18th May 2022 Poster Competition Group G QI in Progress Medicines Management
Prescribe. Review. Now!
an assessment of adequate PRN analgesia and associated laxative prescribing using HEPMA (Hospital Electronic Prescribing and Medicines Administration)
Dr Matthew McMillan & Dr Alexandra Burgess
Introduction & Aim
HEPMA (Hospital Electronic Prescribing and Medicines Administration), has recently been introduced to our District General Hospital. It was noted that patients’ analgesia use was poorly reviewed on a regular basis, and there is no way to notify a prescriber if patients are regularly accessing PRN (as-required) analgesia. Previously All-Wales paper drug charts were used, which had a distinct PRN section. Aim: To assess how well prescribers identify a patients’ use of PRN analgesia, and the necessary escalation of the WHO analgesic ladder and whether laxatives were prescribed with opioid analgesia, due to the increased risk of delirium in older adults.
Method & Interventions 3 data collection cycles were carried out for all medical inpatients at Singleton General Hospital between February and April 2022. Medication was reviewed using HEPMA, to determine: 1) PRN analgesia prescribed? 2) Is the patient accessing it >3 times in a 24hr period? 3) Con-current laxatives prescribed for those on opioid based analgesia or any patient >65years old? Between each data collection cycle, a new intervention was implemented.
Comparison of recommended changes in prescribing for Cycle 1
Intervention 1: Posters were designed and placed on each medical ward as a cue to a review and change analgesia when appropriate “Prescribe. Review. Now!”. This poster was circulated electronically to all the medical doctors in the hospital. Intervention 2: A presentation on collected data, the WHO analgesic ladder and laxative prescribing was created, and circulated to all prescribers.
Analgesia Both
31% 37%
Laxative None 13%
Results Cycle 1
19%
Figure 1
• 167 inpatients surveyed, 58% female, 42% male, mean age of 78 (±13.4). 37% (n=62) had appropriate prescriptions of both analgesia and laxatives. 31% (n=52) inadequate analgesia, 19% (n=32) inadequate laxatives, and 13% (n=21) inadequate analgesia and laxatives. (Figure 1)
Comparison of recommended changes in prescribing for Cycle 2
19%
Cycle 2
Analgesia
• 159 inpatients surveyed, 65% female, 35% male, mean age of 77 (± 15.7). 58% (n=92) had appropriate prescriptions. 19% (n=30) inadequate analgesia, 15% (n=24) inadequate laxatives, and 8% (n=13) inadequate analgesia and laxative. (Figure 2)
8%
Both Laxative
58%
None 15%
Figure 2
Cycle 3
• 157 inpatients surveyed, 62% female, 38% male, mean age of 78 (± 15.7). 68% (n=107) had appropriate prescriptions. 12% (n=19) inadequate analgesia, 14% (n=22) inadequate laxatives, and 6% (n=9) inadequate analgesia and laxatives. (Figure 3)
Comparison of recommended changes in prescribing for Cycle 3
12%
6%
Analgesia
Improvement
Both 14%
None
Recommended Change Outcome None
Analgesia
Laxatives
Both
Cycle 1 (n=167)
37% (n=62)
31% (n=52)
19% (n=32)
13% (n=21)
Cycle 2 (n=159)
58% (n=92)
19% (n=30)
15% (n=30)
8% (n=13)
Cycle 3 (n=157)
68% (n=107)
12% (n=19)
14% (n=22)
6% (n=9)
31%
19%
5%
7%
Improvement
Laxative
Conclusion Adequate analgesia and laxative prescriptions on HEPMA improved by a total of 31% (p<0.005), over 3 cycles and 2 interventions. After each intervention there was a significant statistical improvement in prescribing analgesia and laxatives. However, there is still room for further improvement, especially in ensuring adequate laxative cover is prescribed for all patients either >65 years old, or those on opioid-based analgesia. Visual reminders on wards of regularly checking PRN medication showed to be an effective intervention to improve patient care and safety.
68%
Figure 3
Improving documentation of VTE prophylaxis prescriptions in surgical ward round notes Dr Katie Prior & Dr Sarah Burge, Royal United Hospital Bath
Scan for references
Introduction •
Hospital admission and surgical intervention are well-documented risk factors for thromboembolic events1.
