Audits trigger rapid responses to ARF & Rheumatic Heart needs
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East of Matata Eastern BOP Stunning but Low income; in the Red Zone Brief audits while prescribing Benzathine Penicillin, “Bicillin” for Acute Rheumatic Fever (ARF ) secondary prevention; a practical quality improvement tool for Rheumatic fever/Rheumatic Heart Disease areas without registers. John Malcolm MRCP, FRACP, DTMH, DCH, PGCertPH, Paediatrician, Bay of Plenty District Health Board, Whakatane NZ. Contact; [email protected] for expanded abstract, references and discussion; Korero mai koa! Audits trigger rapid responses to ARF & Rheumatic Heart needs Learnt from Acute Rh fever diagnosis Analgesia helps IM adherence! ARF/RHD Register essentials More patients get Benzathine Penicillin IM cardio protection from District Nursing Service (DNS) and more heart follow-up Clinical follow-up for those with Rheumatic Hearts is improvable Age at Rh fever diagnosis Learning from rural town, Opotiki 2012 audit of 12 children & their 12 ARF presentations. Q ... ● Who got ARF & Why? ● What made diagnosing ARF so hard? ● Who is on IM penicillin - who is not? ● What else is happening medically and socially? ● How many grandparents are parenting? A ... ● Kids with group A strep sore throats not prescribed 10 days Penicillin or had Rx short course Penicillin 5 day; n=2 (adherence is best on once daily Amoxil) ● Mono articular Arthritis, first exclude septic arthritis AND acute Rh fever. The cost of delayed diagnosis includes rheumatic heart disease n=1. ● Arthritis in Maori kids think ARF; admit for rapid work-up (not Outpatients). Diagnosis delay, 2 year before Echocardiograph & heart surgery, n=1. ● Early NSAID masks diagnosis; Rx paracetamol or codeine first; n=3. ● ARF presents with RHD, some heart failure; some ARF=subclinical. n=2. ● Psychosocial reasons why children don’t say “sore throat”; some shy, some putup/shut up, some not articulate, boys intellectual disability n=2. ● Families face multiple challenges; shifted towns before diagnosis; n=3. District Nursing aim; effective analgesia to help adherence for IM Benzathine Penicillin for secondary ARF prevention. ● 2011 - Benchmark Buzzy Bee + Lignocaine CMDHB Nicholson ref Russell, Nicholson, Naidu JPCH 2014,50,2,112-8. ● 2013 - BOP DNS Introduce gate theory tool Rx Buzzy Bee. Paediatric clinic feedback to DNS some pain scores. ● 2014 - BOP DN Service plan individual analgesia from Pre injection EMLA, ICE, Buzzy Bee PLUS. ● Some with 0.25ml 2% Lignocaine with IM Benzathine. ● Some day 2 muscle pain; Ice, Paracetamol or NSAID. What would a Register ARF RHD control programme look like? Recommended Elements, National Heart Foundatoin NZ guidelines 2006 ● Computer based, regional commitment. ● Local evidence based guidlines. ● Partnership