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National reduction in “4C” antibacterials in primary care

Introduction to the Infection Intelligence Platform (IIP) Professor Marion Bennie National Services Scotland University of Strathclyde. National reduction in “4C” antibacterials in primary care. Target antibacterials: Cephalosporins Ciprofloxacin Clindamycin Co-amoxiclav.

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National reduction in “4C” antibacterials in primary care

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  1. Introduction to theInfection Intelligence Platform (IIP)Professor Marion Bennie National Services Scotland University of Strathclyde

  2. National reduction in “4C” antibacterials in primary care Targetantibacterials: Cephalosporins Ciprofloxacin Clindamycin Co-amoxiclav Data from Scottish Antimicrobial Prescribing Group Primary Care Prescribing Indicators reports, 2010 and 2012-13

  3. From Strategy To Bedside Care

  4. Better Access To And Use Of Surveillance

  5. IIP - Vision Improving patient outcomes and reducing harm from infection through an innovative, integrated database, to support clinicians within the NHS in Scotland

  6. PATIENT (Community and Healthcare acquired Infection) IIP - Vision Intrinsic (patient) • Age/gender • Colonised • Morbidity • Drug history • Vaccine history Extrinsic (environment) - Medicines (prior use) • Lines/Catheters • Hand Hygiene • Surgery • Length of stay Prevention Intervention SIPS - Standard infection control precautions Antimicrobial stewardship Infection Management Antibiotic policy Infection control (TBP - Transmission based precautions) Patient outcome Monitoring/Surveillance Intended consequences Unintended consequences

  7. Step 1 - AMIDS (Antimicrobial Integrated Database Scotland) ECOSS (resistance) PIS (prescribing) HMUD (prescribing) ACaDMe (acute cancer, deaths and mental health) AMIDS Combined Data: • Use & AMR • Use & CDI • Standard reports • Snapshot all NHS boards • Trend board vs Scotland PCs (users in NHS)

  8. Fluoroquinolone use and resistance(Ecoli bacteraemia)NHS Board and Scotland 2008-11

  9. Step 2 - Unintended Consequences Orthopaedic Surgery Local Hospital Medicines Database Serum Creatinine SCI STORE SMR01 Local Prescribing Post-operative Acute Kidney Injury, all patients, unadjusted analysis – pre vs. last post-operative creatinine measurement (NHS Tayside, Peter Davey) Antibiotic Policy Change New Antibiotic Policy fully implemented

  10. Step 3 – Policy Support Strategic Case NHS Scotland eHealth Strategy Board in March 2013 (agreed) Business Case Clinical engagement (review group) SGHCD HAI National Advisory Group in July 2013 (approved)

  11. IIP - Road Map Further enhancement of connectivity to include current and future local databases. Full Capability Incremental planned studies focussing on key infection related clinical goals. Capability building Future Position Infrastructure to routinely connect current relevant national databases with infection information. Generic capability to support patient care, enable measurement of intended and unintended consequences of interventions. Setup Enhanced connectivity and linkage of existing national and local information to improve prevention and management of infection, reduce harm and minimise waste Current Position No strategic approach: Uncoordinated integration of databases through small pockets of resources from national and local programmes on an hoc basis

  12. IIP - Benefits (improve care - reduce harm - reduce variation) Patients Support individual prevention/treatment plans NHS Boards Drive quality improvement in local service delivery model (intended/unintended consequences) National Surveillance Identify emergence of antimicrobial resistance Research Support evidence based clinical practice

  13. A 75 year old man in a residential home with long term catheter multiple co-morbidities (diabetes mellitus and congestive heart failure) Discharged from hospital 6 weeks ago following a catheter related UTI. Since return home he has had a non-severe episode of C.difficile (CDI) diarrhoea which resolved with treatment. Seen by the out of hours service with a probable recurrence of a catheter related UTI and prescribed trimethorpim. 24 hours later he has become more unwell with sepsis and is admitted to hospital and treated with empiric amoxil and gentamicin. Risk factors Is this patient at increased risk of CDI in both settings? Is the patient at increased risk of CDI recurrence within 3 months of the original episode? Treatment What is the likely local and national antibiotic sensitivity and clinical effectiveness of different antibiotics in both clinical settings? Outcomes Is current treatment of UTI in the community associated with increased hospital admissions with sepsis? What is the 30-day mortality of patients admitted with sepsis? Is the use of gentamicin in the acute empiric setting associated with increased acute kidney injury (AKI)? Case Vignette - Patient with catheter urinary tract infection (UTI)

  14. Deliverables (2013-2016) To gain the necessary information governance approvals To build the required IM&T Infrastructure to support the IIP by technically linking six sources initially To complete a series of exemplar clinical studies to test the IIP capability and effectiveness

  15. IIP - Project Governance

  16. Key Datasets • ECOSS Electronic Communication of Surveillance in Scotland (antimicrobial resistance data) • HMUD Hospital Medicines Utilisation Database • PIS Prescribing Information System (primary care prescribing) • SCI Store Clinical Information (e.g. Lab results, Radiology reports) Repository • SMR Scottish Morbidity Record (SMR) • SMR01 – Inpatients, Day Cases, Discharge & Diagnosis • SMR02 – Maternity Inpatients, Day Cases, Discharge & Diagnosis • SMR99 – Mortality • SSIRS Surgical Site Infection Reporting System

  17. IIP – Clinical studies

  18. Acknowledgements • IIP Core Project Team • IIP User Group • IIP Joint Project Board

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