•
Systems exist to ensure patients are prescribed appropriate venous thromboembolism (VTE) prophylaxis on admission. However, surgical patients may require alteration of their VTE prophylaxis.
•
Without ongoing measures to monitor VTE prophylaxis, surgical patients may be at increased risk of omitted VTE prophylaxis.
•
Local guidelines recommend that if VTE prophylaxis is withheld, this should be documented2.
•
Guidance given to new foundation doctors suggests that VTE prophylaxis status should be a routine part of ward round documentation3. However, this is rarely monitored.
Plan
Do Planned to target our intervention towards general surgical F1s as they are most commonly responsible for ward round documentation
Message sent to F1s on general surgery about the importance of checking VTE prescriptions and encouraging documentation
We found peer to peer intervention resulted in a mild improvement in VTE documentation. For PDSA cycle 2 planned to extend our intervention to registrars
Examined ward round notes 1 and 3 weeks after the intervention, and recorded how many times VTE mentioned. This was compared with baseline data
Act
Study
Aims To audit and improve documentation of VTE prophylaxis in surgical ward round notes.
Results
Methodology
•
PDSA cycle 1: Intervention targeted at F1s working in general surgery, highlighting the importance of checking and documenting VTE prophylaxis when preparing ward round notes. PDSA cycle 2: Intervention extended to registrars. Intervention involved both written and verbal explanations of our project to the target group. Post-intervention data was collected one and three weeks after each cycle.
Workload
↑ patients
Busy seniors Inexperienced juniors Insufficient PCs Outlying wards
Environment
Fast pace No feedback on quality of documentation
Poor VTE documentation
Feedback
Figure 1: Fishbone diagram to identify root causes of poor VTE documentation
Baseline data Collection 1
Baseline data collection 2
Intervention 1
• • • • • % of notes with documented VTE prophylaxis
Baseline data: We examined ward round entries on 3 wards and recorded how many times VTE prophylaxis was documented over a period of seven days.
Clinicians
Figure 1: PDSA cycle 1
Baseline data showed poor documentation of VTE amongst surgical specialties. Amongst medical specialities, VTE was documented in at least 75% of notes samples. General surgery had the lowest incidence of VTE documentation. After PDSA cycle 1, there was a moderate improvement in VTE documentation. This varied greatly between individual doctors. Specialities with no intervention saw no change in VTE documentation. Results following PDSA cycle 2 in progress. Baseline data week 1 Baseline data week 2
100%
40%
75%
30%
50%
20%
25%
10%
0%
0% General surgery
Other Medical surgical specialities specialities
Figure 2: Baseline data. Percentage of notes where VTE prophylaxis is documented in ward round notes at least once in the last 7 days per speciality. Different colours indicate different weeks baseline data collected.
Data collection week 1
Data collection week 3
PDSA cycle 1: intervention targeted at F1s
Baseline data range for general surgery
1 week post 3 weeks post intervention intervention Figure 3: Percentage of general surgical notes where VTE prophylaxis is documented in ward round notes at least once in the last 7 following intervention 1.
Intervention 2
Data collection week 1
PDSA cycle 2: intervention targeted at registrars
LIPID MANAGMENT FOR SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE IN TORBAY HOSPITAL Authors: Merson S1, Nakou D2
Introduction Aim
Hypercholesteraemia refers to the elevated levels of low-density lipoprotein (LDL) >3mmol/L or non -high- density lipoprotein (non-HDL) >4mmol/L. It is usually the result of unhealthy lifestyle choices. It can also be due to faulty genes, known as familial hypercholesteraemia, something to be considered when total cholesterol >7.5mmol/L or LDL> 4.9mmol/L. Hypercholesteraemia is an important risk factor for atherosclerosis and subsequently for cardiovascular disease (CVD).1
This project aims to improve the care of the patients who are admitted on Coronary care unit (CCU) and Cardiac pain unit (CPU) in Torbay hospital with acute coronary syndrome (ACS) in line with national guidance for lipid management in secondary prevention of CVD.