clinicians, public health. ● Support the needs of those with ARF RHD. ● Assess and monitor burden of disease. ● Educate health workers ARF, RHD, whanau. ● Follow-up system; dedicated clinics that ensure ongoing care delivered; esp high risk. 2007 goal to improve effective secondary prevention of recurrent Acute Rheumatic fever ● Rural town ARF 3 patients on IM and 6 oral penicillin. ● Efficacy IM 95%; oral Penicillin 65%; Frankish 1984. ● Prevalence from clinic >9/8000 population. ● =112/100,000 total population; 2007-8 Opotiki ARF RHD 2014 Transitioning with Paediatric overlap to adult cardiology ● 10/12 ARF initial diagnosis was with paediatric service. ● Second surgery as adolescent, after a period on oral Penicillin n=1 ● 12/13 locals on Benzathine Penicillin (17yr old on orals new aortic and mitral mild incompetence). ● All moderate, severe and post-operative RHD see cardiologist. ● Clinical follow-ups = NHF NZ guide 6-24 months. ● 5 Adult Cardiology, 2 Paediatric Cardiology, 9 Paediatric FU. ● Transitioned 3, Transitioning 2 Pardiatric to Adult Cardiology (no adult physician follow-up clinics). Benchmark; NHF NZ & Starship Cardiology Rheumatic Heart Echo & Clinical Follow-up www.nhf.org.nz 2006 Carditis p16,echos p9-21, routine review p43 Kawerau ARF RHD Audit of Secondary Prevention & Clinical Follow-up Dr Rebecca Garland Paed SHO and John Malcolm 2011 ● 3/9 suboptimal secondary Benzathine Penicillin and clinical follow-up. ● Adolescents / young adults; all moderate to severe RHD. ● Suggest follow-up guides to general practice. ● General practice support examine, Cardiology safety net. ● Education opportunities, practice and district nurses, Eastern Bay PHA community health workers. ARF; Years since last physician/paediatrician exam Whakatane audit 2010; 3/16 outside NHF 2006 guide ● 3 yr Moderate - severe aortic incompetence Benchmark 1-2yr followup. ● 3 yr One mild mitral and aortic incompetence A1. ● 4 yr A1 MI Mstenosis low pump function Benchmark 1-2yr followup. ● 4 yr Moderate A1 Benchmark 1-2yr followup. ● 7 yr No RHD. ● 5 yr Mild mitral incompetence. ● 9 yr Normal exam and echo exit examination. ● 10 yr Mild Aortic incompetence stable. Years of clinical follow-up achieved; some get District Nurse penicillin but no medical review n=29 Audit 2007 for DNS Whakatane Opotiki Rh fever patients Youngest 2 years (In recent years 1:6 in 20s) Whakatane Opotiki DNS 2008 Ϭ ϭ Ϯ ϯ ϰ ϱ ϲ Ϯ ϯ ϰ ϱ ϲ ϳ ϴ ϵ ϭϬ ϭϭ ϭϮ ϭϯ ϭϰ ϭϱ ϭϱ ϭϳ 1XPEHUV RI FKLOGUHQ E\ DJH RI RQVHW RI $FXWH 5KHXPDWLF IHYHU ŶƵŵďĞƌ $JH LQ \HDUV 1XPEHUV RI FKLOGUHQ Severity RHD Description, Definition (Echo or clinical grade) First follow -up including echo Subsequent followup NHF and Eastern BOPDHB Mild or nil RHD ^ƵďĐůŝŶŝĐĂů ĐĂƌĚŝƟƐ ͻͲŵŝůĚ DZ Žƌ Z ͻͲƉĞƌŝĐĂƌĚŝĂů ĞīƵƐŝŽŶ ͻͲ Ɛƚ ĚĞŐƌĞĞ ďůŽĐŬ ǁŝƚŚŽƵƚ ǀĂůǀĞ ƌĞŐƵƌŐŝƚĂƟŽŶ Echo only if new