Leading change

Nurse leaders in the Greater Nottinghamshire Clinical Commissioning Partnership Commissioning Group’s Quality Team worked with the Lead Pharmacist and Medicines Management Team. This partnership was led in collaboration with Nottingham North and East (NNE), Nottingham West (NW) and Rushcliffe Clinical Commissioning Groups (CCGs) to conduct an audit and subsequently improve the immunisation care pathways for asplenic patients. The results have been demonstrable improvements in patient care and outcomes.

Where to look

National guidance identifies that individuals with an absent or dysfunctional spleen are at increased risk of severe infection, particularly those caused by encapsulated bacteria. All patients with absent or dysfunctional spleens should be fully vaccinated according to the national schedule. Because of the high risk of overwhelming infection, vaccination against pneumococcal infection is recommended for all individuals who have or are at high risk of developing splenic dysfunction (including coeliac disease) in the future. Given the high risk of secondary bacterial infection, annual influenza vaccine is also recommended for these patients.

Asplenia or dysfunction of the spleen (including sickle cell and coeliac disease) vaccination schedule includes:

• A dose of Haemophilus Influenzae Type b (Hib) and Meningitis C (Hib/MenC)
• A dose of Meningitis A, C, W and Y (MenACWY) conjugate vaccine (at least one month after Hib/MenC)
• A dose of Pneumococcal Polysaccharide (PPV23) (and one every five years after the first)
• Two doses of Meningitis B (MenB) vaccine, at least a month apart
• Flu vaccine should be given annually

Public Health England (2016)

The nurse lead and pharmacist identified unwarranted variation in the process of ensuring asplenic patients received the appropriate vaccinations. They identified this variation when working with a GP practice where there had been a serious incident involving an asplenic patient. Following the detection of this incident by the pharmacy lead, the nurses in the CCG’s Quality Team worked closely with the Medicines Management Team and lead Pharmacist to undertake a project to review all asplenic patient treatment across their geographical area, to support the improvement of immunisation schedules and to promote the improvement in patient care, reduce the risk of asplenic patients contracting life threatening illness and improving quality of care and outcomes.

What to change

Nursing leads from across the three CCG Quality Teams, in collaboration with their Medicines Management Teams and Lead Pharmacists undertook an audit, initially piloted in one CCG area, and then rolled out across the other CCGs. The focus of the audit was to identify asplenic patients registered with all GP providers, utilising a specially designed audit tool designed to review GP record read codes. The tool could identify patients quickly and then identify if they had received the appropriate immunisations.

The audit revealed a need to improve the immunisation care pathway for asplenic patients – notably to ensure all patients receive the appropriate immunisations according to optimal treatment pathways. The Nursing Quality Team and Medicines Management Team identified an opportunity to improve patient care by:

• Reviewing individual vaccination schedules;
• Inviting asplenic patients and patients with related conditions for a review;
• Reaching out to patients who may have been previously hard to engage;
• Establishing a comprehensive understanding of the number of patients affected across the geographical area.

How to change

The Nursing leads from across the CCG Quality Teams, in collaboration with the Medicines Management Teams and Lead Pharmacists undertook a review of the initial audit findings and developed a plan to improve the quality of care.

A follow-up of the audit results showed the benefits of working collaboratively across the piloted Nottinghamshire CCGs – enabling a broader and more comprehensive understanding of the needs of asplenic patients within the community.

The findings have been shared with the National Reporting and Learning System (NRLS) and at the East Midlands Primary Care Quality Working Group. The recommendations were:

• Continue the momentum of the quality improvement initiative for asplenic patients
• Re-audit using agreed, standardised criteria – including a review of antibiotic prophylaxis and identification of patients who decline vaccination
• Collaborate with secondary care to improve documentation and communication regarding the asplenic vaccination schedule
• Share results and learning across local and national teams including NHS Improvement and the NRLS

Adding value

Better outcomes – better patient safety and the quality of care of asplenic patients has significantly increased across all the General Practice providers across all 3 of the CCGs. There is still work to do, but the clear health improvement work has been identified by the ongoing work the pharmacy team undertake with the GP providers.

Better experience – the nurse leaders in the CCG Quality Team, in collaboration with the Medicines Management Team have reduced the risk of preventable life-threatening illness and improved the quality of care of asplenic patients. Quality monitoring and quality improvement initiatives ensure a continued focus on this cohort of patients and improving their quality of life.

Better use of resources – collaborative working across the Nursing Quality Team and the pharmacy colleagues has ensured good quality working and clear, shared goals for patients. This has been a useful piece of work to support integrated working and shared initiatives across the CCG directorates and across all 3 CCGs and is now being rolled out across all 6 CCGs across Greater Nottingham.

Challenges and lessons learnt

• Timescales to get the data have been tight and often challenging;
• There needs to be strong leadership to ensure there is a drive to make the changes and keep the work ongoing;
• When you work across several CCGs it can be difficult to ensure that the project can be translated across all the areas and replicated effectively to ensure that there is consistent data and evaluation to monitor outcomes and risks;
• Pressure within GP providers can often be a barrier to resources being available to action changes quickly, there needs to be a balance regarding expectations and realistic timescales for change and review;
• Ensure shared outcomes and partner investment in the shared goals
• Keep the focus and ensure the reason for change is reviewed through the project to remind partners why change was necessary;
• Have the space to spend time with partners and to learn from each other, the Quality team, Medicines management team and pharmacy leads had an opportunity to learn from each other and identify further opportunities for collaborative working and join initiatives in the future.

Find out more

For more information contact:

• Esther Gaskill, Head of Quality, Patient Safety and Experience, Greater Nottingham Clinical Commissioning Partnership Commissioning Groups, esther.gaskill@nhs.net