Children and adults with asplenia or splenic dysfunction may have an increased risk of infection and may have 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. Immunisation can take place in either primary or secondary care, or both and therefore it is imperative to have effective communication across the interface.
The project aims to ensure that asplenic or splenic dysfunction patients across Nottinghamshire are identified and managed by general practitioners (GPs), in line with recommendations made by Public Health England, to minimise their risk of overwhelming infection and avoidable harm. It aims to do this by both identifying patients and reviewing their treatment whilst working with GP practices to identify potential system failures, improving systems and processes.
It can be difficult to effectively share the learning from a medication related incident in a way that results in a change of practice and a reduction in the potential for harm across a wide population. This project aims to show that high impact quality improvement in medication safety can be achieved by the collaboration of Medicines Safety Officers and Quality Teams across neighbouring CCGs.
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. The Medicines Safety Officers (MSO's) and head of the primary care quality team worked together to co-ordinate the review of patients and systems across three neighbouring clinical commissioning groups (CCGs). It was hoped by working collaboratively this would enable a broader and more comprehensive picture to be established.
The initial phase of the project was achieved by undertaking an audit to check the vaccination status for all asplenic patients. One CCG also audited whether prophylactic antibiotics were prescribed in this group of patients. The audit data was collected between November 2016 and May 2017 and was collated and analysed by the teams.
A total of 435 patients in 44 South Nottinghamshire GP practices were identified and reviewed in this initial audit. In addition, the results were shared with individual practices and at CCG protected learning time events.
The results demonstrated that there were a significant number of patients at risk of harm. This was replicated across all three CCGs. Of particular note, was the number of patients who had not received Men B or Men ACWY vaccinations. These were new additions to the vaccination schedule in 2015 and many GP practices appeared to be unaware of this update. An effective recall system for the five yearly pneumococcal vaccination was often absent. As a result, practices have been strongly encouraged and supported to implement a robust system through shared learning. At this stage only one of the CCGs reviewed antibiotic prescribing but this highlighted that this area should be a focus for further work.
As a result of the initial audit the following actions were agreed and undertaken:
The re-audit reviewed 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.
However, what has remained clear throughout this project was that the audit alone would not create the necessary change and it was important to understand more about the systems and processes happening within each GP practice, despite some areas such as ineffective recall systems being identified as potential system failures. This has led to the development of an on-line survey (using Survey Monkey®) that GP practices are being asked to complete. It is hoped that this will lead to a greater understanding of systems and processes that happen in GP practices and the sharing of good practice, which GP practices can adopt.
Existing asplenic or hyposplenic patients will be the main beneficiaries of the project as their clinical management will be reviewed to ensure that this cohort of patients are effectively vaccinated and have access to appropriate antibiotics, minimising their risk of serious infection and death.
By GP practices starting to look at their systems and processes of managing this cohort of patients and making these more robust, it is hoped that future asplenic or hyposplenic patients will be at lower risk of avoidable harm.
It is hoped that the health economy will benefit from reduced episodes of acute illness and potential secondary care admissions.
As a result of this project:
The CCG Medicines Safety Officers have worked together successfully with the quality team to share the learning from a significant event and produce a robust work stream that will improve patient safety for a significant number of the health community.
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
