Basildon & Thurrock University Hospital

Provide a brief overview of your project?
The development of a novel method of generating referrals, with an increased use of automated technologies to make best use of resources to support the antimicrobial stewardship agenda. An automated intranet-based referral service was developed using “concrete5” an Open Source Content Management System (CMS) to improve access for clinical advice requests.

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

1. Increased number of referrals by 59% – allowing greater numbers of stewardship interventions
   2. An efficient portal via which ward pharmacists can refer questionable antimicrobial prescribing in real time to the microbiology clinical team for review
   3.  Has led to a substantive decrease in inappropriate broad spectrum antibiotic prescribing (piperacillin-tazobactam (tazocin) reduced by 61% and carbapenem usage reduced by 34%)

How is the project to be developed in the future?
The system has proved so successful that we are working with neighbouring trusts to introduce similar systems.

Public Health Agency

Provide a brief overview of your project?
Imagine you are tasked with reducing gram-negative bacteraemias (GNBs) without understanding the risk factors for these infections or reducing antibiotic consumption without knowing your baseline. What does improvement look like? And how do we know if interventions have been effective?  This was the situation in Northern Ireland (NI) during 2017 when we committed to halving GNBs and antibiotic consumption in secondary care by 2021. The solution: a web-based platform built in-house, at no cost, to create a “one-stop shop” for intelligence on GNB and antimicrobial consumption in secondary care; HI-Surv.

The aim of HI-Surv is to empower local teams by providing them with the information they need to take action to reduce the burden of antimicrobial resistance. We developed existing team member expertise in the Public Health Agency to create a SharePoint web-based platform (hosted within the Health and Social Care network) which provided a regional solution to access local data, accessible by the five Trusts in NI.

HI-Surv enabled the collection of risk factor information for GNB. For the AMC data, we established data flows from the five Trust data centres and prepared the data, using R software, for visualisation on HI-Surv. The result was a set of Trust specific dashboards which allowed the timely analysis of GNB (real time) and secondary care AMC data at a ward level (monthly).

We conducted a pilot and embarked on a process of engagement with key stakeholders, hosting a workshop in February 2018 for infection control Doctors and Nurses, information analysts, antimicrobial pharmacists and DoH colleagues. In March 2018, we conducted a series of Trust visits where we met with local teams and conducted training / took feedback and made further updates to ensure that HI-Surv was fit for purpose for frontline staff.

Hi-Surv went live in April 2018.

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

1. Hi-Surv provides an interactive dashboard that allows Trust teams to view quality assured antimicrobial usage data. One chart shows the top 10 highest consuming wards for chosen antibiotic criteria (all versus specific antibiotic) which was used by a Trust team to improve stewardship in the Emergency Department: this was previously not a focus for improvement work. The data on Hi- Surv showed an issue in ED and drilling into the data a particular antibiotic, which the Trusts should conserve, was the largest. This led to a focused audit and the consumption of the drug has since been decreasing.
   2. Hi-Surv has helped Trusts to understand the profile of patients who have Gram-negative bacteraemia. One Trust was able to identify cases where the infection may be associated with the presence of a urinary catheter. Though small in number, this allowed them to look at catheter management for patients in their own homes. This Trust is supporting a Trust Improvement initiative to develop district nursing and patient knowledge in the aspects of good care and management of long-term urinary catheters. The identification of people who have risk factors for urinary tract infections and have been prescribed long-term antibiotic prophylaxis by their general practitioner allowed a Consultant Microbiologist in this Trust to link directly with the patient’s General Practitioner to review antimicrobial prescribing. This is part of a Trust wider initiative in improving antimicrobial stewardship and addressing antimicrobial resistance.
   3. Developing this IT solution presented an opportunity to empower surveillance staff to develop their data science skills and importantly to use these skills to provide information for action for frontline staff. We encouraged collective leadership both within the team but also with the pilot Trusts who were able to act as ambassadors for the new system.

How is the project to be developed in the future?

