Name: Shahzad Razaq, Principal Pharmacist for Medicine & Anti-Infectives
Brief overview of the project: Mortality from sepsis is reduced if antibiotics are prescribed and administered without delay. Administration of the STAT antibiotic must be regarded as urgent and should be commenced within one hour. In 2013, at Heart of England Foundation Trust (HEFT), only 40% of patients received their antibiotic within one hour, which was similar to the reported national performance for sepsis treatment in acute medical units. We set out to improve this by a structured quality improvement (QI) project in order to improve our time to administration performance to an aspirational target of 80 %.
An Electronic Dashboard was initially developed and made available for staff to view performance of administration of STAT doses by ward/hospital site. Working with the education team we improved nurse IV cannulation and reconstitution of drugs competencies. We developed an iSkills video for training of ward managers, pharmacists and porters on using the dashboard. Extensive ward-ward education of junior doctors was done to a) emphasise the roll of effective direct communication with the nurse looking after the patient prescribed a stat dose b) to ensure antibiotic stat doses are only prescribed for sepsis c) to administer the drug themselves if the nurse is not available.
Crucial to the further and sustained improvement in the timely administration of antibiotic STAT doses has been the deployment of bleep/pagers to each Electronic Prescribing(EP) ward in the Trust.
Linking our electronic prescribing system automatically to our bleep system was our key innovation.
These pagers bleep to inform the nurse that a STAT dose has been prescribed, and continues to bleep at 15 minute intervals until the STAT dose is administered or the time to administer the dose has lapsed. Accessing the electronic dashboard allows the nurse to identify which patient(s) have been prescribed STAT doses.
Performance relating to the timely administration of the STAT doses is now being routinely reported as a nursing metric at executive level, broken down to hospital site and ward level. This has resulted in the improvement project now being fully integrated as part of the culture of our organisation.
The Trust performance for administration of STAT doses of antibiotics within one hour now stands at 82.3% (average of last 28 days [25/02/17 – 26/03/17]). This represents a 105 % improvement since our 2013 baseline.
List any supporting partners or organisations worked with: The core team comprising the ‘Antibiotic Safety Team’ included consultant microbiologist, antibiotic pharmacists, ICT developers, patient safety team and corporate nursing. To help us deliver the project recruitment of ward pharmacists, education leads, medical illustration and Trust communication team was crucial. Underpinning this whole development was the talent of our software development team, who were able to develop our unique dashboard and link our EP system with our bleep system.
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? This project demonstrates that innovation technology has been used to improve antibiotic safety for patients with sepsis. We programmed and linked our Trust Electronic Prescribing JAC system to send information via the pager system to alert nursing staff of urgent medication to be administered which they can then view on a unique Trust Intranet Dashboard is unique in enabling nurses to administer urgent doses to patients.
Protecting antibiotics is not only ensuring reducing inappropriate prescriptions, but to ensure when prescriptions are indicated they are given on time and are not missed. Our dashboard-bleep electronic system has enabled us to secure urgent antibiotic administration in our Trust.
Cite 3 examples within the project which highlight promotion of the protection of antibiotics? Use of antibiotics promptly for patients with sepsis has been shown to reduce mortality and morbidity. Mortality is reported nationally as HSMR. In 2016 HEFT HSMR was 89.7 which is below the average for Midland’s trusts of 92.7 and has shown a favourable downward trend; of 137 trusts the Trust was positioned at 45, the lowest position being best.
Patients treated on time have reduced length of stay and therefore do not require extended courses of antibiotics which may lead to resistance. This has contributed to us being now the 111th (128 submitted on PHE fingertips) lowest hospital antibiotic users in England, as documented by Total DDDs per 1000 admissions at end of Q2 2016/7.
The bleep/dashboard help ward managers review where lapses are occurring so that measures can be put in place to reduce the number of missed doses of urgent antibiotic treatment. Missed doses may result in sub-therapeutic concentration of antibiotics which is a known risk factor for the selection of antimicrobial resistance.
Key outcomes of project?: Approximately 1500-2000 antibiotic stat doses are prescribed at HEFT per month. Over 80% of these patients now receive their STAT dose antibiotic within one hour. This compared with 40% at the start of project in 2013.
