Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event. Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development. This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being. More information is available online: www.expo.nhs.uk

1. MicroGuide App: decision-support
Accelerating development and adoption of innovation through partnership
David Meehan, Deputy CEO, Wessex Academic Health Science Network
Kieran Hand, Consultant Pharmacist Anti-infectives, University Hospital
Southampton NHS Foundation Trust
Eamus Halpin, Design Mentor, Horizon Strategic Partners Limited

2. What are AHSNs ?

3. The 15
AHSN
regions

4. What do AHSNs do and How?
Every AHSN shares a focus on:
– Promoting economic growth
– Diffusing innovation
– Improving patient safety
– Optimising medicine use
– Improving quality and reducing variation
– Putting research into practice
In addition AHSN priorities and programmes reflects the diversity of the
challenges of improving health and wealth in each region.

5. AHSNs different and distinct
• Everything we do is driven by two imperatives: improving health and generating economic growth in
our regions.
• We are partnership bodies -we are the only place where the whole of a regional health economy comes
together voluntarily to improve the health of local communities.
• We have a remit from NHS England to occupy a unique space outside of the usual NHS service
contract and performance management structures. This enables us to foster collaborative solutions.
We use our local knowledge and harness the influence of our partners to drive change on the
ground and integrate research into health improvement.
• We are as interested in seeing healthcare businesses thrive and grow, creating
jobs and bringing in investment to the UK, as we are in seeing the healthcare
system improve.

6. What do AHSNs do and How?
• AHSNs connect academics, NHS, researchers and industry in order to
accelerate the process of innovation and facilitate the adoption and spread of
innovative ideas and technologies across large populations.
• We are catalysts and facilitators of change across whole health and social
care economies, with a clear focus on improving outcomes for patients.
• We open doors and create a more conducive environment for
relevant industries to work more effectively with the NHS and
other parts of the UK healthcare sector.

7. A Systematic Approach to Adoption and Spread
• Spot - identify the innovations that can give greatest impact or align with
our work
• Seed - get the first few places or settings to use or apply the innovation,
evaluating if needed
• Spread - ‘duplivate’ to next settings or areas with support,
then get much wider adoption

8. Innovationand Wealth Creation Accelerator Funds
2013/14 2014/15
Applications 59 72
Successful 17 13
WAHSN Investment £301k £333k
Stakeholders’
in kind contribution
£398k £558k

9. Making Oakley and Overton Partnership a Dementia Friendly
General Practice
• Dr Nicola Decker- Dementia Champion
• Memory Screening increase from 1 to 144 patients
and diagnosis increased by 20% in first 6 months
• Power of Attorney and resuscitation status in place
• Patient and Carer experience significantly improved
• Spread to 25 + GP practices

10. Bournemouth University Orthopaedic Research Institute
Prof.Rob Middleton–
ConsultantOrthopaedicSurgeon
Tom Wainwright –
Clinical Researcher & Visiting Fellow
1000 Additional Trials
£4m Investment

11. Innovation and Wealth Creation Accelerator Fund
The Wessex Faecal Microbiota Bank – Dr Robert Porter,
Portsmouth Hospitals NHS Trust
An innovative pilot service to create a frozenfaecal microbiota store
and provide Faecal Microbiota Transplantation (FMT)
to treat recurrent Clostridium Difficile,
SAVING LIVES AND REDUCINGCOSTS.

12. MicroGuide App
Antibiotic Prescribing Decision Support
Kieran Hand, Consultant Pharmacist Anti-infectives,
University Hospital Southampton NHS Foundation Trust

13. U.S. CDC “Threat Report”: Sept 2013

14. The problem with antibiotic prescribing…
• Under treatment
– A 2010 systematic review of 70 prospective studies of the effect of initial antibiotic treatment on all-cause
mortality among adult inpatients with sepsis reported that 46.5% of patients were given inappropriate initial
therapy (pathogen non-susceptible) and this was associated with an adjusted odds ratio for fatal outcome of
1.6 fold (95% confidence interval 1.37-1.86). [Paul M et al, AAC 2010]
• Over treatment
– The 2011 ECDC point prevalence survey of healthcare-associated infection (HCAI), recruiting 59% of NHS
acute trusts in England, reported that one-third of patients prescribed antibiotics intended for treatment of
HCAI did not meet the case definition for HCAI. [HPA 2012]
• Misuse of broad-spectrumagents
– The period between 2004 and 2009 saw a 50% increase in the prescribing of the carbapenem class of
antibiotics English hospitals, representing the most broad spectrum antibiotics currently available. [Ashiru-
Oredope D et al, JAC 2012] These trends have continued.

