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This consultation describes a situation whereby the author was asked to review a child with pyrexia and rash who also had a three day history of earache with discharge. The parents had contacted NHS 24 regarding their child and were referred for assessment to the Minor Injury and Illness unit. A copy of the NHS 24 referral stating the concerns of the parents and the completed history sheet has been included. Names have been removed to protect patient confidentiality (NMC 2008). For the purpose of this essay the child will be referred to as Tom.In this consultation the author has supplied medication under a Patient Group Directive (P.G.D) as the author has not yet qualified as a non medical prescriber. However, as this type of scenario presents fairly frequently to the Minor Injury Unit the rationale used for supplying and prescribing medication will be comparatively similar.
In the following paragraphs the author will discuss and reflect on the rationale for treatment. Prior to the patients arrival the author had time to review the reason for referral and also to review Toms previous record of Out-of-Hour attendances. Only one attendance had been recorded two months prior and on that occasion an otitis media had been diagnosed and an antibiotic supplied via P.G.D.
On arrival the concern of the parents was apparent as they conveyed their anxiety concerning Toms symptoms. They expressed equal concern over the high temperature and the ear pain.
At the beginning of the consultation the author first established that the referral notes contained a true account of the symptoms that Tom had been experiencing. On some previous occasions the author had experienced referral notes which had been inconsistent with the patients’ illness, which created some confusion during assessment. Therefore as acknowledged by Jones O, Gautam N (2004) it is important to confirm the accuracy of referral notes to ensure mutual understanding of the clinical complaint and furthermore to reach an accurate diagnosis.
Once this had been confirmed the author established the onset and progress of Toms illness and whether any medication (prescribed or over the counter) had been administered. Additionally, a past medical and allergy history was obtained.
Past medical history was unremarkable other than previous ear infections on two prior occasions. Childhood immunisations were up to date. No previous allergies were known.
The initial history had established that Tom had “cold symptoms” prior to onset of earache and it was noted that rhinorrhoea was still present. Progressing with the examination the author moved onto the physical examination of the child.
The child was alert and responding to conversation. A pyrexia of 39.2c was present despite regular four hourly calpol. Enlarged lymph nodes were palpable on the neck. The right ear examination revealed inflammation and a bulging tympanic membrane. The left ear had some light inflammation present in the ear canal. The rash was only present on the face and had the appearance of a heat rash.
Although the primary concern of the parents was the continuing fever and pain in Toms right ear, concerns also arose as they were all due to fly on holiday over the coming week. They had concerns that the earache would not be better in time and they had hoped to get an antibiotic on the basis that Tom had been prescribed antibiotics on previous occasions which subsequently had cured the earache.
With regard to Tom symptoms the author concluded that an otitis media was present and antibiotics would likely be of benefit in resolving the problem. The parents were in agreement with the treatment plan and after discussion with the Doctor amoxicillin 125mg/5ml suspension was supplied as per departmental P.G.D. Analgesic advice regarding use of ibuprofen for pain relief was recommended and physical measures to aid cooling such as light clothing, cool drinks were also discussed.
Follow up advice was given and the parents agreed to call NHS24 or see their own G.P. if further concerns were to arise.
Reflection on the Consultation
Throughout reflection of this consultation the author will refer to the stages as described in the prescribing pyramid (National Prescribing Centre (NPC, 1999).
Stage one of the prescribing pyramid refers to needs of the patient and clinical assessment.
Otitis media can be hard to accurately assess (Rothman et al 2009) however as the symptoms and clinical findings were congruent with current guidelines (SIGN 2003) the author is confident that a correct diagnosis was ascertained through the assessment. The parents had observed the illness for a few days and had tried to reduce the pyrexia through regular calpol but symptoms had not improved and pyrexia and pain were not resolving.
Stage two of the prescribing pyramid considers which strategy is appropriate for the patient.
