A Critical Analysis of a Prescribing Intervention

Introduction

This essay will look at a patient that was seen in a General practice setting by a Non-medical prescriber student under the supervision of a General Practitioner. It will look at an overview of the patient, her presenting symptoms, brief assessment and about the decision to suggest seeking healthcare dissertation help. The Essay will also look at the rationale for choosing the particular medicines and other options that could have been used instead. The essay will go on to analyse the evidence provided for the use of the product, and its suitability. It will go on to discuss the role of the non-medical prescriber and the professional body that governs them, their responsibilities as a prescriber and accountability to their patients and the public as a whole. The essay will have a brief overview of clinical governance, the fundamental pillars that form the basis of its processes, and it will especially explore staff training and the importance of this in the role of a non-medical prescriber.

The care provider is a Practice nurse, currently working at a General Practice (GP) Surgery within Barnet borough. She finished her Practice nurse training in January 2017 and has been working soon after. Notable responsibilities of the author includes consultations with patients within surgeries and health care centres, physical examination of the patient, diagnosis of disease and prescribing treatments, wound dressings, providing first aid care and treatment, assisting in minor operations performed under local anaesthetic, educating the patients about varied illness and their cause, cessation of smoking, about weight loss, collecting clinical samples of patient, checking the vital symptoms of patient, family planning, immunization and vaccinations, discussing with other healthcare professionals and maintenance of patient record, doing NHS screening and reviewing patients with long term health problems. The role of the author allows her to build up a long-standing relationship with the patient and their families which help to manage their conditions by bringing certain changes in their total well being. Before writing a prescription, a clinician is expected to do a comprehensive assessment, diagnose and make a treatment plan with the patient (Poitras, et al, 2016). All the assessment, the decision to prescribe and the prescribing was done under the supervision of a GP (General Practitioner), who is a Designated Medical Prescriber (DMP) and Mentor over-seeing assessment, decision to prescribe and rationale for using a particular medication. This patient was seen with his guidance, and the decision to prescribe was authorised by him.

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Clinical Manifestations and Background history of the patient: An evidence-based and critical justification of the chosen products

In July of this year, a 55years old female presented to the GP surgery with a history of cough for the past two weeks. During every consultation, the history of the patient is recorded as it is an essential practice; it is the process of communication between the clinician and the patients, intending to get a diagnosis while ruling out differential diagnoses. History taking helps the clinician come to a decision based on their findings.

The patient reported that the cough was initially non-productive, she then started producing whitish phlegm, and then in the last 2 days, she has been producing greenish phlegm. She reported pain while swallowing, and is not improving even after administration of drug Ibuprofen. She reported that she was experiencing chest discomfort and tightness while coughing in the last one day with recurrent fever. Depending on her symptomatic features she had gone for a check-up by another clinician five days ago, and her clinical manifestations were; Blood pressure 124/84mmHg, pulse 74/min, respiratory rate 16/min, oxygen saturation 99% on room air, tympanic temperature 36.9c. She was sent home with advised to drink lots of fluids, prescribed with the drug Ibuprofen and return for a follow up check-up within 3 days only if her condition does not show any improvement or in case her condition worsens with time. According to the background history of the patient recorded: Mrs X is currently working in the accounts department at an NHS organisation, she’s married, has three children, all grown up. She’s a non-smoker, has never smoked cigarette, used to regularly go to the gym, but hasn’t visited in the past 2 years. She reported that she has a past medical history of malignant neoplasm of her right breast and reconstruction done 2 years ago, ventricular cardiac arrhythmia, Iron deficiency anaemia and recurrent UTI. Following the breast surgery, she was started on pregabalin 100mg three times a day for neuropathic pain, she was also on Sodium Feredetate 27.5mg/5ml, taking 10mls three times a day for anaemia, and on Tamoxifen 20mg daily. She reported that she’s allergic to penicillin when asked, but wasn’t sure what happens when she takes it, but her mother had told her so. All the history she gave corresponded with the entries in her notes. Further history was taken, she denied having diarrhoea, says she’s eats little, but drinks a lot of fluids and passes urine. The patient denied having any urinary symptoms, no recent travel and denied having any earache or discharge. The patient also reported about sore throat and nasal congestion.