Methods Act: March 2022 Education
Plan: February 2022
• Present findings and actions at Cardiology Departmental meeting- Consensus opinion was that the management of secondary prevention in CVD should be the remit of GPs. • Cardiology nurses as above and write in on improved blood tests recording sheet. • Emergency department and Medical receiving unit to request lipid profile blood test for all ACS patients. • Junior doctors to add instructions for GP in the care plan summary (CPS).
• •
Do: Is the following happening?
Study: Results
Current strength: • 94% (30/32) were prescribed a high intensity statin (66%), or lower dose statin or ezetimibe with appropriate rational (28% ) . Areas for improvement: • 34% (11/32) had repeat lipid profile. • 45% (5/11) achieved reduction of non-HDL>40% from baseline. • 17% (1/6) with reduction of non-HDL <40% GP was advised to consider adding ezetimibe 10mg daily and then PCSK9i.
Patients admitted to CCU and CPU with ACS between 01/07/21-30/12/21 with LDL ≥ 3mmol/L . 32 patients in total Male to female ratio 2:1
•
• • • •
PDSA cycle 1
Please add the following to CPS for all ACS patients.
•
Prescribe a high-density statin: Atorvastatin 80mg daily. Repeat lipid profile after 3 months. Achieve reduction of non-HDL >40% from baseline in 3 months. If non-HDL <40% add ezetimibe 10mg daily or monotherapy if statin intolerance. If non-HDL remains >2.5mmol/L consider injectable therapies (Inclisiran or PCSK9 inhibitors).
Conclusion
ALT/ASTNon HDL Cholesterol LDL Cholesterol (LDL cholesterol may not be available in which case fine to just mention non HDL cholesterol) GP- please measure full lipid profile and AST/ALT again after 3 months (non-fasting). High intensity statin treatment should achieve reduction of non-HDL-C > 40% from baseline. For this patient aim for Non HDL Cholesterol of less than …………………….
Optimising lipid management is an essential component of secondary prevention of CVD. Initiating high dose statins is performed well in Torbay. Improving further monitoring and management is challenging, factors include: • Transient and rapidly changing team of junior doctors who populate the CPS. • Hand over between secondary and primary care. • Timely blood tests and medication reviews.
If this is not achieved after 3 months then please follow the National Guidance for Lipid Management for Primary and Secondary Prevention of CVD NHS Accelerated Access Collaborative » Summary of national guidance for lipid management (england.nhs.uk)
NEXT PHASE OF PROJECT
References 1. 2. 3.
In June 2022 review CPS and follow up lipid profile and management for patients with ACS discharged in March. If GPs are not consistently following follow up guidelines then consider cardiology based follow up.
Cholesterol levels. https://www.nhs.uk/conditions/high-cholesterol/cholesterol-levels. Accessed in April 2022 Heart picture was taken by: https://www.socialconnectedness.org/keeping-the-heart-beating-social-isolation-and-cardiovascularhealth/. Accessed in April 2022 PDSA picture was taken by: https://deming.org/explore/pdsa/. Accessed in April 2022
T. Santaannop, K. Small, N. Fitzpatrick
IMPLEMENTATION OF A GENTAMICIN PRESCRIBING PLAN IN A SECONDARY CENTRE INTRODUCTION • •
. Gentamicin is a common inpatient antibiotic with a narrow therapeutic window.
Achieving safe gentamicin levels requires accurate, individualised prescribing adjusted for weight, height and renal function. This drug is commonly incorrectly prescribed with previous studies showing an error rate of 70% within our trust. Incorrect prescriptions leads to increased risks of toxicity and renal failure. A gentamicin dose calculator therefore could help reduce errors in gentamicin dosing, improving patient safety.
• •
PLAN: AIMS
DO: METHODOLOGY
• Assess if a mandatory Gentamicin Prescribing plan . with integrated dose calculator and peer education improves gentamicin prescribing.
