Audit and Practice Survey Posters 207 – 213
207 Management of Patients following an MI (Myocardial Infarction) in the Community
The audit was selected to improve management following Myocardial infarction. A questionnaire was composed from the NICE guidelines, the GP contract, the OHS Long term conditions long term guidelines and Local Commissioned Service for long term conditions LTC LCS. 17 audit standards were set and results recorded in graph form. This was a retrospective audit of all patients who had had an MI in the last 5 years (total 35 patients).
The audit demonstrated that patients were on the register, on correct drugs (ACEi, Statin, antiplatelet and Beta blocker) and received a cholesterol check. Patients however were not all offered a flu vaccine, advised about smoking cessation, given lifestyle counselling, managed for BP, their bloods checked annually or had an individualised management plan. There were insufficient medication reviews and attendance at nurse led annual review was low. There was a mixture of information in the discharge summaries.
The audit was discussed at a clinical meeting. We agreed continuing to opportunistically give flu vaccine, provide smoking cessation advice and manage BP. We also noted the need to improve attendance at the annual review where these things could also be done. Improving attendance would be by reminders on the notes, limiting medication after 3 recalls. The individualised plan would empower patients. A practice protocol for 1, 3 and 12months post MI has been generated and is being finalised to capture information about up titrating drug dosages in particular. There will be a re-audit.
208 Antibiotic prescribing for children with upper respiratory tract infections: an audit in general practice
Aims: To establish how successfully the practice is adhering to the NICE guidelines for the appropriate prescription of antibiotics in children with self-limiting upper respiratory tract infections (URTIs). The audit standard was set at 60%.
Method: A retrospective search of paediatric patients prescribed antibiotics for an URTI between 01/01/16 – 18/01/16 was conducted. The search successfully identified 73 patients. Each patient’s records were analysed against a set criteria developed from the NICE guidelines to establish whether the antibiotic had been prescribed appropriately.
Relevance: URTIs are prevalent in children and are generally self-limiting and of virus aetiology. Differentiating between a bacterial and viral infection is often difficult, hence the clinical decision to prescribe antibiotics can be challenging. Despite the clinical recommendations in NICE guidance, high numbers of children with viral URTIs are prescribed antibiotics inappropriately, generating avoidable adverse drug-reactions as well contributing to the public health threat of antimicrobial resistance.
Outcomes: The first data collection demonstrated that 26/73 patients (35.62%) were prescribed antibiotics appropriately. After identifying the reasons why the practice fell short of the audit standards, a change involving clinician education was implemented. The second data collection demonstrated that 32/59 patients (54.24%) were prescribed antibiotics appropriately, indicating a significant improvement.
Discussion: Clinician education successfully decreased the number of inappropriate antibiotic prescriptions, however further improvement is still required in order to meet the audit standard. Future suggestions include the development of computer pop-up reminders for clinicians when prescribing antibiotics, as well as providing education for patients and parents.
209 Medical therapies for migraine prophylaxis
Aims/objectives To identify which drugs were being prescribed for migraine prophylaxis within a GP practice, for comparison against guidelines and to analyse usage patterns.Content of PresentationWe searched patient records at a single GP surgery, reviewing all prescriptions for migraine prophylaxis from the introduction of NICE guidelines in September 2012 until August 2015. We then compared current prescribing habits to past data from 2000 – 2012.
We found large variations in prescribing, with 11 different drugs used for migraine prophylaxis. Amitriptyline was the most commonly used since the introduction of the guidelines, representing 24 of 54 prescriptions for migraine prophylaxis. The second most common drug was pizotifen (8 courses), followed by propranolol and topiramate. This mirrored pre-existing prescribing habits prior to September 2012.
Prescribing data from 2000 onwards shows many courses were stopped within 1 month, beta blockers and pizotifen were often used for longer time periods of over 1 year.Relevance/ImpactWe highlighted a need to update prescribing practices, as amitriptyline and pizotifen are widely used but not recommended by NICE. We also highlighted differences between the guidelines produced by NICE and those produced by BASH.OutcomesWe raised awareness of the NICE guidelines, and practitioners showed willingness to reduce prescribing variability in future.
DiscussionThere is clearly disagreement between advisory bodies as to the best first line therapy for migraine prophylaxis. This uncertainty is reflected by variability in prescribing within practices. Further research to generate a definitive set of guidelines would be of benefit.
210 Audit on implementation of NICE guidelines regarding physical activity, in an Outer London General Practice
Background: Physical inactivity is the 4th leading cause of preventable death from non-communicable disease (NCD) worldwide. NICE guidance exists on promotion of physical activity (PA) in General Practice (GP)1. The aim of this audit was to determine how often PA was discussed with patients and whether NICE Guidance was being followed.