Her clinical examination was done; her blood pressure was 101/71mmHg, Pulse 98/min, respiration rate 16/min, oxygen saturation 98% on room air, tympanic temperature 37.7c. The patient is alert, no confusion noted, interacting well with a clinician, well hydrated. Physical examination showed slight redness in throat, no collection of pus was seen, there was tenderness around her sinuses, no lymph nodes were palpable and no redness was seen in both ears. Auscultation was done, there was no wheezing heard in the lungs, but there were crackles heard on the right middle segment of the lung. Patient current medications are as follows; pregabalin 100mg three times a day, Sodium Feredetate 27.5mg/5ml, taking 10mls three times a day and Tamoxifen 20mg daily. Based on the history taken, the clinical observations and examination, it was agreed that Mrs X is likely to be suffering from sinusitis and Lower respiratory Tract Infection (LRTI).

Lower respiratory tract infection (LRTI) can be considered to be a broad expression as it includes conditions of pneumonia, acute bronchitis, acute exacerbation observed during bronchiectasis and acute exacerbations of COPD. Mortality due to LRTI occurs mostly due to pneumococcal pneumonia. Typical clinical manifestations of pneumonia include pleuritic chest pain, chills, acute fever for about ≥ 4 days, production of cough, tachycardia whereas atypical CAP (community-acquired pneumonia) demonstrates headache, myalgias, unproductive cough and fever without chills. Symptomatic features of sinusitis include nasal congestion, pain, hyposmia, facial pressure, fever, tenderness and malaise (acute infection). Several symptoms of both the disease are observed in the patient (Mahashur, et al, 2018; Ah-See, 2007).

There is a rising concern about antibiotic resistance as a worldwide public health issue due to factors like misuse or overuse of the medications and pharmaceutical companies not developing new antibiotics for a long span of time because of the reduced monetary investment and other demanding regulatory constraints (Ventola, 2015). Therefore, to focus on the aspect of antimicrobial stewardship, it is even more important for prescribers to ensure that they have exhausted other options; self-care, use of over the counter (OTC) medication like non-steroidal anti-inflammatory drugs (NSAID), early review of the patient and delayed prescribing, before giving an immediate prescription for antibiotics. Based on the evidence provided by the study conducted by Kraus, et al, 2017 it was observed that antibiotics were administered for 41% of the study populations and were not prescribed in case of 52% of the populations based on the guidelines of national S3 guideline cough from the German Society of General Practitioners and Family Medicine. At this current presentation, which is the second visit for similar symptoms, Mrs X has been coughing for the past 2 weeks, with the production of cough with greenish phlegm. She’s having fever with a tympanic temperature of 37.7c and slightly tachycardia as observed from the pulse rate of 98/min. Her BP was lower than normal, there was concern about the risk of sepsis, therefore a sepsis screen was carried out, and she was found at lower risk but needs monitoring, she scored a 2 on the National Early Warning Score (NEWS).

Antibiotics that were prescribed to the patients were grouped by Anatomical Therapeutic Chemical (ATC) Classification Index (Kraus, et al, 2017). The individuals who are suffering from community acquired pneumonia not associated with any risk factors should be prescribed with an aminopenicillin (such as amoxicilline), or with newer available macrolides (such as clarithromycin, azithromycin, roxythromycin) or doxycycline (tetracycline). But in case of patients having any risk factors should be prescribed with broad spectrum antibiotic, i.e., penicillin along with β-Lactamase inhibitor, fluoroquinolones or cephalosporins. Now if the choice of antibiotic by the General Practitioner is according to the guidelines mentioned then it is referred as “recommended choice” and if it is advised outside the guideline or a different antibiotic regime then it is referred as “not recommended choice”. Based on this report, patients who are younger than 65 years of age can be prescribed with macrolides such as clarithromycin and azithromycin or with tetracycline (doxycycline). According to the local guidelines (Management and treatment of common infections in North Central London) and the NICE guidelines (NICE guidelines on Respiratory tract Infections - antibiotic prescribing (2008), the first option for when a patient presenting features of respiratory tract infection is reassurance and advice on self-care and use of OTC medications e.g. NSAID. It goes on mentioning about the policy, clinicians should explain to patients that most respiratory tract infections are self-limiting and they should explain the duration of the symptoms, offer self-care advice. When antibiotic is required for treatment, antibiotic Tetracycline and amoxicillin are the first-line antibiotics prescribed for the treatment of LTRI. Dosage regulations of amoxicillin 500mg is three times a day for 5 days and doxycycline (tetracycline group) 200mg start, then 100mg daily from the following day for a total of 5 days can be prescribed. In case hypersensitivity is reported macrolides such as clarithromycin 500mg twice a day for 5 days or for patients with penicillin allergies is preferred. Patients showing dry cough are generally prescribed with dextromethorphan (a cough suppressant) and codeine (medication used to relieve mild to moderate pain). Medications such as expectorant, antihistamines, mucolytics, and bronchodilators should never be prescribed for a patient suffering from acute LRTI in the primary health care setting. Antiviral treatment suspecting influenza is generally not recommended unless any symptomatic features of influenza during an influenza epidemic is suspected or confirmed. Every patient suffering from fever for the past four days; who have reduced or stopped drinking, decreasing consciousness and worsening dyspnoea should contact their physician immediately (Woodhead, et al, 2005; Wilson, et al, 2017).