The author next considered the action to take. The importance of holistic intervention to ensure accurate assessment outcomes (Edwards M 2008) and not base treatment solely on clinical finding has to be considered in the treatment options. Otitis media is self-limiting and approximately 80% of children recover in around three days without antibiotic treatment (N.P.C. 2006) however the author had to also take into consideration:
• symptoms had already been present for three days with no improvement
• Calpol had been given regularly, there remained a persistent pyrexia
• Tom was a child of three years of age with a history of previous infections
• They were due to fly on holiday in one week
• The parents had expectations of receiving an antibiotic
Although Toms examination findings were suggestive of an otitis media it was arguable whether antibiotics would be of useful benefit.
Health professionals are now very much aware of antimicrobial resistance to antibiotics and the increasing public health concerns. The need to tackle this problem and adhere to `Prudent antimicrobial use` was recognised in 2000 when a government action plan was launched (DH 2000).
Indeed, Reacher et al (2000) reports that one of the most notable problems that has arisen from anti biotic overuse is MRSA (methicillin resistant Staphylococcus aureus).
There is evidence to suggest antibiotic resistance in children is increasing which can be associated to antibiotic overuse (Kozyrskyj et al 2000). Moreover, overprescribing of antibiotics in otitis media is common practice (Mills L 2008). It has been estimated that 97% of children with otitis media will receive antibiotics (0`Neill P 1999) even although much of the general evidence points towards there often being little clinical benefit in prescribing antibiotics (Bradley-Stevenson C, O’Neill P, and Robert T 2007).
Arguably however, some studies have also shown that antibiotics can have a significant impact on pain when otitis media has been present for 2-7 days (Damoiseaux, R et al 2000). Moreover there is also further evidence to support antibiotic use in whereby symptoms such as fever or vomiting are still present after 72 hours (Little P, Gould C, Moore M, et al. 2002).
It is apparent to the author that conflicting evidence exists in regard to the treatment of otitis media and that while Health professionals obviously need to limit the use of antibiotics they must also be able to judge when not to withhold antibiotics where it could provide symptomatic relief to the patient and reduce complications such as Chronic suppurative otitis media, mastoiditis, labrinthitis and meningitis (O`Neil et al 2006)
In Toms case the author felt that the symptoms alone justified the use of antibiotics but in addition to the symptoms the author also considered the fact that they were due to fly in one week. Although this in itself is not an indication to alter treatment it needs to be considered in a holistic sense. The current recommendations from British Airways are that cabin pressures can cause severe pain or rupture of tympanic membrane if any Eustachian tube blockage is present (B.A. Medical Information) and flying is not recommended until resolved. Therefore there were added concerns in ensuring Toms otitis media was resolved.
It is also worth mentioning at this point that antibiotic cost is not sole component in treatment and rarely reflects the total cost of treating an illness.
In instances where antibiotics are incorrectly withheld the extended period of illness could mean further medical consultations and also additional childcare costs or loss of work. In this case it could also involve loss of a family holiday. All of which are also important factors when comparing the cost of the antibiotic (Pichichero, M 2000)
Although the parents had mentioned concerns over previous ear infections the author explained that antibiotic use on this occasion would not prevent further infections from occurring (Worral G 2007) and that antibiotics would not always be indicated in any further episodes. The parents although expectant of an antibiotic on this occasion did show some awareness over overuse of antibiotics and current practice on antibiotics prescribing for otitis media.
Stage three of the prescribing pyramid considers the choice of product. In considering the choice of antibiotic the recommended first line antibiotic using the national guidelines (SIGN 2003) is amoxicillin, this is also concurrent with local guidelines PGD`s and the British National Formulary for Children (2008).
Amoxicillin (see appendix 1 drug profile) is effective against the bacterial agents (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) which are most commonly identified in acute otitis media (Rothman,R, Owens T, Simel D L. 2009). Although it was established Tom was not penicillin allergic the author is aware that erythromycin is an alternative antibiotic for penicillin allergic patients.
