Local Prescribing Policy Research Articles

1050 An Audit of the Management of Acute Epididymo-orchitis

Abstract Aim To evaluate the management of patients referred to our Surgical Assessment Unit presenting with acute epididymo-orchitis. Concordance with local antibiotic guidance, the use of ultrasound scanning, and microbiological testing were all assessed over a one-year period. Method All adult patients presenting with acute epididymo-orchitis in 2019 were identified retrospectively using ICD-10 codes and the choice of antibiotic used was compared to our own local guidance. The use of ultrasound scanning was recorded and whether this led to a change in diagnosis or management. Use of microbiological investigations including urine microscopy & culture and sexual health screening were assessed. Results After exclusion criteria were applied 64 cases were identified with an average age of 55 (16-88). Concordance with local antibiotic guidance was low with 3/64 patients receiving antibiotics in-line with local guidance. This was predominantly due to the frequent use of Ciprofloxacin (49/64) which is not advised locally, however is in-keeping with guidance from organisations such as EAU/BASHH. Ultrasound was used acutely in 46/64 patients with 28/46 showing evidence of epididymo-orchitis, 15/46 were normal and 1/46 confirmed an abscess which required surgical drainage. All normal scans were still treated with antibiotics based on clinical findings. 25/64 had a urine sample sent for MC&S and uptake of sexual health screening was low. Conclusions Urologists should be aware of differences between local prescribing policy and broader guidance from relevant organisations. Epididymo-orchitis remains a clinical diagnosis and ultrasound should be reserved acutely for diagnostic uncertainty, unwell patients, or failure to improve.

Emergency physician risk assessment practices prior to prescribing opioids.

Safer opioid prescribing remains a crucial issue for emergency physicians. Policy statements and guidelines recommend deliberate risk assessment for likelihood of current or future opioid use disorder prior to prescribing opioids. However, the practice patterns of emergency physicians remain underreported. We surveyed emergency physicians across Canada about their local opioid prescribing policies, their practice patterns of risk assessment prior to prescribing opioids, and which clinical risk factors they find most important. The response rate was 20.4% (n = 312/1532). 59.8% of respondents report usually or always assessing for risk. Physicians rely on gestalt (80.3%), targeted histories based on risk factors in the literature (55.6%) or their experience (57.6%), and reviewing medical (83.1%) and medication records (75.6%). Contacting primary prescribers is uncommon (16.3%). A minority routinely use opioid prescribing risk assessment tools (6.4%), have local opioid prescribing policies (27%), or make use of electronic medical record functions to assist risk stratifying (2.4%). Many Canadian emergency physicians make risk assessments based on gestalt rather than identifying literature-based risk factors. This conflicts with guidelines calling for routine comprehensive assessment. Further efforts should be directed towards education in optimizing risk assessment; and towards system-level initiatives such as clear local prescribing policies, electronic-systems functionality, and developing assessment tools for use in the ED.

Trends in anticoagulant prescribing: a review of local policies in English primary care

BackgroundOral anticoagulants are prescribed for stroke prophylaxis in patients with atrial fibrillation, which is the most common heart arrhythmia worldwide. The vitamin K antagonist (VKA) warfarin is a long-established anticoagulant. However, newer direct oral anticoagulants (DOACs) have been recently introduced as an alternative. Given the prevalence of atrial fibrillation, anticoagulant choice has substantial clinical and financial implications for healthcare systems. In this study, we explore trends and geographic variation in anticoagulant prescribing in English primary care. Because national guidelines in England do not specify a first-line anticoagulant, we investigate the association between local policies and prescribing data.MethodsPrimary care prescribing data of anticoagulants for all NHS practices from 2014 to 2019 in England was obtained from the ePACT2 database. Public formularies were accessed online to obtain local anticoagulation prescribing policies for 89.5% of clinical commissioning groups (CCGs). These were categorized according to their recommendations: no local policies, warfarin as first-line, or identification of a preferred DOAC (but not a preferred anticoagulant). Local policies were cross-tabulated with pooled prescribing data to measure the strength of association with Cramér’s V.ResultsNationally, prescribing of DOACs increased from 9% of all anticoagulants in 2014 to 74% in 2019, while that of warfarin declined accordingly. Still, there was significant local variation. Across geographical regions, DOACs ranged from 53 to 99% of all anticoagulants. Most CCGs (73%) did not specify a first-line choice, and 16% recommended warfarin first line. Only 11% designated a preferred DOAC. Policies with a preferred DOAC indeed correlated with increased prescribing of that DOAC (Cramér’s V = 0.25, 0.27, 0.38 for rivaroxaban, apixaban, edoxaban respectively). However, local policies showed a negligible relationship with the classes of anticoagulants prescribed—DOAC or VKA (Cramér’s V = 0.01).ConclusionsNationally, the use of DOACs to treat atrial fibrillation has increased rapidly. Despite this, significant geographical variation in uptake remains. This study provides insights on how local policies relate to this variation. Our findings suggest that, in the absence of a nationally recommended first-line anticoagulant, local prescribing policies may aid in deciding between individual DOACs, but not in adjudicating between DOACs and vitamin K antagonists (i.e. warfarin) as general classes.

