Northern pharmacies cough cold flu service via Diagnostics

Editor's Notes

• #2: Good morning all. My name is Emma Kelly and I’m a community pharmacist with Northern Pharmacies. I’m here this morning on behalf of my colleague Terry Maguire to share with you some information regarding our recent ‘Cough, Cold and Flu Service’ that we rolled out amongst our branches in the winter months just past. We wanted to assess the potential reduction of inappropriate antibiotic prescribing by offering a point-of-care testing service within a community care setting. The service itself targeted the treatment of simple RTI such as coughs and sore throats. Its aims were to promote better self-care within our client base, reduce the number of GP appointments regarding these sorts of infections and therefore attempt to limit the amount of antibiotics being inappropriately prescribed for them; by offering pharmacist led consultations and Point of Care Testing for CRP and for Strep throat. Aims also included offering patient education regarding antibiotic resistance. Ultimatley we wanted to do our bit to tackle the ABR issue – albiet on a small scale. Id like to discuss briefly the context behind the service, provide an overview of the service itself and share with you some of the results from the initial six week pilot period of the service that we’ve had a chance to analyse.
• #3: Working in the healthcare industry we’re all aware of the threats of AMR. You can see from the slide here some worrying statistics that illustrate the scale of the issue. Without effort and policies to stop the spread of ABR the already large 700,000 annual deaths today will become a disturbing 10million per year by 2050. Ref. Davis, S, 2011. Annual Report of CMO; vol II DOH London Tackling drug-resistant globally; 2016; Doh London
• #4: As well as the tragic human cost AMR has a very real economic cost which continues to grow. It is estimated that between now and the year 2050 AMR will have cost us £66 trillion in terms of lost global production. Reference – Public Health England. Antibiotic awareness key messages 2017. available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/652262/Antibiotic_Awareness_Key_messages_2017.pdf
• #5: AMR puts modern medicine as we know it today at risk. Growing resistance means poorer clinical outcomes for patients, simple infections will no longer be simple to treat. For obvious reasons, if antibiotics no longer work there will be serious limitations with Cancer treatments and transplants. And also – day to day surgical procedures like joint replacements and even caesarean sections will be put at risk and may not be possible if prophylactic antibiotics become redundant.
• #6: So what’s to be done? Antibiotic conservation requires a coordinated, multi-disciplinary approach and understanding, underpinned by national and international policies for the good of the public worldwide. Solutions to the resistance issue can be outlined with the following GRIP framework for change and their 5 P’s; We need to tackle PATIENTs and their education and drive a behavioural change, empowering them to better self-manage through appropriate symptomatic relief. POLICY interventions that are endorsed by local governments and clinical communities of practice will also be key in driving change. Vaccines, hygiene and sanitation are important tools in the PREVENTION and spread of infections. PRESCRIBERS ill have to better manage patients’ expectations. And our service targeted PHARMACISTS – giving them the opportunity to play a pivotal role in the spread of AMR by trying to promote the rational use of antibiotics, by acting as community educators and providing advice on symptomatic management and guidance on when to consult GP services.
• #7: A review on AMR in 2016 chaired by economist Jim O’Neill made 10 recommendations on how we should tackle the issue on a global scale – of which I’m sure most are aware – these are listed on the current slide;. Our service focused mostly on points 1 – public awareness - via patient education and campaigns to try and changed learned behaviours. 2 improving hygiene and spread prevention – again via patient education and lastly on 5 – rapid diagnostics or more accurately near patient testing to try and decrease the amount of inappropriate antibiotic prescribing. (1. Increasing public awareness via patient education and public health campaigns to try and changed learned behaivours 2. Improving hygiene and preventing infection spread 3. Promoting the use and development of vaccinations 4. Tackling the unnecessary use of AB in agriculture 5. Promoting the development and use of Rapid Diagnostics – near patient tests that not only identify the microbe causing the infection but also detect it’s sensitivities resulting in effective and appropriate treatment 6. Improved global surveillance of AMR 7. Promoting the development of new drugs 8. Investing in the number, pay and recognition of people working in infectious disease 9. Investing in and utilizing a global innovation fund for R&D 10. By committing to an international coalition for action)
• #8: In an ideal world we would be using rapid diagnostics on an everyday basis that not only identified the microbe causing infections but also detected it’s sensitivities resulting in safe and effective treatment. However at this point there are no such tests developed that have been put into mainstream circulation. However, tests for CRP level – an indicator of infection, and tests for the presence of StepA in throat infections have been used independently in the past to advise on appropriate treatments for RTI in community care settings and have identified some benefits in potential reduction of inappropriate prescribing of AB. We wanted to see if using both of these ‘point of care tests’ as part of a Winter Service within our branches would support better self care for RTI in our patient base, as an alternative for using GP and OOH services and in turn reduce inappropriate antibiotic use – doing our bit, albeit on a small scale to tackle the AMR issue. The goal being, should the service be a success, to approach commissioners to roll out such a service on a wider scale. Ref (3) Cooke J. C-Reactive Protein (CRP) as a point of care test (POCT) to assist in the management of patients presenting with symptoms of respiratory tract infection (RTI) – a new role for Community Pharmacists? Pharm Manag 2016;32:25–29. (4) Thornley T, Marshall G, Howard P & Wilson AP. A feasibility service evaluation of screening and treatment of group A streptococcal pharyngitis in community pharmacies. J Antimicrob Chemother 2016;71(11):3293–3299.
