NHS Fife Antimicrobial Management Team
Item 7.3
Local Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP)
Refer to AMT meeting minutes and action lists for specific details of the actions outlined in this plan.
10. Action Plan: NHS Boards and their Area Drug and Therapeutics Committees
Recommendations
1
2
3
Action
All NHS Boards should immediately set up, as a
subgroup of their Area Drug and Therapeutics
Committee (ADTC), Antimicrobial Management
Teams (AMT), where these are not already in
place.
Progress
The AMT is a sub group of the Fife Area Drugs and Therapeutics
Committee
COMPLETE
To maximise implementation and monitoring of
the impact of any actions required or taken, the
Antimicrobial Management Team in liaison with
the Area Drug and Therapeutics Committee
should also link closely with:
 clinical governance and risk management
teams within NHS Boards and other
appropriate bodies
 NHS Board Infection Control Committee
 the Infection Control Manager
 appropriate ‘out of hospital’ agencies.
In collaboration with their Area Drug and
Therapeutics Committees, Antimicrobial
Management Teams would receive,
disseminate and ensure implementation of
advice from the Scottish Medicines Consortium
at NHS Board level regarding antimicrobial
resistance and antimicrobial utilisation, and coordinate work across hospital and ‘out of
hospital’ care areas.
Responsible
Person
SS/BM
Follow SAPG directives.
SS/GB
The AMT has reporting arrangements with the NHS Fife Operational
Clinical Governance Committee. This reports to the Strategic
Management Team (Risk Management).
SS/GB
The AMT has reporting arrangements with Fife ICC, and DL, NP
and SS attend ICC.
DL
Infection control manager is a member of AMT
SS/NP/IM
SS represents NHS Fife AMT on SAPG. Various AMT members
attend AMT network events.
SS/NP
COMPLETE
SAPG Minimum requirements for antimicrobial prescribing policies:
The initial aim was for these to be in place by end of April 2009. The
target for data collection for antibiotic prescribing indicators later
moved to August. Data collection and feedback of these indicators is
now occurring.
SAPG advice on Tazocin use in non-neutropenic sepsis discussed
at AMT and ADTC meeting.
COMPLETE/ONGOING - SAPG communicate with AMT leads and
AMPs. Actions are taken forward accordingly and this will occur on
a continuous basis.
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4
All ADTCs should ensure that Antimicrobial
Management Teams involve and engage with
members of the public in a meaningful way.
These persons would link into existing formal
Patient Focus and Public Involvement (PFPI)
structures.
Appoint public involvement
representative to AMT.
SS/NP
5
NHS Boards should also ensure that the
antimicrobial Automated Sensitivity Testing
equipment, recently funded by the Scottish
Government via a new national contract, is
adequately supported in terms of purchase of
consumables and participation in the national
surveillance arrangements as specified by
Health Protection Scotland.
Implement AST
SS/OG
Participation in national surveillance as
specified by HPS
HPS/CF/SS
Public involvement representative appointed March 2009, attending
meetings from 20th May 2009. Current member has resigned from
patient’s forum/AMT. Aim to recruit new representative but not
essential as more recent SAPG communications have stated it is
adequate if groups which AMT link to have representation (there is a
rep on ICC)
COMPLETE
Fully funded from April 2009
(Implemented January 2009)
Observa software functional from November 2009. Now able to
report AMR data directly to HPS via ECOSS. SAPG guidance to
AMTs received 30/6/10 – progressing with this. Note, there has
been a recent field safety notice alerting labs to a problem with
tazocin susceptibility testing on Vitek, this will pose a problem in
terms of reliability of our surveillance data. Update – a further field
safety notice has been issued expanding this to include further GN
organisms.
The problem with tazocin appears to have been resolved but it will
be a few months before the new tests will be implemented at local
level. Jan 2012.
NHS Fife will, via ECOSS, be participating in national surveillance of
AMR in urinary tract isolates. Jan 2012.
11. Action Plan: Antimicrobial Management Team (AMT)
1
Recommendations
Action
For the purpose of appropriate patient
management and antimicrobial resistance
surveillance, blood cultures should be submitted
before antimicrobial administration in all patients
with possible bacteraemia.