Many QI projects fade after initial gains. Our project is an exemplar of sustainability. We have consistent improvement over the last 18 months of STAT administration of antibiotics >80% for patients with sepsis.
We showed it was possible to succeed in a QI project at huge scale, in a large Trust with 3 different hospital sites with 11,000 staff.
How is the project to be developed in the future?: We have begun sharing our development model on antibiotic safety in sepsis with other hospitals that use JAC Electronic Prescribing system.
We are extending the use of pager bleep for other time critical medicines within HEFT. It has now been successfully implemented for another group of time critical medications i.e. Parkinson’s drugs.
We are planning on extending our project to non-electronic prescribing areas
Name: Shabana Ali
Brief overview of the project: The SWBCCG antibiotic protection project aims to increase understanding of the issue of antibiotic resistance and motivate antibiotic stewardship in a highly innovative and inspirational manner.
Having tackled the issues of unnecessary antibiotic prescribing using innovative methods to change prescribing behaviour at GP level, we had to take it to the next level, including our patients in improving their knowledge and understanding of the topic. The main challenges we had to address in the patient arena were the wide variation in their understanding of antimicrobial resistance, the varied demographic population in this CCG, and the beliefs of the different types of communities we serve. This led to the introduction of a patient/public education and engagement program.
From the offset, the antibiotic protection project has been underpinned by education and awareness delivered to a wholly inclusive population by a variety of mechanisms to elicit a change in demand, and prescribing habit. Patient groups that we normally work with are linked to GP practices and have proactive patients attending who already have some basic knowledge of such issues, and we needed to speak to patients who aren’t as proactive or knowledgeable in this area.
We developed engagement strategies for the different communities including migrant groups to deliver a multi-faced education programme. The highest prescribers of antibiotics within the CCG were identified, and we targeted populations around these practices for education. Patients were ultimately at the centre of this project, we raised awareness across our demographic population by working with churches, temples, various patient groups and specific community groups to convey our key educational messages, with the intention that they take the messages back home to their friends and families. We have reached out to a wide audience via a BBC Asian Network radio discussion with antibiotic resistance as the topic.
After having reviewed all of our engagement techniques the decision was made to take the subject to patients targeting high prescribing practices. Each locality team identified 2 high prescribing practices in their area including walk-in-centres and organised an event, during World Antibiotic Awareness Week, to educate the public and measure patient learning pre and post antibiotic talk. We were also approached by our neighbouring CCG who were delivering educational sessions to community pharmacies, and we have now launched a similar programme of training to Pharmacies in SWBCCG to ensure a consistent approach across the STP.
List any supporting partners or organisations worked with:
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category: Having evaluated feedback from both GPs and patients it was clear that the key to sustaining appropriate prescribing would be to engage with patients as well as clinicians. We had already presented at patient network groups etc. about antibiotic resistance and had anecdotal evidence that our project was successful. On evaluation of our target audience, we decided that we needed to engage with patients who are not as proactive on accessing information as those that we had been speaking to. The next step was to take the information to our patients. I addition to this, we needed to measure the outcome of our events, in order to evidence the difference we were making. So a tool was developed to enable us to measure patients understanding before and after we discussed the topic of antibiotic resistance with them. The tool we used during patient engagement was in the form of a quiz which was split into 2 sections, the first section to be completed before the discussion, and the second after.
This talk proved to be very useful in explaining what antibiotic resistance really is. Many patients thought they knew what antibiotic resistance was because they had heard people refer to the term, but the majority of them didn’t know the process or the implications.
The results from this piece of work were as follows from 154 responses:
Name: Heather Edmonds, Head of Medicines Management
Brief overview of the project:Development of resources suitable for people with learning disabilities and people for whom English is not their first language.
Leeds North CCG is the lead commissioner for “Learning disabilities” services within the Leeds city areas. As part of this role we try to recognise the needs of people with learning disabilities and support them to access services and information to support their health needs.
