Knowledge Natter: Cat bite abscess audit

Knowledge Natter: White Lodge Veterinary Surgery 2023 Antimicrobial Stewardship Champions

Paul Stanley BVM&S PGCertSAM MRCVS

Emily Parr BVSc CertAVP(SAM) PGCertVBM PgDIPVPS MRCVS

RCVS Knowledge:

Welcome to this Knowledge Natter by our RCVS Knowledge. Here, we have friendly and informal discussions with our Knowledge Award champions and those who are empowered by quality improvement in their work. Whether you are a veterinary surgeon, veterinary nurse, receptionist, or member of management, quality improvement will and can positively impact your everyday life. Listen and be inspired.

Pam Mosedale:

Hi, everyone. Today, I’m going to talk to some of our winners from the Antimicrobial Stewardship Knowledge Awards, which is very exciting and a subject that’s so relevant to all of us. So I’m going to talk to Paul Stanley and Emily Parr. Paul is a vet and head of QI at White Lodge Vets. And Emily is the head vet at White Lodge Vets in Exmouth in Devon. Hi, Paul and Emily.

Emily Parr:

Hi.

Paul Stanley:

Hello.

Pam Mosedale:

Hi. So how did you get involved in running an Antimicrobial Stewardship project in the first place?

Paul Stanley:

So it all started, really, at a vets meeting. And we were going through the BSAVA PROTECT ME poster, which if you haven’t seen it, is a poster where you can go through, as a practice, and select what antibiotics you can use or not for which relevant conditions. It’s a very good resource, making sure that you’re not using protected antibiotics and things like that. And we got onto the subject of cat bite abscesses. And we’d all heard before, essentially from either university or colleagues or at CPD, that we don’t need to use antibiotics for them. But we’ve never really been brave enough, essentially, not to use them. So we went away and we had a look to see if there was any available papers or information to give us confidence. And we didn’t find anything, really.

So we made a conscious step as a team to try and see if we could prove it to ourselves, which was very scary. But then it set up in discussion, trying to figure out a way that we could audit it and make sure that we keep animal welfare at the forefront. But, also, see if we don’t have to use antibiotics so you clear up those cat bite abscesses. And it was quite scary, but also quite slightly exciting to be involved in. But certainly at the beginning, before we had some results, it was a bit of backing each other up and a bit of a time. But it was something that, in the end, I’m sure as we’ll discuss, it had some great results. And we massively managed to reduce our antibiotic usage. But it was a conversation really off the back of that, really, that got us involved in it.

Pam Mosedale:

Great. Being a bit of a dinosaur vet myself, I’ve obviously used antibiotics in cat bite abscesses. And so I think, yes, you were very brave to take that step to actually believe that you could do that. So, Emily, what was the aim of the project?

Emily Parr:

So, really, the aim was to give confidence to our vets in our practice, but then in other practices as well, that you can follow the PROTECT ME guidelines. And, really, that you can do that through clinical audit as well to back up your results. So that you know that, actually, you are following best practice and you can prove that through audit. But it was also, more broadly, to open a discussion within the practice about One Health approach and focus on our antibiotic prescribing culture. And so, really, I suppose our broader aim was to change the prescribing culture across the practice, starting with the cat bite abscesses, adopting a more case by case approach. And then giving confidence to our peers to use the up-to-date clinical guidelines, and only use antibiotics where absolutely necessary.

Pam Mosedale:

Well, that’s music to my ears, being a huge fan of clinical audit, that you actually used clinical audit to check what you were doing in your own practice, and if it was working or not, and using guidelines. So that was your theory, but how did you actually carry out the project?

Paul Stanley:

So, essentially, what we did is, we used some of the audit templates that are available, I know there are plenty available on the RCVS Knowledge website as well, to essentially come up with a plan that everyone could follow so they knew what they were doing. And, certainly, we did it as a team to come up with the inclusion bacteria so everyone was on board. Particularly with something like this, where it’s taking a big step not to use the antibiotics, you need to make sure that people are comfortable with what they’re doing. We’re also quite lucky we’re a CVS practice and we had access to other people in the company that we could email and say, “Look, we’re trying to do this. Can you help us?” Because we have a lot of ideas, but at the end of the day, we want to do lots of exciting things but we don’t actually fully know what we’re doing. So, thankfully, there were a lot of people that we could speak to.