Education and audit.
Responsible
Person
NP
Progress
Approx 30% of blood cultures are not taken prior to starting
antibiotics. This has already been fedback to Clinical Governance
and presented by an FY1 doctor to the clinicians involved (2008).
Dr Adam Brown, Consultant Microbiologist/ICD was leading on work
re taking blood cultures but has now left Fife. The final
recommendations are now being driven through IC team among
others. The protocol in the pack states this should be done.
Update: there is uncertainty as to where /how the packs will be
made up and it unlikely the protocol will be included in it. The plan
now is that the protocol will be included on ‘blood culture trolleys’ but
these have still to be introduced.
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SPSP / SAPG sepsis management initiative – blood cultures should
be taken within first hour of recognition of sepsis. However, this
should not delay administration of antibiotic therapy. Jan 2012.
2
MIC or zone sizes must be measured for all
clinically relevant bacterial isolates.
SS/CF
3
Susceptibility to non formulary or restricted
agents should not routinely be reported by
microbiology departments.
SS/CF
4
Standard systems should be in place for
bringing antimicrobial resistance alerts to the
notice of the infection control team and
clinicians/prescribers.
AMR Advisory
Group.
Microbiology
Lab.
5
The institution laboratory susceptibility data
should be published annually. Duplicate isolates
should be removed from the analysis. Local
susceptibility data should be used to inform
prescribers, policies and formularies.
6
All acute hospitals should analyse and report
antimicrobial use using the World Health
Organization Defined Daily Doses numerator
and total occupied bed days as the
denominator.
SS/NP/JS
Collection, analysis and feedback.
SS/NP/AT.
A national training resource on taking blood cultures is being
produced. Mar 2012.
We are now using either automated AST, standardised disc testing
or E-test.
COMPLETE
Current practice but recent (May 2011) decision by micro comm. to
release temocillin routinely. SS to discuss with micro colleagues.
Temocillin will now only be released on ESBL positive urine and
blood culture isolates.
COMPLETE
National:
HPS weekly report
ARMRL Newsletter
AMR advisory group – “Alert Notice”
Local:
ICNet to alert ICNs
Advisory comments on lab reports when ‘alert’ organism identified.
COMPLETE
BMS Manager (JS) – Antimicrobial resistance testing and data
collection commenced Feb 2009. Data collection occurring, need to
finalise how will be analysed and used to inform antibiotic guidance.
Starting to look at data on blood cultures and urines first. Observa
software functional from Nov 2009 and should greatly facilitate
progress with this recommendation. SAPG guidance to AMTs on
AMR surveillance received 30/6/10 – progressing with this. Note
issue re tazocin etc. See previous.
Haematology bacteraemia data used to inform neutropenic sepsis
policy – December 2011.
JS will have a report prepared for the next AMT meeting.
Lack of Pathmanager training hampering progress – Nov 2012.
Data analyst for Antimicrobial Consumption (KL) employed March
2009 - March 2010. IT worked with KL to finalise system for
collecting hospital antibiotic consumption data. The system is now
populated with data and functionality being tested. AT looking at
preliminary data. Main issue now is getting software installed on
appropriate PCs.
There have been further setbacks with this system. It had been
working but now needs to be reconfigured following the move to the
new hospital at VHK.
SAPG guidance to AMTs on antibiotic consumption surveillance
received 30/6/10 – progressing with this.
HMUD provides this data at hospital level but it too has some issues
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with accuracy of data.
It is proving difficult to electronically link systems for analysing DDDs
with systems for occupied bed days. Reports being scheduled to
look at DDDs by areas in the first instance (see below). Nov 2012
7
8
The use of key antimicrobials should be
analysed and evaluated on a monthly to 3
monthly basis for each hospital, group of
hospitals, directorates and specific wards.
The Antimicrobial Management Team should
liaise and co-ordinate with the Area Drug and
Therapeutics Committee on controlling the
introduction and the use of new antimicrobial
medication.
NP/KL/SS
See above
SS/IM
Chair of AMT and clinical effectiveness pharmacist attend ADTC
AMT agenda has New Medicines as a standing agenda item.