1. We are currently in the process of evaluating the first 6 months of HiSurv focussing on completeness of risk factor information, usability and utility of the dashboards. We will use this information to ensure that HI-Surv remains fit for purpose.
   2. The focus to date has been the development of local intelligence for front line staff but we will move during 2019/20 to develop dashboards at a regional level for policy makers to assess progress towards targets.
   3. By developing the team expertise there is now confidence to consider expanding HI-Surv to other programmes. For example, work us underway to capture community Clostridium difficile data from our national enhanced programme. We also plan to expand the system to include the key drug-bug AMR combinations that are monitored as part of AMR surveillance in the UK.
   4. Finally, we are working with primary care colleagues to share our knowledge of dashboard development to develop complementary systems for antimicrobial consumption in that setting. This will enable progress towards a vision for a healthcare system wide approach to antibiotic stewardship and AMR.

Nottingham University Hospitals NHS Trust

Provide a brief overview of your project?

Background
This is a collaboration between the Information and Insight the Antimicrobial Stewardship Team and Antimicrobial Consultant Specialty Champions to produce a bespoke Antimicrobial Stewardship Interactive Dashboard for Nottingham University Hospitals NHS Trust. The initial aim was to improve the accessibility of antibiotic usage for each specialty and divisions, improving engagement with the Antimicrobial Stewardship Programme and CQUIN targets.

Functionality
Data is displayed in defined daily doses (DDDs) per 1000 admissions. Each admission is allocated to the relevant wards according to the fraction of the total length of stay on each ward.
Modules allow users to drill down and compare different areas with data presented both longitudinally and per calendar month to allow for seasonal differences (i.e. comparing January 2019 with January 2018 and January 2016 within the baseline year). This enables the consumption to be filtered by Division, Specialty and/or Ward level. Consumption can also be split by product group and antibiotic drug and into monthly or weekly usage.  The dashboard also allows consumption to be displayed in DDDs without adjustment for activity. There is a separate module focused on the proportion of antibiotics for each WHO AWaRe category.

Implementation
A guide to using the dashboard was developed to facilitate its adoption (see PowerPoint training pack for Specialty Champions).
The dashboard updates are included within the Monthly governance team reports to Divisional management and to the Specialty Antibiotic Consultant Champions to improve local engagement and highlight areas/issues for audit and improvement in a Trust without e-prescribing.
Since its launch, the dashboard has been developed to include performance on 24-72 hour antibiotic review, again allowing greater visibility and engagement across a large 1,700 bed tertiary referral organisation.

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

1. Performance visibility:
   Up to date antibiotic consumption performance data is instantly available to grassroots clinicians thus the dashboard has improved Board to ward engagement with Antimicrobial Stewardship Initiatives. The Trust’s Antimicrobial Stewardship Work plan (see attached) incorporates Specialty and Divisional actions to review their consumption data on a regular basis and explain/report back any trends and action (e.g. planned audits).

   2. Performance monitoring:
   The dashboard has provided the Antimicrobial Stewardship Team with a detailed, timely and accurate overview of consumption within the Trust. This allows early recognition of worrying trends of increasing usage within the Trust and this can be used as evidence to initiate discussions with the relevant clinical teams. For example, within Haematology we noticed an increase in co-trimoxazole prescribing (see additional slides). Discussions with haematology consultants and specialist pharmacists have uncovered an increase in new anti-cancer drugs regimens (including Pl3Ki and BTKi for lymphoma/CLL, ibrutinib, Bendamustine and rituximab) which warrant PCP prophylaxis with co-trimoxazole.
   Similarly use of the dashboard has allowed us to spot an increase in doxycycline DDDs within Genitourinary medicine prescribing. A discussion with the Antibiotic Consultant Champion has highlighted a change in national guidance due to increased resistance leading to an appropriate change in practice.

   3. Prioritising areas for intervention:
   The dashboard has allowed us to identify areas which would benefit from antimicrobial stewardship interventions and to monitor their effectiveness. For example we planned to implement a “dip or not to dip” project to improve UTI diagnosis and prescribing. The dashboard identified one of the admissions wards as an area with increased UTI medication prescribing. We used this area as a focus in the initial roll-out of the project in December 2018 and have been able to use the dashboard to monitor reductions in consumption.