In terms of the inclusion anterior really for the cat bite abscesses, we came up with a template that would automatically come on the, perhaps, management system when you typed it. So you type it through letters, and then a checklist would come up, essentially. So everyone knew they was on board. And, essentially, we decided that it would be that if the cat wasn’t pyrexic, and we decided on a weird cutoff point, but this is what everyone was comfortable on, which was 39.4 degrees and above was considered pyrexic. If cellulitis was present as well, or if there’s any underlying health conditions, these would be reasons that we might consider giving antibiotics. Anything else, we decided just to essentially lance and flush, send home on obviously pain relief, and either they were cleaned often with Hibi, or sometimes just salty water if owners didn’t want to do that. And then they were made sure that they were rechecked within a week’s time with a nurse, free of charge.

The owners were obviously told everything that’s going on. We tried to communicate the results with them as they went along to get them on board. But we also used the BSAVA no prescription required forms to also give that extra bit of information to the owners. Encourage them, if they had any concerns or questions, to come back sooner. This made it quite standardized so everyone could follow it. The checklist also included things, essentially whether the cat bite abscess was open or closed, whether sedation was needed, to check that it would remind people to lance and clean it. And then this is also extra things that we could collect and audit. And then if we realized, “Okay, all the closed abscesses need antibiotics, and all the open…” We could pick this up early and didn’t carry on essentially compromising welfare. But, frankly, that didn’t matter and that didn’t seem to matter. But it just made it standardized across all the vets.

And we were quite fortunate that, talking to our sister practice, Raddenstiles in Exmouth, they followed the same audit. And then I got speaking to other people, and the company of another vet’s practice joined as well. And having a standardized audit meant everyone knew what they were doing, and they could follow it quite reliably to also make the results more relevant. Because if we’re all doing different things, then we wouldn’t be able to really put much emphasis on the results because we wouldn’t know exactly what was going on.

Pam Mosedale:

That’s excellent. So you get your own results, but then if other practices are doing it, you can eventually get some benchmark results, and you can all compare to a benchmark. Now, you said that everyone was on board in the team, but were they all? Or was the problem getting any of the vets on board?

Emily Parr:

I think, initially, there was a bit of… People were worried. I don’t think they didn’t want to be on board. Because the first thing we did was we held a vet meeting and we discussed the PROTECT ME poster. We agreed on the project as a team that we were all going to be brave and in it together. And, yes, some of the vets were very worried, but we supported each other. So if there was a vet consulting, and a cat turned up with a cat bite and there was an abscess, they’d go and chat to another vet. And together they’d say, “No, you don’t need to give it antibiotics. We’ve decided that together.” So it was very much a team effort.

And I think because we developed the audit with the involvement of the clinical staff right from the word go, and vets and nurses, that really encouraged participation, really. And we had posters in each of the clinical rooms to remind the vets about the audit. And Paul kept giving the results out as they were coming through so that it stayed relevant and everyone stayed on board. So yeah, I think keeping everybody involved at every stage meant that we had complete buy-in from the whole team.

Pam Mosedale:

That’s brilliant. So it was the communication and involving everybody, so everybody knew what was happening. Nobody thought something was going on they didn’t really understand. That sounds brilliant. And you said the vets and nurses, did you get the reception team involved too?

Emily Parr:

Go on, Paul.

Paul Stanley:

So they were aware of everything that was involved. Everyone was involved in the meeting in regards to that. But the reception knew that the routine would be, if it is a cat bite abscess, they’d be sent out, they’d see the notes, they’d come back in in a week’s time to have a free check with a nurse. So they were aware. But I think with the clients, because we were ourselves quite scared, we were so invested, we said, “Look, any problems, call us. We don’t mind. We’re happy to see them again and check it over.” And to be honest, I think the owners just really appreciated the sitting down, talking through why you’re doing it. But, also, they did appreciate the free re-exam as well.

I think part of the uptake helped that the owner was at no loss, if you see what I mean. Because, technically, they were saving money because they weren’t having antibiotics. But, also, they didn’t have to worry about the cost of a re-exam. Which, one thing in the audit is, we wanted to make sure is that the cheaper option necessarily wasn’t just antibiotics because they were avoiding… We wanted to remove any cost bias. And do you know what? The owners were really on board. A lot of them actually pointed out the poster in the consult room and wanted to discuss about it. And I was pleasantly surprised, actually. I thought there would be a lot more resistance from clients. But I think because of the way things are in the media, they’re a lot more aware of it. They’re certainly very keen to not have antibiotics if needed. And, particularly, if you’re incentivizing it, come back, it’s free of charge, don’t worry, and then we’ll just do it, they were a lot more on board.

And I’d say, since we’ve done it, to be honest, I’ve been challenged by a few clients, in some cases, that definitely need antibiotics traditionally, which always makes to an awkward conversation. It’s like, “No, please take this. I wouldn’t give it if you didn’t need it.”