COMPLETE
9
Receive, and ensure implementation of, advice
from the Scottish Medicines Consortium at local
level about antimicrobial resistance patterns
and antimicrobial utilisation in a timely manner.
Follow advice from SAPG/HPS
SS
Will be ongoing as per other actions.
10
Ensure that information sent from Scottish
Medicines Consortium is disseminated in a
timely manner to all relevant parties.
Disseminate as required
SS
Guidance on meropenem use/carbapenemase producers
dissemintated March 2009.
COMPLETE/ONGOING
11
Co-ordinate the work across hospital and ‘out of
hospital’ care areas.
Ensure representation from operational
division and CHPs on AMT.
AMT
AMT has representation from hospital and ‘out of hospital’ areas.
COMPLETE
12
Link with the Scottish Medicines Consortium in
determining new risk factors and drivers for
resistance. Where risks are identified, AMTs
should work with local infection control teams
and area drug and therapeutics committees,
clinical governance and risk committees to
minimise emergence of resistance.
Link with SAPG/HPS.
AMT/SAPG.
SS/NP
Limited Antibiotic Formulary introduced 01/07/08 to Acute Medical
Admissions Unit, QMH and 01/08/08, AMAU VHK.
Restricted list introduced to hospital wards 02/03/09.
Hospital Pocket Antibiotic Guidance distributed 05/08/09
Communtiy Over 65 Guidance for common infections distributed
24/09/09
Antibiotic prophylaxis for general surgery – implemented January
2010
Updated Hospital Pocket Guidance, completely revised Community
Antibiotic guidance and updated restricted list all distributed
Aug/Sept 2010
See previous links to other groups/organisations.
COMPLETE/WILL CONTINUE TO BE UPDATED AS PER REVIEW
DATES OR SOONER IF REQUIRED
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13
Monitor the burden of disease caused by
antimicrobial resistant strains and antibioticrelated infections (initially targeted at key
organisms e.g. MRSA bacteraemias,
pneumococcal bacteraemia and Clostridium
difficile infection).
Comply with appropriate surveillance
requirements.
Microbiology
Department,
FAL
Staph aureus bacteraemia and Clostridium difficile mandatory
surveillance already in place.
EARRS ongoing (MRSA, pneumococcal bacteraemia).
COMPLETE – for initial organisms.
See also above - SAPG guidance for AMR surveillance by AMTs.
EDUCATION OF STAFF
Action
To ensure quality and safety objectives are achieved,
Antimicrobial Management Teams should help
ensure the implementation of multiprofessional
educational programmes developed by NHS
Education for Scotland for contracted and employed
staff, including staff in the independent sector. These
will relate to healthcare associated infection,
antimicrobial resistance and prudent antimicrobial
prescribing, working in collaboration with infection
control committees and Infection Control Managers.
Action
Responsible
Person
NP
Progress
DOTS training module mandatory for all junior doctors - ongoing
Mandatory Training for Consultants in HAI / Antimicrobial
Prescribing - ongoing
Antibiotic prescribing added to junior doctors induction (20 min
session from Feb 2009) – ongoing
Core curriculum teaching to FY doctors on sepsis and antibiotic
use - ongoing
PLT sessions have taken place in all 3 CHPs.
Education plan for Nursing Staff commenced Spring 2010
Education for non-medical prescribers began June 2010 but now
needs to be followed up as the previous NMP advisor is no
longer in post. NMP advisor now in post and AMP to contact her
– Jan 2012.
SAPG/NES Education Pack – ‘Training on the use of
antimicrobials in clinical practice’ – this has now been
incorporated to some extent in both acute and community
education sessions. A meeting with the IC education lead to
discuss this is required.
COMPLETE/ONGOING
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CLINICAL GOVERNANCE IN ANTIMICROBIAL UTILISATION AND MEASURES FOR IMPROVEMENT.
1
2
3
Recommendations
Action
Appropriate use of antimicrobials is an
important clinical governance issue. The
Antimicrobial Management Team should
ensure compliance with evidence based
infection related Scottish Intercollegiate
Guideline Network (SIGN) guidelines and audit
recommendations within these guidelines,
which should be used to monitor quality of
prescribing practice in hospitals and
community.
