CQUIN 2 Overview CQUIN ‘Commissioning for Quality and Innovation’ Guidance and CQUIN Indicator Specific Information 2017/18- 2018/19 CQUIN 2- Reducing the impact of serious infections PP-GEP-GBR-1194. October 2018

13 Introduction 2 1 Clinical quality and transformation indicators The focus of the CQUIN scheme remains the same and is intended to deliver clinical quality improvements and drive transformational change. The CQUIN scheme has been updated to reflect the ambitions of the Five Year Forward View Next Steps, the NHS Mandate and the Planning Guidance. 1 2 Clinical quality and transformation indicators Supporting local areas 13 Indicators have been defined which aim to improve quality and outcomes for patients including… A proportion of the CQUIN funding has been earmarked to support the development of….. Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) Encourage collaboration across different providers Reducing health inequalities Improve the working lives of NHS staff …reinforcing the critical role local partners have to deliver system wide objectives

This document has been produced to reflect updates to CQUIN indicator 2 ‘Reducing the impact of serious infections (AMR and Sepsis)’ of the Clinical quality and transformational indicators for 2017 - 2019 Commissioning for Quality and Innovation (CQUIN) Guidance for 2017 – 2019. Updated April 2018. NHS England. Last accessed May 2018.

CQUIN 2 GOAL ‘Reducing the impact of serious infections’ (Antimicrobial Resistance and Sepsis) There are four parts to this indicator. GOAL National CQUIN Indicator Indicator weighting (% of CQUIN scheme available) CQUIN 2a Timely identification of sepsis in emergency departments and acute inpatient settings.   25% of 0.25% (0.0625%) CQUIN 2b Timely treatment for sepsis in emergency departments and acute inpatient settings. CQUIN 2c Antibiotic review. CQUIN 2d Reduction in antibiotic consumption per 1,000 admissions and proportion of antibiotic usage (for both in-patients and out-patients) within the Access AWaRe category. Timely identification and treatment for sepsis and a reduction of clinically inappropriate antibiotic prescription and consumption.

Description of indicator: Timely identification of sepsis in emergency departments and acute inpatient settings Rationale: Description of indicator: The percentage of patients who met the criteria for sepsis screening and were screened for sepsis. The indicator applies to adult and child patients arriving in hospital as emergency admissions and to all patients on acute in-patient wards. To embed a systematic approach towards the prompt identification and appropriate treatment of life-threatening infections, while at the same time reducing the chance of the development of strains of bacteria that are resistant to antibiotics. In December 2017, NHS England and NHS Improvement jointly endorsed the National Early Warning Score (NEWS) 2 as the standardised early warning system for identifying acutely ill patients – including sepsis – in hospitals in England. During 18/19, acute and emergency units should be transitioning to use NEWS 2 to screen patients. By Q4 of 2018/19, payment will only be made if over 90% of screened cases have been screened using NEWS 2. National Early Warning Score (NEWS) 2 Executive Summary Royal College of Physicians. Updated December 2017. Last accessed August 2018. The ‘screening for sepsis’ involves a senior clinical decision-maker using their judgement to decide if it’s likely that the patient has sepsis, and if so to start sepsis treatment.

Description of indicator: 2B Timely treatment of sepsis in emergency departments and acute inpatient settings Rationale: Description of indicator: The percentage of patients who were found to have sepsis in sample 2a and received IV antibiotics within 1 hour. The indicator applies to adults and child patients arriving in hospital as emergency admissions and to all patients on acute in-patient wards. Prompt treatment of sepsis reduces the mortality and the morbidity associated with this condition.

Appropriate clinical review Documented outcome of review recorded Antibiotic Review Rationale: Description of indicator: Year 2 (18/19) Percentage of antibiotic prescriptions documented and reviewed by a competent clinician within 72 hours meeting the following three criteria To embed a systematic approach towards the prompt identification and appropriate treatment of life-threatening infections, while at the same time reducing the chance of the development of strains of bacteria that are resistant to antibiotics. 1 Appropriate clinical review 2 Documented outcome of review recorded 3 Where appropriate an IV to oral switch decision was made. If the decision was for the patient to remain on IV antibiotics, a documented rationale for not switching is clearly documented:

1 Appropriate clinical review by either.. Infection (infectious diseases/clinical microbiologist) senior doctor (ST3 or above) Senior member of clinical team (ST3 or above) Infection pharmacist