Pam Mosedale:

Yeah, that’s why I asked you about the receptionist because I think they’re the ones who might’ve got the backlash a little bit from clients. Because, often, people will come out the consult room, having been quite polite and so on with the vet, and then start saying the receptionist, “I can’t understand why they didn’t do this and that.” So that’s really interesting. And I loved your poster idea.

Emily Parr:

Yeah, I was also going to say that actually we include our reception team in our QI meetings. So, obviously, this was something that was discussed at our clinical vet meetings, but we discussed it very much during our QI. So the receptionists were all there and they were maybe slightly in the background of the conversations, but they were there for it. And, certainly, if there’d have been any problems with any clients, they would’ve felt quite happy to speak to the vets about it and clarify. We’re very close-knit team when it comes to QI. It’s just a-

Pam mosedale:

Excellent. Because it is a whole team effort, isn’t it, QI?

Emily Parr:

It is, yeah.

Pam: Mosedale

And the idea of the free follow-up consults, these were with the veterinary nurses, were they, the follow-up consults?

Emily Parr:

Yes, they were, yeah.

Pam Mosedale:

Did you find that really reassured the owners, the fact that they were going to get that free follow-up consult?

Emily Parr:

Yes, absolutely. It helps build the relationship with the nurses as well, the nursing team. And, again, it got the nurses really on board with the project because they were the ones that were actually seeing these cats come back in doing really well, despite not having had antibiotics. So, yes, I think just more generally, I think that helped build the relationship with nurses. And the nurses, again, with the vets too.

Pam Mosedale:

Excellent. And the poster, tell me about the poster you had in the consult room?

Emily Parr:

So the poster was the best bit of the audit for me. It was very fun. So we had a picture in each consult room of Keith, who is Paul’s very naughty cat, who is constantly fighting other cats in the neighborhood. And on the poster there’s a speech bubble from Keith that says, “I don’t need antibiotics, I’m just a naughty boy.” And the clients thought that that was absolutely brilliant. And it certainly made the vets and nurses laugh. And it was there as… Lightened the project because these things can be a little bit serious. But it was absolutely brilliant. It was a stroke of genius from Paul. And I think it was actually really fundamental to the success of the project.

Pam Mosedale:

Brilliant. And what about the results that you got? Can you tell us about the results?

Paul Stanley:

So the results were really, really rewarding. So certainly in terms of… So what we did, we were monitoring basically which cats came back after that week and whether they needed antibiotics. So when we submitted our application for the award, we had 22 cases. And 86% of them got better without antibiotics, which is a large number of cats, essentially, that didn’t need it. But we actually carried on the project with three practices involved. And, in the end, we had 52 cases, with a 85% cure rate, which was really rewarding to see that, even when we carried it on, the cure rate didn’t drop. And we weren’t getting exceptionally lucky. That was obviously quite nice to see. But we also tracked how much reduction in antibiotics. And particularly at White Lodge here, we had a 32.6 reduction in… I always pronounce the drug name wrong.

Emily Parr:

Cefovecin.

Paul Stanley:

Cefovecin, thank you very much. Since we started the audit, which is fantastic. And that was just in, that was volume, wasn’t it? Was that number of times?

Emily Parr:

That was reduction in the number of times it was dispensed. But that represented a 62% reduction in the number of times it was dispensed in the second half of the audit.

Pam Mosedale:

So you had some amazing results. Can you tell us about them, please?

Paul Stanley:

Yeah, of course. So it was really satisfying. When we submitted the award, we had 22 cases. And we found out that 86% of them got better without antibiotics. But after that, we carried on collecting the data essentially, and across three practices, we found out that we had 52 cases in total and it was 85% that cured. And that was really great to see the results didn’t drop, despite over doubling the number of cases. And it also means it’s a… I always think that case numbers are quite hard to come by in veterinary quality improvements. So to have that number is quite reassuring.

The other very satisfying thing is the reduction we had in long-acting antibiotic usage, which Emily will say the name [inaudible 00:15:41].

Emily Parr:

Cefovecin.

Paul Stanley:

Thank you very much. So we tracked it in two periods, the first half of the audit, and then after we started sharing our results. So in the first half, while we were doing the audit, we had a 32.6 reduction in our use of that drug. And we started sharing the results, and this increased confidence in the team, and more and more people stopped using the antibiotics. And we actually got up to a 61.9% reduction in the amount of drug that we used, which is a huge difference. Because it’s a very important antibiotic, particularly in the wider world with humans as well. So it was really satisfying results that we got.

