Developing Specialist Perinatal Mental Health Services: the door of opportunity

The development of Specialist Perinatal Mental Health Services in Ireland in recent years (2018-2021) is described. The paper highlights the role of unexpected opportunity in advancing this much needed service for women, infants and their families. It also emphasises the need for funding combined with an implementation mechanism to ensure that the service emerging is true to the Model of Care designed and is available in a uniform manner to women nationally.

46 MEASURING THE IMPACT OF COVID-19 RESTRICTIONS ON MOBILITY IN OLDER ADULTS WITH FRAGILITY FRACTURES USING THE NEW MOBILITY SCORE

Background

Methods

Results

Conclusion

References

47 DOSING OF DIRECT ORAL ANTICOAGULANTS IN OLDER ADULTS

Background

Direct oral anticoagulants (DOACs) are approved for a variety of uses including prevention of stroke in non-valvular atrial fibrillation and treatment and prevention of deep vein thrombosis and pulmonary embolism. Adjustment to DOAC dosing may be required for age, weight and renal impairment. Incorrect lower dosing puts patients at risk of thromboembolic events whereas inappropriate higher dosing increases the risk of bleeding. We compared current DOAC dosing for patients admitted to our hospital and compare this against HSE best practice to determine if patients were receiving the correct dose [1].

Methods

A prospective single-centre study. Patients admitted to our hospital following a fracture and reviewed by the Orthogeriatric team between August–October 2020 were eligible for inclusion. We recorded admission DOAC dose, age, weight and renal function. We also obtained data including sex and Clinical Frailty Scale (CFS).

Results

Thirty-one patients were included. Mean age was 86 years [range 66–99] and 21(68%) were female. Apixaban was the most commonly used DOAC; 25(81%). Stroke prevention in non-valvular atrial fibrillation was the most common DOAC indication; 29(93%). Twelve patients (39%) had an inappropriate DOAC dose prescribed. Eight patients (67%) had an inappropriately low dose and 4 patients (33%) had an inappropriately high dose. The mean CFS was 5 [Range 2–7] classifying our cohort as mildly frail.

Conclusion

Our study has shown that over one-third of our patients were on an inappropriate DOAC dose on admission with the majority (67%) due to under-dosing. Many factors may have influenced dosing choices by clinicians but our findings highlight the challenges in dosing, monitoring and the overall management of DOAC therapy in older people. Further studies and research are required to establish the most accurate and effective dosing strategies for DOACs in older adults.

Reference

1. Health Service Executive [Internet]. Ireland ‘Anticoagulation Prescribing Tips’ https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/noac-prescribing-tips-for-noacs.pdf.

Antimicrobial use and antimicrobial resistance in Enterobacterales and Enterococcus faecium: a time series analysis

BACKGROUND

Irish and European antimicrobial resistance (AMR) surveillance data have highlighted increasing AMR in Enterobacterales and vancomycin resistance in Enterococcus faecium (VRE). Antimicrobial consumption (AC) in Irish hospital settings is also increasing.

METHODS

A retrospective time series analysis (TSA) was conducted to evaluate the trends and possible relationship between AC of selected antimicrobials and AMR in Enterobacterales and vancomycin resistance in E. faecium, from January 2017 to December 2020.

RESULTS

Increased AC was seen with ceftriaxone (p= 0.0006), piperacillin/tazobactam (p = 0.03) and meropenem (p = 0.05), while ciprofloxacin and gentamicin use trended downwards. AMR rates in E. coli, K. pneumoniae and other Enterobacterales were largely stable, an increase in ertapenem resistance in the latter from 0.58% in 2017 to 5.19% in 2020 (p= 0.003) being the main concern. The proportion of E. faecium that was VRE did not changed significantly (64% in 2017; 53% in 2020, p = 0.1). TSA identified a correlation between piperacillin/tazobactam use and the decreasing rate of ceftriaxone resistance in E. coli.

CONCLUSION

Our data suggest that hospital antimicrobial stewardship programme is largely containing, but not reducing AMR in key nosocomial pathogens. An increase in AC following the COVID-19 pandemic appears as yet to have had no impact on AMR rates.

Quality indicators for hospital antimicrobial stewardship programmes: a systematic review

BACKGROUND

Measuring the quality and effectiveness of antimicrobial stewardship (AMS) programmes with quality indicators (QIs) is an area of increasing interest. We conducted a systematic review to identify QIs of AMS programmes in the hospital setting and critically appraise their methodological quality.

METHODS

We searched the Cochrane Library, PubMed, MEDLINE, EMBASE, CINAHL, Scopus/web of science databases and the grey literature for studies that defined and/or described the development process and characteristics of the QIs developed. The Appraisal of Indicators through Research and Evaluation (AIRE) instrument was used to critically appraise the methodological quality of the QI sets.

RESULTS

We identified 16 studies of QI sets consisting of 229 QIs. The QI sets addressed a broad range of areas of AMS in the hospital setting and consisted of 75% process indicators, 24% structural indicators and 1% outcome indicators. There was a wide variation in the information and level of detail presented describing the methodological characteristics of the QI sets identified.