STUDY: RESULTS AND DISCUSSION 1. Correct gentamicin doses (adjusted to weight and height) prescribed in 77% of patients after . implementation of the prescribing plan compared to 30% previously. 2. Adjusted body weight used in all patients ≥20% IBW and 5% increase in up-to-date weight documentation. 3. 98% of levels were taken one hour pre- next dose if poor renal function compared to 92% previously. Ø The Gentamicin calculator has therefore, improved prescribing accuracy. 100 99
98
90
Before
92
80
% of prescriptions
After
79
77
70
74
60 50 40
42
30
30
20 10 0
Care plan use
Correct dose
Level taken 1hr pre dose if eGFR < 60
Weight documentation
• 472 prescriptions analysed between 04/01/21 . to 23/02/21 prior to calculator implementation against the following quality standards: Ø Correct dose prescribed. Ø Up-to-date weight and adjusted body weight in patients ≥20% ideal body weight (IBW). Ø Gentamicin levels measured 20-24hrs post first dose and one hour pre-dose if reduced eGFR (<60). • Implementation of mandatory electronic prescribing plan with integrated dose calculator. • Peer-peer education about the gentamicin care plan at departmental meetings. • 241 adult prescriptions between 01/10/21 01/12/21 analysed after interventions.
ACT: ADAPTATIONS FOR NEXT CYCLE .• Increased up-to-date patient height/weight
documentation. • Pull-through of gentamicin calculator dose onto electronic prescription charts automatically to reduce chance of error. • Improved accuracy of gentamicin levels monitoring by increasing education, including nursing staff, on when to take levels for each individual patient.
LEARNING POINTS •. Small changes can result in significant improvements to accurate prescribing • Multidisciplinary team education is key to maintaining changes implemented – increase education to include other MDT members • Prescribing care plans can help reduce human error and maintain patient safety.
Ensuring Optimisation of Heart Failure Prescribing in Patients Discharged from a Tertiary Cardiology Centre Dr Alexander Morgan, Dr Matthew Edmunds, Dr Yorissa Padayachee, Dr Rajalakshmi Valaiyapathi Imperial College Healthcare NHS Trust Corresponding address: a.morgan10@nhs.net
INTRODUCTION •The British Heart Foundation predicts 920 000 people are living with heart failure (HF) with 200 000 new cases diagnosed annually, resulting in significant morbidity and mortality •The European Society for Cardiology (ESC) published updated guidance on prescribing in heart failure with reduced ejection fraction (HFrEF) in August 20211. •An important change was the addition of a 4th prognostic medication – the sodium-glucose co-transporter-2 (SGLT-2) inhibitor which has been shown to improve morbidity & mortality associated with HF
THE AIM
DAPA-HF TRIAL (Dapagliflozin vs. Placebo) LVEF ≤ 40%
The first seminal trials in heart failure demonstrating the clinical effectiveness on outcomes in patients with heart failure with reduced ejection fraction in HFrEF. Taken from Cardiovascular Medicine editorial online2,3,4.
To assess compliance of prescribing in accordance with 2021 ESC heart failure guidelines.
DAPA-HF trial (2019) showing cumulative incidence of hospitalization and death were reduced with dapagliflozin5.
To identify areas where improvements could be made and enact changes to improve patient morbidity and mortality by the appropriate and timely initiation of prognostic medications.
METHODOLOGY Highlight new guidelines to the SHOs and ANPs
Limited awareness of the new ESC guidelines
Informal teaching by SHOs and guideline summaries produced
Low confidence in more complex prescribing
Unfamiliarity with the newer SGLT2 inhibitors
Focus on SGLT2 inhibitor prescribing confidence
Heart Failure Consultant Led Teaching Program
QIP presentation at Heart Failure MDT highlighting our compliance so far and gain ideas for future improvements
Heart failure pharmacist led teaching program
RESULTS
CONCLUSION
Mean Change in Number of Prognostic Heart Failure Medications Prescribed to Patients with HFrEF. Admission vs Discharge. 1.8 1.6 1.4 1.2
• Repeated PDSA cycles showed consistent increases in adherence to ESC guidelines and greater prescriber confidence • Reduction in quality of prescribing during round 3 • This coincided with the changeover of junior doctors. • There was still persistent improvement vs baseline.
LESSONS LEARNT
1 0.8 0.6 0.4 0.2 0 Baseline
450
Round 1
Round 2
Round 3
Percentage Increase in Numbers of Patients Prescribed a SGLT2 inhibitor. Admission vs Discharge.
