Development and implementation of a national antimicrobial stewardship surveillance system, with open access data sharing.

BACKGROUND: Public Health England (PHE) developed an antimicrobial stewardship (AMS) surveillance system and conducted a national pilot to test the feasibility of centrally collecting data from AMS audits performed by NHS hospital trusts. The system was simplified, focusing on requirements of the NHS AMR CQUIN (Commissioning for Quality and Innovation; a financial incentive quality improvement scheme). AIM: To present results and user feedback from the national pilot, and results from using the AMS surveillance system as part of the AMR CQUIN. METHODS: An AMS surveillance system was developed and a national pilot conducted in which 33 NHS trusts submitted data and feedback on system utilization. The system was refined based on feedback and deployed nationally to collect AMS data for the 2016-17 AMR CQUIN. FINDINGS: Most trusts participating in the pilot collected data on documentation of indication (90%). Fewer collected data on documenting review decisions at 48-72 h (36%). On average 83% of patients had an indication documented, whereas 71% had formal documentation of 48-72 h review. AMR CQUIN data were submitted by 88% of trusts for at least one quarter of 2016-17. Approximately 92% of prescriptions had an indication documented and 87.5% of prescriptions had evidence of review within 72 h; these increased by 7 and 10 percentage points respectively between the first and final quarters. CONCLUSION: The AMS surveillance system allowed AMS audit data from NHS trusts in England to be collected centrally. PHE publishes these data openly online, on PHE Fingertips portal, a national public health data portal. The reported data highlight improvement in the percentage of antibiotic prescriptions with evidence of a documented review within 72 h.

A national quality incentive scheme to reduce antibiotic overuse in hospitals: evaluation of perceptions and impact.

Background: In 2016/2017, a financially linked antibiotic prescribing quality improvement initiative Commissioning for Quality and Innovation (AMR-CQUIN) was introduced across acute hospitals in England. This aimed for >1% reductions in DDDs/1000 admissions of total antibiotics, piperacillin/tazobactam and carbapenems compared with 2013/2014 and improved review of empirical antibiotic prescriptions. Objectives: To assess perceptions of staff leading antimicrobial stewardship activity regarding the AMR-CQUIN, the investments made by hospitals to achieve it and how these related to achieving reductions in antibiotic use. Methods: We invited antimicrobial stewardship leads at acute hospitals across England to complete a web-based survey. Antibiotic prescribing data were downloaded from the PHE Antimicrobial Resistance Local Indicators resource. Results: Responses were received from 116/155 (75%) acute hospitals. Owing to yearly increases in antibiotic use, most trusts needed to make >5% reductions in antibiotic consumption to achieve the AMR-CQUIN goal of 1% reduction. Additional funding was made available at 23/113 (20%) trusts and, in 18 (78%), this was <10% of the AMR-CQUIN value. Nationally, the annual trend for increased antibiotic use reversed in 2016/2017. In 2014/2015, year-on-year changes were +3.7% (IQR -0.8%, +8.4%), +9.4% (+0.2%, +19.5%) and +5.8% (-6.2%, +18.2%) for total antibiotics, piperacillin/tazobactam and carbapenems, respectively, and +0.1% (-5.4%, +4.0%), -4.8% (-16.9%, +3.2%) and -8.0% (-20.2%, +4.0%) in 2016/2017. Hospitals where staff believed they could reduce antibiotic use were more likely to do so (P < 0.001). Conclusions: Introducing the AMR-CQUIN was associated with a reduction in antibiotic use. For individual hospitals, achieving the AMR-CQUIN was associated with favourable perceptions of staff and not availability of funding.

Implementation of antimicrobial stewardship interventions recommended by national toolkits in primary and secondary healthcare sectors in England: TARGET and Start Smart Then Focus.