How is the project to be developed in the future?

The dashboard will be further developed in line with national targets for 2019/20. We aim to expand the current functionality to include consumption of antifungal and antivirals within separate modules.
We plan to develop a module to display the results of the Trust-wide antimicrobial stewardship audit. This is an audit led by the Specialties looking at the quality of infection management and antibiotic prescribing in line with Start Smart then Focus.
We have developed a beta-module for outpatients with prescribing listed as DDDs per 1000 outpatient attendees per consultant clinic.
In the future, we plan to add antimicrobial resistance and healthcare acquired infection rates (eg C. difficile) to allow Specialties and Divisions to correlate performance with changes in antibiotic usage.

NIHR Newcastle In Vitro Diagnostics Co-operative (The Newcastle Hospitals NHS Foundation Trust)

Provide a brief overview of your project?

The National Institute for Health Research Newcastle In Vitro Diagnostics Co-operative (NIHR Newcastle MIC, Director Prof John Simpson), was established in January 2018, building upon the success of the previous NIHR Diagnostic Evidence Co-operative (DEC) Newcastle (2013 – 2017).

The role of the Newcastle MIC is to work with technology developers in academia and industry to deliver high quality scientific evidence on their in vitro diagnostic tests and medical devices. Our work is focused on the analysis of the care pathway (the journey of a patient with a specific condition in the healthcare system), economic modelling and clinical evaluations. The care pathway analysis supports identification of the patient population; the role(s) of the test (with the aim of maximising value to patients and clinicians); the cost of the test (to be cost-effective for the NHS); and potential barriers to adoption. These barriers might be overcome if the technology is tailored to the user’s needs. Our work increases the chances that the test is fit for purpose and, thus, adopted.

We have positioned ourselves as a MIC specialising in infection with Dr. Ashley Price leading this theme since 2013. We supported companies and researchers to obtain funding and helped them to secure around £7.4 million from various funding schemes.  Dr. Sara Graziadio and Dr. Joy Allen, MIC senior methodologists, have engaged with more than 40 companies developing infection diagnostics. This includes innovative tests which could help to diagnose sepsis, pneumonia and exacerbations of chronic obstructive pulmonary disease (COPD) earlier, allowing antibiotics to be prescribed only when necessary and for a shorter period of time. We are also supporting companies who are developing rapid point of care tests for diagnosing influenza.

Therefore, our project seeks to reduce unnecessary antibiotic use through evaluation of rapid, accurate diagnostics, using expertise in the MIC.

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

1. We collaborated with Mologic Ltd. on a project aimed to monitor symptoms in patients with COPD and to discourage antibiotic usage when an exacerbation is unlikely. Our economic evaluation informed the price of their test (they decided to halve it after our evaluation) and the patient population where the test was most likely to be cost-saving (inclusion criteria for the following clinical study were based on our results). A clinical study to develop the algorithm of their home-monitoring test has just been concluded and we are currently planning its validation.

   2. We participated in a large randomised controlled trial in suspected ventilator-associated pneumonia (VAP; led by Simpson). VAP has the highest mortality of all hospital-acquired infections, and is commonly caused by antimicrobial-resistant pathogens. The research group previously established biomarkers that effectively exclude VAP, and the trial randomised patients with suspected VAP to routine care or to biomarker-guided antibiotic recommendations, with the aim of determining whether antibiotic stewardship could be improved by the use of biomarkers. The trial ran across 24 UK intensive care units, in collaboration with Becton Dickinson Biosciences and recruited to target. Results have been collated and a manuscript submitted for publication.

   3. Our work with Alere and Cepheid enabled us to develop a care pathway for patients with suspected influenza. The model demonstrated significant cost savings associated with a point of care test for influenza. Newcastle upon Tyne Hospitals NHS Foundation Trust has now adopted this technology and this has led to early identification of patients with influenza. This means that patients can be discharged earlier and more appropriate therapy can be started with narrower spectrum targeted antibiotics used if secondary infection is suspected and stopping antibiotics in patients with influenza.

