The Chair welcomed all present and announcements were made with regards to changes in membership.

Transcription

1 Minutes of the Scottish Antimicrobial Prescribing Group Meeting held on 24 th October 2011 Healthcare Improvement Scotland, Delta House, 50 West Nile Street, Glasgow Present: Professor Dilip Nathwani (Chairman), NHS Tayside Ms Susan Paton, Project Co-ordinator, Scottish Antimicrobial Prescribing Group Dr Jacqueline Sneddon, Project Lead Scottish Antimicrobial Prescribing Group Mrs Anne Lee, Chief Pharmaceutical Advisor, SMC Mr Grant Archibald, Director, Emergency Care and Medical Services, NHS Greater Glasgow and Clyde Professor Marion Bennie, Chief Pharmaceutical Advisor, National Medicines Utilisation Unit, Information Services Division Dr Anne Eastaway, Consultant Microbiologist, Health Protection Scotland Mr William Malcolm, Pharmaceutical Advisor, Health Protection Scotland Ms Tracey Cromwell, Principal Information Analyst, Information Services Division Dr Andrew Seaton, NHS Greater Glasgow and Clyde, ADTC Dr Stephanie Dundas, Consultant in Infectious Diseases, NHS Lanarkshire Dr Susan Smith, Consultant Microbiologist, NHS Fife Dr David Wilks, Consultant Physician, NHS Lothian Dr Camilla Wiuff, AMR Programme Manager, Health Protection Scotland Ms Andrea Patton, Information Analyst, Scottish Antimicrobial Prescribing Group Dr Gail Haddock, General Practitioner, NHS Highland teleconferencing Dr Emma Watson, Director of Medical Education, NHS Highland - teleconferencing Mrs Helen Maitland, Programme Director HAI, NHS Education for Scotland Mr Andrew Wilkinson, Head of Healthcare Associated Infection and Regulation Team, Scottish Government Professor Peter Davey, NHS Tayside, International Liaison Dr Nicholas Reid, Lead Antimicrobial Pharmacist, NHS Ayrshire & Arran Mr Graeme Bryson, Prescribing Adviser, NHS Ayrshire and Arran Dr Simon Hurding, General Practitioner, NHS Highland Mrs Gillian Stevenson, Nurse Consultant (HAI), NHS Tayside (attending for Ms Deidre Harris) Guests: Pauline Hyland, Antimicrobial Pharmacist, NHS Lanarkshire Yvonne Semple, Project Lead, Gentamicin and Vancomycin (GaV) Quality Improvement Programme, Scotland Strathclyde Institute of Biomedical Sciences University of Strathclyde Mr Stephen Dewar, MPharm ClinDip, Clinical Pharmacist, Southern General Hospital, Glasgow; Clinical Researcher, Gentamicin and Vancomycin Quality Improvement Programme Alison Hunter, National Patient Safety Facilitator, Healthcare Improvement Scotland Kirsty Macfarlane, temporary senior pharmacist appointed to the SMC team Melanie Barnes, Management Accountant for Healthcare Improvement Scotland Dr Alison Thomson, Senior Lecturer, Strathclyde Institute of Pharmacy and Biomedical Sciences University of Strathclyde Apologies: Professor Robert Masterton, Medical Director, NHS Ayrshire & Arran Mrs Gail Caldwell, Director of Pharmacy, NHS Forth Valley Dr Lorna Willocks, HAI Senior Medical Advisor, Scottish Government 1

2 Ms Ysobel Gourlay, Lead Antimicrobial Pharmacist, NHS Greater Glasgow and Clyde Dr Andrew Hay, Consultant Microbiologist, NHS Highland Dr Alexander Crighton, Consultant in Oral Medicine, NHS Greater Glasgow & Clyde Mrs Helen Cadden, Public Partner Ms Catriona Innes, Antimicrobial Pharmacist, NHS Orkney Dr Mike Jones, Acute Medicine Representative, NHS Lothian Ms Deidre Harris, Nurse Consultant Infection Control, NHS Fife and Infection Prevention Society Dr Alexander Mackenzie, Consultant in Infectious Diseases, NHS Grampian Dr Anne Maree Wallace, Director of Public Health, NHS Forth Valley Mr Sam Whiting, Infection Control Manager, NHS Borders Dr John Porter, UK Medical Team Lead for Specialty Medicines, Pfizer Professor Ian Gould, Consultant Microbiologist, NHS Grampian and Scottish Microbiology Forum Dr Craig Williams, Infectious Diseases Doctor, NHS Greater Glasgow and Clyde Mr Robert Wilson, Infection Control Manager, NHS Ayrshire and Arran Dr Martin Connor, Consultant Microbiologist NHS Dumfries and Galloway, Mrs Alison MacDonald, Area Antimicrobial Pharmacist, NHS Highland Dr Peter Christie, Consultant in Public Health Medicine, Healthcare Improvement Scotland 1. Welcome and Apologies Action The Chair welcomed all present and announcements were made with regards to changes in membership. The Chair announced Mrs Gail Caldwell, Director of Pharmacy representative and vice chair of SAPG is stepping down and thanked Gail for her contribution to SAPG. Mr Grant Archibald, Director Emergency Care and Medical Services, NHS Greater Glasgow and Clyde as the new Chief Executive Representative. Professor Patricia Murray, Director of NHS Lothian Pharmacy Services as new representative for the Directors of Pharmacy. Dr Kevin Rooney Lead Clinician in Critical Care and Consultant Anaesthetist NHS Greater Glasgow and Clyde and Dr Daniel Beckett, Consultant Acute Physician, NHS Forth Valley who will share the role of representative for SPSP Sepsis. 2. Minutes of the previous meeting held on 29 th August 2011 The minutes of the meeting held on 29 th August 2011 were agreed subject to one small amendment on Page 4. 2

