Strep A – enough is enough

In 2016 a third of GPs thought that the downward pressure on antibiotic prescribing was fueling the increase in cases of bacterial infections such as Scarlet fever. The recent report by Public Health England shoed that the number of notifications were double the average of the past 5 seasons. All nine regions in England are reporting an increase and the North East, North West, Yorkshire and Humber, the South East and South West reporting rates more than twice as high.

The reporting of invasive strep A infection is up 73% on last season. This is particularly worrying as the mortality in this condition is high at 15-20%. 14% of these are children under 10 and consequently an increase in the number of children dying is also expected to be higher than last season. In 2012 two children died. In 2016 twenty children died. Will it be thirty or forty this season? Every child is valuable – we should not accept this.

We are the only country in the western world, perhaps the whole world to be experiencing this high level of Strep A infection. Where many countries have introduced rapid tests, we have not. Is that a coincidence – I think not.

The good news is that no isolates have been found to be resistant to penicillin and general resistance patterns to other antibiotics has not changed.

The same bacteria cause strep throat, scarlet fever and invasive strep A. Transmission from person to person must be controlled. People with a strep A sore throat will remain infection for 14 days or more, returning to work or school and supporting the transmission of the bacteria. Within 24 hours of starting an antibiotic people cease to be infectious and can return to work or school without transmitting the bacteria.

Lord O’Neil in his report, commissioned by David Cameron, recommended that we should make better use of rapid diagnostics to cut unnecessary use of antibiotics. He went further to recommend that it should be mandatory by 2020 that the prescription of antibiotics should be informed by testing technology where available.

Where are we up to on this? Apparently NICE believes that there are some GPs that routinely test, but I am not sure where they are. The Birmingham Children’s Hospital routinely tests children and they have reduced antibiotic use by 70%. The use in community pharmacy was lauded into the NHS Innovation Accelerator and the local innovation networks, but as far as I know no CCG has commissioned it. NICE sticks with the clinical risk score FEVERPAIN – it is better than nothing, but it is hardly very sensitive, contributing to the unnecessary use of antibiotics and missing many patients with infections.

However, several community pharmacies have gone it alone. They have introduced testing to patients as a program of test and treat with advice to reduce transmission. Well done – it needs healthcare professionals to make a stand.

It is about time that Mr Hunt took a lead in this. He should insist that every GP and every community pharmacy that manages a patient with a sore throat completes a proper examination and uses a rapid antigen detection test to confirm the presence of strep A in the throat. In patients that are positive, appropriate antibiotics should be started immediately and the patient should be given information to reduce transmission.

Further more Mr Hunt should support the diagnosis and reporting of Scarlet Fever in community pharmacy.

We need to get on top of this. Indiscriminate downward pressure on antibiotic prescribing and the failure to use available technology as recommended in the report commissioned by the Government is not acceptable.

 

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AMR – failing to join up the dots

 

If anyone is attending the Chief Pharmacists conference and listening to Dame Sally Davies would you ask her a question for me. “Why is there not an antiseptic guardian program?”

Antiseptics are very important. Most surgical infections are caused by bacteria that are lurking on or within the skin. The solution that you apply to the skin is very important to reduce the chance of a surgical site infection. These infections can be deep and very dangerous or superficial and very annoying, sometimes appearing days after discharge from hospital. They all require the use of an antibiotic. I agree wholly with Dame Sally that unless we tackle antimicrobial resistance then routine operations will become more dangerous, however it is equally important that we tighten up the use of antiseptics to reduce surgical site infections to reduce the use of antibiotics. Even Lord Carter mentioned the need to reduce surgical site infections – it is an unnecessary waste of money and cause of suffering to patients.

The problem in the UK started over 10 years ago when we allowed, perhaps even supported, a workplace disinfectant (biocide) to be introduced and bypass both the medicines and biocide legislation. We played on the inadequacy or perhaps just the unwillingness of the Health and Safety Executive to get involved in the NHS and the blind side of the CQC to implement the existing biocidal products regulations. The MHRA battled to ensure appropriate labelling, but we know that few surgeons read the label. This failure was ignored by NHS England and even the RPS who, to this day, have consistently failed to clarify biocides and their legal position to members. It is perhaps sad to reflect that the use of workplace disinfectants (biocides) on patients in the NHS is now considered custom and practice.

