50. Impact of Antibiotic Stewardship Interventions on Colistin Use and Acinetobacter Resistance

Background Our hospital had a widespread use of colistin and tigecycline, and very high resistance of Acinetobacter Spp. to colistin. The hospital did not have any infectious disease (ID) pharmacist and had only one ID consultant physician. The objective of this study was to evaluate the impact of our intervention on the utilization of colistin and tigecycline and resistance of Acinetobacter Spp. Methods This was a before an observational before-and-after study at a tertiary medical center. An ID pharmacist trained in antibiotic stewardship program (ASP) was invited by a tertiary hospital to help create an ASP. The hospital also hired four ID assistant consultants to help the primary ID consultant and pharmacists. The ASP started by restriction of colistin and tigecycline. The study outcomes were antibiotic consumption and resistance of Acinetobacter spp. Results Colistin utilization decreased by 60%, and the resistance of Acinetobacter spp. to colistin significantly decreased from 31% to 3% in a year. In addition, tigecycline utilization decreased by 46%. On the other hand, there were no significant changes in carbapenem utilization and resistance, which could be explained by switching from colistin and tigecycline to carbapenems. Conclusion Adding an ID pharmacist and ID assistant consultants to the ASP team, and the strict restriction of colistin use was associated with significant reduction in colistin use and Acinetobacter resistance. Disclosures All Authors: No reported disclosures

Gladys Mary Wauchope (1889–1966): Brighton physician and second female medical student at the London Hospital Medical College

Gladys Mary Wauchope was a pioneering woman physician and general practitioner in London and Brighton. Descended from an ancient Scottish family, she was the second female medical student at the London Hospital Medical College after Elizabeth Garrett Anderson, enrolling during the brief period from 1918 to 1928 in which women were permitted to study medicine in mainstream London medical schools due to shortages of doctors caused by the First World War. Unperturbed by opposition to her gender from male colleagues, she was initially house physician on the firm of Sir Robert Hutchison at ‘the London’, and went on to hold an array of posts in large London hospitals at a time when finding such work was challenging for women doctors. She settled in Hove as a general practitioner in 1924, later becoming a consultant physician at several major Brighton hospitals. Made only the eighth female fellow of the Royal College of Physicians, she also set up the first diabetic clinic in Sussex and Kent. Gladys authored several books, including her autobiography ‘The Story of a Woman Physician’, which documents life through two world wars and the introduction of the National Health Service, whilst keenly observing the changing landscape of medicine and its place in society.

‘Foreseeing well-being’: developing a physical health strategic vision across a large mental health trust ‘foreseeing well-being’: developing a physical health strategic vision across a large mental health trust

AimsStatistically, suicide is less than half as deadly as poor physical health for people with severe mental illnesses (SMI). For every 1000 SMI patients, diseases such as diabetes cause 10-20,000 ‘years of life lost’ compared to 4,000 ‘years of life lost’ to suicide. National charity Rethink dubbed the failure of the NHS to act on this as tantamount to “lethal discrimination”.We aim to reform the physical health care provision for service users under the care of Avon and Wiltshire Mental Health Partnership NHS Trust (AWP).MethodTo evaluate the current service within AWP, we combined data from a comprehensive audit of 106 inpatients, local Quality Improvement (QI) Projects, and qualitative feedback from a pilot Medical-Psychiatric Liaison Service (MPLS).ResultKey findings included: High rates of physical comorbidities among psychiatric inpatients of all agesNovel illnesses occurring during admissionsEvidence that patients are not receiving adequate physical healthcare from wider NHSJunior doctors receiving inadequate support from Seniors and acute Hospital services when managing physical illnessesPoor recording of cardiometabolic monitoring with few interventions delivered (even when indicated) and challenges finding relevant data in records.During the MPLS pilot, a Consultant Physician provided virtual ward rounds and advisory sessions. 100% of staff involved reported the service was beneficial for their clinical practice and patient outcomes.ConclusionTaking these findings and input from colleagues within AWP and nationally, we created a comprehensive strategic overview on how AWP can deliver high quality physical health care, detailing improvements to make across 5 key domains: Inpatient, Community, Workforce, Education and Information Technology (IT).Presently, we are working with Clinical Commissioning Groups developing protocols clarifying roles and responsibilities across primary and secondary providers. We are standardising communication between AWP and primary care and expanding links with specialist secondary services (e.g. endocrinology and cardiology). We formed the BRIGHT (Better Recording of Information for Governance and Healthcare in the Trust) project workgroup alongside IT to build safer and more effective records systems.Medium term recommendations include employing a full-time MPLS Consultant Physician, in addition to ‘Physical Health and Wellbeing Workers’ in all localities, Advanced Nurse Practitioners (working within structured physical care systems) and more allied health professionals (dieticians, speech therapists and physiotherapists).In the long term, the new Physical Health, IT and QI working groups will maintain development of these proposals, improve training and supervision for clinicians, and achieve healthcare parity for patients across localities.