3 3. Matters Arising National Point Prevalence Study (PPS) WM advised that the study is now near completion and that informal feedback from participants suggests it has been beneficial in strengthening links between infection control teams and antimicrobial management teams. Concerns were raised about the impact of completing the PPS on other local antimicrobial stewardship activities, particularly in larger boards. AE advised there will be a formal evaluation to assess the impact of the study which will inform the future national approach to point prevalence work. WM advised that each board contact will be given the opportunity to submit comments and that WM will communicate to SAPG members when this feedback is required. Local hospital reports will be available by the end of this calendar year and the national report by March GP Audit Tool WM advised that Andrea Patton, SAPG Information Analyst, has agreed to produce a Microsoft Access database which will allow GPs to collect their own data and produce reports. This audit tool will be piloted in early 2012 and will form part of the toolkit to support the proposed quality indicator to reduce unnecessary antibiotic prescribing within primary care. Action: Report back at December meeting. Co-trimoxazole JS updated that National Procurement have advised that problems with cotrimoxazole injection supply should be now be rectified. Staph. aureus bacteraemia (SAB) The SAB algorithm has now been tested by junior doctors in Glasgow and Tayside with positive feedback. DN highlighted the tabled paper from Dr Andrew Seaton which details four measures to evaluate implementation of the algorithm. Greater Glasgow and Clyde Infection Control Team has agreed to pilot data collection and Forth Valley have also agreed to pilot to have a view from a smaller board. DN advised that any other boards are welcome to be involved in the pilot. GS advised that the measures may not be suitable for collection by Infection Control Nurses as they involve interpretation of complex clinical information. It was agreed this may be a role for Infection Control Doctors (ICDs) or other medical staff. JS fed back on behalf of LW from the meeting of the ICDs group where Dr Keith Morris had agreed to lead a gap analysis to inform on potential 3

4 development of a national SAB database. This will compare a tool drafted by the ICDs group and the tool proposed by Dr Ian Gould and SAPG have been asked to feed into this process. Action: Update at December meeting on data collection. AS European Antibiotic Awareness Day (EAAD) 2012 JS advised that this year s EAAD day on 18 th November would not have a specific national focus and that individual boards will decide on local activities. NHS Scotland badged resources are available on the SAPG website and have been circulated to Antimicrobial Management Teams (AMTs). It was agreed Boards would contact SP to advise on their focus for the day for feedback to Scottish Government and the European Centre for Disease Control. LW has also advised there will also be media coverage of the day.. Update on Nursing Role It was agreed at the August meeting of SAPG that it would be valuable to have nursing leadership on SAPG and it is hoped to have a positive update at the December meeting. Future funding of SAPG/ Benefits realisation At the request of the Project Board, the future funding of SAPG was raised. It was confirmed that Scottish Government (SG) remains committed to delivering in full the Healthcare Associated Infection (HAI) agenda and would like to see the current funding maintained as part of the outcome from the 2011 spending review. The SG Finance Department is, however, unable to give assurances over the funding at present. AW intimated that the details of funding for will be communicated to SAPG as soon as this information is available. A piece of work on the benefits realisation of SAPG with contributions from all boards is currently being undertaken and findings will be reported to SAPG. 4. Gentamicin and Vancomycin Quality Improvement Project (GaV) (Presentation and Paper 1) Yvonne Semple presented on the Gentamicin and Vancomycin Quality (GaV) Improvement Project and the outcomes of the three studies undertaken. Study 1 - National survey to establish use of guidance and local implementation strategies. Study 2 - National point prevalence study to determine appropriateness of gentamicin and vancomycin prescribing and monitoring Study 3 - Qualitative study to assess how fit for purpose guidance is in supporting front-line clinicians. The results will also be presented at the forthcoming AMT event and actions for future work will be agreed within event workshop sessions. 4