We face a future is simple a rush to the bottom. Who can sell the cheapest antiseptics to the NHS. And when you don’t want to use workplace disinfectants – can you find the cheapest alternative. There are no new antiseptics coming into the UK market – what is the point of researching new products and getting a licence – being sterile, single use and evidence based – when austerity and apathy means that nobody will use them.

Let us reflect on what is actually happening. You can split the hospitals into four groups:

  • Using workplace disinfectants (biocides) in patient care
  • Using lower strength chlorhexidine off label where you might expect an excess of late onset superficial infections
  • Using aqueous povidone iodine (may be masquerading as povidone iodine alcoholic tincture) where you might expect an excess of both deep and superficial infections
  • Using a sterile, single use, evidence based, licensed medicine

If you want to overlay this with clinicians who like to use two layers of one over the other, those that use 70% alcohol you have a total hotch-potch.

So we find ourselves in a position where we do not have high quality research. Surveillance rarely goes outside the hospital to pick up late infections that would present to the GP and there are usually no feedback mechanisms. Many hospitals select the cheapest product that they can source. Some are happy to put the use of workplace disinfectants on their risk register and avoid telling patients what they are using. And the MHRA and CQC who acknowledged that gap in the implementation of the existing legislation within their memorandum of understanding have done nothing.

If you ask others you may find that NHS England believe it is a regulation issue and the CQC believe it is a hospital management issue. The RPS don’t believe it is a priority for them. So come on Sally – get a grip – and launch an antiseptic guardian program. At least get us some decent research.

Note: when I refer to biocides as workplace disinfectants it is because the legislation supporting the biocides fits under the Department of Works and Pensions and not the Department of Health and Social Care. The implementation responsibility sits with the Health and Safety Executive, but is delegated to the CQC in hospital premises.

Public Health England’s team recently published their research on antiseptics. They found that when subjecting certain bacteria to very low concentrations of a common antiseptic, the bacteria coped and became resistant to colistin and many other antibiotics. This is important research telling us that improper use of low strength antiseptics may influence bacterial resistance.

 

 

 

 

 

How prepared is your A&E

What would you expect the NHS to do? Cancel all planned, but non emergency operations until February leaving thousands of surgeons with nothing to do.

The MMP Blog

I was reading some of the work of Professor Enrique Casalino in Paris. Last year he noted that the number of patients attending his A&E had increased by 10%. On January 1st 2017 he noted that the average attendance had risen from 215 to 231 and the number of admissions from 25-35 a day to 30-40a day. He points out that this is an additional 5 to 10 admissions a day and this small increase puts the hospital into a precarious balance.

“The problem comes from the tension on the availability of hospital beds downstream of emergencies.”

I believe that is a problem faced all around the world and particularly in the UK. Pauline Philip, the National Director for Urgent and Emergency care believes that we need to free up more than 3,000 beds this winter and the government have responded by providing £350mto NHS trusts to help them…

View original post 290 more words

How safe is your A & E

This winter will be particularly difficult. Following a significant increase in the number of cases of influenza in Australia NHS managers and politicians are worried. We already know that our A & E departments are full and many are failing to hit their 4 hour targets. When you walk through the ‘major’ section is usually full with people waiting on beds and trolleys waiting for the hospital to find them a bed.

I worry about the staff. Despite a valiant effort there will still be a significant number of members of NHS staff who have not been vaccinated. Having said this, we cannot be absolutely sure that the immunisation we have will be as effective against predominant strains as we would have wished. The last thing a hospital wants is an outbreak in their staff.

I was reading an assessment of an A&E department in Paris. Over the last influenza season 21% of attendances had signs and symptoms compatible with influenza. When tested 36% of these actually did have influenza. Of course the rates were higher in older people and particularly those with at least one underlying medical condition. When you think about this approximately 8% of the attendances actually had influenza. That is about one in 12.

The scary bit is that they don’t know and they can’t put all 21% of their attendances into isolation. So while you are sitting in the crowded waiting room or worse still on a bed in the ‘majors’ one in 12 of those patients will have influenza.

There is a potential solution. The ambulance service and the hospital could use a rapid antigen influenza test. If you start with a product that is approved by the FDA (the US have very good standards) and it is CLIA waved (suitable for use by non-laboratory staff) then you can have a nose swab done and a result within 10-15 minutes.

The hospital would be able to isolate those patients with influenza very early in their route through the system. They could get fast tracked to appropriate treatment and kept isolated from the other patients. Hospital staff would be able to implement control of infection procedures to protect themselves and other patients.