Audit compliance with SIGN 104
AMTs should also feed back to Scottish
Medicines Consortium information on effective
actions and good practice which promote
prudent antimicrobial prescribing and reduction
in antimicrobial resistance.
Infection Control Managers, working with the
AMT, will have managerial responsibility for
ensuring implementation of, compliance with,
and review of, prudent antimicrobial
prescribing policies.
Responsible
Person
NP
Progress
Audit compliance with local empirical
antibiotic guidance
NP
Began August 2009 in QMH, March 2010 in VHK. Data is being
collected and fedback. Note as of April 2011 no longer occurring in
VHK Med ad or QMH surg ad. See below for update.
Audit compliance with surgical
prophylaxis guidance
NP
General surgeons engaged. Data collection proving a challenge but
began in Feb 2010. Plan is to collect data for orthopaedics as well.
SAPG have intimated that the methodology for this is currently
being reviewed but to continue as are at present.
Update March 2011 – requirement for national reporting is now for
elective colorectal surgery only and our auditing has been unable to
continue – looking at ways of recommencing this.
Recommenced as part of SPSP peri-op pt safety checklist Sept
2011.
Undertake Annual Point Prevalence
Surveys
NP
Participated in ESAC PPS in 2009 (all 3 acute and 1 community
hosp).
2010 survey has taken place (all community and acute hosps in
NHS Fife)
Participated in HPS /SAPG HAI/Antimicrobial point prevalence
survey 2011.
SS/NP
Two-way discussions between AMT members and SAPG at AMT
Network Meetings and SAPG meetings.
Distribution of Antibiotic Guidance to all
prescribers in NHS Fife
Monitor compliance with guidance
through antibiotic prescribing
supporting indicators.
DL
NP audited against SIGN 104 (complete Nov 2008). SS submitted
report on SIGN 104 to Clinical Governance for March 2009
meeting. Action plan for this is being overseen by clin gov/NHS Fife
SIGN implementation group. AMT actions will be covered by review
of surgical prophylaxis.
COMPLETE/ONGOING
COMPLETE/ONGOING
See previous.
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4
5
6
ICM and AMT will implement, deliver and
supervise: Specific competencies and
capabilities for each healthcare professional
group based on national core competencies as
defined by NHS Education for Scotland.
Await guidance from NES
ICM and AMT will implement, deliver and
supervise: Identification of an education
facilitator or education subgroup within their
institution. This person or group should
oversee the achievement and
maintenance of specific competencies and
capabilities for antimicrobial
prescribing for individual prescribers and
groups of prescribers.
In terms of clinical governance for antimicrobial
utilisation and measures for improvement, data
relating to antimicrobial performance indicators
should be fed back to risk management and
clinical governance bodies to help ensure best
standards of good quality and safe care.
Systems to be developed to
1. monitor uptake, and
2. evaluate
education.
Feedback on
● compliance with SIGN 104
● Antibiotic Supporting Indicators for C
difficile HEAT target
7
In relation to hospital policies and audit, the
AMT should ensure that, where appropriate, all
new staff are aware of antimicrobial policies at
induction.
Distribution of Antibiotic Guidance at
induction
8
In relation to hospital policies and audit, the
AMT should ensure that:
All microbiologists, pharmacists and
prescribers are aware of hospital
policies relating to antimicrobial use and
antimicrobial resistance.
Increase awareness of Antimicrobial
Guidance and Policy
DL
NES have produced a bacterial resistance online tutorial aimed at a
wide variety of healthcare professionals. Looking at how this
should be used/promoted locally.
DL / AMT
SAPG/NES Education Pack ‘Training on use of antimicrobials in
clinical practice’ - May 2010 . Incorporated into education sessions,
also see prev.
Senior infection control nurse (IC Education Lead) was in process of
developing tools that could be used for these purposes. This is now
being taken forward by the IC nurse consultant who is currently
piloting an evaluation tool.
SS
SIGN 104 report gone to clinical governance – see previous
SS/DL
Agreed these indicators will be discussed at AMT meetings, AMT
minute goes to clinical governance (and through this route would go
to SMT (risk management) if required).