400 350
%
Discussion with experts on the topic
300
1. Empowering juniors (through teaching) and promoting them to take initiative in starting these medications improved the initiation of prognostic medications and resulted in sustainable change. 2. Combined working between different grades and members of the MDT has led to improved co-operation, quality of prescribing and longevity of change. 3. Further work is needed to ensure quality of prescribing continues after changeover of medical staff 4. Up-titration of medication remains low. This will be the focus of future PDSA cycles. Acknowledgments: Thank you to all the Heart Failure team at Hammersmith Hospital. Special thanks to Dr Carla Plymen, Dr Punam Pabari, Dr Graham Cole and Tom Cooper for their teaching and guidance.
250 200
References
150 100 50 0 Baseline
Round 1
Round 2
Round 3
1. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A; ESC Scientific Document Group. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-3726. doi: 10.1093/eurheartj/ehab368. Erratum in: Eur Heart J. 2021 Oct 14;: PMID: 34447992. 2.Swedberg K, Held P, Kjekshus J, Rasmussen K, Rydén L, Wedel H. Effects of the early administration of enalapril on mortality in patients with acute myocardial infarction. Results of the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II). N Engl J Med. 1992 Sep;327(10):678–84. 3.Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Carvedilol Prospective Randomized Cumulative Survival Study Group. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med. 2001 May;344(22):1651–8. 4.Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Randomized Aldactone Evaluation Study Investigators. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med. 1999 Sep;341(10):709–17. 5.McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Anand IS, Bělohlávek J, Böhm M, Chiang CE, Chopra VK, de Boer RA, Desai AS, Diez M, Drozdz J, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Merkely B, Nicolau JC, O'Meara E, Petrie MC, Vinh PN, Schou M, Tereshchenko S, Verma S, Held C, DeMets DL, Docherty KF, Jhund PS, Bengtsson O, Sjöstrand M, Langkilde AM; DAPA-HF Trial Committees and Investigators. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019 Nov 21;381(21):1995-2008. doi: 10.1056/NEJMoa1911303.
PROCALCITONIN LEVELS TO GUIDE ANTIBIOTIC USE IN COVID-19 PATIENTS DR JOSEPH EWER, DR XI LIN LEE, DR EMMA CHANG, DR ESTHER HUIYI LAW, DR CLAIRE McBRIEN & DR JIMSTAN PERISELNERIS
3. RESULTS & ANALYSIS
1. INTRODUCTION
DATA ANALYSIS:
Preceding influenza pandemics have had diagnostic and treatment ambiguity surrounding the need for antibiotics in treating bacterial coinfection for a viral disease. In the time of COVID-19, similar issues have meant that patients presenting with respiratory symptoms are often treated empirically with antibiotics whilst awaiting COVID-19 results. A recent metaanalysis1 found that bacterial co-infection at presentation was estimated to be 3.5%, however, 71.9% of the patient population still received antibiotics. To tackle antimicrobial resistance, a 2020 WHO Bulletin2 highlighted the need for daily antibiotic de-escalation considerations and a research agenda for diagnostic tools that differentiate between bacterial and viral infections. Serum procalcitonin (PCT), as an acute inflammatory marker, has proved effective in guiding antibiotic prescribing in respiratory tract infections by limiting antimicrobial use without compromising patient safety outcomes3,4. Thus, there is a similar role for it to be used in antibiotic prescribing in COVID-19.
•
• •
•
AIM: 1. Encourage PCT value use in diagnosis of superadded bacterial infection in COVID-19 2. Improve antimicrobial stewardship by employing PCT-guided antibiotic prescribing for COVID-19 patients
•
The use of Day 1 PCT increased between pre-intervention (64.18%) and post-cycle 2 data (78.00%). Overall antibiotic use following medical review was reduced by 19.69%. There was an increase of 24.16% in references to the role of PCTvalues in clinical decision making noted. The average number of days of antibiotics prescribed for patients with a low PCT value was reduced from 3.44 (+/-1.85) to 3.27 (+/-0.92), by a total of 4.9%. For patients requiring day 3 PCT tests due to a high day 1 PCT, compliance increased from 33.3% to 45.5% between preliminary and post PDSA2 data, and from 16.7% to 40% for day 5 PCT.