In Paris they are changing. When you go into A&E with signs and symptoms compatible with influenza you will have to have a nose swab taken. It will help them use their precious isolation facilities better and accelerate their clinical decision making. It is actually going to save them money – lots of it.

If you want to be sure that fellow patients in the waiting room haven’t got influenza – I suggest you go to France.

How prepared is your A&E

I was reading some of the work of Professor Enrique Casalino in Paris. Last year he noted that the number of patients attending his A&E had increased by 10%. On January 1st 2017 he noted that the average attendance had risen from 215 to 231 and the number of admissions from 25-35 a day to 30-40a day. He points out that this is an additional 5 to 10 admissions a day and this small increase puts the hospital into a precarious balance.

“The problem comes from the tension on the availability of hospital beds downstream of emergencies.”

I believe that is a problem faced all around the world and particularly in the UK. Pauline Philip, the National Director for Urgent and Emergency care believes that we need to free up more than 3,000 beds this winter and the government have responded by providing £350mto NHS trusts to help them cope with increased pressure over winter.

So Professor Casalino tried something…..

There were 1,099 patients admitted to his A&E service during 2016/7 winter with the signs and symptoms of influenza. They all had nose and throat swabs which were run at the time and then stored. The medical records of 500 of these were examined by experts (A&E and infectious diseases) and nurses and physicians from the A&E performed a rapid antigen test on the samples. They compared the results of the rapid test to the results produced by laboratory based PCR tests. They concluded that there was no difference in test performance as well as confirming the feasibility of point of care testing in A&E.

He hypothesised that the use of an efficient rapid diagnostic test may result in changes in the management of patients by ED physicians and facilitates a reduction in hospital costs in adult and geriatric patients by limiting examinations and treatments in the ED and reducing the number of hospitalisations.

He developed a decision-tree model for his total population of patients. The implementation of rapid tests was associated with a reduction in costs when the prescription of standard care in A&E is limited to patients that are influenza positive and especially with a fall in admissions of 20% in Influenza negative patients and a fall of 10% in influenza positive patients. He estimated that compared to their usual care, the implementation of rapid antigen tests may produce a saving for his hospital of 1.7million euros.

What would you expect the prof to do now? That’s right he is implementing it. He is using new diagnostics to increase the efficiency of his A&E service and to save money.

What would you expect the NHS to do…………..

 

Guest Blog: Is brushing your teeth more important than checking your feet?

GUEST BLOG BY SOLESEE

I have been to a few presentations and talks recently, raising awareness of Solesee to groups of podiatrists and people with Diabetes. Through listening to comments on feet and foot health I have had a few more thoughts about the importance of foot health within this sector.

The more people I meet, the more this has turned into a crusade.

My crusade is to change the way people think about the two parts of their body that are literally with them ‘every step of the day’.  From the moment we get out of bed in the morning to the moment we get back into bed in the evening, they are supporting and transporting us, every second of every day. They give us our freedom and our independence, the ability to work and provide for our families, and support us in our enjoyment of life.

Like all parts of our body we take them for granted…. until something goes wrong or we encounter a bit of pain. ‘My feet are killing me’ is a phrase most of us have used or heard before.

How does this relate to the title of this blog?

Do you think that brushing teeth is more important than checking your feet?

Do you brush your teeth every day?

Most people do to prevent – tooth decay.

Figures taken from the *‘NationalSmileMonth’ say that 75% of adults do brush their teeth twice a day. That is twice a day they take a few minutes to clean their teeth and check to see if there are any problems in their mouth.

Subsequently the number of adults with no natural teeth has dramatically reduced from 37% in 1978 to only 6% now. This increased awareness of good dental hygiene and regular cleaning has helped to improve the health of the nation’s teeth. This is reflected in the number of adults with 21 or more natural teeth which has risen from 68% in 1978 to 86% today.

If 75% of adults are cleaning their teeth twice a day it must be clear that this is an important task and should be done. A huge amount of education is distributed to new mums, children and to the general public as to the importance of good dental hygiene and these figures show that in the last 40 years, more and more people are retaining their teeth.

The habit of cleaning your teeth twice a day is established early on in life. Indeed, like most habits, guilt kicks in if you happen to get into bed at night without cleaning your teeth, so much so, that it kicks you out again to grab the toothbrush and give them a quick scrub!

Do you check your feet every day?

The majority of people will probably answer ‘no’ to this question.

“Why would I?”

“They are fine!”

“If there is a problem or I have trodden on something I would feel it and then deal with the problem.”

