Alasdair MacGowan BMedBiol (Hons), MD, FRCP, FRC.Path Professor of Clinical Microbiology & Antimicrobial Therapeutics, University of Bristol and North Bristol NHS Trust.

Alasdair MacGowan is Professor of Clinical Microbiology and Antimicrobial Therapeutics at the University of Bristol and Honorary Consultant at North Bristol NHS Trust. He graduated in Medicine at the University of Aberdeen, and trained in Infection in Aberdeen, Birmingham and Bristol. At present, he is Head of Research and Specialist Services in the Department of Medical Microbiology, North Bristol NHS Trust. His main research interests are in antibacterial pharmacokinetic/pharmacodynamics, resistance epidemiology in the community and understanding risk factors for poor outcome in hospitalised patients. He is a former President of the British Society for Antimicrobial Chemotherapy, and Chair of the Journal of Antimicrobial Chemotherapy Editor Board. Presently, he is Chairman of the BSAC Working Party on Antibiotic Resistance Surveillance, a member of the BSAC Working Party on Antimicrobial Susceptibility Testing, and a member of the European Committee on Antimicrobial Susceptibility Testing (EUCAST).

 

 

 

 

Andrew Lovering, BSc, PhD Consultant Clinical Scientist, North Bristol NHS Trust

Andrew Lovering is a Consultant Clinical Scientist and the scientific lead for the Antimicrobial Reference Laboratory at Southmead Hospital in Bristol. He graduated from the University of Reading and trained as a Clinical Scientist in Bristol, where he undertook his PhD. His main area of scientific interest is in the field of antimicrobial chemotherapy and many of the research studies that he has been involved with relate to the assay of antimicrobials, their pharmacokinetic/pharmacodynamic evaluation or the surveillance of antimicrobial resistance. He is a former editor of the Journal of Antimicrobial Chemotherapy. Currently, he is a member of the UKNEQAS Steering Committees for both Microbiology and Drug Monitoring and a member of the UKNEQAS Executive Committee. He is also the Clinical Lead for Infection at the Western Comprehensive Local Research Network and a member of the British Society for Antimicrobial Chemotherapy Working Party on Therapeutic Drug Monitoring.

 

 

 

 

Karen Bowker, PhD Principal Clinical Scientist, North Bristol NHS Trust

Karen Bowker has been an active research Clinical Scientist at the North Bristol NHS Trust since 1992 where she trained as a clinical scientist and undertook her PhD. She is scientific lead for the pharmacokinetic/pharmacodynamic (PK/PD) laboratory.  Her other main area of research is antimicrobial chemotherapy, antibacterial susceptibility testing and, assay of antimicrobials. She is currently a member of the BSAC working party on antimicrobial susceptibility testing. She is the lead organiser of the Antibiotic Assay Course held annually in Bristol. She is the author of over 80 peer-reviewed scientific publications and approximately 50 scientific abstracts and is a reviewer for several current journals.

 

John Leeming, BSc PhD Principal Clinical Scientist, North Bristol NHS Trust.

John joined the team in 2010, with a remit to lead molecular investigations. His academic training was undertaken at the University of Leeds and he then moved to Bristol become a clinical scientist. His interests include exploiting molecular biology techniques in the detection and characterisation of microbial pathogens, control of hospital infection, pneumococcal disease and the microbiology of skin. He is an honorary lecturer at the University of Bristol and has published over 50 peer-reviewed papers.

 

 

 

 

 

 

Alan Noel, MSc, Clinical Scientist, Antimicrobial Reference Unit, North Bristol NHS Trust

Alan Noel has been an active research Clinical Scientist at North Bristol NHS Trust since 2001. He has trained as a clinical scientist, with a focus on the Therapeutic Drug Monitoring of antibiotic, antifungal and antiviral agents. He has recently started a PhD – looking at the use of in-vitro pharmacokinetic infection models in anti-infective drug development. He is deputy scientific lead for the pharmacokinetic/pharmacodynamic (pK/pD) laboratory.  He has a keen interest in laboratory quality and has been the UK NEQAS for Antibiotic Assays Scheme Manager for 10 years. He is the deputy organiser of the Antibiotic Assay Course held annually in Bristol. He is the author of over 20 peer-reviewed scientific publications and approximately 50 scientific abstracts.

 

 

 

Members of BCARE have a considerable commitment to teaching undergraduate and postgraduate health care and associated workers in the area of antimicrobial chemotherapy. These include:-

• BSc and MSc courses and supervision of PhD students at the University of Bristol and the University of the West of England (UWE). Various staff are registered for MD, PhD or MSc degrees. Tutorials for medical students, registrars, infection control nurses and laboratory staff are regularly held at Southmead and Frenchay Hospitals
• ‘The Antibiotic Testing Course’ is held annually at University of the West of England in July. This covers all aspects of susceptibility testing, antibiotic assays, quality assurance / control / assessment, antibiotic/prescribing/guidelines/usage.