% of antibiotic courses stopped following medical review Day 1 PCT ≥ 0.25 Day 1 PCT < 0.25 Pre-intervention 9.09% 28.57% Post PDSA 1 20.00% 33.33% Post PDSA 2 18.18% 31.82%
2. METHOD • Data collection occurred between Jan - Nov 2021 • Inclusion Criteria: Adult patients >18 years of age, admitted from A&E with COVID positive swabs on admission • Exclusion Criteria: Patients transferred from other hospitals with known COVID positive status • N.B. For overnight ED admissions, the PCT days were subtracted by 1 to accurately represent PCT requests/reviews
Average No. of Days of antibiotics prescribed during initial treatment Day 1 PCT ≥ 0.25 CI Day 1 PCT < 0.25 CI Pre-Intervention 6.8 +/- 1.42 3.44 +/- 1.85 Post PDSA 1 4.9 +/- 2.26 3.0 +/- 1.22 Post PDSA 2 5.9 +/- 2.28 3.27 +/- 0.92 % Change ↓ 13.23% ↓ 4.9%
4. DISCUSSION • There was a clear increase in requests and use of PCT values from preintervention to post-PDSA 2. However, there was an unexpected reduction in compliance of PCT guidance in post-PDSA 1, due to several reasons: • PCT had not yet been adopted by all medical / post-take consultants • Despite it being added to the EPR system, this was not widely known • There is an importance of both changing, and disseminating information about changes to truly impact clinical practice
Updated COVID-19 antimicrobial guidelines
• There were also some technical barriers initially, involving the failure of the EPR system to display PCT results that were "add-ons”, thus impeding PCTguided antibiotic changes
DATA COLLECTED: PROCESS MEASURES: - Whether Day 1/3/5 PCT values were available - Documentation of PCTguided / clinical override prescribing OUTCOME MEASURES: - Days of antibiotics prescribed BALANCING MEASURES: - Patient deaths
• We were unable to show a clear association between PCT result and decisions to stop/continue antibiotic treatment due to small sample sizes, and the complexity of concurrent clinical symptoms that override PCT value decisions alone. • However, if we were able to extrapolate this data to a wider population, even the small reduction in antibiotic course length, may translate to significant monetary savings and improved antimicrobial stewardship. SCOPE FOR FURTHER INTERVENTIONS: •
Prescribing cues to be implemented based on PCT values itself (e.g. for earlier reviews / to re-consider prescriptions)
•
Implementation on other wards / departments (e.g. ED)
•
Use of scoring-based prescribing to include other facets (e.g. as in CURB)
References: 1) Langford, B., So, M., Raybardhan, S., Leung, V., Westwood, D., MacFadden, D., Soucy, J. and Daneman, N., 2020. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clinical Microbiology and Infection, 26(12), pp.1622-1629. 2) Getahun, H., Smith, I., Trivedi, K., Paulin, S. and Balkhy, H., 2020. Tackling antimicrobial resistance in the COVID-19 pandemic. Bulletin of the World Health Organization, 98(7), pp.442-442A. 3) Schuetz, P., Christ-Crain, M., Thomann, R., Falconnier, C., Wolbers, M., Widmer, I., Neidert, S., Fricker, T., Blum, C., Schild, U., Regez, K., Schoenenberger, R., Henzen, C., Bregenzer, T., Hoess, C., Krause, M., Bucher, H., Zimmerli, W., Mueller, B. and ProHOSP Study Group, f., 2009. Effect of Procalcitonin-Based Guidelines vs Standard Guidelines on Antibiotic Use in Lower Respiratory Tract Infections. JAMA, 302(10), p.1059. 4) Burkhardt, O., Ewig, S., Haagen, U., Giersdorf, S., Hartmann, O., Wegscheider, K., Hummers-Pradier, E. and Welte, T., 2010. Procalcitonin guidance and reduction of antibiotic use in acute respiratory tract infection. European Respiratory Journal, 36(3), pp.601-607.