15. New problem:  Rx of very broad-spectrums driving resistance
Further 31% increase from 2010 to 2013

16. Why do these problems exist? Complexity
16
Other diseases Infectious diseases
Diagnosis – Is bacterial infection present?Diagnosis
Bacteria species causing infection unknown
Antibiotics not active against all bacteria
Treatment regimen Treatment regimen
Variable local antibiotic resistance
Patient factors Patient factors

17. The problem with education…
• A survey of doctors in Johns Hopkins Medical Institutions in 2004 reported that 90% wanted more
education about antibiotics with only 21% of doctors feeling very confident they were using
antibiotics optimally. [Srinivasan A, Arch Intern Med 2004]
• A more recent survey of junior doctors in a Scottish hospital suggested that 75% (47/63) were
confident to choose the correct antibiotic but only 36% felt confident to plan the duration of
treatment. [Pulcini C, Clin Microbiol Infect 2011]
– The availability of guidelines was found to be the intervention rated most highly by junior doctors to improve
antibiotic prescribing.
• Research carried out in two university hospitals in Paris used brief case studies to explore
physician knowledge of antibiotic prescribing and 86% of the 206 physicians who participated felt
they had insufficient knowledge. [Lucet JC, J Antimicrob Chemother 2011]
• A 2012 survey of 317 (61%) fourth year medical students from three US medical schools reported
that 90% said they would like more education on the appropriate use of antibiotics and only one
third perceived their preparedness to be adequate in some of the fundamental principles of
antibiotic use. [Abbo LM, Clin Infect Dis 2013]

18. From maps to Apps
2008 2011 2013

19. Survey of guideline users in UHS
Published at Federation of Infection Societies 2013 (n=49)
0
5
10
15
20
25
30
Numberofrespondents
Initiativesto improveguidelineadherenceat UHS: relative
importance
Highest importance
High importance
Moderate importance
Some importance
no importance

20. Evidence of success of decision-support
• Sintchenko V et al 2005
– Handheld decision support system RCT
– Reduced length of stay on ICU from 7.15 to 6.22 days
– Reduced carbapenemprescribing by 7%
• Paul M et al 2006
– Desktop decision support system cluster RCT
– Effective initial treatment improved from 64% to 73% (p=0.033)
– 30-day mortality improvement trend from 11.9% to 9.7% (p=0.72)
• Thursky K et al 2006
– Desktop decision support system time series analysis
– Carbapenemprescribing reduced by 25%

21. MicroGuide Decision-Support wins 2014 Award in
the Infection Prevention Category: funding for
software development (£50k)

22. MicroGuide Decision-Support secures
funding for clinical algorithm
development (£25k)
Innovation and Wealth Creation Accelerator Fund 2014/15

23. Decision support concept
• Evidence of infection
• Likely pathogens
• Local/national antibiotic resistance data
• Clinical evidence of treatment efficacy & safety
• Risk of mortality (severity)
• Risk of antibiotic resistance
• Risk of Clostridium difficile
• Penicillin allergy

24. Acute exacerbation of COPD: Evidence of infection
• Patients reporting a change in the colour of spontaneously expectorated
sputum samples over the past 72 h from uncoloured to yellow-green should
receive antibiotic treatment. [Soler N, Eur Respir J 2012]
• Uncomplicated patients* who do not report changes in sputum colour may
be managed without antibiotics.
• *not pneumonia / immunocompromised / ICU / NIV / CHF / neoplasm /
recent hospitalisation