As Tom was only three years old the dose required would need to be calculated with
reference to the British National Formulary for Children (RPS & BMA, 2008). Children differ from adults in many ways such as in gastrointestinal function, higher percentage of water ratio and less efficient liver and kidneys (Thorpe C 2008). All of which affects the predictability of the rate and extent of absorption, distribution, metabolism and elimination of drugs in children (Costello et al 2006).
The dosage recommended for otitis media in the (BNF) for children (2008) was:
By mouth Child 1 month-18 years – 40 mg/kg daily in 3 divided doses (max. 3 g daily in 3 divided doses) as Tom weighed just over twelve kilo this would equate to 480 mg daily or 160 mg in each of three divided daily doses. Preparations of amoxicillin are supplied in preparations of 125mg/5ml.
In calculating the dose, 160mg of amoxicillin would equate to 6.4mls to be given at each of the three divided doses. The author recognised that this dose was incongruent with the local PGD guidelines for otitis media which recommends 125mg/ 5ml for children in the age range of one month – four years. As the author is not yet qualified as a non medical prescriber, medication can only be supplied with adherence to local guidelines unless a prescription is received from the on call G.P.
The NMC ‘Standards of proficiency for nurse and midwife prescribers’ (May 2006) state that: ‘Only nurses with relevant knowledge, competence, skills and experience in nursing children should prescribe for children. This is particularly important in primary care (e.g. out of hours, walk-in-clinics and general practice settings). Anyone prescribing for a child in these situations must be able to demonstrate competence to prescribe for children and refer to another prescriber when working outside their area of expertise or level of competence.’ (NMC Standards, page 7).
The author, due to inexperience in medication doses for children, and moreover as there was some doubt whether supplying the low dose was” in the best interest of the patient” (NMC 2008) decided to refer onto the on-call G.P. for further advice over the most appropriate medication dose to supply.
After discussion, although the author had mentioned the recommended dose, the G.P. concluded that standard 125mg/5ml dose would be sufficient. Interestingly, a study (Woolley S L, Smith D R K 2005) highlights a two month study in which 86% of 50 children receiving antibiotics for otitis media had in all cases received antibiotics below the recommended guideline dose. Similar studies by (Akkerman A et al 2005) also showed frequent anomalies in antibiotic dosing in children.
On reflection, the author can rationalise that when supplying medication from a PGD the procedure is simpler and there is a lower margin for overdosing errors when standard doses are supplied rather than calculating individual doses, however when medicines are being prescribed there should be no reason for the recommended dosage not to be given, this would not only combat the infection more effectively but also assist in the overall reduction in antibacterial resistance.
As one of
Toms main complaints had been pyrexia and pain and no contra-indications for the use of ibuprofen were elicited from the history such as asthma or gastro intestinal concerns, the author discussed the use of ibuprofen, as paracetamol had been used with little effect for three days. Ibuprofen achieves reduction in inflammation and pain through inhibition of the enzyme cyclooxygenase which results in a reduction of prostaglandins, the mediators of inflammation (Medpedia-Ibuprofen). Some studies provide evidence suggesting that ibuprofen is a more potent antipyretic (Purssell E 2002) and moreover has a better effect in relieving pain and inflammation.
Commonly, the author has noted that G.P’s often recommend alternating doses of paracetamol and ibuprofen to control fever. There is some evidence to support this practice (Medscape 2006) and favourable outcomes in control and duration of pyrexia have been reported (Vega C 2006), however (Nice 2007) states that Paracetamol and ibuprofen should not routinely be given alternately to children with fever. However, use of the alternative drug may be considered if the child does not respond to the first agent. As clinical evidence was not supported by guidelines and considering the accountability aspects (NMC 2006) in recommending this course of treatment the author declined to commend it.
Stage Four of the prescribing pyramid considers negotiating a shared contract with the patient. In this case, the reason for attendance was for an acute episode of otitis media and a parental expectation that antibiotics were required.
As the author had confirmed the need for antibiotics and was willing to supply them it might appear that there was no further intervention required.
