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

•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

To assess compliance of prescribing in accordance with 2021 ESC heart failure guidelines

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

Methodology

Limited awareness of the new ESC guidelines

Highlight new guidelines to the SHOs and ANPs

Informal teaching by SHOs and guideline summaries produced

Results

Low confidence in more complex prescribing

Discussion with experts on the topic

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.

Heart Failure Consultant Led Teaching Program

Unfamiliarity with the newer SGLT2 inhibitors

Focus on SGLT2 inhibitor prescribing confidence

Heart failure pharmacist led teaching program

Conclusion

QIP presentation at Heart Failure MDT highlighting our compliance so far and gain ideas for future improvements

• 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.

Lessonslearnt

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.

Percentage Increase in Numbers of Patients Prescribed a SGLT2 inhibitor. Admission vs Discharge.

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.

1.INTRODUCTION

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

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

3.RESULTS & ANALYSIS

DATA ANALYSIS:

• 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.

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

• 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

• 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.

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

• 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)