Even though symptoms of Mrs X had worsened, from her first presentation, the recommended examination for similar patients is a chest X-ray to observe any shadowing in the lung field and a blood test for inflammatory markers: C-reactive protein (CRP) and White blood cell count (WBC). In the primary health care setting, these investigations are not readily available, so patients have to book an appointment to have these investigations done, and the process can sometime take from a few days to a week. During this time to avoid the deteriorating condition of the patient clinicians generally commence treatment with the above-mentioned antibiotics. The United Kingdom has a culture of prescribing antibiotics frequently. Though it is reported in the guidelines that most self-limiting respiratory tract infections can be managed without antibiotics still about 50% of primary health care centres prescribe antibiotics for this condition. If the rate is compared with international standards of Sweden and the Netherlands, the rate of prescribing antibiotic is only half in comparison to the above mentioned rate (Gulliford, et al, 2019).

The possible findings of sinusitis and LRTI were disclosed only to Mrs X, maintaining the statement of confidentiality. Maintaining confidentiality is a precondition for accurate diagnosis followed by proper treatment. It also strengthens the relationship between the clinician and the patient (Watwe, 1998). She was explained about the cause of starting course of antibiotics prescribed for her treatment by a GP, as her symptoms worsened with passing days. Her clinical manifestations were also not improving and were slightly worse than her previous consultations about 5 days ago, and her recent history of breast malignancy made her more prone to infection. Based on the present scenario the above-mentioned treatment plan was discussed with Mrs X and her opinion and beliefs about medication were also taken into consideration, and the effects of all the three antibiotics were also discussed including side effects and drug interactions if any. According to Cox, et al, 2002, discussions like this, is said to improve patients’ trust in clinician and patients adhere to prescription guidance. It is important to highlight at this point that, the NICE, 2008 guideline on respiratory tract Infections – antibiotic prescribing was published in 2008, which means the initial trials were done even earlier. Based on the report of a prospective cough complication cohort study which included 28 883 patients infected with LRTI patients and among them 0.4% (104) patients were considered for radiographic examination after hospital admission death occurred among 0.3% (26/7332) with no prescription of antibiotic, 0.9% (156/17628) were prescribed with antibiotics immediately, and 0.4% (14/3819) were given a delayed prescription of antibiotics. The outcome of the study revealed that prescribing antibiotics immediately may not show any change in the reduction of hospital readmission or death for young and adults suffering from uncomplicated LRTI. Clinicians should give delayed antibiotics prescription as it reduces the load of consultations concerning worsening illness (Little, et al, 2017).

As a nurse prescriber, it is expected that they should work within the recommended guidelines. It is clearly stated in the guidelines about the non‐medical prescribers’ codes of conduct that prescribing practice wherever possible, it should be evidence-based and following relevant national and local guidance (Nuttall, et al 2015). Considering the case of the above patient, she does not fit within the criteria, but then at the same time, these guidelines as clinicians always say, that “guidelines, not track lines”, meaning, it should not be considered as a rule, but only as a guide. The NICE, guidelines on respiratory tract infection stated that “healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer and informed by the summary of product characteristics of any drugs they are considering”(NICE, 2008).

During their review about patients’ feedback, Cox et al revealed that doctors were good at initiating discussions about medication with the patient but dominates the interaction as they are mostly concerned about the benefits of medication and didn’t mention about the side effects. Therefore when the patients were asked about their opinion, they mostly remain silent. In recent years, there has being a lot of focus on shared decision making between patients and clinicians. Mrs X reported pain while swallowing, and it did not improve even after administration of drug Ibuprofen (NSAIDs). Moreover, Mrs X has a history of penicillin allergy; she cannot be prescribed with the penicillin group of antibiotics, amoxicillin. The second antibiotic option for the patient with an LRTI is Clarithromycin, which also contraindicated for Mrs X, as it causes QT prolongation, and because of her cardiac condition, it cannot be prescribed. The third option for treatment is Doxycycline 100mg; two doses to be taken on the first day, then one dose daily for consecutive five days. All of this was discussed with Mrs X, she agreed with the decision to be prescribed with Doxycycline; she stated that the dosage prescribed would be easier for her to follow since it was only for once a day.