25. In vitro antibiotic susceptibility: local data
Gram +ve Gram +ve Gram –ve Gram –ve Gram –ve Atypicals
1 2 3 4 5 6
DrugOrganism S. pneumoniae Staph. aureus
(MSSA only)
H. influenzae Moraxella
catarrhalis
Pseudomonas
aeruginosa
Chlamydophila
Mycoplasma
Prevalence in COPD
(Sethi S & Murphy TF 2008)
10-15% Unlikely to be a
pathogen
20-30% 10-15% 5-10% 5-7%
a Benzylpenicillin 99% R - - R R
b Amoxicillin 100% R 74% 1% R R
c Co-amoxiclav 100% 100% 93% 99% R R
d Pip-taz 100% 100% 93% 99% 95% R
e Doxycycline 86% 85% 99% 100% R +++
f Co-trimoxazole 86% +++ ++ +++ R -
g Chloramphenicol 100% 98% 99% 100% R ++
h Clarithromycin 80% 72% 99% 100% R +++
i Moxifloxacin +++ +++ 97% 99% + +++
j Ciprofloxacin ++ 88% 97% 99% 77% +++
k Teicoplanin 99% 99.5% R R R R
l Ceftazidime ++ ++ +++ +++ 92% R

26. Clinical trial efficacy: quinolones vs
macrolides [Siempos I 2007]
Treatment success in clinically evaluable patients with acute bacterial exacerbations of chronic bronchitis in randomised controlled trials.
Favoursquinolone Favoursmacrolide
Levo 750 od3d Azithro 500/250 od 5d
Levo 500 od7d
Levo 500 od10d
Gemi 320 od 5d
Moxi 400 od5-10d
Moxi 400 od5d
Moxi 400 od5d
Azithro 500/250 od 5d
Clari 500 bd 10d
Clari 500 bd 7d
Clari 500 bd 10d
Azithro 500/250 4d
Clari 500 bd 7d

27. Severity assessment [Archibald R et al, 2012]
• CAUDA-70
• One point each for:
– Confusion
– Acidosis (pH <7.35; first ABG
post-admission)
– Urea >7mmol/L
– Dyspnoea (MRC score ≥4)
– Albumin <35g/L
– Age >70y
• Predicted in-hospital mortality
– Score 0 = 0%
– Score 1 = 1%
– Score 2 = 2%
– Score 3 = 6%
– Score 4 = 20%
– Score 5 = 53%
– Score 6 = 100%
• Severe = score of 3 or higher
(mortality 14%)

28. Risk assessment (resistance)
Risk factors for Pseudomonasaeruginosa isolatedfrom sputum on hospital
admission [Garcia-VidalC et al, 2009, n=188 patients]:
• Evidence of bronchiectasis as co-morbidity [local consensus]
• Previous isolation of Pseudomonas aeruginosa fromsputum or bronchial
lavage (n=31; 61% had P. aeruginosa on admission)
• Systemic steroid treatment (n=17; 41% had P. aeruginosa on admission)

29. New sputum purulence?
YES
(Patient reports change in the colour of
spontaneously expectoratedsputum
samples over the past 72 hfrom uncoloured
to yellow-green )
UNCERTAIN
(Purulent sputum at baselineordifficulty
identifying anincrease in purulence)
NO
(Uncomplicated patient*whodoesnot
report changes in sputum colour )
Bacterial infection unlikely.Antibiotics not
indicated.
SIRS?
(2 or more criteria):
• Temperature >38.3°C or<36°C
• Heart rate> 90/min
• Respiratory rate> 20/min
• White cells >12or <4 x 109/L
NO YES Severe sepsis? YES
NO
Follow severe sepsis
treatment guideline
Any convincing
radiological evidence
of pneumonia?
Any convincing
radiological evidence
of pneumonia?
YES YESFollow CAP guideline
NO NO
Acute exacerbationof ChronicObstructivePulmonary Disease:
algorithm 1
Go to algorithm 2 Go to algorithm 3

