NON MEDICAL PRESCRIBING ESSAY
Independent prescribing is ‘prescribing by a practitioner (e.g. doctor, dentist, nurse, physiotherapist, and pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing’ (DH, 2006). Prescribing is an extremely complex process – a systematic approach using the Prescribing Pyramid model (National Prescribing Centre, 1999) helps to ensure prescribing is appropriate, evidence-based and cost-effective.
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Working as an Advanced Physiotherapist Practitioner within a Raid Response (RR) team, I was allocated a patient to assess at home, referred by their General Practitioner (GP) with a presenting complaint of lower abdominal pain.
Guided by the Prescribing Pyramid (National Prescribing Centre, 1999) and by following a consultation model, a diagnostic decision will be arrived at, treatment options considered and a prescribing decision made. Throughout the whole process, ethical, legal and professional issues would be considered.
In order to protect the patient’s identity and maintain confidentiality (Healthcare professional council HCPC 2017) the patient throughout this case study will be referred to as Mrs. X.
This consultation has been written from the perspective of a prescriber; in reality, the actual prescription issued for this consultation was written by a qualified prescriber as per legal requirements by HCPC prescribing standards (reviewed 2018).
Mrs. X.is a 72-year-old lady of English origin living with her husband in a privately owned bungalow. Her past medical history was nil. She also stated to having no allergies and has never taken any recreational drugs. She is a non-smoker and non-drinker. Mrs. X stated that she has not bought any other over the counter medications including any herbal remedies except paracetamol. Three days ago Mrs. X developed some discomfort in her lower abdomen which she reports as worsening but said it is relieved with a hot water bottle. She also reported to buying Paracetamol from the shop but said this is having a little effect on the pain in her abdomen. She is having an increased frequency and urgency to pass urine, nocturia, lower abdominal pain and a slight burning sensation on passing urine. Mrs. X herself thought of having a UTI as she had similar symptoms before when she had a UTI previously.
In order to confirm the diagnosis, a full assessment was carried out. Prescribers are encouraged to do consultation in a structured way (national prescribing centre, 2003), the Calgary-Cambridge model of the medical interview was used to carry out full consultation (Kurtz et. al, 2003).
Taking into account the history taking an assessment, Mrs. X’s symptoms and the physical examination author was able to provisionally diagnose a UTI and all other differential diagnosis were rule out. The author asked Mrs. X to provide a urine specimen to dipstick it to try and confirm her diagnosis. The author recognizes that NICE (CKS) (2015) guidelines suggest there is no need to dipstick when symptoms are present such as the ones Mrs. X was showing but the author felt that this would give her reassurance in her decision making. The dipstick result was positive for leucocytes and nitrites which confirmed author’s thoughts of a UTI (NICE CKS, 2015). Author informed Mrs. X that author thought she had a recurrence of a UTI which she agreed with. An author would send the urine specimen to microbiology for analysis on her return to the hospital, recognizing the fact that prolonged exposure to room temperature can have an effect on test results (Mason, 2014).
Mrs. X had blood taken earlier that day by one of my colleagues, but the results were not available at this time, however, having a work laptop author was able to check her most recent blood test results which were from two weeks ago. The author was particularly interested in her estimated Glomerular Filtration Rate (eGFR) which will give an indication of impaired renal function (NHS choices 2016). Her latest eGFR was 64mI/min. An eGFR of less than 90/ml/min could indicate kidney disease (NHS choices 2016) which would have an impact on the medication that should be prescribed. However, eGFR can decline with age and therefore further investigations would need to be carried out to confirm kidney disease. It appeared that her eGFR of 64 was her baseline. It had been around that value for the last few years. I also checked for her most recent MSU result but the latest was from six months ago however that result did show the infection as being sensitive to Trimethoprim.
A prescription seemed necessary in this situation and patient factors, drug effectiveness, tolerability, safety, the person’s individual clinical circumstances, needs and preferences, available licensed indications were all taken into account before issuing prescription.
An author wants to critically analyse the prescribing intervention based on clinical evidences for justification of product prescribed, professional and ethical responsibilities as prescriber and clinical governance relevant to patient in reference.