Professional responsibilities as a prescriber

The roles of nurses have evolved greatly in the last two decades, with lots of medical skills expanding the nursing roles into specialist roles which also include prescribing. For the Non-Medical Prescribing (NMP) to become more widely accepted, healthcare managers, clinical care quality and safety agencies, as well as the general public require evidence of the overall value of NMP; through the implementation of services that are patient-centred, improving the quality and safety of patient care, while simultaneously reducing costs and improving efficiency of treatment and patient-outcomes (Noblet, et al, 2018). A range of robust studies utilising survey designs has concluded that NMP practice is considered to be safe and appropriate, exhibiting better patient satisfaction (Noblet, et al, 2018).

As a trained nurse, working in the United Kingdom, you are expected to register with the Nursing and Midwifery Council (NMC), which is the regulatory body for all nurses and Midwives. As a registered nurse, there is a professional standard that is expected to be upheld, and in training as a prescriber, there is an even higher expectation of accountability and professionalism, the virtues of openness, transparency and a duty of candour must be embedded into clinical practice to demonstrate their enhanced responsibility and accountability for the protection of the public. It is suggested that to attain this, a minimum standard of awareness of legal, ethical and professional matters should, therefore, be a prerequisite for prescribing (Nuttall, et al 2015). Then there are the ethical issues that are also overarching these professional governing bodies; the main one being ethical principles of Beauchamp and Childress; Respect for Autonomy; Everyone has a right to make choices, have a view, and have a personal values and beliefs, Justice, to treat everyone fairly, non-malfeasance; not harm intentionally and lastly, beneficence be good to everyone. “We can take action if those on our register fail to uphold the Code” (NMC code, 2018). As part of the nursing code of conduct, nurses are expected to; prioritise people, listen to people, treat them with kindness, respect and compassion and give care to the best of their interest (NMC code, 2018). As mentioned in the local and national guideline, the nurse prescriber prescribed the medication to the patient after consulting a DMP, after listening all the recording all the details about her past and present clinical symptoms before prescribing the medications for her present condition and after going through evidence based data for similar cases. As expected from a trained nurse registered with Nursing and Midwifery Council, the legal, ethical and the professional matters were considered to ensure effective care and protection to the patient. The antibiotics were also prescribed following the prescribed guidelines and depending on the allergy history of the patient to antibiotics. Moreover, an informed decision has been taken with the patient to avoid any discrepancy, to maintain the duty of transparency and after listening to the beliefs of the patient about the choice of antibiotics (NMC code, 2018).

Clinical Governance issue relevant to your patient and his/her management

Clinical governance is “a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish" (Scally and Donaldson 1998). This is a government initiative, to ensure that, quality care is provided by every health services, to promote integration between health and social care partners. There are several pillars of clinical governance depending on which article is being read, some highlight four pillars, others report six and according to some campaign that there are seven. The NHS categorises it under the following headings; Performance review including quality issues, I, Clinical auditing, II, clinical risk management, III, quality assurance, IV, clinical effectiveness, V, staff and organisational development (NHS Executive 1999). According to the nursing guidelines approved by the Nursing Clinical Effectiveness Committee, the points that have been taken into consideration are:

1) Admission assessment: a detailed history, the general appearance, physical examinations of the vital signs of the patient was recorded in details;

2) Shift Assessment: Assessment of the patient condition at the beginning of each shift by the nurse

3) Focused Assessment: Detailed assessment of the patient concerning present problems was performed for the patient (Baid, 2016; Bickley, 2009)

For professional development in the career of a non-medical prescriber the key skills that are considered are updated knowledge and skills which will enhance their confidence (R. Weglicki et al, 2015). Even though CPD is important for staying up to date with current researches and recommended practices, different people had different methods of preferred ways to meet these updates. While some felt that e-learning training was appropriate, whereas others felt that, a face to face training is better where there is an exchange of practical ideas. The patient was assessed based on the following three assessment approaches (Admission assessment, Shift Assessment, Focused Assessment) as mentioned above. The patient reported to have a history of penicillin drug allergy so advised with tetracycline group of drugs as mentioned in the guidelines of prescribing antibiotics by a designated medical practitioner. The patient had a history of breast surgery which made her more prone to infection therefore administration of antibiotic was essential and an informed decision was made with the patient concerning her treatment. This is in support of the categories provided by NHS to ensure performance review, clinical risk management, quality assurance and clinical effectiveness. Regular follow up of the patient symptoms assessed the progressing / worsening condition of the patient easier and accordingly measures were implemented.