However the importance of ensuring that the recipients of medicine fully understand their course of treatment, how and when to take it and for long along with an explanation of any possible side effects has to be emphasised to the patient (NPC 1999). Non-adherence should not be seen as the patient’s problem. It often results from an initial failure to agree the prescription fully with the patient or to identify and provide the support that patients need once the medicine has been dispensed (Nice guideline76). The failure to take prescribed medication not only impacts on the patient it also has wider reaching effects.
According to a costing report published by the National Institute for Health and Clinical Evidence (NICE-costing statement) the cost to the NHS of non-adherence to medicines resulting in hospital admissions could be as high as £196 million. Moreover a report of prescribing costs (DOH 2008) estimates that £100 million of drugs are returned to pharmacists each year. This obviously suggests that patients are failing to follow treatment and prescription medication.
Terms used to describe the process of gaining informed cooperation from the patient have included compliance adherence and concordance. Each term embraces the same aim but have a slight difference in their meaning. Compliance suggests following the advice given by the health professional and similarly adherence means to keep to the agreement.
Hobden A (2006) suggests patients often do not comply with medications as consultations are often not patient centred and fail provide sufficient information, which is one of the key differences of concordance. The aim is to achieve a partnership and empower patients through providing information and considering the patient and any treatment in a holistic manner thus improve adherence to medications prescribed (Cheesman S 2006).
Although it was established earlier that Tom was not allergic to penicillin the author in gaining concordance with the parents discussed some of the possible adverse effects that Tom might experience such as gastro intestinal disturbances (nausea, diarrhoea) and rash (see amoxicillin drug profile).
The author believed that the consultation had been informative for the parents and their concerns over the rash, pain and ear infection had been allayed. Moreover the author felt and that a partnership agreement had been reached and medication would be taken as discussed.
Stage five of the prescribing pyramid is concerned with patient review and establishing if medications prescribed are effective. In the acute area where the author works patient follow up for review of medications are not routinely carried out. Patients that present generally have acute conditions often only requiring short courses of antibiotics or pain relief. Chronic or complicated conditions requiring longer term management are routinely carried out by the G.P.
In this instance as otitis media is a short term condition and was unlikely to need review unless the Tympanic membrane is perforated (SIGN 2003) the author provided follow up advice emphasising the need to be checked by the GP or practice nurse should any discharge from the ear arise. The parents were also provided with information over whom to contact (NPC 1999) should they have any further immediate concerns over symptoms (see patient history sheet).
Stage six of the prescribing pyramid emphasises the importance of maintaining records.
Out of hours patient contacts are recorded on a computerised record system which is used across the area for all instances of Out-of-Hour patient contacts. This system is available within GP practices thus maintaining a good communication and multidisciplinary approach to continuity of care (NMC 2008)
The author recorded aspects of care given factually and accurately (NMC 2008) including the medication which had been advised and also supplied under P.G.D.
Stage seven and the final stage of the prescribing pyramid suggests reviewing prescribing decisions which will improve knowledge and practice. Regarding the antibiotic supplied in this instance the author was not influenced by any external pressures such as patient or advertising and the choice of antibiotic was made through national prescribing guidelines and local PGD`s. The author however does recognise that drug companies do promote their products will try to influence prescribing decisions through advertising and drug representatives.
Summary of Consultation
The consultation presented the author with a number of challenges and decisions that needed to be reached. In ascertaining the diagnosis of otitis media the author was aware of the difficulty in diagnosing this condition. Moreover the author was aware of the parents wish to be provided with antibiotics. Diagnosis was reached through patient assessment and clinical findings but the author was also partly influenced when considering the holistic aspects regarding the impending holiday.
Regarding the dose of antibiotics supplied the author had conflicting views on whether this would realistically result in poor treatment outcomes and will need to research and discusses this further with other healthcare professionals and D.M.P.
The author is satisfied that full concordance with the medication was achieved and the parents were aware of how to obtain further health care advice if required.
In continuing professional development in this area the author has prepared a personal development plan which is intended to provide a structured process for learning and improvement of knowledge and skills.
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