by the Welsh Government, which formally commenced in January 2016 following appointment of a dedicated team. 2. Situation and Key Issues Antimicrobial resistance (AMR) is one of the greatest health threats to humans and animals. The problem has been building over decades so that today many common and life-threatening infections are becoming difficult or even impossible to treat. The effectiveness of many invasive medical procedures and treatments routinely undertaken now such as organ transplantation and chemotherapy would be at considerable risk without antibiotics being available. The seriousness of this threat is recognised by the UK Government in its 2015 National Risk Register of Civil Emergencies. The scale of the threat of AMR and the need for action was set out in the UK Five Year Antimicrobial Resistance Strategy 2013-18. This outlined the actions being taken at UK level to address the key challenges in slowing the development and spread of AMR by improving knowledge and understanding; conserving the effectiveness of existing treatments; and stimulating the development of new antibiotics, diagnostics and therapies. The Antimicrobial Resistance Plan for Wales has set out a target for Health Bodies of a 50% reduction in inappropriate antibiotic use by 2020, thus a multifaceted approach to the delivery of antimicrobial stewardship is essential. Despite significant work to improve antimicrobial prescribing over a number of years, ABM continues to demonstrate the highest rate of prescribing of antibacterial agents and the second highest incidence of C.Difficle in Wales. Total antibacterial items per 1,000 STAR Pus Quarter ending March 2016 (England & Wales)
Number and rate of C. difficile, bacteraemia per 100,000 population by health board, Apr - Aug 16 Health Board/ NHS Trust Number of C. difficile Rate of C. difficile /100,000 population Abertawe Bro Morgannwg 87 39.50 Aneurin Bevan 61 25.01 Betsi Cadwaladr 134 46.03 Cardiff and Vale 70 34.45 Cwm Taf 22 17.69 Hywel Dda 53 32.99 Powys 10 17.99 Velindre 1 N/A All Wales 438 33.72 The Big Fight Campaign was introduced with the primary aim of intensifying the approach to improve patient outcomes and minimise the potential risks of increasing antibiotic resistance and C. difficile infection through the development and implementation of a multidisciplinary programme.
Key outcome measures for the Campaign for the next six months are: A reduction in overall antibacterial prescribing in primary care across ABMU HB by at least 1 percentage point better than the Welsh national average trend (December quarter 2016 vs December quarter 2015) A reduction in variation of overall antibacterial prescribing in primary care across ABMU HB between December quarter 2016 vs December quarter 2015 A reduction in overall C. difficile infection cases in non-inpatients across ABMU HB by at least 1 percentage point better than the Welsh national average trend (December quarter 2016 vs December quarter 2015) Additional outcome measures: 90% of key stakeholders (including care homes staff, GP practice staff and community pharmacy staff as a minimum) surveyed understand the importance of and feel well informed and supported regarding antimicrobial stewardship by September 2017 90% of key stakeholders (including care homes staff, GP practice staff and community pharmacy staff as a minimum) surveyed have a good working knowledge of prevention and optimal management of C. difficile infection, reinfection and relapse by September 2017 A reduction in inappropriate GP appointments for self limiting viral infections by March 2018 3. Actions and Progress to Date The Big Fight Campaign is focused on changing the culture around antimicrobial use by implementing interventions to improve the quality and quantity of antibiotic prescribing, thereby improving patient outcomes and minimising the potential risks of increasing antibiotic resistance, antibiotic related side effects and C. difficile infection Key interventions in primary care include: Engagement with key stakeholders Promoting clinical leadership to implement antimicrobial stewardship in practices Introduction of non-clinical local Campaign Managers in practices Practice based improvement plans, clinical audit and patient engagement activities linked to the Prescribing Management Scheme Prescribing visits targeted at 20% of highest prescribing practices Toolkit to support cluster based pharmacists and technicians to support antimicrobial stewardship activities. The launch of a Big Fight Intranet site with tools, resources and links Provision of resources to support patient education and co-production. Analysis and dissemination of GP level prescribing data for national prescribing indicators Inclusion of Antimicrobial Stewardship in Cluster Plans Engagement/education with care homes