5 YS advised that three areas require consideration by SAPG: Education additional resources to support clinical staff in using gentamicin and vancomycin safely and effectively Documentation standardisation to facilitate improved prescribing and monitoring Guidance development some indications requiring specific dosage regimes are not covered in the current SAPG guidance e.g. infective endocarditis, surgical prophylaxis. Paper 9 on current orthopaedic antibiotic choice was also discussed as this contains information about gentamicin regimes. It was agreed that standardisation of gentamicin dosage for surgical prophylaxis may not be possible due to the lack of supporting evidence and boards should make their own decision based on local risk assessment. However it was agreed that Paper 9 should be shared with AMTs and be considered when SAPG guidance on surgical prophylaxis is reviewed early in Action: Paper 9 to be circulated to AMTs SP Following feedback on the online dosage calculator for gentamicin/ vancomycin it was noted that a revised version is being developed by Stephen Dewar as an MSc project and will be available in early Urinary Tract Infection Antimicrobial Resistance (UTI AMR) Surveillance. (Paper 2) Paper 2 is the final protocol for UTI AMR Surveillance for SAPG agreement. DN advised that the protocol will need to reflect any revised antibiotic advice in the current review of Scottish Intercollegiate Guideline Network (SIGN) 88 Management of suspected bacterial urinary tract infection in adults. Action: Summary of changes to SIGN 88 to be sent to CW JS Subject to this amendment the protocol was accepted by SAPG. 6. Primary Care Proposal to HAI Task Force National Advisory Group (NAG). (Paper 3) DN advised that feedback from the NAG was positive and supportive. Comments raised by the Scottish Microbiology Forum (SMF) have been collated along with a suggested SAPG response. The response to SMF was agreed and will be copied to the Chair of the NAG. The proposal will be submitted to Scottish Government by the Chair of the NAG for implementation. HM offered joint working with NHS Education for Scotland on development of the implementation toolkit. It was agreed that this would be helpful. 5

6 7. Cefazolin clinical risk assessment. (Paper 4) JS advised that the clinical risk assessment for Cefazolin, a cephalosporin antibiotic licensed elsewhere in Europe and in the USA but not in the UK, is now complete. The risk assessment includes information on efficacy, C. difficile risk and availability of cefazolin injection products. The weak evidence base for cefazolin and the potential cost and quality assurance issues associated with its use were noted. Although a licensed cefazolin product from USA is available at reasonable cost it was agreed that the unlicensed status of the product in the UK may present problems with procurement and clinical governance therefore its use cannot be recommended by SAPG. Next steps will be to share information with AMTs and individual boards can decide if they wish to use cefazolin. The formal local Area Drug and Therapeutics Committee process for unlicensed medicines requires to be followed and boards will deal directly with the import company to purchase it. It was agreed that SAPG should supply this information to NHS boards to provide an overview of the evidence base on cefazolin. SAPG will request feedback on effectiveness and unintended consequences from boards who decide to use cefazolin. Action: Communicate information on cefazolin to AMTs highlighting process for use. JS/SP 8. Caesarean section Revised NICE guidance on caesarean section. (Paper 5) The Chair advised that the recent review of National Institute for Clinical Excellence (NICE) guidance on Caesarean section had been raised by Dr Martin Connor as there are concerns about the advice on antibiotic prophylaxis. Consultation on this guidance is now closed and the final version is expected to be published in November Key issues are that the guidance advocates avoidance of co-amoxiclav, which is currently commonly used, and recommends use of ampicillin or a first generation cephalosporin. Ampicillin is unlikely to provide sufficient antimicrobial cover for Caesarea section and there are no injectable first generation cephalosporins available in the UK. PD advised that the British Society for Antimicrobial Chemotherapy (BSAC) have communicated these concerns to NICE and it was agreed the outcome of the BSAC petition will be reported back to SAPG. The revised will be discussed at the December SAPG meeting when national advice will be agreed. Action: Feedback to SAPG outcome of BSAC petition Action: SAPG response to NICE guidance on agenda for December meeting. PD SP 6

