Liz Cross, advanced nurse practitioner and non-medical prescriber, is taking huge steps in reducing the unnecessary prescribing of antibiotics to address antimicrobial resistance (AMR).
What is your background? I’m a shop floor nurse who is passionate about trying to improve primary care. I’m an advanced nurse practitioner and non-medical prescriber working in a large GP practice in Watford, Hertfordshire. My clinics are varied; divided between chronic disease management, minor illness and anything else you would see your GP nurse for.
Tell me about the AMR pilot, how did it come about?
This project was really born of frustration; essentially, I was looking for a more efficient way of running my minor illness clinics. During my busy peak winter months, about half the patients presenting to my clinics will have a cough or respiratory infection and up to 50% of these patients would be seen more than once for the same infection.
“I wanted to know why we can’t get the diagnosis right at the first presentation, reducing the need for the patient to come back”
Imagine, Mrs A comes into clinic with her chesty cough with fevers and green phlegm she has had for over a week, you give her a course of antibiotics and tell her if she is no better in a week come back. Guess what? She comes back! If I had correctly identified that her cough was caused by a virus which may last for two to three weeks, but will get better with time and rest, perhaps she wouldn’t need that second appointment.
I wanted to know why we can’t get the diagnosis right at the first presentation, reducing the need for the patient to come back. I noticed that we have two main problems. Firstly, out in general practice, without easy access to diagnostics or imaging, it’s difficult to determine who will benefit from a course of antibiotics and who would get better by themselves. Secondly, if the patient is worried and believes they need antibiotics, it’s really hard to convince them otherwise in a 10-minute appointment.
C-reactive protein (CRP) is a biomarker produced by the liver in response to inflammation. When used alongside standard history-taking and examination, it can help the clinician decide if a course of antibiotics would be appropriate for a chest infection. Normally, this test is done in a lab, but now we can analyse a finger prick blood sample and get the results back in less than four minutes.
How did you get involved in it?
The project started off small and has grown. I called up a couple of diagnostic companies and asked them to demonstrate their kit. One company offered me the loan of a machine for three months and 100 tests.
Using the National Institute for Health and Care Excellence guidelines, I started using the tests in my clinics then reviewed the patients’ notes after a month to see what happened to them. I compared these against patients presenting to my clinics in the corresponding months of the previous year. In doing so, I was encouraged that my prescribing rates had fallen dramatically, but I was astonished that my unscheduled re-attendances had halved.
This really piqued my interest. I’d reduced my antibiotic prescriptions and saved appointments in our busiest winter period. A double win! So I applied for an NHS Innovation Award and won a £10,000 seed fund to roll it out to five practices in Herts Valley Clinical Commissioning Group (CCG). Supported by a National Institute for Health Research (NIHR) fellowship, I was able to dedicate more time to the project.
At Herts Valleys CCG, we trialled CRP testing over a three-month winter period in five high to medium antibiotic prescribing GP practices. We then compared the prescribing rates against three similar local practices using standard care.
We evaluated how often patients were prescribed antibiotics. We also reviewed patients’ notes after 28 days to see if they came back for another appointment, presented to A&E, called out of hours, required a chest x-ray or were prescribed more antibiotics. We found that patients in the testing group were prescribed antibiotics less frequently and were also less likely to come back for unplanned follow up appointments.
What have been the results?
The availability of CRP testing equipment has reduced antibiotic prescription at initial presentation by around 62% and follow-up consultation by around 32%. Compared to the group using standard care, the testing group saw a reduction in presentation due to side effects of antibiotics, reduced visits to
out-of-hours and A&E and reduced requests for chest x-rays. Annual cost projections based on this suggest that the mean cost of associated healthcare events per patient is lower for practices where CRP testing is available, even after overhead costs have been taken into account.
Will there be a national roll out?
I’m ever-hopeful there will be a national roll out. Some practices have made great progress and really reduced antibiotic prescribing, and thanks to national awareness campaigns, patients are certainly more aware of the dangers of taking too many antibiotics. However, for those practices that are struggling to make changes, I think CRP is a practical option.
What else are you doing around antimicrobial resistance?
I do quite a bit of public speaking now. I was invited to present the work in Mumbai, India as part of the Longitude Prize, and I’ll be heading to Los Angeles and Boston to do the same.
Uptake across the five practices was variable. One of the barriers was the increased workload of doing a test within a busy clinic. To address this problem, I have another project where we have based the CRP test within a community pharmacy. By changing the patient flow, we hope that more GPs will offer the tests and the community pharmacist will get more footfall.
How have patients benefitted from CRP?
CRP is a practical solution to a real problem. Patients love it. They are reassured that they have had a thorough examination by their local GP or nurse. Near-patient diagnostics takes the consultation from appearing rather subjective to giving them something objective, helping them to understand why antibiotics were or weren’t prescribed for their cough. They are reassured that they are getting a thorough examination at their local GP surgery without having to travel to hospital for x-rays or tests.
Liz featured in the Pf Power List published in the October issue of Pf Magazine.
Read the full magazine here: April Pf Magazine