Percentage Annual Change (Items) 3.1 Prescribing Data Analysis Variation in prescribing trends still exists between ABMU and other Health Boards which cannot be explained by differences in local guidelines and formulary choices. This will only be addressed by a sustained focus on the prudent prescribing of antibiotics. This will include a focus on the appropriate choice, dose and duration of the antibiotics used. It is anticipated that the full impact of these initial interventions will be seen following the peak period for antibiotic prescribing (November 2016- March 2017) robust data for which will not be available until June 2017. Underlying prescribing trends show ABMU Health Board s antibiotic prescribing reduced more than the national rate in the year up to June 2016 (see table below). Health Board Jun-15 Sep-15 Dec-15 Mar-16 Jun-16 Items Per Items Per Items Per 1000 Items Per 1000 1000 STAR- 1000 STAR- STAR-PU(13) STAR-PU(13) PU(13) PU(13) Items Per 1000 STAR- PU(13) % change June 15 - June 16 Abertawe Bro Morgannwg Uni 403.08 320.44 369.20 392.67 325.99-19.13 Aneurin Bevan 375.14 293.62 344.77 368.85 310.28-17.29 Betsi Cadwaladr Uni 382.77 296.72 342.05 359.18 309.81-19.06 Cardiff And Vale Uni 344.18 275.85 321.11 330.84 281.68-18.16 Cwm Taf 393.27 320.10 366.29 377.75 325.52-17.23 Hywel Dda 389.09 297.06 353.60 371.58 309.11-20.56 National-GP 377.33 296.94 344.86 362.57 307.56-18.49 Powys Teaching 308.10 245.65 278.94 290.79 261.59-15.10 An alternative analysis looking at a 12 month rolling trend also demonstrates a narrowing gap between the Health Board s percentage change in prescribed items, compared with Wales. Percentage annual change in antibiotic items period (year on year) 3.00 2.00 1.00 - (1.00) (2.00) (3.00) (4.00) (5.00) (6.00) (7.00) Welsh Delivery Agreement Target Month ABMU Wales The box and whisker plot below demonstrates that both the overall variation in prescribing between practices across the Health Board and the difference between the highest and lowest prescribing practices has reduced between June 2015 and June 2016 quarters.
Difference in antibiotic prescribing between the highest prescribing practice and lowest prescribing practice In conclusion early data suggests the Health Board is making good progress towards meeting the Delivery Agreement target of a 1 percentage point better than the Welsh national average trend (December 2016 vs December 2015) and in reducing variation in practice. However, these results must be viewed with caution and closely monitored. 3.2 Clostridium Difficile Clostridium difficile Acquired Disease (CDAD) remains an unpleasant, and potentially severe or fatal infection that occurs mainly in elderly and other vulnerable patient groups especially those who have been exposed to antibiotic treatment. Progress is being made against the Delivery Agreement to reduce the number of cases of non-inpatient CDI. Number of non-inpatient CDI cases Period ABMU Wales April 14 - August 14 29.00 205.00 April 15 - August 15 31.00 219.00 April 16 - August 16 22.00 183.00 This reduction can be explained in part a greater awareness amongst GPs of factors contributing to CDi and will be underpinned by a reduction in antibiotic prescribing in particular cephalosporins, quinolones, and the broad spectrum antibiotic, coamoxiclav, known to have the greatest association with CDi. The primary aim of this element of the Big Fight Campaign is to reduce the risk of patients acquiring their first episode of CDi. Further improvement on the current position is also likely to require a greater understanding of the individual causes of CDi cases and any learnings shared A tool has been developed for use by GPs to facilitate an event analysis to be undertaken when patients are found to have CDi in primary care. Plans exist for learning to be captured and shared across primary care using the Health Board s Datix system. GPs are receiving letters from the Infection Prevention and Control Team (IPCT) when their patients are found to have CDI. The letters include advice on flagging patients notes, management of the infection, and actions to prevent relapse and reinfection. The receipt of the letters is being audited; 100% had received the letters at the last audit undertaken in August. The weight of evidence from systematic reviews/meta-analyses supports a positive association between acid suppressant medicines and CDi. However, a causal link has not been proven. There is plausible explanation and some evidence of a dose