How is the project to be developed in the future?

Improving antibiotic stewardship through the evaluation of high-quality, rapid tests for the diagnosis of infection is an ongoing project for us, with continuous development and refinement. We actively encourage engagement with in vitro diagnostic companies in the infection space, and we have an annual conference to highlight opportunities. For every enquiry related to a new infection diagnostic, we rapidly create a working group to map out in detail the care pathway in paediatrics and adult of patients with suspected infection, and approach companies to develop technologies that we require across that pathway.  We identify areas for future high value collaborate, and have identified Sepsis and Urology as areas for focused activity.  We continue to engage with the public, survivors of infections and their families, so that our pipeline of activity is informed by patient experiences. Our aim remains the development of tests that can prompt and appropriate de-escalation of antibiotics, targeting antibiotics to exactly the patients who most need them, and stopping antibiotics safely where they are not required.

University Hospital Southampton NHS FT

Provide a brief overview of your project?

University Hospital Southampton (UHS) introduced a 5-day automatic course length (5-DCL) policy within the main hospital electronic prescribing system for IV antibiotics (IVABs) and oral antibiotics in December 2018.  The aim of this intervention was to minimise prescribing of unnecessary doses of antibiotics and thereby reduce selection pressure for antimicrobial resistance.  Longer courses of antibiotics are associated with increased likelihood of resistance emerging and 5-DCL is supported by a growing body of evidence of the efficacy and safety of shorter courses of antibiotics for most common uncomplicated infections [Spellberg B, JAMA Sept 2016].

There are legitimate patient safety concerns surrounding 5-DCL and pharmacists have a role in risk-mitigation to ensure that patients who should remain on antibiotics after 5 days are highlighted to medical teams.  6-weeks after the introduction of 5-DCL, CPs were asked to record interventions made as a result of 5-DCL for a 2-week period to assess increase in work-load, identify near misses and opportunities to reduce risk.

UHS has 1100 beds with an average of 55 ward pharmacists.  Over a 2-week period 54 interventions were recorded representing a modest increase to pharmacist workload.  Of those interventions the majority (72%) involved the pharmacist removing the stop date for indications requiring longer courses e.g. infective endocarditis.  Training was provided to empower pharmacists to liaise with medical teams to make these decisions.  The specialist microbiology pharmacist team also reviewed patients on IVABs the day after they had been stopped for a period of 5-weeks after policy implementation.

The introduction of a 5-DCL has reduced antibiotic consumption within UHS with no apparent detriment to patient care but with a modest increase in pharmacist workload.  However, it is important to note that alternative robust risk-mitigation strategies were also in place to manage the implementation.

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

1. Implementation of the 5-day course length (5-DCL) policy coincided with a reduction in total antibiotic consumption (expressed as defined daily doses per 1000 admissions) of 13% comparing December and January 2017/18 (pre-intervention) with the same months 2018/19 (post-intervention).

   2. A total of 234 prescriptions were reviewed by the specialist microbiology pharmacist team during the five weeks post-implementation of 5-DCL. Fifty-five patients (24%) had IV antibiotics re-prescribed by the medical team on day 6.  The remaining patients did not re-start antibiotics (150) or were switched to oral antibiotics (29).  No patients were identified who had stopped IVABs on day-5 inappropriately.

   3.     Antimicrobial stewardship (AMS) is increasingly a priority for pharmacists.  Prior to implementation of the 5-DCL policy, not all antibiotic prescriptions were reviewed by UHS pharmacists from an AMS perspective, with priority given to identification of dosing errors and drug interactions.  The potential threat to patient safety of the 5-DCL policy has raised the profile of AMS within the pharmacy department.  Pharmacists, supported by training, report intervening at a higher frequency to ensure appropriate antibiotic prescribing within UHS.  Pharmacists are confirming indications for antibiotics, reviewing treatment choices in accordance with trust guidelines and liaising with the medical teams to optimise care for a higher proportion of patients.