Supporting indicators now (July 2010) also to go to NHS Fife HAI
HEAT target group.
DL/KM/SS
Update May 2011 – reporting arrangements reviewed following
CMO (2011) 5 and data will now go to ICC.
Hospital Guidance distributed to new junior doctors at their induction
– a presentation given at their induction includes the topic of
antimicrobial prescribing.
During the infection control session of corporate induction for all
staff, the ICNs will include a short overview of the importance of
appropriate antibiotic prescribing. (Spring 2010)
Non-medical prescribers receive appropriate information through
NMP Advisor. (March 2010)
Hospital guidance highlighted to locums/temporary staff via email
and link to electronic version.
Permanent consultant staff new to the organisation are given a copy
of the hospital pocket-guidance when they start by Morag Ross.
COMPLETE/ONGOING
Hospital pocket guidance successfully distributed 05/08/09 to all
hospital doctors, non-medical prescribers and pharmacists.
Occurs at junior doctors induction. Permanent hospital staff –
medical, pharmacist and non-med prescribers - receive via BNF
distribution.
Community prescribers received most recent guidance via email
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(hard copies when/if applicable will be distributed via ADTC
distribution).)
Policy distributed to all consultants via email Jan 2009.
Policy available on NHS Fife intranet Jan 2009.
Updated guidance will be issued in the same way as and when
available (has been done August 2010 and 2011).
Link to all guidance now on intranet homepage/internet via ADTC
site.
9
10
11
In relation to hospital policies and audit, the
AMT should ensure that:
Antimicrobial policies are regularly updated,
with stated review dates, to reflect local
antimicrobial resistance patterns and inform
appropriate treatment.
In relation to hospital policies and audit, the
AMT should ensure that compliance with
antimicrobial policies is audited regularly and
results fed back to local users.
In relation to hospital policies and audit, the
AMT should ensure that information on
NP/SS/AMT
COMPLETE/ONGOING
Register of all AMT documents and their review dates compiled.
COMPLETE/ONGOING
Carry out regular audits.
NP/SS
Audits of limited antibiotic formularies in AMAUs at cycle 3 (KM)
Audit of antibiotic supporting indicators
as per CEL 11 2009 – hospital
empirical prescribing indicator data for
QMH AMAU and SAU
This data is being fed back by display of data on noticeboards in
each of these units and monthly email of data and non-compliances
to consultants (as of Jan 2010). Data collection at VHK AMAU
began March 2010.
Feed back on noticeboards unsuccessful – they were put up in
doctors rooms but frequently removed or covered up. Currently
reviewing presentation and which notice boards are used.
Audit of revised prescribing indicators
as per CMO (2011) 5
Currently auditing QMH med ad only. Other audits and feedback
incl non-compliances – planning stages.
As at Sept 2011 it was agreed with GB/RC that ad hoc data
collection will occur until move to VHK site at which time robust
system will be implemented, probably through acute med cons.
Surgical prophylaxis has system in place as prev.
Nurse practitioners commenced auditing in surgical admissions in
Sept 2011.
Jan 2012 – re med admissions – AMP will collect data for Feb and
March. To arrange definitive data collection, non-compliance follow
up and feedback from April 2012.
March 2012 – re med admissions – Nurse practitioners collecting
data and giving instant feedback on ward round.
July 2012 – re med admissions – data has not been collected by
nurse practitioner for the last three months, NP will collect for July
and is in discussion with Laura Clark re how this will be continued.
Nov 2012 – Data collection / feedback has recommenced.
See above.
Feedback of above.
NP/SS/DL
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12
13
unexplained departures from prescribing
policies is fed back to prescribers and to the
risk management and clinical governance
groups in order to optimise patient care.
In relation to hospital policies and audit, the
AMT should ensure that, working with the
infection control manager they are active in
ensuring that national and local policies are
followed in the boarding-out of potentially or
actually infected patients. Generally such
patients should not be boarded to other wards
except for clinical reasons and in major
emergencies.
All Antimicrobial Management Teams should
ensure that they have adequate public
representation as fully engaged and involved
members.