response relationship with the association being stronger for Proton Pump Inhibitors (PPIs) than histamine H2 receptor antagonists (H2RAs). Data suggest that PPI therapy may double risk of CDi. Across primary care PPIs account for almost 6% of all prescription. Health Board Abertawe Bro Morgannwg Uni - GP 5.36% Aneurin Bevan - GP 5.41% Betsi Cadwaladr Uni - GP 6.00% Cardiff And Vale Uni - GP 5.53% Cwm Taf - GP 5.48% Hywel Dda - GP 5.56% Powys Teaching - GP 5.86% Percentage of prescription items prescribed for a PPI PPI prescribing rates continue to grow by 3% nationally. A range of options is currently being discussed to aid in the management of PPI prescribing including whether it should be part of the scope of the Big Fight Campaign. 3.3 Care Home Sector The Infection Prevention and Control Nurse (IPCN) has developed a training package for care homes. The primary aim of the training is to improve staff knowledge of: the prevention and management of CDi; the risks of inappropriate prescribing of antimicrobials; and the risks associated with antimicrobial resistance. The objective is to visit all care homes within the first year of the campaign. To the end of August, the presentation has been delivered to 53% of care homes. Feedback has been positive; a questionnaire is given after the training and learning is apparent. Using a Plan, Do, Study and Act (PDSA) improvement methodology, the training package has and will continue to evolve. Quarter 1: (Apr Jun 2016) Training for Care Homes Quarter 2: (Jul - Sep 2016) Quarter 3: (Oct - Dec 2016) Quarter 4: (Jan Mar 2017) Target 25% 50% 75% 100% Current position 31% 53% - - An information pack to support the training session is given to care home staff for reference and sharing. A decision aid for the diagnosis and management of urinary tract infection (UTI) in older people in care homes has been developed to facilitate the correct diagnosis of UTI, thereby reducing unnecessary antimicrobial prescribing. Visits to care homes have strengthened relationships between the care home staff and the infection prevention and control team (IPCT), allowing ease of access to specialist infection prevention and control advice as necessary. Training sessions for nurses in primary care have commenced; these reflect the information shared with care home staff and promote good antimicrobial stewardship.
Posters and leaflets are to be developed for key stakeholders (care home staff, staff in GP practices and primary care) to further raise awareness of the risks of inappropriate antimicrobial use and of the optimal management of CDI - March 2017. A system is to be developed to analyse the learning in care homes following training - March 2017. 4. Further Activity The Big Fight s strategic aim is to embed Antimicrobial Stewardship across the Health Board. This work will be accelerated further in November following European Antibiotic Awareness Day and the ABMU HB Big Fight Conference, Antimicrobial Stewardship A Partnership to Tackle Antimicrobial Resistance, which aims to bring together patients, carers, educators, third sector partners and a range of health and social care professionals, to discuss issues and explore solutions to take forward that will change the beliefs and attitudes that are leading to inappropriate and ineffective antibiotic use. 5. Recommendations The Quality and Safety Committee are asked to note: The dedicated campaign approach to antimicrobial stewardship, which aims to support cultural change through engagement with key stakeholders, drive forward improvements which embed changes into everyday life. The progress to date in delivery of the key outcome measures for the campaign The Conference on 9 th November antimicrobials Stewardship A partnership to tackle Antimicrobial Resistance.