G538(P) Reducing prescribing errors by introducing a paediatric prescribing web-based learning module in a tertiary children’s hospital

Background Medication errors are a significant problem in theUK, and have the potential to cause harm. Children are particularly vulnerable. Errors occur at different decision-making points in the medicines pathway, and prescribing errors constitute a significant but potentially modifiable step in this process, which we targeted. Our hospital regularly audits prescribing against our local prescribing policy (the gold standard), which is based upon GMC guidance for safe prescribing. The rate of prescription error was 67% in 2010. We defined ‘prescription error’ as any deviation from the gold standard. From August 2010, our mandatory junior doctor induction was modified to include a 2 h lecture on paediatric prescribing (delivered by pharmacist and doctor) and a paediatric prescribing test. This combination was shown to reduce prescribing errors from 67% to 52%, and reduce incorrect or absent allergy information on prescription charts from 36% to 15% in 2010 and 2012 respectively. The problem Although effective in improving prescribing, the lecture had a large volume of information to deliver in a limited time. Administering and marking the test was time consuming and providing individual feedback was logistically challenging. A potential solution Web-based learning modules (WBLM) are accessible, low cost and can facilitate simultaneous education and assessment. Aim To design and pilot a WBLM to replicate the previous content of prescribing induction. The long-term aim is to continue to improve paediatric prescribing within our hospital. Primary objective Assess feasibility of introducing a WBLM as part of paediatric induction. Secondary objective Assess the effect of the WBLM on prescribing practice. The intervention The WBLM was designed by paediatricians (the authors) working with a Learnpro designer. It can be accessed remotely and is PC or tablet compatible. There are 3 main sections. The first is an introduction to paediatric prescribing, revising pharmacokinetics and local policy for safe prescribing. The second section uses clinical cases to illustrate prescribing challenges and focuses on areas where errors frequently occur. Adverse drug reactions, antibiotic monitoring, medication error reporting and discharge prescriptions are covered. The final section focuses on intravenous fluids. All sections contain links to relevant local clinical guidelines. Summative assessment questions are incorporated into the module, requiring trainees to obtain the correct answer before progressing. Implementation The WBLM was designed in early 2014. Usability was tested in a small group prior to a pilot in August 2014 for junior medical and surgical doctors attending hospital induction. Measurement of Improvement The Plan-Do-Study-Act cycle (PDSA) provides a structure for iterative testing of changes to improve quality. We are currently in the third cycle following the August 2014 pilot. All post-completion evaluations were positive. Minor technical issues reported have been addressed. The small scale testing has allowed adaptation according to feedback received. All inpatient prescription charts, excluding PICU who use electronic prescribing, were audited in November 2014 (Figure 1). There were 78 prescription charts containing 904 individual prescriptions. 85% of ‘regular’ prescriptions were prescribed correctly. Although only 68% of total prescriptions were correct, a significant proportion of errors were in ‘once only’ and ‘PRN’ sections, commonly completed in A+E by doctors, who had not undertaken the WBLM. From 2015 the WBLM will be mandatory for all trainees rotating through the hospital, including A+E, anaesthesia and PICU. Conclusion It is feasible to implement a WBLM as part of paediatric prescribing induction. Extending implementation to all hospital departments has the potential to be effective in improving paediatric prescribing practice. The WBLM must work in conjunction with other measures to address human and system factors in prescribing errors. These effects should be studied with ongoing PDSA cycles.

Audit of ventriculoperitoneal shunt infections in paediatric patients, 2006-2013.

Infection following ventriculoperitoneal shunt placement remains a significant complication with an incidence of 3-27% cited in literature. Infections cause significant morbidity, and it is important that empirical antibiotic therapy for management is guided by accurate knowledge of prevailing aetiologies and local antibiotic sensitivity patterns. To establish the incidence of shunt infections in our paediatric population, to identify the causative micro-organisms, and to determine the antibiotic resistance patterns of the responsible micro-organisms. Retrospective data collection utilising existing databases in the Royal Hospital for Sick Children, Yorkhill, between 1 January 2006 and 30 September 2013. Total number of shunt operations was 308 with 28 episodes of infection involving 27 patients (male = 12, female = 15). The incidence of infection was 9%. In all, 79% of the episodes involved a single pathogen with 21% being mixed pathogens. Coagulase-negative staphylococci were the most common cause of infection (44%). Gram-positive sensitivity to flucloxacillin and gentamicin was noticeably low at 22% and 14%, respectively with 87% of coagulase-negative staphylococci resistant to gentamicin and 81% resistant to flucloxacillin. The changing spectrum of Gram-positive organisms has impacted on antibiotic sensitivity patterns, and our local prescribing policy has been adapted in order to manage shunt infections most effectively.

