NAMM Student Guidance

1. NAMM Student Guidance Eloisa MacLachlan (NSAMR Audit Co-Lead)

2. Background • Incidence of bacterial meningitis is decreasing • Mortality remains high • Important that management is optimal despite rarity of disease

3. Background - 2 • Recently updated national guidelines • Previous studies shown poor adherence to guidelines in the UK • Other international studies suggest guidelines can improve outcome in meningitis • Concern regarding delays in processing CSF with centralisation of laboratories

4. Aims and Objectives Aims • To assess clinical adherence to the new, current guidelines • To evaluate if laboratories are meeting the turnarounds times as stated in the Standards for Microbiological investigations Objectives • To identify areas of poor performance with regard to the standards identified in the national guidelines and SMI • To suggest ways in which the performance might be improved • To feedback to individual sites regarding their performance (and how they compare nationally) • To re-audit after feedback to see if any improvement • To provide data to input to revisions of the guidelines in due course • To publish national data on the clinical and laboratory management of meningitis in the UK

5. Set-up • Each site will have a consultant lead who will have overall responsibility for guaranteeing the data. • Each site can also have trainee and medical student investigators as well. • If none of the investigators have access to the laboratory information system to assess the timing of the CSF microscopy there should also be a microbiology lead. • All contributing investigators, which will include a named consultant and trainee and/or medical student will be acknowledged in any reports or publication arising from the audit.

6. Methods • Inclusion criteria: • Adult patients (>= 16 years) with meningitis seen in 2017. • Meningitis is defined as: • Patients with a CSF WCC >4 x106 cells/L (regardless of whether a pathogen is identified or not) and a clinical suspicion of meningitis • OR • In the case of bacterial/fungal meningitis symptoms and signs of meningitis with a significant pathogen in the CSF (culture or PCR) or blood regardless of CSF leukocyte count.

7. Methods - 2 • Exclusion criteria • Tuberculous meningitis • Nosocomial meningitis (Meningitis that occurs during a hospital admission or within 30 days of discharge AND there were no signs of meningitis on admission to hospital OR meningitis associated with indwelling devices in the central nervous system regardless of duration) • Encephalitis (Altered consciousness for >24 h (including lethargy, irritability, or a change in personality) with no other cause found and two or more of the following signs: fever or history of fever (≥38°C) during the current illness; seizures or focal neurological signs (with evidence of brain parenchyma involvement); CSF pleocytosis (>4 × 10⁶ cells per L); EEG suggesting encephalitis; and neuroimaging suggestive of encephalitis) • Cyrptococcal meningitis • Patients 15 years or less Any concern or query regarding eligibility should be referred to the lead investigators.

8. Suggested methods of patient identification – your consultant or reg will lead this!! 1. ICD10 codes: • A32.1+ Listeria meningitis/meningoencephalitis • A39.0+ Meningococcal Meningitis • A87 Viral Meningitis • A87.0+ Enteroviral meningitis • A87.8 Other viral meningitis • A87.9 Viral meningitis, unspecified • B00.3+ Herpesviral meningitis • B01.0+ Varicella meningitis • B02.1+ Zoster meningitis • G02.0 Meningitis in viral diseases classified elsewhere • B26.1+ Mumps meningitis • G00 Bacterial meningitis, not elsewhere classified • G00.0 Haemophilus meningitis • G00.1 Pneumococcal meningitis • G00.2 Streptococcal meningitis • G00.8 Other bacterial meningitis • G00.9 Bacterial Meningitis, unspecified • G01 Meningitis in bacterial diseases classified elsewhere • G02 Meningitis in other infectious and parasitic diseases classified elsewhere • G03 Meningitis due to other and unspecified causes 2. Laboratory information management systems (LIMS) can be interrogated for CSF samples with leukocyte count >4 x10^6 cells/L received in 2017. 3. LIMS can also be interrogated for target organisms identified in CSF or blood cultures or by PCR in CSF/blood (e.g. Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae and Listeria monocytogenes, Enteroviruses, Herpes simplex virus, Varicella zoster virus) Once a list of potential patients has been generated they MUST be checked to confirm eligibility

9. Case Report Form (CRF) • Data Collection will be online via REDCap™ (Research Electronic Data Capture) • Only anonymised data will be inputted onto REDCap™ • A linkage record to link your local patient identifiers with the audit identifier should be recorded on the ‘Master Identification List’ – this should not leave your trust.