That is all very well if you are sure that your pain receptors are working correctly to alert you when there is a problem. Yes – then it is clear, if I have a blister I will feel it, take my shoe off and put a plaster on it – job done! And oh yes, replace my tight-fitting shoes once I have put a plaster on the blister and I can hobble back to work. In feet where there is no problem with circulation, these will heal quickly.

However, what about when you have diabetes?

What happens when those very special nerve endings that tell the brain you have hurt yourself by ringing the alarm bells of pain, so that you react and take action, don’t work very well?

This could be something as simple as the pain you assume you would feel when you leave your feet too long on a hot water bottle on a cold winters night. This is the pain that would tell you that you need to remove your feet from the hot water bottle or you will burn them.

What happens when those ‘life saving nerve endings’ eventually stop working all together as happens with neuropathy?  How will you know when your foot is too hot and has been burnt or has been cut, or you have been walking around with a stone in your shoe for days which has created a nasty blister?

If the nerve endings stop working, the only way you will know you have a problem is when you actually look at your feet.  Or someone takes a look at your feet for you.

What happens if, at the same time as your nerve endings stop working properly, the blood vessels taking blood to and from your feet get damaged and therefore can’t transport blood as well as they used to?  When this happens, blood doesn’t get to all parts of our feet as well as it should which in turn means that blisters or cuts won’t heal as quickly as they ought, if at all.

With Diabetes, these complications can occur due to damage to the nerve endings and blood vessels. This results in cuts, blisters and breaks in the skin, which ordinarily will be healed quickly by the body, not healing at all.

Not only has the body’s defence mechanism of pain been damaged but also the body’s natural healing ability has been affected.

In these cases, a seemingly innocent cut can escalate rapidly to an ulcer, infection and potentially lead to amputation of the infected part, to stop the infection spreading to the rest of the body.

The Bare Facts of Diabetic Foot Disease                             

 

  • In England, according to the latest figures from Diabetes UK, there are now 160 lower limb amputations due to diabetic complications every single week. This figure was 140 this time last year so the situation is clearly getting worse.

 

  • Diabetes UK also state that 80% of amputations due to diabetic complications are preventable.

 

  • Figures show that 8 out of 10 people who have suffered an amputation will die within 5 years of surgery.

 

  • £1 out of every £140 spent in the NHS is spent on foot care for people with Diabetes

 

So why do you NOT check your feet daily but will brush your teeth daily – especially if you have Diabetes?

Is it simply that you are all aware of the risks associated with not cleaning your teeth every day? i.e. could end up losing your teeth.

If the motivation is vanity, surely losing your foot through amputation will have just as much effect on your day to day life as losing your teeth. I would argue more, due to the debilitating effect of losing a lower limb.

I think it is more the lack of knowledge and awareness of how devastating the effects of diabetes on your feet can be. I also feel after speaking to many podiatrists and people with diabetes, that there is an apathy to foot care, an assumption that someone else will look after them.

 

‘I see my podiatrist every 3 months, so I don’t need to do anything else’

‘I will start checking them regularly when I have a problem’

 

it is very common to hear that the relatives of people with Diabetes are also unaware of the potential danger to their loved one’s feet.

 

 Final thoughts

Why would you clean your teeth daily to help prevent 

but not check your feet daily to prevent ulcers and amputations

 

After reading this blog I hope that you agree that it is equally as important to check your feet daily, as clean your teeth daily. We don’t even question why we clean our teeth every day now – we just do it.

Establishing a habit of checking your feet daily will allow you to take responsibility of your foot health, just as you do your tooth health.

All I would ask you is “would you expect your dentist to clean your teeth every day?”

*NationalSmileMonth – http://www.nationalsmilemonth.org/facts-figures/

To find out more visit or follow us at:

www.solesee.com  info@solesee.com   twitter@soleseeUK  facebook.com/@soleseeUK

Sorting out influenza

The MMP Blog

The NHS has been given a severe flu warning from Simon Stevens at the NHS Expo conference. It is not too unexpected. Systems that calculate the probability of bad seasons have been issuing gentle warnings for a while, doubts about effectiveness of the last vaccine and the reports from Australia of a rapidly mutating virus add an additional worry.

I don’t need to explain the impact of flu and what might happen if we have a particularly bad season. The whole point of Simon’s warning was to ensure that the NHS was prepared, but there is still no plan.

