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Shared Learning Archive 2017-2019: Diagnostic Stewardship

2019 Entries

Mid Yorkshire Hospitals NHS Trust

Provide a brief overview of your project?

We evaluated the effectiveness of a point-of-care testing (POCT) model for influenza A/B and respiratory syncytial virus (RSV) in an NHS Trust without onsite laboratory-based virus diagnostics. A retrospective before-and-after intervention study was conducted to compare outcomes between off-site and POCT for influenza/RSV. A polymerase chain reaction (PCR) influenza A/B and RSV POCT machine (Cepheid®) was introduced to the emergency department (ED) of Pinderfields Hospital in November 2017. POCT was available for all inpatients, and full respiratory virus screens were processed off-site if requested. ED nurses underwent training to ensure consistent nasopharyngeal sampling and use of POCT equipment. Patients were selected for testing based on likelihood of requiring treatment according to Public Health England guidance. Study patients were identified from pathology records for the time periods 1 December 2016 to 28 February 2017 and 1 December 2017 to 28 February 2018. Positive influenza A/B and RSV tests were compared for: length of hospital stay (LOS), length of ED stay, hospital costs, antibacterial duration, ratio of oseltamivir use to positive tests, and inpatient mortality. Hospital outbreaks and test costs were also evaluated. Ethics approval was not required. A chi-square test was used for proportions and Mann-Whitney U-test for LOS comparison.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

In patients who had a positive test, median antibacterial duration reduced from 6 days (IQR 2.5-7) to 4 days (IQR 2-6). This potentially attenuated AMR through more appropriate use of antibacterials.
The ratio of oseltamivir use (full courses) to positive tests reduced from 386/46 (8.4) in 2016/17 to 758/346 (2.1) in 2017/18. This indicated more rational use of oseltamivir, thereby reducing the overall burden of exposure to  oseltamivir.
Median LOS decreased from 8.5 days (IQR 4-21 days; n=46) in 2016/17 to 4 days (IQR 2-8; n=346; p=0.12) in 2017/18. Length of stay was shorter in the patients who received a POCT. This reduced exposure of those patients to other potentially resistant organisms in the hospital setting.

How is the project to be developed in the future?

Further development in this project will look at the impact of different POC testing methodologies to increase the number of patients tested.

Schwabe Pharma UK

Provide a brief overview of your project?

The project is a development of a pilot study of Point-of-care C-reactive protein testing (POC) in community pharmacy to deliver appropriate interventions in respiratory tract infections. It demonstrated 86% of patients receiving the POC test did not require referral to their GP or an antibiotic prescription. The study was published in Clinical Pharmacist in May 2018 and selected for inclusion the Royal Pharmaceutical Society Science and Research Conference in January 2019.
As a result of the success of this pilot study, the project is planned to be extended into another 9 pharmacies already providing enhanced services to manage antibiotic prescribing in ear, nose, throat and skin infections, and a further 15 pharmacies that are about to enter this scheme, within the next 6 months. The existing scheme permits participating pharmacies to perform examinations using an otoscope, where necessary carry out testing for streptococcus A and when appropriate-based upon an approved clinical protocol-issue antibiotic prescriptions using the Patient Group Directive Initiative.
It is anticipated that by autumn 2019 the number of community pharmacies offering this service will rise to 70, with each one also providing CRP testing in respiratory tract infections. All interventions will be recorded using the Pharmoutcomes reporting system, where details of the first contact will be summarised as will patient follow-ups, 7 days subsequent to the initial entry. This will enable any engagements with GPs relating to the initial condition to be assessed, along with details of any antibiotic prescriptions recorded.
Additionally, a small chain of pharmacies, with a presence in GP surgeries are using the study to develop a project whereby CCG funding is used to locate POC testing within the pharmacy to optimise that resource and as a triage for patients with respiratory tract infections, in order to reduce GP appointment loads and antibiotic prescribing.


Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

The result of the initial pilot study has been to
a) Enable the community pharmacy originally involved in the pilot study to develop relationships with the local GP practices, such that the service is seen as a valuable resource that can reduce unnecessary GP appointments and provide a more objective rationale around the prescribing of antibiotics for respiratory tract infections. Furthermore, as a result of coverage of the service in the local press, its availability has raised awareness in the local community regarding antibiotic guardianship. This experience is now to be used as a model for the roll-out of the scheme to other pharmacies within the Local Pharmaceutical Committee  delivering the expanded service provision described above.
b) Create confidence amongst those procuring enhanced service provisions of the value of community pharmacy in terms of providing a meaningful contribution to improving GP efficiencies and reducing antibiotic prescribing. This will also provide a possible, as yet to be explored role within community pharmacy which can add value to the profession in terms its role within the new primary care landscape.
c) Deliver a structured platform to enable other pharmacy organisations to seek opportunities to extend their enhanced service provision into POC testing and add an extra evidence based dimension to the anticipated role of community pharmacy within Department of Health and Social Care’s five year plan ‘Tackling antimicrobial resistance 2019-2024’


How is the project to be developed in the future?

The future development of the project will be based upon the data generated from the extended scheme, where all initial engagements and subsequent follow ups will be recorded on Pharmoutcomes. Hence during the 2019/20 winter the effectiveness of POC interventions in a significant number of pharmacies will be able to be analysed to provide a meaningful assessment of the contribution community pharmacy can make in this arena. It will enable the beneficial role that community pharmacy can play in improving GP efficiencies in managing respiratory tract infections to be explored as well as provide insight into the way in which POC testing can help reduce antibiotic prescribing.

Attenborough Surgery

Provide a brief overview of your project?

The project follows on from a previous pilot using CRP point of care testing for the management of lower respiratory tract infections in a GP setting. In last year’s work the uptake of tests was lower than predicted, with some GPs feeding back that during their busy clinics they did not have time to carry out testing. This project looked to address some of these issues highlighted by hosting the CRP testing within a pharmacy local to the GP surgery.
Patients with symptoms of an acute cough for less than 3 weeks were seen and assessed at the GP surgery. If the clinician wasn’t sure if they should prescribe or if the patient had a high expectation for antibiotics the clinician would send an EPS prescription directly to Abells with a pharmacy note directing them to follow the CRP POCT protocol. The patient was sent an SMS text (via Accurx) explaining why the test was ordered and where to present for the testing.
Following the NICE guidelines (NICE 2014, 191) the result of the CRP test would determine if the prescription was dispensed, delayed or returned to the spine. The pharmacy team would offer self care advice supported by the “Treating your infection” patient advice leaflet.
There was no financial incentive, however the pharmacy team was willing to host as it increased footfall and gave them an opportunity to make secondary sales.
Posters were displayed in all the clinical rooms prompting GPs to offering CRP testing.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

IT support –
1. The SMS text messaging support instructed the patient where to go, why the test was being offered and why antibiotics are not always the answer. The message was saved automatically into the patient’s notes.
2. An EMIS template was developed. I also contacted EMIS and requested 2 new codes for ‘CRP point care test requested’ and ‘CRP point of care test result’ so results could be recorded and differentiated from lab results. These codes are now available nationally
Increased uptake – Far more GPs offered CRP testing because they didn’t have to make any adjustments to their busy clinics. However, the lack of connectivity was a trade-off for not doing the tests themselves.
Upskilling and involving the pharmacy team- The training and setting up of the project was simple as the pharmacy team was small making it easy to arrange competency training in one visit.
Fewer patients re-attending and reduced antibiotic prescriptions- 79% of patients had a CRP less than 20mmol so were not dispensed antibiotics. When patients clinical notes were reviewed after 28 days 73% of patients didn’t require a follow up appointment.

How is the project to be developed in the future?

The next stage of this project is to add in connectivity. I need an efficient way of getting the results back to the clinician. This would give the clinician an opportunity to learn and reflect on their decision to prescribe and make any adjustments to borderline or unexpected results.

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