12. Action Plan: Diagnostic Services
Recommendations
1
2
3
4
5
Microbiology laboratories should implement the
antimicrobial sensitivity testing methods and
implementation of automated sensitivity testing
as recommended by the Scottish Microbiology
Forum Antimicrobial Sensitivity Testing
subgroup.
At a local level, turnaround times for antibiotic
sensitivity tests should be as short as possible,
and the advice made available timeously to the
clinician at the point of delivery of care to the
patient.
Routine reporting of sensitivity to antimicrobial
agents which are not included in the local
Laboratories should implement rapid diagnostic
methods such as Polymerase Chain Reaction,
antigen testing or markers of infection, where
consensus exists around methodology, and
normally in conjunction with advice from the
Scottish Microbiology Forum.
Reference laboratories have a role to play in the
monitoring of resistance and emergence of new
resistance mechanisms. Service level
Refer to NHS Fife Boarding Out Policy.
DL
This is a clinical management policy with IC input. It has just been
reviewed and is going through the final approval process. It is being
used in draft form (March 2010).
This is now on hold as National guidance in expected though still
awaited.
As at March 2011, no further update at National level, local policy
now being progressed.
NHS Fife Boarding Out Policy now in place (August 2011)
Appoint public involvement
representative to AMT
SS/NP
Public involvement representative appointed March 2009, attending
meetings from 20th May 2009. Member has now resigned – see
previous.
COMPLETE
Action
Responsible
Person
SS/OG
Progress
CF/SS
Turnaround times are audited on a regular basis.
Audit reports available in Microbiology Department
COMPLETE
CF/SS
See previous.
CF
PCR: Chlamydia, norovirus, respiratory viruses
Viral serology: Bloodborne viruses
Antigen Testing: Legionella, pneumococcus
Ref labs / HPS
See previous
COMPLETE/ONGOING
Microbiology lab refers unusually resistant isolates to reference
laboratories as advised.
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6
agreements between Reference Services and
HPS should be reviewed to ensure this is
included within their remit.
Turnaround times for disseminating results from
reference laboratories need to be rapid to be
clinically meaningful and thereby facilitate
control of spread of target organisms and to
disseminate reports at a local and national level.
Audits required.
CF /
Microbiology
Department
Ongoing
Responsible
Person
DL
Progress
13. Action Plan: Prescribers’ Individual Responsibilities
1
2
3
Recommendations
Action
Infection prevention and control is an essential
part of preventing the spread of antimicrobial
resistance and guidelines developed by the
Healthcare Associated Infection Task Force
should always be followed. A plan of action for
combating the development of antimicrobial
resistance must include measures that deter
the spread of bacteria in general - and
antimicrobial resistant strains in particular both in hospitals and in care homes.
Prudent prescribing following local and
national guidelines in line with local formularies
should be encouraged and actively managed
as a matter of good clinical governance.
All antimicrobial prescribers, including
supplementary and independent prescribers,
should have specific continuing professional
development (CPD) objectives related to
antimicrobial prescribing, antimicrobial
resistance patterns and healthcare associated
infections, which is mandatory in the
NHSScotland Code of Practice for the
Management of Hygiene and Healthcare
Associated Infection. Each prescriber should
update their knowledge in this area on a
regular basis, usually annually in the case of
trainee prescribers.
Reorganisations in the health service aimed at
staff efficiencies and higher patient
throughputs have led to greater mobility of
patients between different wards during single
episodes of hospitalisation. While there may
Refer to Infection Control programme.
Recommendations are included in Infection Control Manual
HPS have published ‘Infection Prevention and Control Guidance for
use in NHS and Non-NHS Community and Primary Care Settings’
This is covered in more detail in the new, still draft, HAI delivery
plan, timescales and priorities within it have yet to be confirmed.
From AMT point of view actions
pertaining to this are covered elsewhere
in the action plan.
AMT
See previous
Refer to Boarding Out Policy.
DL
See previous
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be operational reasons for this, patient
movements inevitably carry a risk of spreading
infection with antimicrobial resistant
organisms. This risk must be weighed against
the clinical requirements for moving patients
within a hospital.
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