30. Penicillin allergy?
SevereMild / non-severeNone
Patient risk for C.difficilePatient risk for C.difficile
Acute exacerbationof ChronicObstructivePulmonary Disease:
algorithm 2
Sputum purulence =yes/uncertain; SIRS =no; pneumonia =no
• Check for previous culture and
susceptibility results before
selecting treatment
• If recent (<3 months) antibiotic
exposure, use alternative class
of antibiotic
Choose from:
• Doxycycline (1st line)
• Co-trimoxazole
• Azithromycin
• Moxifloxacin (2nd line) (not if
cardiac disease duetoQT-
prolongation)
• Check for previous culture and
susceptibility results before
selecting treatment
• If recent (<3 months) antibiotic
exposure, use alternative class
of antibiotic
Choose from:
• Doxycycline (1st line)
• Co-trimoxazole
• Check for previous culture and
susceptibility results before
selecting treatment
• If recent (<3 months) antibiotic
exposure, use alternative class
of antibiotic
Choose from:
• Doxycycline (1st line)
• Co-trimoxazole
• Azithromycin
• Co-amoxiclav (2nd line)
• Check for previous culture and
susceptibility results before
selecting treatment
• If recent (<3 months) antibiotic
exposure, use alternative class
of antibiotic
Choose from:
• Doxycycline (1st line)
• Co-trimoxazole
High riskLow risk High riskLow risk

31. Acute exacerbationof ChronicObstructivePulmonary Disease:
algorithm 3
Sputum purulence =yes/uncertain; SIRS =yes; severe sepsis =no; pneumonia =no
Risk of colonisation/infectionwithPseudomonas
aeruginosa? Any of:
• Previous isolation of Pseudomonas
aeruginosa from sputumor bronchial lavage
• Systemic corticosteroid treatment (ongoing
prior to admission)
• Evidence of bronchiectasisas co-morbidity
YES
Note: Frequently colonising
flora but if suspected
pathogen, thencontinue:
NO
Penicillin allergy?
SevereMild / non-severeNone
Choose from:
• Chloramphenicol (1st
line)
• Co-amoxiclav
• Ceftriaxone
• Moxifloxacin (2nd line)
(not if cardiac disease
due to QT-
prolongation)
Choose from:
• Chloramphenicol (1st
line)
• Ceftriaxone
• Moxifloxacin (2nd line)
(not if cardiac disease
due to QT-
prolongation)
Choose from:
• Chloramphenicol
• Moxifloxacin (2nd line)
(not if cardiac disease
due to QT-
prolongation)
Penicillin allergy?
SevereMild / non-severeNone
Choose from:
• Piperacillin-tazobactam
(1st line)
• Ceftazidime high-dose
Review MC&S after 48hto
confirm susceptibility
• Ceftazidime high-
dose
Review MC&S after48h
to confirm susceptibility
Contact microbiology
urgently
• Chloramphenicol • Chloramphenicol • Chloramphenicol
Contact microbiology
urgently
Contact microbiology
urgently
Contact microbiology
urgently
Patient risk for C.difficile Patient risk for C.difficile Patient risk for C.difficile Patient risk for C.difficile Patient risk for C.difficile Patient risk for C.difficile
LOW
LOW
HIGH LOW HIGH LOW HIGH LOW HIGH LOW HIGH LOW HIGH

32. Treatment regimen permutations
Decision Detail Answerchoices Permutations
1 Evidence of infection: Sputum purulence 3 1x
2 Severity: Inflammatory response (SIRS) 2 2x
3 Severity: Severe sepsis 2 1x
4 Severity: Pneumonia 2 1x
5 Risk of resistance: Pseudomonas risk 2 2x
6 Penicillinallergy 3 3x
7 Clostridium difficile risk 2 2x
Total 16 24

33. ‘Tailoring’ choices

34. Decision support system
Acuteexacerbation
of COPD
 Sputum
purulence
O No O Don’t
know
O Yes
 SIRS O No O Yes
 Severe sepsis O No O Yes
 Pneumonia O No O Yes

Pseudomonas
risk
O No O Yes
 Penicillin
allergy
O
None
O Mild O Severe
 C. difficile
risk
O Low O High
Continue

35. Decision support system
Acuteexacerbation
of COPD
 Sputum
purulence
O No O Don’t
know
 Yes
 SIRS O No  Yes
 Severe
sepsis
 No O Yes
 Pneumonia  No  Yes

Pseudomonas
risk
 No O Yes
 Penicillin
allergy
O
None
 Mild O Severe
 C. difficile
risk