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Conclusion

There is a lot of pressure on healthcare services worldwide due to the ageing population, people living with multiple comorbidities, shortage of staff; it takes a long time to train a doctor. Therefore, health-care managers are training other clinical staff to perform specialist roles, including prescribing medication. This will be a better option for all patients, as they will be prescribed medication much quicker, within one consultation. This essay looked at a patient that came up with a lower respiratory tract infection and had undergone treatment previously, after considering the most suitable treatment option for her, taking into account drug sensitivity and interactions the suitable medications were prescribed. The essay goes on to look at the evidence and choice of antibiotic. The essay looks at the role of the non-medical prescriber, and their clinical responsibilities, the governing body and their accountability. It goes on to look at continuous professional development with clinical governance and how that can improve practices. Perhaps one of the major challenges in training as an independent nurse prescriber is the acquisition of effective clinical reasoning and diagnostic skills that are achieved with continuous practice.

References:

Poitras, M.E., Chouinard, M.C., Fortin, M. and Gallagher, F., 2016. How to report professional practice in nursing? A scoping review. BMC nursing, 15(1), p.31.

Mahashur, A., 2018. Management of lower respiratory tract infection in outpatient settings: Focus on clarithromycin. Lung India: official organ of Indian Chest Society, 35(2), p.143.

Ah-See, K.W. and Evans, A.S., 2007. Sinusitis and its management. Bmj, 334(7589), pp.358-361.

Kraus, E.M., Pelzl, S., Szecsenyi, J. and Laux, G., 2017. Antibiotic prescribing for acute lower respiratory tract infections (LRTI)–guideline adherence in the German primary care setting: An analysis of routine data. PLoS One, 12(3).

Woodhead, M., Blasi, F., Ewig, S., Huchon, G., Leven, M., Ortqvist, A., Schaberg, T., Torres, A., van der Heijden, G. and Verheij, T.J., 2005. Guidelines for the management of adult lower respiratory tract infections. European Respiratory Journal, 26(6), pp.1138-1180.

Wilson, G., Bryan, J., Cranston, K., Kitzes, J., Nederbragt, L. and Teal, T.K., 2017. Good enough practices in scientific computing. PLoS computational biology, 13(6).

Watwe, J.M., 1998. Disclosure of confidential medical information. Indian J Med Ethics, 998(6).

Little, P., Stuart, B., Smith, S., Thompson, M.J., Knox, K., van den Bruel, A., Lown, M., Moore, M. and Mant, D., 2017. Antibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study. bmj, 357, p.j2148.

Baid, H., 2006. Patient assessment. The process of conducting a physical assessment: a nursing perspective. British Journal Of Nursing, 15(13), 710-714.

Bickley, L. S., Szilagyi, P. G., & Bates, B., 2009. Bates' guide to physical examination and history taking (10th ed.): Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins,

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Dhillon, S. and Sodha, M. (2009). Non-medical prescribing. 1st ed. London: Pharmaceutical Press.

Gauld, R. and Horsburgh, S. (2015). Clinical governance: a key, but under-researched, health system foundation. Journal of Health Organization and Management, 29(4).

Gulliford, M., Juszczyk, D. and Yardley, L. (2019). What is “normal” antibiotic prescribing?. BMJ, 364.

Maier, C., Köppen, J. and Busse, R. (2018). Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries. Human Resources for Health, 16(1).

National Institute for Health and Care Excellence (2008). Respiratory Tract Infection. London: NICE Publications.

Noblet, T., Marriott, J., Graham-Clarke, E., Shirley, D. and Rushton, A. (2018). Clinical and cost-effectiveness of non-medical prescribing: A systematic review of randomised controlled trials. PLOS ONE, 13(3).

Nursing and Midwifery Council (2015). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: NMC Publications.

Nuttall, D. and Rutt-Howard, J. (2015). The textbook of non-medical prescribing. 2nd ed. Wiley-Blackwell.

Scally, G. and Donaldson, L. (1998). Looking forward: Clinical governance and the drive for quality improvement in the new NHS in England. BMJ, 317(7150), pp.61-65.

Weglicki, R., Reynolds, J. and Rivers, P. (2015). Continuing professional development needs of nursing and allied health professionals with responsibility for prescribing. Nurse Education Today, 35(1), pp.227-231.

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