PHARMACY DEPARTMENT Education, Vaccination and Antibiotics. Improving

PHARMACY DEPARTMENT Education, Vaccination and Antibiotics. Improving the management of our splenectomy patients. Katie Jodrell and Karen Watt AMS Clinical Pharmacists October 2017

Background More than 25000 Australians have a non-functioning spleen Asplenia or hyposplenism Lifetime higher risk of contracting bacterial infections Infections may become life-threatening Encapsulated bacteria Occurs post-splenectomy in 4% patients without prophylaxis Highest risk in children and those on immunosuppressants Greatest risk of mortality is in the first 2 years and is 50%

Coroners report into the death of Lilli Sweet Lilli was born 4 December 2006 as one of twins th Hereditary spherocytosis Splenectomy to manage condition aged 4.5yrs 2 day history of vomiting, diarrhoea and headache GP referred to ED 25th August 2013 stating she had a splenectomy and it was unclear if fully immunised On arrival temp 37.6, given IV fluids and paracetamol/ibuprofen White cell count at midnight 46.5 – no further action taken at this time Following morning severe headache, high fever and neck stiffness. Antibiotics then started Soon after Lilli became unresponsive. CT scan showed brain stem herniation. BC grew Streptococcus pneumoniae. Lilli died 27th August 2013 Findings A letter in plain terms should have been addressed to Lilli’s GP and her mother setting out the vaccination schedule Antibiotics should have been given much earlier

St John of God Subiaco Hospital SJGSH Splenectomy patients had been identified as high risk patients by AMS (Antimicrobial Stewardship) Committee Incidents Splenectomy patient almost not seen by the Infectious Diseases (ID) Physician and didn’t receive vaccines, antibiotics and education in hospital Supply and administration of the incorrect meningococcal ACWY vaccine (polysaccharide supplied instead of conjugate vaccine)

Management of splenectomy patients Management Immunisations Prophylactic antibiotics Emergency antibiotics Education More than a quarter of patients who undergo splenectomy in Australia do not receive the appropriate vaccines Critical role of patient education Risk of OPSI (overwhelming post-splenectomy infection) can be reduced by half with education, vaccination and antibiotics Patients and families need to be educated about Possible consequences of splenectomy Recognising early signs of infection Vaccination can NOT provide protection against all bacterial infections Need for early presentation for medical care

Spleen Australia and WATAG Aims to reduce the occurrence of OPSI in asplenic/hyposplenic patients 70% reduction in severe infection risk shown Registry with names and relevant medical information on these people Cost effective service Provide information and strategies to both patients and health professionals to help prevent serious infection WA patients are currently NOT eligible to register with Spleen Australia https://spleen.org.au/VSR/Index.html WATAG Excellent resources Vaccination and prophylaxis for asplenia: Guideline for clinicians (adult and paediatric) Immunisation plan template Patient information http://www.watag.org.au/watag/publications.cfm

St John of God Subiaco Hospital Strategy to improve management of splenectomy/asplenic patients 1. 2. 3. 4. 5. Improve identification of these patients Improve patient education Improve staff education Improve dispensary procedures to ensure correct vaccine supply Develop Pharmacy Ward Manual Guideline

1. Improve identification of these patients Pre-admissions clinic (PAC) email alert to infection control and AMS pharmacists For patients being admitted for a splenectomy Patients with a prior history of splenectomy Infection control alert Added if either a history of splenectomy or admitted for a splenectomy New patients added when email received Old patients added retrospectively during setup Can click on and see details Patients flagged for review on AMS rounds Seen by ID Physician

2. Improve patient education AMS Pharmacist to provide counselling Review vaccination status, prophylactic and emergency antibiotics Developed patient information sheet (adapted from Spleen Australia) Developed wallet card (adapted from Spleen Australia) Provide vaccination card (WA Health) Provide copy of vaccine schedule clearly identifying what further vaccines are required Provide MedicAlert form I do not have a functioning spleen I am at risk of overwhelming infection, especially pneumococcal infection. I nfection can be very rapid, within hours, and may lead to serious impairment or death I am to show this card to a doctor if I am unwell with fevers or shivers I must always carry this card in my wallet or purse What I need to remember - SEE DOCTOR I F UNWELL WI TH SHI VERS, SWEATS, DI ARRHOEA, VOMI TI NG OR HI GH TEMPERATURES - Take antibiotics daily if recommended - Keep emergency supply of antibiotics - Booster doses of pneumococcal and meningococcal vaccines - Yearly influenza vaccines - Show this card to all my doctors - See doctor after animal bite or scratch - Wear or carry medic- alert - Get medical advice before overseas travel - My increased risk of infection is lifelong

3. Improve staff education and awareness Education sessions to pharmacists and infection control staff Grand round planned Education for resident medical officers planned Strategy presented at various executive meetings Drug and Therapeutics Infection Prevention and Control Nursing and Midwifery Practice Council Medication Safety Committee

4. Improve dispensary procedures Splenectomy kit Contains information on the supply process and patient information including: Required vaccinations WA Health vaccination card SJGSH patient information splenectomy leaflet Spleen Australia information Medic alert brochure SJGSH patient wallet card to identify splenectomy status Notification of the need to add emergency antibiotics as prescribed by the doctor Checked by AMS Pharmacist BEFORE supply to the ward

5. Pharmacy Ward Manual Guideline Collated all the information Available hard copy and online

Conclusion Guidelines, alerts and procedures should significantly improve our management of splenectomy patients We are recording the details of all our patients that are seen and the outcomes for their management Spleen Australia and WATAG Guidelines