• #9: Patients were made aware of the service through local advertising, or reffered at GP reception or triage level or indeed by our own counter staff. Those who accessed the service were seen by the pharmacist and questioned on their symptom profile and medical history. Those who presented with a sore throat had the pharmacist physically examine the appearance of their throat and they were screened via a CENTOR scale. Those who scored less than 3 via the CENTOR scale were offered advice and we recommended symptomatic OTC relief as it was most likely that their throat infection was viral. Those who scored 3 or more were offered a throat swab test for the presence of Strep A. We used the OSOM testing kit. If they tested positive they were offered Pen or Clarithromycin via a PGD, without the need to see their GP. If they tested negative they were offered advice and recommended symptomatic relief as it was unlikely their throat was bacterial. Its important to note that GPs largely use the CENTOR scale as a diagnostic tool for sore throats and if you score 3 or more you are, in the vast majority of cases automatically prescribed an antibiotic –therefore its clear to say that the strep tests have added diagnostic benefit. Those with a cough again were questioned on their symptoms and history. These patients were offered a test to investigate their levels of CRP. If the result was under 20mg/L it was most likely the patient was suffering from a viral infection and was therefore offered advice on self care and we recommended symptomatic relief. Those who scored between 20-80 were treated similarly, however they were put on a ‘watch and wait’ list and followed up at 48hours for further investigation to see if they had deteriorated. Those with a CRP level of 80 or over were automatically referred to their GP for antibiotic treatment as it was more likely they were suffering from a bacterial infection. A pharmacy PGD for the provision of amoxicillin in this situation was developed but could not be implanted in time for the service. Patients who were deemed high risk or had red flag symptoms were referred to their GP at the pharmacist’s discretion regardless of test result – that included those with wheeze, SOB, those with COPD, Diabetes, those who were immune suppressed and those under 12 or over 75. All patients were followed up at day 3 and if necessary again after 7 days as a safety net. We also took the opportunity during the consultations to educate our patients about the appropriate use of antibiotics and the consequences of not doing so.
• #10: This service has been a while in the making as you can see from the time frame here. We launched on Antibiotic Awareness week in November past. There was an initial 6 week pilot period so that we could find our feet and then the service was officially rolled out at the beginning of the year for three months. Since then the data has been submitted and is being assessed. We are currently in the process of assessing the data from the proper 12 week service period and producing a final report. We would like to share the results from that initial 6 week pilot period – really to get an appreciation of why we are doing this.
• #11: Over the period of the first 6 weeks there were a total of 308 patients who accessed the service across our five branches. 205 females and 103 males. 260 (that’s 84% of the total) were referred via their GP surgery. Its clear to see the impact GP support had on the service. Certain literature would suggest that 90% of patients who see their GP for an RTI are prescribed an antibiotic so by displacing patients alone we hoped we would make a difference in the amount of antibiotics given to our patient base. Initial informal GP feedback has been excellent. 45 were walk ins – those that saw an advert or heard about the service through word of mouth. The few remaining were referred from counter staff consultations. 189 patients were treated exclusively via the service, that is, by the pharmacist with symptom relief or advice. There was no need for them to see their GP, or to receive and antibiotic. 218 patients were tested for CRP. The vast majority of these (185) scored less than 10mg/L largely indicative of viral infection. 20 scored between 10-20 12 between 20-40 And only 3 between 41-58 NO patients scored more than 80 and so none qualified for referral for antibiotics based on their CRP score. 117 were offered screening via the CENTOR scale. The majority of these (78) scored less than 2, again indicative of viral infection. Of the 39 who had a score of 3 or more and who were swabbed for strep A only 4 tested positive and were offered antibiotics. Our findings are reflective therefore of the literature that would suggest that 90% of RTI are viral in cause with most of our throats and coughs appearing viral in nature according to our screening and test results. 25% of the patients seen in total were referred to their GP – despite their score or test result, either at their initial consult or on follow up. This was done at the pharmacist’s discretion as they were considered higher risk patients or had worrying symptoms. Of the patients that were referred to their GP – some, but however not all received and antibiotic. 39 received amoxicillin, 12 penicillin, 1 azithromycin. 12 received steroids only and no AB 14 received nothing from their GP As I’ve stated we only provided 4 of our 308 patients seen with PGD antibiotics. A 3rd of those we refferred to their GP still didn’t receive an antibiotic – and we only referred a quarter of our 308 patients. Literature suggests that a staggering 90% of patient’s who visit their GP for a RTI will get an antibiotic. 17% of our cohort received antibiotics. Therefore these initial findings indicate a potentially significant impact on the inappropraite prescribing of AB resulting from the provision of this service and the use of these Point of Care tests. (5) McNulty C, Joshi P, Butler CC et al. Have the public’s expectations for antibiotics for acute uncomplicated respiratory tract infections changed since the H1N1 influenza pandemic? A qualitative interview and quantitative questionnaire study. BMJ Open 2012;2:e000674. doi: 10.1136/bmjopen-2011-000674
• #12: Now that the service from January to March and all of the data collection is complete – it will be assessed using the following evaluation framework. We hope to compare prescribing data from our significant GP surgeries with regards common RTI antibiotics from 17/18 to 18/19 to see if there is indeed any significant difference by running the service. Patient displacement data will also be assessed – that is, how many patients would have accessed their GP or OOH/A&E services should the scheme not have been available to them. Patient details and satisfaction will be assessed – as will feedback from our staff and GPs who were involved. The service will be fully costed and with the help of MOIC at Aah an audit report will be produced. We hope to see some difference from our efforts. With any success it is the company’s intention to possibly approach commissioners for a wider roll out once assessment and feedback is completed and we have a better and bigger picture. Many thanks.