OBJECTIVES: To assess and compare the implementation of antimicrobial stewardship (AMS) interventions recommended within the national AMS toolkits, TARGET and Start Smart Then Focus, in English primary and secondary healthcare settings in 2014, to determine the prevalence of cross-sector engagement to drive AMS interventions and to propose next steps to improve implementation of AMS. METHODS: Electronic surveys were circulated to all 211 clinical commissioning groups (CCGs; primary sector) and to 146 (out of the 159) acute trusts (secondary sector) in England. Response rates were 39% and 63% for the primary and secondary sectors, respectively. RESULTS: The majority of CCGs and acute trusts reported reviewing national AMS toolkits formally or informally (60% and 87%, respectively). However, only 13% of CCGs and 46% of acute trusts had developed an action plan for the implementation of these toolkits. Only 5% of CCGs had antimicrobial pharmacists in post; however, the role of specialist antimicrobial pharmacists continued to remain embedded within acute trusts, with 83% of responding trusts having an antimicrobial pharmacist at a senior grade. CONCLUSIONS: The majority of healthcare organizations review national AMS toolkits; however, implementation of the toolkits, through the development of action plans to deliver AMS interventions, requires improvement. For the first time, we report the extent of cross-sector and multidisciplinary collaboration to deliver AMS interventions in both primary and secondary care sectors in England. Results highlight that further qualitative and quantitative work is required to explore mutual benefits and promote best practice. Antimicrobial pharmacists remain leaders for implementing AMS interventions across both primary and secondary healthcare sectors.

Unsupervised and uncued segmentation of the fundamental heart sounds in phonocardiograms using a time-scale representation.

A methodology is proposed to segment and label the fundamental activities, namely the first and second heart sounds, S1 and S2of the phonocardiogram (PCG). Information supplementary to the PCG, such as a cue from a synchronously acquired electrocardiogram (ECG), subject-specific prior information, or training examples regarding the activities, is not required by the proposed methodology. A bank of Morlet wavelet correlators is used to obtain a time-scale representation of the PCG. An energy profile of the time-scale representation and a singular value decomposition (SVD) technique are used to identify segments of the PCG that contain the fundamental activities. The robustness of the methodology is demonstrated by the correct segmentation of over 90% of 1068 fundamental activities in a challenging set of PCGs which were recorded from patients with normally functioning and abnormally functioning bioprosthetic valves. The PCGs included highly varying fundamental activities that overlapped in time and frequency with other aberrant non-fundamental activities such as murmurs and noise-like artifacts.

On the control of ecdysone biosynthesis by the central nervous system of blowfly larvae.

Ecdysone was found to be the major secreted steroid of ring glands dissected from blowfly larvae and incubated in vitro. Other secretory products such as 3-dehydroecdysone and 20-deoxy-makisterone A could not be detected when the glands were labelled with tritiated cholesterol. Ecdysone synthesis and secretion were found to be tightly coupled. The highest rate of secretion was observed a few hours before pupariation. In vitro, the rate of ecdysone secretion by ring glands was affected significantly by coincubation with the central nervous system (CNS). Modulating effects from the CNS to the gland were mediated both by culture medium and by nerve connections. Distinct parts of the CNS revealed multiple and partially opposite effects on ecdysone secretion, suggesting a more complex control than had been anticipated. Multiple neural control systems appear to be involved. Moreover, the observed effects changed with development during the second half of the third instar, reflecting a significant plasticity of neural control.

Home-based palliative care for children--Part 1: The institution of a program.

To assess the necessity and feasibility of introducing a home-based palliative care program for children admitted to our neurosurgical unit and diagnosed as being terminally ill, we conducted an analysis of all such patients admitted to our unit over an 18-month period. Of a total of 30 patients, 22 (73.4%) had central nervous system tumors, 6 (20.0%) had myelomeningocele/hydrocephalus, and 2 (6.6%) had arteriovenous malformations. The mean duration +/- SEM of hospitalized days prior to death and the proportion of time spent hospitalized during the terminal phase of illness were 28.8 +/- 4.77 and 0.327 respectively, for the 23 patients who died and on whom adequate data were available. Sixteen (70.6%) of these 23 patients died in hospital. Nine (30.0%) of the total group of patients were studied prospectively during the last 6 months of this study to determine the extent of their symptoms and to ascertain whether it would be feasible for them to be managed at home. The most troublesome symptoms in this subgroup were feeding difficulties, gastrointestinal symptoms, breathing difficulty, and seizures. These symptoms were managed either by (a) medications administered orally or by feeding tube or rectally, or by (b) noninvasive procedures carried out by a nurse under the direction of the admitting neurosurgeon. This study suggests that prolonged hospitalization for children diagnosed as being terminally ill can be avoided by introducing a home-based palliative program with involvement from a nurse and a physician familiar with drug therapy for terminally ill children.