10. CRF - REDCap • URL: https://openclinica.liv.ac.uk/RedCap/ • Individual logins will be issued once you have a confirmed supervisor • Each individual will only have access to their own site’s data – these are called Data Access Groups (DAGs) in REDCap™ • There are 2 Case Report Forms (CRFs) on REDCap™ – one for site specific data (to be filled in only once) and one for individual patient data – to be filled in for each patient.

11. Data storage/sharing • All data shared will be anonymous • Each site will be required to register the audit at their own site before any data collection starts. • Each site will be allowed to review their own data but not the data pertaining to any other individual site. • Data will be stored until all publications from both parts of the audit are complete. • Following that the data will be destroyed – including on REDCap™ and any downloaded versions of the data on excel, SPSS or any other format. Only members of the investigating team will have access to any downloaded data.

12. Set-up • Each site will have a consultant lead who will have overall responsibility for guaranteeing the data. • These can be of Infectious Diseases, Medical Microbiology, acute/ general medicine or neurology • The consultant supervisor will most likely not be involved in collecting data. • Each site can also have trainee and medical student investigators as well. • How many you have is up to the discretion of your consultant supervisor – we recommend at least one junior doctor • Of course, the more people there are the more people to spread to workload with, so this may only be necessary in larger hospitals. • If none of the investigators have access to the laboratory information system to assess the timing of the CSF microscopy there should also be a microbiology lead. • All contributing investigators, which will include a named consultant and trainee and/or medical student will be acknowledged in any reports or publication arising from the audit.

13. Tips for finding a supervisor • Go to relevant department* with the protocol and CRF either printed or downloaded on a phone/ tablet to show the supervisors. In the past we have found that showing prospective supervisors the relevant information first hand gains more interest. • Call your local department*, ask for someone who may be interested and offer to meet with them, emailing them the protocol, CRF and maybe this PowerPoint beforehand. • Contact a local society*, either within the medical school or in your trust. • Contact previous lecturers* who may be able to put you in contact with someone based at your allocated site. *This can be in Infectious Diseases, Medical Microbiology, Neurology, Acute/General Medicine You can either contact a junior doctor or a consultant first, whichever is easiest!

14. I found a supervisor, what now? • Once you have found a consultant supervisor you must send 2 emails: • An email to Fiona McGill with your supervisor copied in, with their permission. This will enable Fiona to provide you with further information about data collection on REDCap™, and set you up REDCap™ login. • An email to your NSAMR lead stating that you have a supervisor and your plan for setting up the audit. AND/OR update your status on the website? With your supervisor you will then formulate your team, register the audit at your site (this will vary between sites) and organise a trust login if you do not already have one – this is all the responsibility of your consultant supervisor and they should be aware of the relevant processes.

15. Audit Timeline

16. Benefits of being involved • Being involved in a national audit that has the potential to change practice • Robust readily identifiable audit standards from national standards • Opportunity to present and change local practice with feedback and re-audit • Particularly good opportunity for students e.g. at grand rounds, (assisting) teaching sessions for medical staff, feeding back to the audit dept • Acknowledgement in resulting publications

17. Thanks and Contacts Thank you to all who are putting in time and effort to contribute to this audit. Please do not hesitate to ask if you have any queries at all. 1. If you have any specific questions, such as relating to issues with finding a supervisor, please contact your NSAMR lead whose email you will have in the original email. 2. If you have questions about Redcap or data input issues, you should first speak to your consultant or junior doctor. If they do not know, please email the lead investigator: • Fiona McGill – fmcgill@liv.ac.uk 3. If you have any other general questions that may benefit other students, please post them on the Padlet. This is an public platform where questions can be posted anonymously. One of the NSAMR team will answer. • https://en-gb.padlet.com/maclachlane/3i1q4p19mabz