Summary of the example
Following the death of a young asplenic patient in 2016 our project involves the identification and review of asplenic or hyposplenic patients in primary care, to minimise their risk of serious infection and death. A standardised audit pack has been developed to ensure this patient group are effectively vaccinated and have access to appropriate antibiotics in line with Public Health England advice. The audit pack has been developed by the Medicines Safety Officers from three South Nottinghamshire Clinical Commissioning Groups in conjunction with the Head of Quality, Primary Care for Greater Nottingham Clinical Commissioning Partnership Commissioning Groups. The group has sought and incorporated advice from local specialists eg NHSE Imms and Vacs team, Public Health and microbiology consultants. As a result there has been a significant reduction in the number of patients at risk of harm.
In addition GP practices have been encouraged and supported to review their existing systems for managing this cohort of patients. Potential system failures have been identified and thus systems and processes improved safeguarding both current and future asplenic and hyposplenic patients.
Furthermore links have been established with the local secondary care trust to improve communication and promote the use of standardised documentation.
Why we think it’s important
Children and adults with asplenia or splenic dysfunction may have an increased risk of infection and a sub-optimal response to routine vaccination. Additional vaccinations and long term antibiotic prophylaxis are therefore advised for these patients. The vaccination schedule recommended by Public Health England, based on the information in ‘the Green Book’,1 is complex and immunisation can take place in either primary or secondary care, or both, further increasing the risk of incomplete or incorrect vaccination occurring. It is therefore imperative to have effective communication across the interface and robust systems within the primary care setting to ensure that this cohort of patients receive the correct vaccination schedule and prophylactic antibiotics in a timely manner.
In 2016, a young asplenic patient in Nottinghamshire, who had not received all the additional vaccinations, died from pneumococcal septicaemia. Sharing the learning from the incident highlighted that this could have happened in many GP practices. This led to the development of an initial audit across three CCGs with one CCG also auditing antibiotic prophylaxis. The results showed a significant number of patients at risk of harm across all three CCGs. This led to the creation of a robust audit pack and a scheduled re-audit.
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Aims and objectives of the work
The project aims to ensure that asplenic or splenic dysfunction patients are identified and clinically managed in primary care in line with recommendations made by Public Health England, to minimise their risk of avoidable harm from overwhelming infection, acute illness and potential hospital admissions. In addition to the audit, GP practices should be encouraged and supported to review and improve their existing systems to identify potential system failures, reducing the risk of potential harm to current as well as future asplenic or hyposplenic patients.
- Identify current asplenic or hyposplenic patients at risk of harm using a standardised audit pack
- Review and improve GP systems for recall, revaccinations, documentation of patient informed decision making
The initial phase of the project was achieved by undertaking an audit to check the vaccination status for all asplenic patients and those diagnosed with splenic dysfunction. One CCG also audited whether prophylactic antibiotics were prescribed in this group of patients and the findings highlighted that this area should be a focus for further work as many high risk patients were not prescribed or compliant with long term antibiotics.
As a result of the initial audit the following actions were agreed and undertaken:
- Practices were made aware of at risk patients to prioritise for review
- Practices were encouraged and supported to review and update their processes for this high risk group of patients
- An audit pack was created to standardise searches and documentation across all the CCGs involved and a re-audit completed by March 2018. This was led by the CCGs Medicines Management Teams
- Collaboration with secondary care to improve documentation and communication for this patient group
- Results and learning were shared with local and national teams including NHS improvement.
The re-audit reviewed a total of 460 patients across the three CCGs. Absolute comparisons cannot be drawn between audits due to differences in methodology but there appeared to be an overall reduction in patients at risk of harm due to an increase in the numbers of patients protected against Meningitis ACWY and B.
Stakeholder engagement was achieved at various levels
- Pharmacist input and education of GPs and nurses at practice level
- Presentation at CCG protected learning events
- CCG quality meetings which report directly to Primary Care Commissioning Groups, overseen by the Director of Nursing and Quality
- Medicine Safety Officer Nottinghamshire / Derbyshire Regional Forum
- There has been an increase in the number of asplenic or hyposplenic patients who have full vaccination protection, through raising awareness of the updated vaccination schedule and implementing robust systems for recall, in addition to audit. . For example, there have been 150 additional patients vaccinated against MenACWY and 166 additional patients given MenB.
- Patients declining vaccination are making informed decisions which are documented and reviewed regularly.
- Antibiotic prescribing has improved in line with local guidelines both prophylaxis and emergency supply.
- Audit alone did not create the necessary change. A survey was created for completion by vaccination leads to provide a greater understanding for system success and failure which will promote shared learning of good practice.
- The CCG MSOs have worked together with the quality team to share learning from a significant event and produce a robust workstream that will improve patient safety for this cohort of patients.
- The success and importance of this piece of work has resulted in the audit being incorporated into the medicines safety work plan for the entire Nottinghamshire heath community (six CCGs) for 2018/19
- Whilst this cohort of patients is small in number it is complex in terms of ensuring recalls and clear documentation of vaccine declination. This has raised the discussion as when a patient can be documented as having enough information to be able to decline a vaccine which has a wider remit than this cohort.
- One reason highlighted for incomplete vaccination was national vaccine shortages eg pneumococcal, strengthening the need for robust review and recall processes to ensure catch up once available.
- Standardised documentation for secondary care to use at discharge is available but ongoing work is necessary to ensure consistent use by all specialities.
Nottinghamshire Antimicrobial Prescribing Guidelines for Primary Care
Practice and CCG spreadsheets
Vaccination Lead Survey
Public Health Advice
National guidance, data and publications