CONCLUSIONS

The QIs identified in this study focused on process and structural indicators with few outcome indicators developed-a major deficiency in this area. Future research should focus on the development of outcome indicators or the use of process or structural indicators linked to outcomes to assess AMS. Testing of the QIs in practice is an essential methodological element of the QI development process and should be included in the QI development study or as planned validation work.

A qualitative process evaluation of the introduction of procalcitonin testing as an antimicrobial stewardship intervention

Background Successful antimicrobial stewardship interventions are imperative in today's environment of antimicrobial resistance. New antimicrobial stewardship interventions should include qualitative analysis such as a process evaluation to determine which elements within an intervention are effective and provide insight into the context in which the intervention is introduced. Objective To assess the implementation process and explore the contextual factors which influenced implementation. Setting An academic teaching hospital in Cork, Ireland. Methods A process evaluation was conducted on completion of a feasibility study of the introduction of a procalcitonin antimicrobial stewardship intervention. The process evaluation consisted of semi-structured face-to-face interviews of key stakeholders including participating (senior) doctors (5), medical laboratory scientists (3) and a hospital administrator. The Consolidated Framework for Implementation Research was used to guide data collection, analysis, and interpretation. Main outcome measures Qualitative assessment of the intervention implementation process, the contextual factors which influenced implementation and identification of improvements to the intervention and its implementation and determine if proceeding to a randomised controlled trial would be appropriate. Results Analysis of the interviews identified three main themes. (1) The procalcitonin intervention and implementation process was viewed positively to support prescribing decisions. Participants identified modifications to procalcitonin processing and availability to improve implementation and allow procalcitonin to be "more of a clinical influence". (2) In the antimicrobial stewardship context the concept of fear of missing an infection and risks of potentially serious outcomes for patients emerged. (3) The hospital context consisted of barriers such as available resources and facilitators including the hospital culture of quality improvement. Conclusion This process evaluation provides a detailed analysis of the implementation of procalcitonin testing as an antimicrobial stewardship intervention. The positive findings of this process evaluation and feasibility study should be built upon and a full randomised controlled trial and economic evaluation should be conducted in a variety of hospital settings to confirm the effectiveness of procalcitonin as an antimicrobial stewardship intervention.

An investigation of the effects of procalcitonin testing on antimicrobial prescribing in respiratory tract infections in an Irish university hospital setting: a feasibility study

BACKGROUND

Diagnostic uncertainty and a high prevalence of viral infections present unique challenges for antimicrobial prescribing for respiratory tract infections (RTIs). Procalcitonin (PCT) has been shown to support prescribing decisions and reduce antimicrobial use safely in patients with RTIs, but recent study results have been variable.

METHODS

We conducted a feasibility study of the introduction of PCT testing in patients admitted to hospital with a lower RTI to determine if PCT testing is an effective and worthwhile intervention to introduce to support the existing antimicrobial stewardship (AMS) programme and safely decrease antimicrobial prescribing in patients admitted with RTIs.

RESULTS

A total of 79 patients were randomized to the intervention PCT-guided treatment group and 40 patients to the standard care respiratory control group. The addition of PCT testing led to a significant decrease in duration of antimicrobial prescriptions (mean 6.8 versus 8.9 days, P = 0.012) and decreased length of hospital stay (median 7 versus 8 days, P = 0.009) between the PCT and respiratory control group. PCT did not demonstrate a significant reduction in antimicrobial consumption when measured as DDDs and days of therapy.

CONCLUSIONS

PCT testing had a positive effect on antimicrobial prescribing during this feasibility study. The successful implementation of PCT testing in a randomized controlled trial requires an ongoing comprehensive education programme, greater integration into the AMS programme and delivery of PCT results in a timely manner. This feasibility study has shown that a larger randomized controlled trial would be beneficial to further explore the positive aspects of these findings.

Antimicrobial usage in an intensive care unit: a prospective analysis

Antimicrobial therapies in the Intensive Care Unit (ICU) need to be appropriate in both their antimicrobial cover and duration. We performed a prospective observational study of admissions to our semi-closed ICU over a three-month period and recorded the indications for antimicrobial therapy, agents used, duration of use, changes in therapy and reasons for changes in therapy. A change in therapy was defined as the initiation or discontinuation of an antimicrobial agent. There were 51 patients admitted during the three-month study period and all received antimicrobial therapy. There were 135 changes in antimicrobial therapy. 89 (66%) were made by the ICU team and 32 (24%) were made by the primary team. Changes were made due to a deterioration or lack of clinical response in 41 (30%) cases, due to the completion of prescribed course in 36 (27%) cases, and in response to a sensitivity result in 25 (19%) cases. Prophylactic antibiotic courses (n=24) were of a duration greater than 24 hours in 15 (63%) instances. In conclusion, the majority of changes in antimicrobial therapy were not culture-based and the duration of surgical prophylaxis was in excess of current recommended guidelines.