Development and validation of an aetiology in delirium diagnostic support tool

Background recognition of the multifactorial causes of delirium represents a clinical challenge. Objectives to develop and show proof of principle of a diagnostic support tool (DST) for identification of causes of delirium. Methods stage 1—development of the aetiology in delirium-diagnostic support tool (AiD-DST); stage 2—validation of the AiD-DST against reference standard diagnosis, based on clinical assessment from two independent consultant geriatricians. Results a series of eight steps AiD-DST were formulated by an expert group to identify possible causes of delirium. Forty inpatients admitted to a general medical unit with a consultant physician/geriatrician diagnosis of delirium were recruited, consented and reviewed against the AiD-DST. Mean age was 85.1 (standard deviation 7.9) years and 26 (65%) of participants were female. Participants had multiple chronic co-morbidities [median Charlson Comorbidity Index 7; interquartile range (IQR 6–9)] and median number of medications was 8 (IQR 6–11.75). Median number of causes of delirium detected on AiD-DST was 3 (IQR 3–4) versus 5 (IQR 3–6) using the reference standard diagnosis, with sensitivity of 88.8% (95% confidence interval, 81.6–93.9%) and specificity of 71.8% (63–79.5%). Conclusions the aetiology in delirium DST shows promise in the identification of cause(s) in delirium.

Physicians perception in the management of allergic rhinitis: a Pan-India survey

<p class="abstract"><strong>Background: </strong>Allergic rhinitis (AR) affects a wide proportion of the population across all age groups. There are several guidelines and consensus statements in AR management, the effect of this is implicit from a physician's perspective. The present cross-sectional survey was conducted to understand physicians approach to the management algorithm in the treatment of allergic rhinitis and medication choice.</p><p class="abstract"><strong>Methods:</strong> Physicians from diverse specialties such as pulmonologists, consultant physician, paediatricians, Allergists, ENT specialists and general practitioners were invited to participate in the survey, which focused on recognizing the burden of disease, clinical presentation, and management methods.</p><p class="abstract"><strong>Results:</strong> 1,261 Physicians participated in this survey, belonging to different specialties. Oral H1 antihistamine was favoured as a first-line therapy, followed by the combination of oral H1 histamine and leukotriene receptor antagonist. Fexofenadine was the most frequently prescribed. Majority believed, bilastine as antihistamine with the least sedative potential and was identified as the most effective treatment. Bilastine was preferred in patients with mild- moderate hepatic/renal impairment and in patients with persistent allergic rhinitis. Most physicians prefer bilastine in all AR clinical profiles. Aside from AR, bilastine is also use in management of upper respiratory tract infections and urticaria respectively.</p><p class="abstract"><strong>Conclusions: </strong>AR is still a growing challenge in India with majority of physician preferring oral antihistamine either as monotherapy or in combination. Bilastine is a preferred choice in patients with impaired liver and renal function and was also referred as least sedative antihistamine by majority of physicians across India. </p>

Pain perception during colonoscopy in relation to gender and equipment: a clinical study

ObjectivesA trend for gender-related differences in pain perception during colonoscopies has previously been observed. No consecutive clinical studies have been conducted to confirm such a relation. We aimed to investigate gender-related differences during the colonoscopy procedure, and the impact of endoscopic equipment and psychological factors on pain management.MethodsIn a consecutive clinical study, 391 patients referred for colonoscopy reported pain perception on a 0–10 visual analogue scale (VAS) after the procedure. A sub-group of patients (n=38) were given alternate instructions expertly tailored by a psychologist and their VAS scores were compared with those from the main study population. Data from a previous study from the same specialist practice and same source patient population using previous-generation equipment was included for comparison.ResultsNo overall gender-related difference in VAS reports was found. There was no reduction in VAS when alternate instructions were given. Female patients were, however, more likely to benefit from light sedation (p=0.012). When compared with previous-generation endoscopes, the current generation equipment resulted in a VAS drop of 1.9 points for women and 1.6 for men (p<0.009) and washed out a previously observed gender-related difference.ConclusionNo overall gender-related differences were found for pain experience during the colonoscopy procedure. Access to up-to-date endoscopic equipment can reduce procedure-related patient discomfort considerably, even at the expert level of a consultant physician.ImplicationsGastroenterologists should consider utilizing high-end endoscopic equipment to improve pain management and reduce VAS to very acceptable levels.