Low
O High
Continue
Acute exacerbation
of COPD
You selected:
• Yes: evidence of bacterial
infection
• Yes: inflammatory response
• No: severe sepsis
• No: pneumonia
• No: Pseudomonas risk
• Yes: mild penicillin allergy
• Yes: low risk ofC. difficile
Recommended treatment regimen
Choose from:
• Chloramphenicol 12.5mg/kg IV
6-hourly (1st line)
• Ceftriaxone 1g IV once-daily
• Moxifloxacin 400mg IV once-
daily (2nd line) (not if cardiac
disease due to QT-prolongation)
Back

36. MicroGuide - Vital Statistics
• Nearly 100,000 app users (42,000 in the UK
alone)
• 72 subscribing Medical Organisations (over 50
NHS Acute NHS Trusts)
• Top 3 downloaded Medical app on
iTunes/Google Play
• Guidance created in England, NI, Scotland,
Wales, Rep of Ireland, New Zealand, Cambodia
and US
• Over 250 Pharmacists creating, editing and
publishing content

37. MicroGuide App
Eamus Halpin - Design Mentor, Horizon
Strategic Partners Limited

38. ContentManagement
Apps
Web Viewer

39. We have now gatheredover4 millionguidancetouch points
within our framework(Researchoutput to follow soon)
0
0.2
0.4
0.6
0.8
1
1.2
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
App - Adult
App - Adult
Rank Count Condition
1 1378 Pneumonia: moderate/ severe (CURB65=2-5) community-acquired
2 1196 Systemic sepsis of UNKNOWN source
3 1031 Pneumonia: with SEPSIS / severe SEPSIS community-acquired
4 909 Healthcare-associated pneumonia: moderate/severe
5 909 Pneumonia : non-severe (CURB65= 0-1) community-acquired
6 747 Healthcare-associated pneumonia: mild
7 611 Cellulitis, lower limb
8 446 UTI, lower, non-severe (not-pregnant)
9 333 COPD: infective exacerbation
10 323 Intra-abdominal infection: lower-risk
11 257 Ebola
12 255 Community-acquired pneumonia: prior treatment with amoxicillin (within 2 weeks) or moderate/ severe (CURB65=2-5)
13 248 Community-acquired pneumonia: with SEPSIS / SEVERE SEPSIS (regardless of CURB65 score)
14 227 Cellulitis, lower or upper limb
15 214 Community-acquired pneumonia : non-severe (CURB65= 0-1)
16 214 UTI, suspected / probable + functional decline (older person)
17 204 Cholecystitis / ascending cholangitis
18 148 LRTI (suspected) + functional decline (older person)
19 124 bacterial keratitis
20 122 Healthcare-associated pneumonia or aspiration: moderate/severe
21 104 What's new in this Version?
22 97 Post operative treatment after complex adnexal procedures
23 92 Epidural or intraspinal abscess / discitis / vertebral osteomyelitis, post-surgical/trauma or potentially epidural-catheter associated
Dailyusage patternsof both
the app and the web viewer
have beenphenomenal
Typically,with
thousands of touch
points, cliniciansstill
only accesscirca20% of
their guidance

40. We have studiesand overviewresearchcreatedby Trusts…
“…we have been monitoring Antibiotic
Prescribing Compliance since 2009 with
a target of 90% which we have NEVER
hit. Since we launched the App (
MicroGuide™) we hit 90% in February
and 90.7% in March”
Antimicrobial Pharmacist UK Acute
Hospital Trust
“ the use of MicroGuide™ has supported a
sustained reduction in the prescribing of high risk
broad spectrum antibiotics from 40% to 28%”
University Hospitals Southampton Foundation
Trust
The introduction of MicroGuide™has “increased
awareness of antimicrobial stewardship” and
“encouraged clinicians to challenge/question
inappropriate prescribing by others”.
Survey at UCLH 2014

41. MicroGuide officiallybecamea MedicalDevice,
and designatedwith the CE Mark, in May 2015

42. Developmental path
• Any type of guidance can now be created and published through the same
platform – 30 different types already exist, from Pain to Oncology
• Design iteration has already begun for the DecisionSupport Module
• When completed DSM will be capable of being applied to any form of
clinical guidance
• Initial testing and early adopter deployment is expected by the end of Spring
2016

43. Thank you
Questions & Answers