Improving antimicrobial stewardship and patient education regarding UTIs at a GP practice - patient information leaflets in the telemedicine era Oliver Skan Royal Free Hospital NHS Trust
Background • Urinary tract infections (UTIs) are the most common bacterial infection seen in general practice, representing an estimated 1-3% of all consultations. • Antimicrobial resistance is increasing globally, as well as in the UK. • Appropriately requesting mid-stream urines (MSUs) for culturing, and correctly prescribing antibiotics, are important both for patient safety and antimicrobial stewardship. • Educating patients about UTIs is an important aspect of management. • The expansion of telemedicine during the pandemic provides new avenues of providing patient information, including electronic patient leaflets.
• Project aims discussed with practice team • Interventions discussed at practice meetings • Background data collected to assess scope of issue
Aims 1) To increase the number of MSUs that are being performed as per NICE guidance (NICE CKS: Urinary tract infection (lower)). 2) To improve correct antimicrobial prescribing for UTIs at the practice (PHE antibiotic prescribing guidelines). 3) To improve patient education regarding UTIs in line with NICE guidance. Specifically, to increase the percentage of patients given advice regarding safety netting, consultation recall, self-care, and avoiding UTI recurrence.
• The percentage of MSUs that were appropriately requested increased from 64% to 91%/92% post intervention. • Percentage of patients who had MSUs successfully processed (requested, taken, cultured, followed up) increased from 45% to 65%/83% post intervention. • Correct antibiotic prescribing increased from 73% to 93%/88% post intervention. • Percentage of patients receiving advice about how to take an MSU, safety netting, appropriate recall, self care advice, and UTI prophylaxis all increased across both dat. collection periods, average scores increasing by 33% and 68.6% across the two periods.
Intervention 1
Intervention 2
90%
92%
80% 70%
Do
Act
Study • Post-intervention data collected (repeat sets collected to assess two different time periods)
• Teaching session following baseline data collection, with open-table discussion about previous MSU requesting or antibiotic prescribing misconceptions. Follow-up reminder session 4 weeks later. • A new UTI text message generated on AccuRX with link to RCGP ‘Treating your infection’ leaflet on UTIs. This text contains all the advice we should be giving patients (as per NICE guidelines).
• UTI text message and leaflet translated into Turkish, Portuguese, Spanish, and Somali • UTI Induction handover teaching to incoming FY2 doctors • UTI management prompt posters installed in practice
Project Timeline
MSU APPROPRIATELY REQUESTED 91%
Plan
• Data analysed to determine effect of intervention • Interventions adopted
Results
100%
• Baseline pre-intervention data collected and analysed • Intervention 1 performed • Intervention 2 performed
64%
60% 50% 40% 30% 20% 10%
Baseline data collected
Nov 2021- Feb 2022
Intervention 1 implemented 2 x repeat rounds of data collection to assess response Intervention 2 implemented 2 x repeat rounds of data collection to assess response
Jan 2022 Feb 2022 – March 2022 March 2022 – April 2022 April 2022 To be completed
Documented patient education
0% Pre-intervention (09/11 – Post-intervention (09/02- Post-intervention (09/03 09/03) 04/04) 09/02)
90% 80%
TOTAL MSU PROCESSED
70%
90%
83%
60%
80%
50%
65%
70% 60% 50%
40%
45%
40%
30%
30%
20%
20%
10%
10%
0%
0% Pre-intervention (09/11 – Post-intervention (09/02- Post-intervention (09/03 09/03) 04/04) 09/02)
93%
90% 80% 70%
88%
60% 50% 40% 30% 20% 10% 0% Post-intervention (09/0209/03)
Recall advice (%)
Post-intervention (09/02-09/03)
Self care advice Prophylaxis advice Post-intervention (09/03 - 04/04)
Conclusion and future directions
71%
Pre-intervention (09/11 – 09/02)
Systemic illness advice
Pre-intervention (09/11 – 09/02)
ABX CORRECTLY PRESCRIBED 100%
Advice on MSU taking
Post-intervention (09/03 04/04)
• Teaching on MSU requesting and antibiotic prescribing with open-table discussion about previous misconceptions improved practice. • AccuRX texts are a simple and time-efficient way of providing patients with information about UTIs that can be easily applied to other practices with similar software. • Telemedicine must not be restricted to those fluent in English and future work is looking to address language barriers in current patient education. • Further rounds of data collections will determine if UTI management ‘prompt sheets’, further teaching sessions, and UTI management texts in other languages can all help to sustain the change seen in the initial interventions