How is the project to be developed in the future?

Following implementation of a 5-day course length policy, clinicians voiced concerns regarding an important limitation of the existing e-prescribing system user interface, whereby drugs ‘disappear’ from the prescription after their stop date and are no longer visible to clinicians in contrast to previous paper prescriptions where recently discontinued medicines are easily visible.

UHS is investing in an upgrade to the e-prescribing system which will display current and recently discontinued medicines in a format familiar to clinicians by replicating paper drug chart in a digital view.  The hospital is also exploring the potential to use the e-prescribing system to alert clinicians to antibiotic prescriptions continuing 24-72 hours after prescription start to prompt medical review and formulation of an appropriate antibiotic treatment plan for individual patients.

The 5-day course length policy will be highlighted during induction training for doctors, to ensure that the message of antimicrobial stewardship and appropriate antibiotic prescribing is robustly communicated to new staff in UHS.

NHS Wales Informatics Service

Provide a brief overview of your project?

In the UK around 60-78% of acute sore throat consultations with GPs result in an antibiotic prescription, even though most are caused by a virus, contributing to the global public health issue of antimicrobial resistance. (1,2) Antibiotic prescribing is partly driven by a desire to prevent suppurative complications in sore throats caused by Group A beta-haemolytic streptococcus (GABHS).   Throat swabs can help guide prescribing, but delays in bacteriology results limit their use in GP practices.
Seeking to guide antibiotic provision, NWIS secured an ETTF to develop a new update to the existing Choose Pharmacy technology, in place in community pharmacies in Wales. Software was developed and a new Sore Throat Test and Treat service (STTT) was integrated as part of the common ailment scheme (CAS) sore throat service, that currently only enables symptomatic treatment. Under STTT, patients with acute sore throat self-presenting to a participating pharmacy are stratified on their likelihood of having GABHS using FeverPAIN or CENTOR clinical scoring. For FeverPAIN >3 or CENTOR >2 an immediate Point of Care Test (POCT) is offered. Pharmacists are able to supply antibiotics to patients with a positive test result, based on predefined dosing schemes.
Two Health Boards in Wales have been funding the pilot of the service in 53 sites, since November 2018. This project is an evaluation of the first three months of the service and assesses the impact STTT has on antibiotic provision and patient education.

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

1) Out of 601 patients who had an STTT consultation, only 410 (68.2%) met the clinical scoring criteria and had a subsequent POCT. This is in line with principles of antibiotic stewardship, as a percentage of population are asymptomatic GABHS carriers but do not have GABHS infection. Without this screening more patients would have ended up with an antibiotic supply.
2) Out of 410 patients who met the clinical scoring criteria for POCT, only 128 (31.2%) had a positive result. Pharmacists referred 2 of these due to them feeling systemic unwell, and eventually 126 were supplied with antibiotics. This is an overall rate of ~1 in 5 patients supplied with antibiotics, significantly lower to the figures reported as resulted from consultations with GPs; hence, STTT further supports the NICE Innovation briefing (May 2018) that concluded that POCT in addition to clinical scoring systems increases diagnostic confidence of a suspected GABHS infection as opposed to carriage of the bacteria.
3) We have received so far 112 patient satisfaction surveys. Even though assumptions were not met to be able to perform statistical analysis (only 1 patient dissatisfied with the service), data suggests there is no link between satisfaction and antibiotic supply. Multiple quotes left by patients show their understanding of a viral versus bacterial infection and the role of POCT.
“I think this service is a brilliant idea especially that they take a swab to make sure whether antibiotics are needed.”
“I was so grateful for the service I received. My sore throat and cough was identified as a virus. So no medication was given. Excellent service.”

How is the project to be developed in the future?

We are planning to make the service available more widely in the current Health Boards that are piloting the service, and also extend it to other Health Boards. We will continue the evaluation to ensure we take into account seasonal variation, and we will investigate prescribing data to explore the impact on antibiotic prescribing rates. We will also obtain GP and OOH consultation data to check on whether the service reduces the number of sore throat consultations across primary care.