Administering anticipatory medications in end-of-life care: A qualitative study of nursing practice in the community and in nursing homes

Background: In the United Kingdom, an approach to improving end-of-life care has been the introduction of ‘just in case’ or ‘anticipatory’ medications. Nurses are often responsible for deciding when to use anticipatory medications, but little is known about their experiences. Aim: To examine nurses’ decisions, aims and concerns when using anticipatory medications. Design: An ethnographic study in two UK regions, using observations and interviews with nurses working in community and nursing home teams (n = 8). Findings: Observations (n = 83) and interviews (n = 61) with community nurses. Nurses identified four ‘conditions’ that needed to be established before they implemented anticipatory medications: (1) irreversibility; (2) inability to take oral medication; (3) where the patient was able, they should consent and (4) decision had to be independent of demands or requests from patient’s relatives. By using anticipation medications, nurses sought to enable patients to be ‘comfortable and settled’ by provision of gradual relief of symptoms at the lowest dose possible. They aimed to respond quickly to needs, seeking to avoid hospital admission or medical call-out, while adhering to local prescribing policies. Worries included distinguishing between pain and agitation, balancing risks of under- and over-medication and the possibility of hastening death. Conclusion: Nurses take a leading role in the administration of anticipatory medications. Nurses apply consideration and caution to the administration of anticipatory medications but some experience emotional burden. Education, training and experience played a role in the nurses’ confidence and should continue to be central to efforts to improving the quality of palliative care in the community and nursing homes.

The impact of a change in prescribing policy on antipsychotic prescribing in a general adult psychiatric hospital.

To examine the impact of a change in local prescribing policy on the adherence to evidence-based prescribing guidelines for antipsychotic medication in a general adult psychiatric hospital. All adult in-patients had their clinical record and medication sheet reviewed. Antipsychotic prescribed, dose prescribed and documented indications for prescribing were recorded. This was done before and after the implementation of the change in hospital antipsychotic prescribing policy. There were no significant differences in age, sex, Mental Health Act status, psychiatric diagnosis or documented indications for prescribing multiple or high dose antipsychotics between the two groups. There was an increase in the preferential prescribing of multiple second-generation antipsychotics (p=0.01) in the context of a significant reduction in the prescribing of multiple antipsychotics overall (p=0.02). There were no significant reductions in prescribing of mixed generations of antipsychotics (p=0.12), high dose antipsychotics (p=1.00) or as required (PRN) antipsychotics (p=0.74). Changes in local prescribing policy can improve adherence to quality prescribing guidelines and cause clinically significant improvements in patterns of prescribing in a general adult psychiatric hospital.

HOW DO COMMUNITY NURSES DECIDE WHEN TO USE ANTICIPATORY PRESCRIPTIONS IN END OF LIFE CARE AND WHAT DO THEY WORRY ABOUT? FINDINGS FROM A QUALITATIVE STUDY

IntroductionIn the UK, a key approach to improving end of life care has been the introduction of ‘anticipatory’ or ‘just in case’ prescriptions (APs). Nurses are often responsible for deciding...

Valproate in acute mania: is our practice evidence based?

This audit was conducted on acute psychiatric in-patient wards with the aim of establishing if valproate prescribing in acute mania followed evidence-based guidelines with particular emphasis on formulations used and whether accelerated valproate dosing was employed. Case notes from 43 (42 percent male) patients admitted with mania and subsequently discharged on valproate were reviewed. Valproate formulation, weight measurement (necessary for dose-calculation in accelerated dosing), initial valproate dose and increments, serum valproate monitoring and other prescribed psychotropic agents were noted. Most (95 percent) patients received sodium valproate (epilim chrono/generic), the remaining received valproate semi-sodium (depakote). All but one patient received antipsychotic medication in combination. Weight was recorded in only four (9 percent) patients. The mean valproate daily dose after the first week was 1,027mg (sd = 408). It took 29 (sd = 42) days to reach the maximum daily dose (1,426 mg sd = 467) from valproate initiation. Serum levels were monitored in 34 (79 percent) cases, but the mean period between valproate initiation to the first serum level test was 38 (sd = 47) days. A significant positive correlation was found between days taken to reach maximum dose and hospital stay (Spearman's rho = 0.41, n = 43, p = 0.006, two-tailed). Accelerated valproate dosing was not common practice, which may have resulted in suboptimal efficacy, probably leading to combination treatment. This study highlights the need for adequate initial dosing and dose increments when treating manic patients and suggests current practice is not evidence-based. Local prescribing policy and national guidelines' influence on practice are discussed.