Molecular analysis

Molecular analysis is becoming increasingly important in the activities of the Laboratory. We are interested in the application of molecular technology for the diagnosis of infection and for characterization of bacterial isolates (detection of antibiotic resistance and virulence markers, sub-species typing). In particular we have introduced, or are working on, assays for:

• Direct detection of Mycobacterium tuberculosis in samples and characterization of mycobacteria in liquid cultures
• Typing and detection of virulence and antimicrobial resistance markers in Staphylococcus aureus
• Detection and typing of Clostridium difficile.

We have also undertaken gene sequencing for determination of resistance mechanisms in Streptococcus pneumoniae and detection of resistance markers in Gram negative bacilli by microarray analysis.

Disc susceptibility testing using BSAC and EUCAST methodologies are performed. Blactamase induction and MLSb testsare available.

MIC determination using BSAC, CLSI or ISO broth and agar dilution methodologies are performed. Determination of hGISA and GISAs are available.

Assay Development

BCARE personnel have considerable in depth knowledge in the development of new high pressure liquid chromatography (HPLC) and LC/MS assays for antibacterials, antivirals and antifungals. Immunoassay technologies have also been extensively trialled prior to introduction into clinical practice. In recent times the BCARE staff have developed HPLC assays for anti viral and anti fungal agents and we are keen to pursue pharmacokinetic studies on antivirals. Our expertise in HPLC assay has also lead to an active research interest in antimicrobial metabolites and/or breakdown products.

Pharmacokinetics

The staff within BCARE have a considerable expertise in antimicrobial pharmacokinetics both in patients and healthy volunteers. In the recent past pharmacokinetic studies have been performed in ITU patients, patients with severe sepsis (bacteraemia, pulmonary infection, after surgery) and orthopaedics.

These pharmacokinetic interests overlap with our knowledge of antimicrobial assay development and pharmacodynamics. In addition to performing pharmacokinetic studies BCARE supports pharmacokinetic research in other centers by the provision of assay services and external quality assurance.

Pharmacodynamics

Pharmacodynamics is an expanding and well established area, and it complements our strong track record in the basic laboratory aspects of antimicrobial chemotherapy and pharmacokinetic evaluations. All pharmacodynamic activities are laboratory based; animals are not used. Expertise exists to perform simple investigations such as post-antibiotic effect through to complex antimicrobial dose fractionation studies using continuous bacterial culture in-vitro models. These models enable intravenous, intramuscular and oral drug concentration serum profiles to be modelled. Hollow fibre in-vitro pharmacokinetic models are also used in preclinical antibacterial drug evaluation. At present we have experience with β-lactams, quinolones, glycopeptides, aminoglycoside and other antimicrobials classes in our in-vitro model systems.

Many major pathogen groups can be studied using these systems, for example, staphylococci, streptococci, enterobacteriacae, haemophilus, pseudomonas and anaerobes.

Sensitivity Testing:

Techniques

Expertise exists to perform susceptibility tests by agar dilution and micro-and macro-broth dilution techniques, and gradient strips. BSAC, EUCAST, CLSI or ISO methodologies are used. In addition, β-lactamase induction tests can be performed. Determination of GISAs, hGISAs are also available.

Bactericidal-time kill curves can be performed and bacterial killing with single agents and combinations studied, using novel, computer generated curve fitting techniques.

Current work:

• In vitro susceptibility testing.
• Determination of minimum inhibitory concentrations (MICs).
• Bactericidal studies on antimicrobials.
• Antibacterial – antibacterial interactions.

How long does the intervention take?

Are there cost implications with regard to staffing resource and the cost of the electronic patient record?

Will my team generate more and more post-discharge enquiries via the electronic portal- is this sustainable?

Will the older patients engage with the website?

Will there be issues with information and clinical governance?

Is there a requirement for my institution’s IT department to be involved?

Do patients use the record?

The effectiveness of the intervention in trauma was measured using three indicators:

1. Unscheduled healthcare attendances following discharge
2. Patient Activation Measure® (PAM®) 10 *
3. Patient satisfaction

Final results show a significant reduction in unscheduled GP attendances in the intervention group by 20%. 37% of patients demonstrated a higher level of activation. Hospital rating scores and individual patient feedback also improved in the intervention group.

 

 

* Suzanne E. Mitchell, Paula M. Gardiner, Ekaterina Sadikova, Jessica M. Martin, Brian W. Jack, Judith H. Hibbard, and Michael K.Paasche-Orlow 2013 ‘Patient Activation and 30-day post-discharge hospital utilization’ Journal of General Internal Medicine: 29 (2), pp349-355.

 

 

North Bristol Trust is one of two Major Trauma Centres in the South West of England treating approximately 1,200 severely injured patients each year. Whilst mortality has reduced since Major Trauma Centres were introduced in 2012, post discharge and rehabilitation concerns remain the most common issues identified.