Pam mosedale:

Wow. Yes, those are amazing results, I have to say. I think that that’s amazing. And the fact that it carried on, that it wasn’t just the first few when everybody was enthusiastic and… Are you continuing to audit this, going forward?

Paul Stanley:

So we’ve stopped auditing the cat bite abscesses at the moment. We’re currently working with yourselves at RCVS Knowledge, hopefully, to get this in a publishable form so we can share it with everyone. And hopefully everyone else can have a go. Because, hopefully, the audit is written in quite a nice way. Well, I think nice, but easy, understandable. Even I can understand it, so that’s the main thing. And we’re actually in contact with… They’re redoing the BSAVA PROTECT ME poster soon, and they’re interested in our results. And would like, once we published it, to link it in. So it’d be quite nice to go full circle, back to where we began really with the poster, and then affecting next year’s, which would be quite satisfying.

Pam Mosedale:

Wonderful. That’s really holistic, isn’t it, to do that. That sounds brilliant. So you’re not auditing it now, but I guess at some point in the future you’ll do a reaudit to check you’re still on track with it, will you?

Paul Stanley:

Yeah, most definitely. We’ll make sure that everyone’s still doing… Just in terms of it’s quite satisfying that I’d say the long acting injection goes out of date in the fridge. It’s not normally opened. I think we will come back to it and do it properly, but it’s quite satisfying that no one really reaches for it anymore. And I’d say even across other cases, not cat bite abscesses, as Emily was saying earlier, that whole approach of, “Okay, do we actually need this?” And then if we are reaching for something that’s a bit more protective, we’ll have a discussion. And then we’ll go, “Can I get someone else to agree with me that this is necessary?” Because it makes you stop and think, essentially.

Emily Parr:

And to know that we’ve decreased our use of critically important antibiotics, not just cefovecin, but also fluoroquinolones, it’s great. And we know we’re contributing to that One Health approach.

Pam Mosedale:

Absolutely. No, that’s amazing. And do you think you’ve reduced antibiotics general use in the practice?

Emily Parr:

Yes.

Pam Mosedale:

Yeah. And are you planning any future audits on any other subjects?

Paul Stanley:

So we’ve got a couple of audits planned. There’s one that we’ve just finished where we pain scored all our operations for a year. And then we identified areas that we thought we could improve. And Emily very kindly got someone down from a referral center to help us see if we could improve our techniques. And we’ve just finished reauditing that to see if we’ve made an improvement. So we need to look at that. And we’re going to look at our antibiotic usage in ear treatments. We just need to tweak exactly how we’re going to audit it and what we’re going to use to make sure everyone’s comfortable before we start that. So we’ve certainly got a few things that we’re going to be carrying on with.

Pam Mosedale:

Excellent. And how would you say this audit, and QI generally, is impacting your team?

Emily Parr:

I think there’s been so many positives from this, from it being just a really good team building exercise, the peer-to-peer support that’s developed. We’ve had improved communication. And it’s really encouraged clinical discussions between vets and nurses as well.

Paul Stanley:

I would say that, particularly as a first opinion practice, it’s very nice to know that we can do this here in first opinion because there’s probably lots of very exciting people do it. My ignorance, when we started this, I assumed this is a referral thing, this is a university thing. We’re in first opinion, we can’t get involved. But, actually, it’s the best place for a lot of things. And I think it’s given the whole team, that we can actually affect things here in Devon as well, which being from Devon, is quite biased. But it’s great to do it in first opinion.

Emily Parr:

And I think the whole team has just been so proud to have been involved in it and to see how successful it is. And they’re desperate to be part of the next audit that we do. And it has given everybody the confidence that actually we can affect change from first opinion practice. And the things that can come out of first opinion practice audits, and maybe even research, affect first opinion practitioners. It’s so relevant. So I think, yeah, the whole team, it’s really gelled everybody together, and the whole team are just really proud of it.

Pam Mosedale:

Excellent. No, I think it’s a brilliant example of how first opinion practice can get involved in these things. And I absolutely agree that first opinion practices are where this should be happening. GP practices are where these things should be happening. Because that’s what the majority of us spend our careers doing, and most of the client interactions are in first opinion practice, so fantastic. So I think that your audit is amazing, and your results are amazing, and just really inspiring. So I hope other people’ll listen to this and be inspired to look at it too. And your case example will be on the RCVS Knowledge website, so anybody who’s been inspired by listening to both of you can read about it too. So thank you again. That’s been brilliant. Thank you so much for your time.

Emily Parr:

Thank you, Pam. Thank you.

Paul Stanley:

Yeah, thank you for having us.

Pam Mosedale:

You’re welcome. Bye.

Emily Parr:

Bye.

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