Home-based palliative care for children--Part 2: The benefits of an established program.

Thirty-four patients have been admitted to our palliative care program since its institution in March 1986. Five were unsuitable and were withdrawn soon after admission. Of the remainder, 22 (75.9%) had central nervous system (CNS) tumors, 5 (17.2%) had myelomeningocoele, 1 (3.45%) had an arteriovenous (AV) malformation, and 1 (3.45%) had a storage disease. Twenty-five (86.2%) have since died and 17 (68%) of these have died at home. In comparison with a similar group of 30 patients studied in a feasibility study prior to the institution of our program, patients admitted to our palliative care program were hospitalized for significantly fewer days during the terminal phase of their illness (p less than 0.05) and a significantly higher proportion died at home (p less than 0.001). Following a survey of the parents of 14 children diagnosed with CNS tumors who died while under our care, we determined that the overall level of satisfaction with the program was high compared to care provided prior to admission to the program (p less than 0.01). Components of the program deemed most satisfactory were (1) being able to care for the child at home (p less than 0.01), (2) having access to a palliative care nurse (p less than 0.05), and (3) having access to a pediatric clinical pharmacologist (p less than 0.05). The most troublesome symptoms occurring in this group of patients were pain, gastrointestinal symptoms, and seizures. Most problems were adequately managed by the parents under the supervision of the team. Eighty percent of the terminal care for these patients was provided at home.(ABSTRACT TRUNCATED AT 250 WORDS)

Meaning of the Repression-Sensitization scale: defensive style or self-report of symptoms of psychopathology.

Two studies were conducted to test the hypothesis that the Repression-Sensitization (R-S) scale assesses self-reported symptoms of psychopathology. In Study 1, 42 subjects were assigned randomly to groups that received differing instructions on the extent to which they should report experiencing distress and reveal personal problems. This manipulation produced highly significant group differences and accounted for most of the variability in R-S scale scores. In Study 2, R-S scale scores and scores of the Health Opinion Survey were correlated in a sample of 100 subjects. The high correlation obtained for these two measures suggests that both measures assess the same dimension, i.e., self-report of symptoms of psychopathology. The results of these studies indicate that the R-S scale is influenced so powerfully by self-report of symptoms of psychopathology that its usefulness in assessing repression-sensitization is questionable.

Determinants of acquiescence and naysaying of mentally retarded persons.

Social desirability and intellectual limitations were investigated as possible determinants of two response biases--acquiescence and naysaying--among mentally retarded respondents. Results clearly indicated that naysaying and acquiescence occur more frequently among lower IQ individuals and naysaying occurs more frequently concerning prohibited behavior, whereas respondents acquiesce regarding desirable behavior. These results suggest that intellectual limitations predispose people to biased responding, whereas social desirability factors determine the type of bias.

Evaluating alternative techniques of questioning mentally retarded persons.

In an examination of methodological issues involved in interviewing retarded persons, alternatively worded or structured questions were embedded in interviews with three samples. Questioning techniques were evaluated according to the extent to which (a) interviewees could provide answers, (b) their answers agreed with parallel responses given by attendants or parents, and (c) answers were free of systematic response bias. Open-ended questions were found to be unanswerable by many persons, and supplementing them with clarifying examples and probes for additional information only exacerbated response bias. By comparison, yes-no checklists enhanced responsiveness but introduced serious acquiescence bias, whereas multiple choice questions, particularly with pictures, yielded valid answers from high proportions of interviewees. Implications for question design were discussed.

Surveying mentally retarded persons: responsiveness and response validity in three samples.

In an exploration of the feasibility and utility of survey research with retarded populations, interviews were conducted with 52 institutionalized children, 58 institutionalized adults, and 57 community children, as well as with their parents or attendants. Analyses indicated that higher IQ interviewees were generally more responsive to questions, more often in agreement with the nonretarded informants, and less acquiescent on yes-no questions than were lower IQ interviewees. Although these relationships varied in strength from sample to sample, overall differences among samples were nonsignificant. Implications for researchers interviewing retarded persons were discussed.