Before Quality Trauma Discharge

The discharge process had been focused solely on the patient leaving hospital rather than as an opportunity to educate and facilitate enhanced recovery. High levels of anxiety, uncertainty about provision of care post discharge and confusion about medication were frequently described at follow up as well as unscheduled healthcare attendances. Over 70% of the patients surveyed in the pre-intervention phase had visited their GP at least once in the first thirty days. Frequently these patients reported that this was because they wanted information about their injuries and about ongoing treatment: GPs are often unable to provide this.

QTD is now an integral part of the service we provide to our patients and their families. The intervention is delivered in the main by the Major Trauma Practitioners working at the Major Trauma Centre and is now being offered to both those patients discharging home and transferring to a local inpatient unit within the Major Trauma Network. Currently approximately 20-30 patients per month receive the QTD ‘package’: decisions to offer this are based on discharge plans and clinical need.

No additional staffing has been required for implementation, but the drive to offer QTD has necessitated re-evaluation and streamlining of the Major Trauma Practitioner or key worker role. There is now evident focus on the needs of each individual patient throughout their pathway beyond emergent and acute care and the preparation for this starts during early contacts turning the ‘discharge’ into a process rather than a one-off event. 

Electronic Portal – Patients Know Best (PKB)

During the development phase, the project team decided that the QTD care plans should be housed in an electronic patient-held record. Currently we are using Patients Know Best (PKB).

Through a web-based application, the PKB solution puts the patient in control of their health records and, by granting access to specific care providers, creates a single instance of the relevant care record that is available wherever the patient receives treatment. It is securely hosted within the NHS N3 network.

Allowing patients to securely access their own health information and providing them with the ability to connect health professionals and carers together in one ‘place’ enables them to take control of aspects of their own healthcare.

In the first year of using the electronic portal as our method of delivery for the AHCP we identified a consistent increase in the number of online messages that the team were receiving. It is clear that patients are using the messaging service to communicate concerns and problems to the team. 

Although the numbers weren’t formally recorded, the trauma practitioners agreed that there was a comparable reduction in the number of telephone calls made to the existing patient helpline over the same time period. This allows the team to interact with their patients and resolve their queries more efficiently. The written messages also provide both a reliable record of advice for the patient to refer back to and also a clinical audit trail. This pattern has remained consistent over the subsequent eighteen months of the QTD initiative.

QTD is now viewed by the Severn Major Trauma team as an integral part of the service we provide to our patients and their families. There is no doubt that the opportunity prior to discharge for a patient and their carers and relatives to sit down and speak with an expert professional is exceptionally valuable. People have described the experience as ‘reassuring’ and as ‘answering questions I didn’t know I had’. Our data suggests that this empowers people to be more confident in managing their care and seeking help appropriately.

The Quality Patient Discharge intervention consists of three simple, interlinked elements: 

Download sample resources:

My Way Forward document

A personalised information pack detailing patient-specific information about diagnosis, medication, outpatient follow-up and signposting the patient which way to turn with any questions or concerns. This is to reinforce information which they have already been given during their admission, not to give new information, and should act to empower patients and carers. This document can be issued as a paper copy, however, by utilising an electronic platform accessible to patients and ‘invited’ others the plan becomes a more dynamic, responsive resource for patient, carers and clinicians.  Download 

Discharge consultation

An Individualised ‘discharge counselling’ session for the patient and family or carers with an appropriately trained keyworker around twenty-four hours prior to planned discharge. A pharmacist will also see the patient at this time and give education around medication. This one-to-one time should give opportunities for any questions or concerns to be addressed prior to discharge and will be based around the ‘after hospital care plan’.
Tailoring the discharge package to the patient based on the consultation means that all of the information given, follow up arrangements, contact details and prescribing information are held by the patient or carers in one format. Download 

Two week call

Two weeks after discharge, the patient will receive a ‘check-up’ telephone call from the major trauma team during which any problems or uncertainties can be identified and appropriately managed. Download 

The NHS Five year forward view sets out an ambition to support people to shape their own healthcare, make informed choices, manage conditions and avoid complications. Evidence shows that a higher level of activation leads to better outcomes, improved experience of care and fewer episodes of emergency and unscheduled healthcare.

The Severn Major Trauma Network hosted by North Bristol NHS Trust undertook a project funded by the Health Foundation in 2015-2016 delivering a discharge intervention focused on increasing patient activation for those patients who had been treated at Southmead Hospital following serious injury. Results showed an improvement in patient activation, in patient experience and a reduction in unscheduled healthcare attendances.  Most importantly feedback from patients has been overwhelmingly positive. This is now being rolled out across the service, the network and adopted in other organisations and specialities.

Whether it’s long term conditions or a one off stay in hospital due to illness or injury every patient should have the right to be made aware of their plan for care and given opportunity to own this plan.