2 Documented outcome of review recorded as one of the following 7 options… OPAT STOP IV to oral switch with a documented review date or duration of the oral antibiotic OPAT (Outpatient Parenteral Antibiotic Therapy) Continue with new review date or duration Change antibiotic with escalation to broader spectrum antibiotic with a documented review date or duration Change antibiotic with de-escalation to a narrower spectrum antibiotic with a documented review date or duration Change antibiotic e.g. to narrower/broader spectrum based on blood culture results with a documented review date or duration

3 Where appropriate an IV to oral switch decision was made. If the decision was for the patient to remain on IV antibiotics, a documented rationale for not switching is clearly documented: Patient is nil by mouth or not absorbing No oral antibiotic option available Patient not clinically improving Based on microbiology/ID consultant/Infection Pharmacist advice Deep seated infection

Description of indicator: Reduction in antibiotic consumption per 1,000 admissions and proportion of board spectrum antibiotic use Rationale: Description of indicator: Year 2 (18/19) There are three parts to this indicator Total antibiotic usage (for both in-patients and out-patients) per 1,000 admissions. Total usage (for both in-patients and out-patients) of carbapenems per 1,000 administrations Increase the proportion of antibiotic usage (for both in-patients and out-patients) within the Access group of the AWaRe category To embed a systematic approach towards the prompt identification and appropriate treatment of life-threatening infections, while at the same time reducing the chance of the development of strains of bacteria that are resistant to antibiotics. NB: For 18/19, the 17/18 indicator for reducing the use of piperacillin-tazobactam per 1,000 admissions has been replaced with an indicator on the Access group of the AWaRe* category.

The AWaRE group categories CQUIN 2 To assist in the development of tools for antibiotic stewardship at local, national and global levels and to reduce antimicrobial resistance, three different categories were developed. Access Group Watch Group Reserve Group To improve both access and clinical outcomes antibiotics that were first or second choice antibiotics in at least one of the reviewed syndromes are designated as key ACCESS antibiotics, emphasizing their role as the antibiotics that should be… This group includes antibiotic classes that have higher resistance potential and so are recommended as first or second choice treatments only for a specific, limited number of indications. These medicines should be prioritized as key targets of stewardship programs and monitoring. This group includes most of the highest priority agents among the Critically Important Antimicrobials for Human Medicine and/or antibiotics that are relatively high risk of selection of bacterial resistance. This group includes antibiotics that should be treated as “last resort” options that should be accessible, but whose use should be tailored to highly specific patients and settings, when all alternatives have failed (e.g. serious, life-threatening infections due to multi-drug resistant bacteria). These medicines could be protected and prioritized as key targets of national and international stewardship programs involving monitoring and utilization reporting, to preserve their effectiveness. Widely available Affordable Quality-assured Selected ACCESS antibiotics may also be included in the WATCH group.

Access Watch Reserve Amoxicillin/ ampicillin Penicillin – all forms Co-trimoxazole Doxycycline Flucloxacillin Fosfomycin oral Fusidate Gentamicin Metronidazole Nitrofurantoin Pivmecillinam Tetracycline Trimethoprim Amikacin, tobramycin, etc. Macrolides Most Cephalosporins Chloramphenicol Fluoroquinolones Clindamycin Co-amoxiclav Other tetracyclines Fidaxomicin Piperacillin-tazobactam, etc. Tamocillin Vancomycin, teicoplanin Aztreonam Ceftobiprole Ceftaroline Ceftazidime-avibactam Ceftolozane-tazobactam Colistin Daptomycin Carbapenems Fosfomycin IV Linezolid / tedizolid Televancin Tigecycline Table 1: Adapted AWaRe categories for use in England[i]

Useful links References Sepsis guidance implementation advice for adults. National Early Warning Score (NEWS) 2. Royal College of Physicians. NICE Sepsis: recognition, diagnosis and early management guideline 2016 (updated 2017) Public Health England AMR local indicators Reducing the impact of serious infections CQUIN FAQs, parts 2c and 2d October 2017. NHSI. References Commissioning for Quality and Innovation (CQUIN) Guidance for 2017 – 2019. Updated April 2018. NHS England. Last accessed May 2018. CQUIN Indicators Specifications 2017 – 2019. Updated April 2018. NHS England. Last accessed May 2018. National Early Warning Score (NEWS) 2 Executive Summary Royal College of Physicians. Updated December 2017. Last accessed August 2018. WHO Model List of Essential Medicines 20th List March 2017. Last accessed June 2018   Emma Cramp, Secondary Care Antibiotic Incentive Scheme for English Acute Trusts. April 2018. NHSI