murmurs Clinical (most benefit from frequent initial/education 3/12ly first yr JM) ϯͲϱ LJĞĂƌ WĂĞĚŝĂƚƌŝĐŝĂŶ WŚLJƐŝĐŝĂŶ Echo ŽŶůLJ ŝĨ ŶĞǁ ŵƵƌŵƵƌƐ ŽŶƐŝĚĞƌ ŝĨ ƉŽŽƌůLJ ĐŽŵƉůŝĂŶƚ ǁŝƚŚ W' ŽŶƐŝĚĞƌ Ăƚ ĚŝƐĐŚĂƌŐĞ ĨƌŽŵ W' ϮϭLJƌ Moderate ͲDŽĚĞƌĂƚĞ DZ Žƌ DŽĚ Z ͲĂƌĚŝŽŵĞŐĂůůLJ ͲŝůĂƚĞĚ >s ŽŶ ĞĐŚŽ Echo in 6-12 months Clinical ŶŶƵĂů WĂĞĚ WŚLJƐŝĐŝĂŶ ĂƌĚŝŽůŽŐŝƐƚ cho ϮͲϯ LJĞĂƌƐ ŝĨ ƌĞŵĂŝŶ ŵŽĚĞƌĂƚĞη ŶŶƵĂů &ůƵ ǀĂĐ ϱLJƌ džϮ WŶĞƵŵŽǀĂĐ Ϯϯ Severe Ͳ^ĞǀĞƌĞ Z Žƌ DZ ͲĂƌĚŝĂĐ &ĂŝůƵƌĞ ͲWŽƐƚ ĐĂƌĚŝĂĐ ƐƵƌŐĞƌLJ Close supervision until stable ĞƚĞƌŵŝŶĞĚ ďLJ /ŶŝƟĂů ŽŶƐƵůƚĂƟŽŶ ǁŝƚŚ ^ƚĂƌƐŚŝƉ ĂƌĚŝŽůŽŐLJ Clinical ŽŶƟŶƵĞĚ ůŝĂƐŽŶ ǁŝƚŚ WĂĞĚ WŚLJƐŝĐŝĂŶ E ĂƌĚŝŽůŽŐŝƐƚ ŝĨ ƌĞŵĂŝŶƐ ƐĞǀĞƌĞ Echocardiogram ϲ ŵŽŶƚŚůLJ ĂŶĚ ŝĨ ǀĂůǀƵůĂƌ ĂŶĚ >s ĨƵŶĐƟŽŶ ƐƚĂďůĞ LJĞĂƌůLJ ƐƐĞƐƐ dŚĞŵĞƐ 'ůŽďĂů ĂŶĚ ƐƉĞĐŝĮĐ ŝŵƐ /ŶŝƟĂƟǀĞ DĞĂƐƵƌĞ \U \U \U SOXV zĞĂƌƐ EƵŵďĞƌ ŽĨ Ɖƚ WĂƟĞŶƚƐ Quality improvement ramp Godfrey Nelson Battenden 2005 Dartmouth
Transcript of Audits trigger rapid responses to ARF & Rheumatic Heart needs
East of Matata
Eastern BOP Stunning but Low income; in the Red Zone
Brief audits while prescribing Benzathine Penicillin, “Bicillin” for Acute Rheumatic Fever (ARF ) secondary prevention;
a practical quality improvement tool for Rheumatic fever/Rheumatic Heart Disease areas without registers.
John Malcolm MRCP, FRACP, DTMH, DCH, PGCertPH, Paediatrician, Bay of Plenty District Health Board, Whakatane NZ.Contact; [email protected] for expanded abstract, references and discussion; Korero mai koa!
Audits trigger rapid responses to ARF & Rheumatic Heart needs
Learnt from Acute Rh fever diagnosis
Analgesia helps IM adherence!
ARF/RHD Register essentials
More patients get Benzathine Penicillin IM cardio protection from
District Nursing Service (DNS) and more heart follow-up
Clinical follow-up for those with Rheumatic Hearts is improvable
Age at Rh fever diagnosis
Learning from rural town, Opotiki 2012 audit of 12 children & their 12 ARF presentations.
Q ...● WhogotARF&Why?
● WhatmadediagnosingARFsohard?
● WhoisonIMpenicillin-whoisnot?
● Whatelseishappeningmedicallyandsocially?
● Howmanygrandparentsareparenting?
A ...● KidswithgroupAstrepsorethroatsnotprescribed10days
Penicillin or had Rx short course Penicillin 5 day; n=2 (adherence is best on once daily Amoxil)
● MonoarticularArthritis,firstexcludesepticarthritis AND acute Rh fever. The cost of delayed diagnosis includes rheumatic heart disease n=1.
● ArthritisinMaorikidsthinkARF;admitforrapidwork-up (not Outpatients). Diagnosis delay, 2 year before Echocardiograph&heartsurgery,n=1.
● EarlyNSAIDmasksdiagnosis;Rxparacetamolorcodeinefirst;n=3.
● ARFpresentswithRHD,someheartfailure; some ARF=subclinical. n=2.
● Psychosocialreasonswhychildren don’t say “sore throat”; some shy, some putup/shut up, some not articulate, boys intellectual disability n=2.
● Familiesfacemultiple challenges; shifted townsbefore diagnosis; n=3.