Evidence Base and Critical Justification:
A systematic review (Falagas et al. 2009; 5 RCTs, n=1,407) assessed the effectiveness of antibiotics in managing symptoms of uncomplicated lower UTI in non-pregnant women with uncomplicated cystitis (lower urinary tract infection), compared with placebo. The age of the included women varied across the studies, ranging from 15 to 75 years. All 5 RCTs enrolled adult women who have mild to moderate clinical symptoms suggestive of a lower urinary tract infection.
Jadad criteria were used for methodological quality of included RCT and only RCTs with a jaded score higher than 2 are considered.
Specifically, this study reported the superiority of a 3-day trimethoprim treatment to reduce the symptom of dysuria in women who had symptoms suggestive of urinary tract infection but had a negative dipstick test for both leucocytes and nitrites.
According to findings, it can be said that antibiotic treatment was superior to placebo regarding the resolution of symptoms of cystitis. This finding was also consistent in terms of eradication of the causative pathogen in women with bacteriologically confirmed cystitis. This justifies the decision to prescribe antibiotics for the patient in reference.
However, in everyday clinical practice, the main reason for which the majority of women with cystitis consult their doctor is the presence of symptoms suggestive of a urinary tract infection, as mentioned above. So, the clinical question that arises is whether or not to start empirical antibiotic treatment in these women without performing a dipstick test or a urine culture. Treating women with symptoms of lower urinary tract infection (LUTI) without laboratory confirmation has advantages and drawbacks. Specifically, it can reduce the number of visits and the number of diagnostic tests performed and, consequently the medical costs deriving from these procedures.
The author reviewed the current guidelines which suggest that there is a possibility to treat symptomatic women empirically, and in the absence of clinical response after 48 h to perform a urine culture in order to identify the causative pathogen and tailor out antibiotic treatment.
However, in women with a history of recurrent bacteriologically confirmed LUTI who also recognize their symptoms, empirical treatment could start without laboratory documentation.
On the other hand, treating dysuric women with antibiotics without bacteriological confirmation can result in increased observed adverse events and increased antibiotic resistance.
This factor, along with the increased costs deriving from antibiotic prescriptions should be taken into consideration when deciding how to treat a woman with a clinical suspicion with a lower urinary tract infection.
Regards to limitations, author noticed firstly the number of the included RCTs is limited. In addition, the majority of women enrolled have mild to moderate clinical symptoms- however as Mrs. X have mild to moderate clinical symptoms – an author can still justify her decision based on the findings from this meta-analysis.
To justify the duration of the treatment with antibiotics Cochrane systematic review of antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women [Lutters, 2008] was reviewed by author.
Fifteen studies (1644 elderly women) were included. Three studies compared single dose with short‐course treatment (3 to 6 days), six compared single dose with long‐course treatment (7 to 14 days) and six compared short‐ with long‐course treatment. Methodological quality of all studies was low except for a more recent geriatric study. There was a significant difference for persistent UTI between single dose and short‐course treatment (RR 2.01, 95% CI 1.05 to 3.84) and single versus long‐course treatment (RR 1.93, 1.01 to 3.70 95% CI), in the short‐term (< 2 weeks post‐treatment) but not at long‐term follow‐up or on clinical outcomes. Patients preferred single dose treatment (RR 0.73, 95% CI 0.60 to 0.88) to long‐course treatments, but this was based on one study comparing different antibiotics. Short versus longer treatments showed no significant difference in efficacy. A rate of adverse drug reactions increased significantly with longer treatment durations in only one study.
Short‐course treatment (3 to 6 days) could be sufficient for treating uncomplicated UTIs in elderly women, although more studies on specific commonly prescribed antibiotics are needed.
Another observational study was reviewed which was published in BMJ 2010 (P. little 2009) to assess the natural course and the important predictors of severe symptoms in urinary tract infection and the effect of antibiotics and antibiotic resistance.
Participants were 839 non-pregnant adult women aged 18-70 presenting with suspected urinary tract infection.
A study highlighted that antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection.