7 Review of SSI in Caesarean section patients with BMI>30 (Paper 5a) EW advised that Paper 5a was a summary of a two year project undertaken within NHS Highland on infection rates in C-section. This project suggests that infection risk may be raised in patients with a BMI >30. It was agreed an evidence review of increased dosage requirements for patients with a high BMI would be useful. DN advised that SAPG, Infectious Disease specialists and others can contribute but Health Protection Scotland (HPS) should be approached to lead this work. It was agreed EW will contact HPS and report back to SAPG. 9. Care Homes Education Project. (Paper 6) JS advised that Paper 6 is the final report on the impact of an education initiative delivered by pharmacists on antibiotic prescribing and management of infection in care homes. The report has been shared with participating pharmacists and Care Home Managers. No conclusive benefits were found due to the sample size but the education was well received and areas for improvement have been identified. A further study by NHS Tayside is underway using self-directed learning and a questionnaire completed by nursing and social care staff before and after education. Development of a national education resource on antibiotics for the care home sector will be taken forward in conjunction with NHS Education for Scotland (NES) and the Care Inspectorate. HM welcomed the paper and advised that NES would support the development of this work as part of their HAI programme. 10. Sepsis and Scottish Patient Safety Programme (SPSP). (Presentation) The Chair updated that sepsis has been identified as a priority for SPSP in 2012 as improving recognition and management of sepsis will make a significant contribution to mortality reduction. Sepsis was introduced at the recent SPSP event and participants were enthusiastic about developing this area of work. SAPG have agreed to collaborate with SPSP to take this forward. The Chair introduced Alison Hunter from Healthcare Improvement Scotland who will be leading this work on behalf of SPSP SAPG and AMTs will have a supporting role providing clinical leadership and subject matter expert advice. 7

8 11. Sepsis 6 (Paper 7) This paper summarises the Sepsis Six project which is being led by Sian Finlay, NHS Dumfries and Galloway and Mike Jones, NHS Lothian. The Acute Medicine teams involved are from Dumfries & Galloway Royal Infirmary, Edinburgh Royal Infirmary, Ninewells Hospital, Forth Valley Royal Hospital, Western Infirmary Glasgow, Aberdeen Royal Infirmary and Raigmore Hospital. The Sepsis six measures have been set up on the SAPG Extranet and the teams are participating in monthly teleconferences to present results, share good practice and discuss challenges. The Sepsis six measures which should be delivered in patients with severe sepsis within one hour of presentation are: High Flow Oxygen Administered Appropriately Blood cultures taken IV antibiotics administered (following local policy) IV fluids commenced Serum lactate and FBC Measured Urinary catheter inserted The aim of the project is to achieve 95% reliability with the Sepsis Six in Acute Medical Admissions by 31 st March Learning from the Sepsis six initiative will inform development of the SPSP Sepsis work. 12. Neutropenic Sepsis JS advised that the best practice statement has been issued to NHS boards by Scottish Government. The statement has also been communicated to AMTs for information and the commencement of the audit by cancer teams should begin in the next couple of months Swiss Project AP reported on the findings of the pilot project in NHS Tayside to evaluate the impact of a new antibiotic policy which was introduced in October 2008 that restricted the use of cephalosporins, fluoroquinolones and broad-spectrum penicillins. SAPG wished to quantify the effect of introducing a restricted antibiotic policy on the incidence of CDI and to ensure that the policy has no unintended consequences on patient outcomes, specifically 30-day mortality. The Chair thanked AP and TC for their work and concluded that this has provided a robust analysis of the impact of the intervention and allowed development of analytical expertise within SAPG. The conclusion is that the original transfer function model methodology is not sustainable and an alternative segmented regression analysis will be used to evaluate the impact of changing antimicrobial policy in other NHS boards. 8

9 14. Unintended consequences in surgical prophylaxis Research Study Flucloxacillin in orthopaedic surgery JS advised that funding for the research proposal to develop methodology to evaluate the effect of flucloxacillin surgical prophylaxis on renal function in orthopaedic surgery patients has now been approved. A steering group will now be set up to oversee the project and invitations will be sent out within the next two weeks. In addition to Tayside who are leading the work, Lanarkshire and Highland have both expressed an interest in being part of the project. 15. Workstream Updates Information Workstream Agreed. Quality Improvement Workstream Annemaree Wallace, Lead for the Quality Improvement unable to attend, workstream update agreed. Education Workstream HM advised on challenges in the senior doctors education. Update agreed. 16. AMIDs WM advised that user group continues to develop standard reports. TC advised that the training programme dates have now been agreed with eight boards and the first training session is scheduled to take place mid November. 17. Liaison with Healthcare Environment Inspectorate (HEI) The Chair advised that at the last meeting of SAPG and HEI the development of inspection to cover both HAI and care of elderly patients was discussed. SAPG will input to this widened remit as required. 18. Conference submissions The Chair advised that SAPG have had four abstracts accepted for the Federation of Inspection Societies Conference in Manchester in November. Abstracts of SAPG work will also be submitted for the 2012 BMJ International Forum on Quality and Safety in Healthcare and 2012 European Congress of Clinical Microbiology and Infectious Diseases Date of next meeting: Monday 12 th December Following meeting Monday 20 th February