I would like to mention that influenza is not a reportable illness. Public Health England does collect some surveillance data on influenza (ILI) like illness from General Practice and NHS England ‘may’ respond by allowing the prescribing of antiviral medication during the period of apparent high reporting of ILI. It all…

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Is the NHS chasing pavements?

The MMP Blog

The NHS seems to be always chasing pavements rather than getting to the point and sorting things out. It has never been about structure and competition – it has always been about relationships and working together. It cannot be all about illness, but must focus on wellness and health creation. It is not about access it is about demand.

Demand has two elements:

Can we share demand – bringing other players in to share the load?

Can we reduce demand – adopting health creating practice and giving people control, connection and confidence?

GPs will tell you that there is too much bureaucracy, the payment systems are fractured and there are too many boxes to tick and too many meaningless pathways. But they will truthfully say that demand is the killer. More patients, with more expectation, more complex conditions and getting older; delivering care to the quality that they desire and…

View original post 478 more words

Sorting out influenza

 

The NHS has been given a severe flu warning from Simon Stevens at the NHS Expo conference. It is not too unexpected. Systems that calculate the probability of bad seasons have been issuing gentle warnings for a while, doubts about effectiveness of the last vaccine and the reports from Australia of a rapidly mutating virus add an additional worry.

I don’t need to explain the impact of flu and what might happen if we have a particularly bad season. The whole point of Simon’s warning was to ensure that the NHS was prepared, but there is still no plan.

I would like to mention that influenza is not a reportable illness. Public Health England does collect some surveillance data on influenza (ILI) like illness from General Practice and NHS England ‘may’ respond by allowing the prescribing of antiviral medication during the period of apparent high reporting of ILI. It all seems a bit hit and miss to me so I would like to suggest a way forward.

Vaccination – increase the campaign activity around vaccination. Stop petty arguments between community pharmacy and general practice by introducing an area wide reward based on joint achievement of vaccination. The more people that are vaccinated the better the community immunity.

Hospital triage – hospital A and E services have already started to purchase point of care tests for influenza A and B. The sensitivity and specificity of recently introduced tests are much improved at over 90% for influenza A. Patients coming through the door can receive a point of care test based on a nasal swab as they enter the system. More hospitals and out of hours services will join in.

General Practice triage – General Practice are waiting for CCGs to explain their preferred course of action. Patients coming into General Practice could be triaged using point of care tests and then managed through an appropriate pathway.

Community Pharmacy triage – Community Pharmacy are also waiting for CCGs to explain whether they will be included within flu triage. They are often the first stop for patients with ILI and it would seem sensible to start the triage process where most patients go. If excluded from the process Community Pharmacy could offer a private triage service to patients in association with anti-viral treatment via a PGD.  The Community Pharmacist would be well placed to advise patients who have flu on how to look after themselves and when to seek additional help.

Treatment – although there are doubts about the absolute effectiveness of treatment, it could be employed as an immediate option following a positive result. A campaign using the strap line ‘get tested – get treated’ might be useful.

Surveillance – Public Health England could create a system based on both laboratory and point of care test reports to obtain a more detailed picture of influenza within England.

It could all work and it might reduce the impact on NHS service and minimise the expected increase in winter deaths, but if you were to ask me what I thought – I would answer:

  • Warnings given to late
  • Not enough thought about how to get Community Pharmacy and General Practice really working together to increase vaccination uptake
  • Hospitals will introduce point of care triage – because they can
  • Commissioners won’t get their act together to introduce locally enhanced services around point of care testing for influenza across primary care (General Practice and Community Pharmacy)
  • A handful of community pharmacies will introduce a private service
  • Public Health England would have to pull out all of the stops to redefine flu as a reportable illness and get the mechanisms in place
  • It will be a bad flu season

Go on – prove me wrong…..

The new pharmacy

The MMP Blog

It is a funny time.

All I hear are discussions about the term ‘clinical’, about supervision, about the law suites and about shortages of medicines. A Pharmacy isn’t a Pharmacy without a pharmacist and you can’t separate supply from clinical services. There seems to be a mist falling demonstrating the whole professions wish to move backwards into the good old times and reluctance to move forwards. The eloquent ask for one voice – but saying what, on behalf of whom, delivering which future? It might be time for a different voice talking about a different future.

I have heard chatter in the backroom about a new breed of pharmacy. The one without a dispensing contract with the NHS. It is not unheard of – the dentists did it – but despite the chatter and the goading – I have not seen a Pharmacy do it.

Now this is the real…

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