Dr Joseph Dudley ‘Benjy’ Benjafield: Microbiologist, soldier and Bentley Boy racing driver

Dr Joseph Dudley ‘Benjy’ Benjafield qualified from University College Hospital Medical School, London in 1912. He joined the Royal Army Medical Corps during World War I and was in charge of the 37th Mobile Bacteriological Laboratory serving with the British Egyptian Expeditionary Force when the Spanish flu struck in late 1918. He observed the features and clinical course of the pandemic and published his findings in the British Medical Journal in 1919. On return to civilian life, he was appointed as Consultant physician to St George’s Hospital, Hyde Park Corner, London where he remained in practice for the rest of his career. He was a respected amateur gentleman racing driver frequently racing at the Brooklands circuit from 1924 after buying a Bentley 3-litre and entering the Le Mans 24 h race seven times between 1925 and 1935, winning in 1927. He was one of an elite club of young men known as The Bentley Boys and went on to become a founding member of the British Racing Drivers Club (BRDC) in 1927. He rejoined the Royal Army Medical Corps during World War II, serving briefly again in Egypt. He died in 1957.

Revenue of consultant physicians for private out-patient consultations

Objective The aim of this study was to determine the revenue to consultant physicians for private out-patient consultations. Specifically, the study determined changing patterns in revenue from 2011 to 2015 after accounting for bulk-billing rates, changes in gap fees and inflation. Methods An analysis was performed of consultant physician Medicare claims data from 2011 to 2015 for initial (Item 110) and subsequent (Item 116) consultations and, for patients with multiple morbidities, initial management planning (Item 132) and review consultations (Item 133). The analysis included 12 medical specialties representative of common adult non-surgical medical care. Revenue to consultant physicians was calculated for initial consultations (Item 110: standard; Item 132: complex) and subsequent consultations (Item 116: standard; Item 133: complex) accounting for bulk-billing rates, changes in gap fees and inflation. Results From 2011 to 2015, there was a decrease in inflation-adjusted revenue from standard initial and subsequent consultations (mean –$2.69 and –$1.03 respectively). Accounting for an increase in the use of item codes for complex consultations over the same time period, overall revenue from initial consultations increased (mean +$2.30) and overall revenue from subsequent consultations decreased slightly (mean –$0.28). All values reported are in Australian dollars. Conclusions The effect of the multiyear Medicare freeze on consultant physician revenue has been partially offset by changes in billing practices. What is known about the topic? There was a ‘freeze’ on Medicare schedule fees for consultations from November 2012 to July 2018. Concerns were expressed that the schedule has not kept pace with inflation and does not represent appropriate payments to physicians. What does this paper add? Accounting for bulk-billing, changes in gap fees and inflation, revenue from standard initial and subsequent consultations decreased from 2011 to 2015. Use of item codes for complex consultations (which have associated higher schedule fees) increased from 2011 to 2015. When standard and complex consultation codes are analysed together (and accounting for bulk-billing, changes in gap fees and inflation), revenue from initial consultations increased and revenue from subsequent consultations decreased slightly. What are the implications for practitioners? Efforts to control government expenditure through Medicare rebate payment freezes may result in unintended consequences. Although there were no overall decreases in bulk-billing rates, the shift to higher-rebate consultations was noticeable.

Outpatient consultant physician service usage in Australia by specialty and state and territory

Objectives To determine national service usage for initial and subsequent outpatient consultations with a consultant physician and any variation in service-use patterns between states and territories relative to population. Methods An analysis was conducted of consultant physician Medicare claims data from the year 2014 for an initial (item 110) and subsequent consultation (item 116) and, for patients with multiple morbidities, initial management planning (item 132) and review (133). The analysis included 12 medical specialties representative of common adult non-surgical medical care (cardiology, endocrinology, gastroenterology, general medicine, geriatric medicine, haematology, immunology and allergy, medical oncology, nephrology, neurology, respiratory medicine and rheumatology). Main outcome measures were per-capita service use by medical speciality and by state and territory and ratio of subsequent consultations to initial consultations by medical speciality and by state and territory. Results There was marked variation in per-capita consultant physician service use across the states and territories, tending higher than average in New South Wales and Victoria, and lower than average in the Northern Territory. There was variation between and within specialties across states and territories in the ratio of subsequent consultations to initial consultations. Conclusion Significant per-capita variation in consultant physician utilisation is occurring across Australia. Future studies should explore the variation in greater detail to discern whether workforce issues, access or economic barriers to care, or the possibility of over- or under-servicing in certain geographic areas is leading to this variation. What is known about the topic? There are nearly 11million initial and subsequent consultant physician consultations billed to Medicare per year, incurring nearly A$850million in Medicare benefits. Little attention has been paid to per-capita variation in rates of consultant physician service use across states and territories. What does this paper add? There is marked variation in per-capita consultant physician service use across different states and territories both within and between specialties. What are the implications for practitioners? Variation in service use may be due to limitations in the healthcare workforce, access or economic barriers, or systematic over- or under-servicing. The clinical appropriateness of repeated follow-up consultations is unclear.