Leeds is the most diverse city in England outside London with a population of 800,000. There are at least 84 different languages spoken with Leeds. There are about 50,000 people for whom English is not their main language and over 10,000 people who do not speak English well or at all http://www.claritysocialenterprise.org/leeds-languages/). Many of these people do read their own language therefore translating any information does not always solve the problems and not always cost-efficient.
Taking these issues into account we worked with a number of agencies to seek the best way to support these patients. The outcome of this work was to develop a patient information leaflet that was pictorial, but contained more detailed safety netting information on the reverse, as usually friends or other family members are able to read English and also to develop translated leaflets in the most common languages.
Supporting partners or organisations worked with:
Service User Involvement Facilitator, Learning Disability Service, Leeds and York Partnership NHS Foundation Trust.
Commissioning Manager, Learning Disabilities & Autism, Leeds Clinical Commissioning Groups Network.
GP, who works with a multi-ethnic population and understands the issues around language.
Leeds Involving People.
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category:
On behalf of the Leeds CCGs Leeds Involving People carried out 7 focus group consultations across various ethnic groups. We had very positive feedback, with members of the focus group reflecting that they had seen the leaflets within their GP practices. Comments fed back from the focus groups:-
• Bold, large font in black and white was the most noticeable and accessible wording format. This was particularly appreciated by those with sight problems.
• Use of humour and striking images, such as the unhappy face, were engaging and aided the message of the text.
• Participants noted that the use of engaging images would be appealing to children and some people with learning difficulties.
Feedback from health professionals working with learning disabilities :
“This looks a great piece of work that would focus as a good tool for practitioners and help raise people’s understanding”
“it looks brilliant. I’m sure it would work well with our client group“
“I like it”
The results of the project showed that we had produced a set of leaflets that were appropriate for our target audience, were being used by our GP practices and that the sample of people who attended the focus groups found the materials memorable and remembered seeing the leaflets even after several weeks. It also meant that the messages around antibiotic stewardship were reaching as wide a range of the population as possible.
This was demonstrated by our evaluation of the campaign as we asked people who recalled seeing campaign material what they felt the main campaign message was. People could enter what text they wanted, and this was content analysed. The top four themes people suggested were:
• Antibiotics are not effective on coughs, colds and sore throats (43.7%).
• Antibiotics do not work on viral infections (22.2%).
• To raise awareness of AMR (11.7%).
• Try not to use antibiotics (11.1%).
Cite 3 examples within the project which highlight promotion of the protection of antibiotics? Max 400 words:
Key outcomes of project?:
The development of the easy read leaflet, which had positive feedback and helped to ensure that key messages around antibiotics were accessible to a section of the population that currently no leaflets have been developed for.
How is the project to be developed in the future?
We intend to use this approach to work with our population to continue to develop materials that are accessible to our whole population to deliver key messages about antibiotics, such as resistance. We are happy to make these resources available to other CCGs and practices in other areas.
Antibiotics Campaign – Update February 2016
Contact has been made with the following 68 Primary schools:
|Park View Primary Academy|
|Brown Hill Primary Academy|
|Woodlands Primary Academy|
|Pudsey Tyersal Primary School|
|Pudsey Bolton Royd Primary School|
|Wigton Moor Primary School|
|Broadgate Primary School|
|Beecroft Primary School|