District Nursing aim; effective analgesia to help adherence for IM Benzathine
Penicillin for secondary ARF prevention.● 2011 - Benchmark Buzzy Bee + Lignocaine CMDHB
NicholsonrefRussell,Nicholson,NaiduJPCH2014,50,2,112-8.
● 2013-BOPDNSIntroducegatetheorytoolRxBuzzyBee. PaediatricclinicfeedbacktoDNSsomepainscores.● 2014 - BOP DN Service plan individual analgesia from PreinjectionEMLA,ICE,BuzzyBeePLUS.● Somewith0.25ml2%LignocainewithIMBenzathine.● Someday2musclepain;Ice,ParacetamolorNSAID.
What would a Register ARF RHD control programme look like?
RecommendedElements,NationalHeartFoundatoinNZguidelines2006
● Computerbased,regionalcommitment.● Localevidencebasedguidlines.● Partnershipclinicians,publichealth.● SupporttheneedsofthosewithARFRHD.● Assessandmonitorburdenofdisease.● EducatehealthworkersARF,RHD,whanau.● Follow-upsystem;dedicatedclinicsthatensureongoingcare
delivered; esp high risk.
2007 goal to improve effective secondary prevention of recurrent Acute Rheumatic fever
● RuraltownARF3patientsonIMand6oralpenicillin.
● EfficacyIM95%;oralPenicillin65%;Frankish1984.
● Prevalencefromclinic>9/8000population.
● =112/100,000totalpopulation;2007-8
Opotiki ARF RHD 2014Transitioning with Paediatric overlap to adult cardiology
● 10/12ARFinitialdiagnosiswaswithpaediatricservice.
● Secondsurgeryasadolescent,afteraperiodonoralPenicillinn=1● 12/13localsonBenzathinePenicillin
(17yroldonoralsnewaorticandmitralmildincompetence).
● Allmoderate,severeandpost-operativeRHDseecardiologist.
● Clinicalfollow-ups=NHFNZguide6-24months.
● 5AdultCardiology,2PaediatricCardiology,9PaediatricFU.
● Transitioned3,Transitioning2PardiatrictoAdultCardiology (noadultphysicianfollow-upclinics).
Benchmark; NHF NZ & Starship Cardiology Rheumatic Heart Echo & Clinical Follow-up
www.nhf.org.nz2006Carditisp16,echosp9-21,routinereviewp43
Kawerau ARF RHD Audit of Secondary Prevention & Clinical Follow-up
Dr Rebecca Garland Paed SHO and John Malcolm 2011
● 3/9suboptimalsecondaryBenzathinePenicillinandclinical follow-up.
● Adolescents/youngadults;allmoderatetosevereRHD.
● Suggestfollow-upguidestogeneralpractice.
● Generalpracticesupportexamine,Cardiologysafetynet.
● Educationopportunities,practiceanddistrictnurses,EasternBayPHAcommunityhealthworkers.
ARF;Yearssincelastphysician/paediatricianexamWhakatane audit 2010; 3/16 outside NHF 2006 guide● 3yrModerate-severeaorticincompetenceBenchmark 1-2yr
followup.● 3yrOnemildmitralandaorticincompetenceA1.● 4yrA1MIMstenosislowpumpfunctionBenchmark 1-2yr followup.● 4yrModerateA1Benchmark 1-2yr followup.● 7yrNoRHD.● 5yrMildmitralincompetence.● 9yrNormalexamandechoexitexamination.● 10yrMildAorticincompetencestable.
Years of clinical follow-up achieved; some get District Nurse penicillin but no medical review n=29
Audit 2007 for DNS Whakatane Opotiki Rh fever patients
Youngest 2 years (In recent years 1:6 in 20s)WhakataneOpotikiDNS2008
Severity RHD Description, De�nition (Echo or clinical grade)
First follow -up including echo
Subsequent followup NHF and Eastern BOPDHB
Mild or nil RHD Echo onlyif new murmurs
Clinical(most bene�t from frequent initial/education 3/12ly �rst yr JM)
Echo
Moderate Echo in 6-12 months
Clinical
cho
Severe Close supervision until stable
Clinical
Echocardiogram
Quality improvement rampGodfreyNelsonBattenden2005Dartmouth