The author felt it was the right decision to prescribe antibiotics by DMP (consultant). Recent guidelines from NICE (NICE CKS, 2015) also recommend analgesia and anti-inflammatory as a treatment for UTI related symptoms. However, Mrs. X already had some so she was being advised to take her Paracetamol 1g four times a day as during the consultation she said she was only taking them ‘now and then’. Mrs. X was 60kgs. The maximum dose in a 24 hour period should not exceed 4g.
First line treatment for an uncomplicated UTI is Trimethoprim or Nitrofurantoin which are both narrow-spectrum antibiotics. These are preferred over bread spectrum in line with Scottish Intercollegiate Guidelines Network (SIGN) (2012). However as Nitrofurantoin has nephrotoxic effects and as Mrs. X had an eGFR of 64, Trimethoprim was being chosen.
DMP prescribed 200mg tablets to be taken orally every 12 hours for 3 days. (BNF 2018) Trimethoprim is totally absorbed from the GI tract, with around 40- 70% being bound to plasma proteins. It has a half-life of between 8-10hours (EMC, 2017). It is believed that Trimethoprim is cost-effective with a 3-day course for women being equally as effective as a 5-10 day course (JFC 2015). That could be the reason for Trimethoprim as a choice in the local prescribing formulary.
Whether to prescribe antibiotics or not to prescribe antibiotics seems to be high on the agenda within the NHS. According to an author, it is important to understand national prescribing rates and trends and are aware of ESPAUR (PHE 2015) which offers comprehensive guidance on antimicrobial resistance and it also influences local trust antimicrobial policy (Local Trust, 2015). Author recognizes the seriousness of antimicrobial resistance with Toska and Geitona, (2015) who suggests that this could lead to an increase in treatment failure with an increase in mortality and morbidity.
Author advised Mrs. X and her husband to monitor for any side effects such as diarrhoea, vomiting, rashes or itchiness in relation to both medications and informed them to stop taking the medication and to contact the RR team or their GP immediately.
Mrs. X was happy that DMP had prescribed Trimethoprim as she had had it before and she said ‘it worked’. NICE (CKS) 2015 suggests that prescribing Nitrofurantoin if a patient has had Trimethoprim within the last 12 months but as mentioned already due to Mrs. X’s eGFR being slightly on the low side trimethoprim was choose especially as it had helped the last time and did not there had been no change in her renal function. The benefits and risks of prescribing decision were explained and Mrs. X was happy and agreed with a treatment plan.
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Concordance in prescribing is of paramount importance with Feltzmann (2012) as being ‘gold standard’. It suggests building a trusting relationship with the patient as well as gaining informed consent. The author believes that throughout this whole prescribing episode full consideration was given to Mrs. X in order to gain concordance. Patient’s beliefs should be taken into account and as Griffiths and Tengnagh (2008) suggest if there are no capacity issues all patients should be treated without discrimination equally.
Mrs. X gave consent to an author to suggest to GP to refer her to an urologist as she has had multiple UTIs.
Mrs. X was being informed that the RR team would visit for the next three to five days to monitor her which would be in line with the review aspect of The Prescribing Pyramid (NPC, 1999). Author told her she would watch out for her MSU results which could take a few days to come back and she would check her recent blood results from the blood that were taken earlier today and would inform her of any abnormalities.
Clinical governance is the system through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish (Department of Health, 1998). It is about the safety and quality of patient care. There are seven pillars of clinical governance which are clinical effectiveness, clinical audit, risk management, education and training, patient and public involvement (PPI), use of information and IT, recruitment and staff management.
Each and every pillar is utmost important; however in this analysis, an author is focussing on clinical audit. In NHS prescribing is the second highest cost and medicine waste accounts for a huge loss to NHS. Audits are carried out nationally, locally, organizational and individual level. An advantage of clinical audits involves patient safety, fulfilling many criteria in different areas of the Quality and Outcomes Framework (QOF), developing a Personal Learning plan for self-appraisal, making most efficient use of therapeutic agents, reducing prescribing costs by reducing unnecessary prescriptions encouraging generic prescriptions and reducing noncompliance. Regular audit of ‘Prescribing Analysis and Cost (PACT) data will allow comparison of an individual prescribing with prescribing by other similar prescriber or with local average. The author strongly suggests that, clinical audit policy should be in place in contract with 100 percent achievement criteria for each non-medical prescribing role. Again all NMPs must be on trust register before commencing prescribing activities, should demonstrate ongoing competence within a role, appropriate and ongoing continuous professional development, and annual appraisals incorporating prescribing issue and must record all prescribing errors via incident recording system. Clinical audit is an integral part of any prescribing process.