Polypharmacy and patterns in drug prescribing at a primary healthcare centre in the Riyadh region of Saudi Arabia

To elucidate the various patterns in drug prescribing in a non-Ministry of Health-affiliated primary healthcare centre model (Riyadh Kharj Military Hospital) in Saudi Arabia. A retrospective analysis of pharmacy records of the Riyadh Kharj Military Hospital was undertaken. A total of 4781 prescriptions archived over a period of 6 months (January-June 2001) were statistically analysed using Statistical Package for the Social Sciences (SPSS). Number, types, therapeutic duration and distribution of drugs were evaluated. Age distribution and documentation adequacy were also reviewed and monitored. Therapeutic classification of drugs was carried out according to the British National Formulary system. Of the total prescriptions, 47.8% were for male patients and 50.1% for females. Prescriptions for the paediatric population accounted for 19.5% whereas 13.7% of drugs were prescribed to the geriatric cohort. A mean of 2.7±1.6 drugs were prescribed per patient. In multidrug prescriptions, 32.3% contained two drugs and 22.1% prescriptions had four drugs or more. Mono-drug prescriptions accounted for 21.6% of prescriptions. Paracetamol (13.9%) was the most commonly prescribed drug followed by multivitamins and cough syrups with 5.0 and 3.7%, respectively. The most common therapeutic classes of drugs prescribed were analgesics, antipyretics, antihistamines, and vitamins and minerals, making up a third of all prescriptions. Dosage form, dose and routes of administration were not present in 21.7, 8.8 and 99.6%, respectively. Polypharmacy appears to be a problem in primary health care, which requires stricter pharmacovigilance and constant reviewing. We recommend the establishment of an efficient local prescribing policy through an effective practice-based Pharmacy and Therapeutic Committee, training in prescribing to be introduced in medical schools and the lending of support to continuous education programmes targeting prescribing skills.

A comparative study of non-fatal self-poisoning with antidepressants relative to prescribing in three centres in England

BackgroundAntidepressants are used frequently in non-fatal self-poisoning. There are national guidelines for prescribing antidepressants. There have been few investigations of how non-fatal self-poisoning with antidepressants varies in relation to prescribing and to patient characteristics. MethodsA comparative study of the use of specific antidepressants (amitriptyline and dosulepin (tricyclics), citalopram, fluoxetine, paroxetine and sertraline (selective serotonin reuptake inhibitors) and venlafaxine (serotonin norepinephrine reuptake inhibitor)) for non-fatal self-poisoning (episode-based), relative to prescribing, in three centres in England, 2004 to 2006. ResultsThere was marked variation between centres in the ratio of rates of self-poisoning to prescribing for specific antidepressants. Higher rates of self-poisoning relative to prescribing for all antidepressants combined, and for venlafaxine, were found in the centre with greater proportions of patients with a history of self-harm and/or previous psychiatric treatment. Within each centre, higher rates of self-poisoning relative to prescribing were found for citalopram and fluoxetine than amitriptyline. However, rates of self-poisoning relative to prescribing for either amitriptyline or dosulepin were also similar to sertraline, which is of concern given the known toxicity of tricyclics. LimitationsAn ecological study, where prescriptions were for all indications and not specifically for the patients who self-poisoned. ConclusionsMarked differences found in ratios of self-poisoning with antidepressants to levels of prescribing, in three centres in England, are likely to reflect differences in both prescribing practices (despite clear national guidance) and patient characteristics. Risk of overdose and toxicity should be considered when local prescribing policy and clinical practice relating to antidepressants are under review.

Hypnosedatives in the Elderly

Hypnosedatives are used extensively in older people, although their usage has fallen since the early 1970s. Increasing consumer concerns now risk underuse of these drugs, even in appropriate situations. High quality prescribing of hypnosedatives requires consideration of the pharmacokinetics and pharmacodynamics of these drugs, an understanding of their adverse effects, efficacy and clinical situations in which they may be of use, and an appreciation of the role of non-pharmacological therapy. If these issues are adequately addressed, hypnosedatives can be used effectively to treat insomnia and some anxiety disorders. Hypnosedative prescribing can be improved through regular audits, and the development of a local prescribing policy and educational programmes.

Implementing a local prescribing policy

We concluded recently that local prescribing formularies are worth the time and money they take to produce.1 If they are well used in hospitals and in general practice they improve the quality of prescribing and reduce overall costs. The NHS Review Working for Patients, published since our report, encourages family health service authorities (FHSA) and district health authorities to develop joint formularies to facilitate continuity of treatment between hospital and community.2 This article reviews how a local prescribing policy can be developed used and monitored.