Methods: The NICE audit tool (PI002) was used to design audit questions2. The main alteration from the NICE audit was inclusion of key word search in addition to GP Physical Activity Questionnaire (GPPAQ). All patients seen at the practice over a two day period were audited. Patients under 18 were excluded.Outcomes:184 patients were included. 5.4% and 9.2% respectively had GPPAQ or PA level recorded via key word search criteria, in the past year. 14.1% had received PA brief intervention in the last year. Of 10 undertaking GPPAQ, four were documented as inactive. Of these, none received written information about PA, had goals set or were subsequently followed up.
Discussion:Discussion of PA at our practice has room for improvement and may be reflective of practices elsewhere. Results were presented at a practice meeting and a hand out explaining importance of PA distributed. Patients were asked to bring a completed GPPAQ with them to annual check-ups. Use of a pre-existing exercise referral scheme in the local area was encouraged. Results of the re-audit will be presented at the meeting, along with discussion of the success/failure of the brief interventions implemented.
211 DOACs. Don’t forget the Hb!
Aims: Assess compliance in a primary care practice (over 20,000 patients) with recommendations that haemoglobin (Hb) be regularly monitored in patients on DOACs. The recommendations were from NICE and EHRA/ESC.
Methods: Patients from the practice register ever prescribed a DOAC (164) were selected and their nine most recent Hb results on OneSystm retrieved. Patients with an Hb drop of ≥1 g/dL were noted and their practice records examined.
Outcomes: Compliance was 87% – very few patients with a drop of ≥1 g/dL in Hb were not investigated. However, two interesting aspects emerged:71.7% of patients did not have baseline Hb recorded on therapy commencement – this may be due in part to segregation of primary and secondary path results.It appeared a below normal range Hb result prompted investigations, not a substantial drop in Hb itself.
Discussion: NICE recommends baseline Hb be recorded on commencement of a DOAC and levels be regularly monitored. Local Trust guidance here did not stipulate Hb should be recorded on initiation of a DOAC. However, not doing so may pose a significant patient safety issue, as assumptions may be made about what tests have been done prior to secondary-initiated care.
Relevance: The use of DOACs is increasing following NICE approval, particularly in elderly patients with atrial fibrillation, and the risk of bleeding is significant. This audit highlights the need for development of Hb monitoring best practice, the adoption of which may avoid the need for such outcomes as unnecessary gastrointestinal investigation.
212 Delays in specialist referral for new inflammatory arthritis: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis
NICE published clinical guidelines for the management of rheumatoid arthritis in 2009 (CG79). Quality Standard 1 (QS1) recommends patients are referred to secondary care within 3 days of presentation to primary care with persistent inflammatory arthritis symptoms.The national audit for rheumatoid and early inflammatory arthritis (EIA) assesses care provided to adults presenting for the 1st time to specialist rheumatology units in England and Wales. Data provided on the time intervals relevant to QS1 from the 1st year (01/02/14–31/01/15) of this national audit are presented.
Data were collected from 135 (94%) secondary care trusts. Data were available from 6,354 patients, of whom 1,072 (17%) were referred within 3 days of presentation. There was substantial variation in QS1 achievement rates across geographical regions; this standard was achieved for only 11% of patients in the Midlands and East of England, compared to 40% in Wales. The median referral delay was 34 days nationally.
The national interquartile range of 8-100 days for referral delay highlights that over a quarter of patients are waiting more than 3 months for referral. All NHS regions reported delays of over 350 days for some patients.This audit provides evidence of significant delay between first GP presentation and referral to rheumatology for most EIA patients. These data indicate that rheumatology services, GPs, commissioners and patient organisations need to work together to:1. promote within primary care the importance of early identification of EIA and prompt onward referral for specialist assessment2. highlight and address organisational barriers that impair access to specialist care.
213 An audit on the monitoring of patients on new oral anticoagulant medication
Background: Warfarin has been the anticoagulant of choice in patients with atrial fibrillation for over 50 years. However with the advent of novel oral anticoagulants (NOACs), there is now more choice in the treatment of non-valvular atrial fibrillation (AF). As AF affects more than 1 million people in the United Kingdom and is associated with thromboembolic complications it is important that these patients are anticoagulated. NOACs are attractive alternatives as they do not require frequent monitoring. NICE guidelines recommend monitoring prior to starting treatment and at least yearly during treatment.
Aims: To determine how well patients prescribed NOACs are monitored in general practice.Method: This is a retrospective audit of patient notes in a suburban general practice. The performance of the practice in initial and on-going monitoring was determined against NICE guidelines.Results: Data was obtained from records of 35 patients (initial renal and liver function tests, full blood count and baseline clotting and renal and liver function tests and full blood count during annual monitoring). Complete initial investigations were documented in 5.7% of patients and some initial monitoring in 77%. Complete monitoring was documented in 57.1% at one year.
Conclusion: The audit demonstrates the need for improved initial and continued monitoring of patients on NOACs. Methods to improve adherence to the guidelines were discussed with the practice. These methods include educating prescribers and providing handouts for ready reference.