After obtaining a prescribing qualification NMP should work in collaboration with a multi-disciplinary team (MDT). In this case, the MDT consists of my team including myself, Mrs. X’s GP, community pharmacist and as recommended by Coulter (2009) Mrs. X and her husband.
NMP should prescribe within their own scope of practice and competencies, working within the law and any regulations (Lynn et at 2010). The NMC (2006) also highlight that the NMP has to take full responsibility for any prescribing decisions made.
Throughout the whole consultation, author adhered to the concepts of being transparent, honest and opens (Btoadhead 2016). There was mutual respect between Mrs. X and myself and duty of candour were achieved as advocated in The Francis Report (Francis 2013).
All the information regarding the treatment including the dose, duration, and side effects were given and Mrs. X had all the information required to make an informed choice and gave consent, which pertains to the legal and ethical principle of autonomy.
Autonomy along with non-maleficence, beneficence, and justice are the four main ethical principles to consider when prescribing. (Lynn et at 2010). Autonomy pertains to a patient being able to take control of their own decisions and to make them without influence. Along with other principles their aim is to improve the quality of health/life, causing no harm to the patient. A prescriber must not intentionally cause any harm. It is the duty of the prescriber to ensure extra vigilance when prescribing as drugs can be harmful even lethal.
According to the Medical Defence Unit (2007), common prescribing errors can be avoided when the prescriber takes extra care and vigilance. It is now clear that a prescriber’s duty of care includes all aspects of practice since the legal case of Chester V Afshar (Wheat, 2005) which includes making sure the patient is aware of any potential risks from taking the prescribed medication. Any omissions may be considered as negligence and could lead to being judged by the responsible professional body (Broadhead, 2016) (The HCPC in my case)
Record keeping is another element to The Prescribing Pyramid. It not only improves continuity of care, it as a legal requirement (NMC 2015) and it can be used in law cases with the NMC (2004) stating that in its absence an assumption can be made that the actions did not take place. As author had a work laptop she was able to document immediately.
Prescriptions have an impact on the patient as well as on the NHS as a whole. They are monitored and audited in order to assess the impact on the outcome to the patient (Tailor and Lewis 2016), and prescribing habits are reviewed by the Practicing Authority who report to the Prescribing Analysis and Cost Tabulation (PACT) who in turn provide feedback and reports on prescribing performance and quantity and cost.
Author is in no doubt that as an NMP she has an obligation to ensure the safe and legal management of medicines (Nuttall and Rutt-Haward, 2016) An amendment to The 1968 Medicines Act in 2006 — The Medicines and Human Use order gives almost free reign for NMPs to prescribe any medication from the BNF except some controlled drugs for AHPs so long as it is within their scope of practice and competency and although this gives privilege it also comes with a higher level of risk and responsibility. Indemnity insurance is therefore necessary in case a civil claim should be brought before them. At the end of this course, an author will ensure that her employers are aware of her extended role of prescribing so that she will benefit from vicarious liability although HCPC advises of also having indemnity insurance.
The author has critically analysed and described the prescribing intervention in practice scenario to meet the module learning outcomes. The author is confident that her rationale for prescribing decision in the future will be based on sound comprehensive guidelines, practice experience, and evidence and planning of future prescribing decisions will be based on the prescribing pyramid model and will make conscious efforts to see outside of prescriptive toolkit so as to remember the importance of other interventions. An author would utilize the clinical supervision and support available in the practice area, including differential diagnosis and treatment options with a multidisciplinary team following the assessments. This will ensure effective and safe practice, continuous professional development and recognition as non-medical prescriber in the wider healthcare team. To maintain all relevant competencies as prescriber these goals are important. (Royal Pharmaceutical Society, RPS, 2016). By ensuring that practice is evaluated and monitored, knowledge updated, patient experience will be improved leading to increased concordance, adherence and better health outcomes. The future of independent prescribing practice will be guided by legal, ethical and professional principles and framework.
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