|Blenhiem Primary School|
|Brudenell Primary School|
|Iveson Primary School|
|Kirkstall Valley Primary School|
|Little London Primary School|
|Quarry Mount Primary School|
|Spring Bank Primary School|
|Rosebank Primary School|
|Adel Primary School|
|Weetwood Primary School|
|Bankside Primary School|
|Chapel Allerton Primary School|
|Gledhow Primary School|
|Talbot Primary School|
|Bracken Edge Primary School|
|Kerr Mackie Primary School|
|Alwoodley Primary School|
|Carr Manor Primary School|
|Highfield Primary School|
|Moor Allerton Primary School|
|Moortown Primary School|
|Ebor Gardens Primary School|
|Harehills Primary School|
|Hovingham Primary School|
|Richmond Hill Primary School|
|Seacroft Grange Primary School|
|Wylebeck Primary School|
|Shakespeare Primary School|
|Greenmount Primary School|
|Hunslet Moor Primary School|
|Middleton Primary School|
|Ingram Road Primary School|
|Hugh Gaitskell Primary School|
|Armley Primary School|
|Farsley Farfield Primary School|
|Burley St Matthias C of E Primary School|
|Christchurch Upper Armley C of E Primary|
|St Bartholomews C of E Primary School|
|St Chads C of E Primary School|
|Roundhay St John’s C of E Primary School|
|St Anthony’s Catholic Primary School|
|St Augustine’s Catholic Primary School|
|Christ the King Catholic Primary School|
|St Francis of Assisi Catholic Primary School|
|Holy Family Catholic Primary School|
|Corpus Christi Catholic Primary School|
|St Joseph’s Catholic Primary School|
|St Nicholas Catholic Primary School|
|Sacred Heart Catholic Primary School|
|St Phillip’s Catholic Primary School|
|St Patrick’s Catholic Primary School|
|Holy Rosary and St Anne’s Catholic Primary School|
|Adel St John the Baptist C of E Primary School|
|St Mathews C of E Primary School|
|All Saints C of E Primary School|
|St Peter’s C of E Primary School|
|Beeston Hill St Luke’s C of E Primary School|
|Shire Oak C of E (VC) Primary School|
|Mill Field Primary School|
|Allerton C of E Primary School|
Engagement with Community Groups/Venues
Engagement (leaflets, posters, talks) in the appropriate language with the following 37 groups/venues:
|Community group/venue, area and demographic|
|Advonet, city-wide, various|
|Hamara Centre, Dewsbury Road, South Asian men and women|
|Dosti, Armley, South Asian women|
|Healthy Living Network, city-wide, various|
|Iqra Centre, Moortown, Muslim|
|Feel Good Factor, Harehills, various|
|Beeston Business Bengali Centre, Harehills, Bengali speaking community|
|Better Leeds Communities, Burley, various|
|Health for All (Sangum Group), city-wide, Sikh and Hindu community|
|Leeds Refugee Forum, city-wide, Refugee and Asylum Seekers.|
|Leeds Black Elders, city-wide, Black Elders|
|Leeds Chinese Community Association, city-wide, Chinese|
|Leeds Kashmiri Elders Association, city-wide, Kashmiri|
|Leeds Swahili Culture Community, East-End Park, Swahili|
|Leeds Migrant Community Network, city-wide, various|
|Nari Ekta, city-wide, Asian women|
|PAFRAS, Harehills, Refugee and Asylum Seekers|
|Polish Saturday School, city-wide, Polish|
|Prince’s Trust, city-wide, young people|
|Russian Speakers Club, city-wide, Russian speakers|
|Shantona Women’s Centre, Harehills, Asian women|
|Sikh Elder’s Service, city-wide, Sikh|
|Swallow Hill Community College, Armley, various|
|Women’s Asylum Seekers Together, city-wide, Asylum Seekers|
|Touchstone, city-wide, various|
|Women’s Health Matters, city-wide, various|
|Woodhouse Community Centre, Woodhouse, various|
|Somali Group, city-wide, Somalian|
|Lincoln Green Support Centre, Burmantofts, various|
|East Leeds Health for All, LS9, various|
|Osmondthorpe Resource Centre, LS9, various|
|Ramagrahia Board, Chapeltown, Sikh|
|Unity Housing Association, Chapeltown, various|
|One-Stop shops, city-wide, various|
|Sangam Group, city-wide, South Asian|
|Leeds Irish Health and Homes|
|Migrant Community Network|
Engagement with places of worship
Engagement (leaflets, posters, talks) in the appropriate languages with the following places of worship:
|Place of worship|
|Lincoln Green Mosque, Burmantofts|
|Masjib E Quba Mosque, Harehills|
|Muslim Cultural Society, Harehills|
|Makki Masjid and Madrasa Mosque, Burley|
|Kashmir Muslim’s Community Centre and Mosque, Dewsbury Road/Beeston|
|The Baab ul ilm Centre Mosque, Alwoodley|