University Hospitals Birmingham NHS Foundation Trust

Provide a brief overview of your project?

A multi-disciplinary team met in summer of 2018 to plan a Trustwide campaign to increase awareness of the national Antibiotic Guardian “Keep Antibiotics Working” campaign during World Antibiotic Awareness Week and ensure this message is sustained. It was identified that in previous years a lot of effort had focussed on messages to reduce antibiotic usage and stop dates. While this made an impact in the short-term our focus needed to be on sustained improvements and it was recognised the key to delivering this was behavioural change. The multidisciplinary team consisted of nursing, medical, pharmacy, communications, graphics, infection control and microbiology staff. Their scoping work identified that peer to peer messages would be very powerful and in this digital era we needed to maximise usage of social media.
Working with the Trust graphics and communications team a series of short videos were filmed with patient facing nursing, medical and pharmacy staff who gave their personal pledge for the campaign. While the videos were shared across multiple platforms, the data below from the Trust Facebook page suggests excellent engagement:
• Consultant Haematologist video – 952 views
• Associate Head Nurse video – 1.1k views
• Diabetes consultant video – 149 views
• Ward Sister video – 103 views
• Pharmacist video– 113 views
On Twitter, to continue the good work planned by a colleague (and previous winner of AG Award) who sadly passed away, a unique hashtag was promoted:  #Doit4Das. This allowed us to track the profile of our campaign and reinforce the messages to use broad spectrum antibiotics responsibly. In excess of 2,000 impressions were captured for each of the 5 videos and media views ranged from 300 to 900.

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

Follow-up visits after World Antibiotic Awareness Week with the individuals who were filmed in sharing their personal message were arranged.  Members of the Trust infection control and antimicrobial stewardship team used these follow up visits to support their pledge and give guidance/advice where necessary. It was clear from these follow-up visits the individuals who were filmed had taken a proactive role in monitoring and improving the use of antibiotics in the clinical areas they were working in.

The infection control and antibiotic stewardship team also learnt from this experience and developed greater understanding of what motivating factors are important to drive sustained changes in behaviour.  Working with the staff who had engaged with social media a poster was developed that brought together the key messages from ‘Start Smart then Focus’ and CQUIN targets in an easy to understand manner.

The video from Associate Head Nurse gathered the best response on social media with in excess of 1,000 views on the Facebook page alone. As a result of increased nurse engagement following the social media campaign changes were introduced to the mandatory training programmes as well as the establishment of nurse link worker roles. Nursing staff now feel supported and empowered to engage with antimicrobial stewardship with issues such as the regular review of IV antibiotics.

How is the project to be developed in the future?

The importance of peers sharing education and awareness was noted as particularly important and one which will be used for future stewardship campaigns. There are plans to use social media to promote improvement in stop dates of antimicrobials and measure this on the Trust dashboard. We also intend to engage with wider group of staff to share their messages on social media and spread this amongst colleagues who work with them. With the far-reaching impact of social media it is likely these positive messages will support the global awareness to use antibiotics appropriately.

Heart of England NHS Foundation Trust (Winner – Antibiotic Guardian Awards 2017)

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

NHS Sandwell and West Birmingham CCG (Highly Commended – Antibiotic Guardian Awards 2017)

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:

• Microbiology & Lead Pharmacist for antimicrobials from SWBH NHS Trust – Local secondary care Trust
• Health Futures College
• Sandwell Academy
• King Edwards School
• Schools in Sandwell & West Birmingham
• Rights & Equality Sandwell
• Church – various
• Temple – various
• University of the third age (U3A)
• BBC Asian Network
• Local Pharmaceutical Committee
• Public Health – Sandwell & Birmingham
• Cross City CCG

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:

NHS Leeds North Clinical Commissioning Group (Highly Commended – Antibiotic Guardian Awards 2017)

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:

• The development of the easy read leaflet
  • Development of several antibiotic leaflets in various languages
  • The positive fed back from patients and health care professionals

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.