|Al Madina Mosque, Woodhouse|
|Grand Mosque, Hyde Park|
|Islamic Centre/Central Jamia Mosque, Chapeltown|
|Jamia Masjid Ghousia Mosque, Armley|
|Leeds Aqra Mosque, Harehills|
|Shahjalal Jamia Masid, Harehills|
|Makkah Masjid Mosque, Woodhouse|
|Hindu Temple, Woodhouse|
|Sikh Temple, Chapeltown|
|Sikh Temple, Chapeltown|
|Sikh Temple, Harehills|
|Sikh Temple, Armley|
|Sikh Temple, Beeston|
|Hope Centre, African|
|Living Hope Church, African|
Leaflets have been distributed in the following shops:
|Shop and area|
|Polish/Eastern European Shops LS7|
|Polish/Eastern European Shops LS8|
|Polish/Eastern European Shops LS9|
|Polish/Eastern European Shops LS12|
|Teck Newsagent, Dewsbury Road|
|Select Housing, South and North Leeds|
|Catlows, Dewsbury Road|
|Sweeny Todd Hairdressers, Chapeltown|
|Dutch Pot, Chapeltown|
|Pretty Woman, Chapeltown|
Talks have been arranged with the following 24 groups/venues:
|Black Elders group|
|Migrant community – Czech and Slovak Roma; Eritrean, Syrian, Ethiopian and Afghan|
|Refugee and Asylum Seeker workshop|
|Female Asylum Seekers|
|English Language class – Kurdish and Arabic|
|Swahili Women’s group|
|Polish Parents group|
|Bangladeshi and Iranian Parent group, Hunslet|
|Afghan Women’s Association|
|South Asian men’s group|
|South Asian women’s group|
|Leeds Combined Arts, BME mixed|
|Prince’s Trust, young BME mixed|
|Shantona, South Asian women|
|Dosti, South Asian women|
|Nari Ekta, South Asian women|
Name: Samantha Lippett, Lead Antimicrobial Pharmacist
Please provide a brief overview of your project? Max 400 words: Following a Pharmacy scoping visit to University Teaching Hospital & The University of Zambia in Lusaka, Zambia during April 2016 it was identified that although antimicrobial stewardship is cited as a priority it is not formally taught on the undergraduate curriculum. An agreement was reached with the University of Zambia to include antimicrobial stewardship within the final year curriculum for pharmacy undergraduates, medical students and nursing students. The Lead Antimicrobial Pharmacist at Brighton & Sussex University Hospitals took responsibility to write & record a lecture on this subject using recording equipment at Brighton & Sussex Medical School for use by the University of Zambia. Care was taken to produce the lecture recording in small sections so that the file could be successfully downloaded in Zambia given the restrictions with their internet speed.
List any supporting partners or organisations worked with: Brighton – Lusaka Health Link (registered Charity)
Brighton & Sussex Medical School
University of Brighton
University of Sussex
University of Zambia
University Teaching Hospital, Lusaka, Zambia
How has your project demonstrated success in highlighting antibiotic stewardship within your chosen category? Max 400 words: All healthcare undergraduates that will influence antibiotic prescribing once qualified have access to tailor made teaching materials on antimicrobial stewardship relevant to Zambia.
Cite 3 examples within the project which highlight promotion of the protection of antibiotics? Max 400 words: Lecture included:-
* concept of ‘review and revise’ by 72 hours for all antibiotic prescriptions.
* influence of animal use of antibiotics on human healthcare
* WHO perspective on antimicrobial resistance
* how to monitor antibiotic consumption utilizing ‘defined daily doses’
Key outcomes of project?: To have antimicrobial stewardship formally included in the undergraduate curriculum for pharmacy, medical and nursing students in Zambia hence raising awareness for when they become practitioners themselves.
Note: All healthcare practitioners in Zambia are trained in Lusaka at the University of Zambia
How is the project to be developed in the future?: Develop further antimicrobial stewardship educational resources to be used within the undergraduate courses e.g. case based learning
Promote access of the recorded lecture to existing pharmacy, medical & nursing staff
Supporting University Teaching Hospital (UTH), Lusaka to monitor antibiotic consumption in areas of high usage (current priority is the neonatal unit)
Implementation of the Microguide App within UTH to disseminate locally produced antimicrobial prescribing guidelines