Establishing priorities on the range of conditions managed by UK community practitioner nurse prescribers: A modified Delphi consensus study.

AIM: To provide national consensus on the range of conditions community practitioner nurse prescribers manage and for which it is considered important that they can prescribe. BACKGROUND: Around 35,000 community practitioner nurse prescribers in the United Kingdom are able to prescribe from a limited formulary. Although prescribing is a key role for these nurses, there has been a decline in the numbers of community practitioner nurse prescribers who prescribe. It is evident that changing patterns of client and service delivery, changes the role of community nurses and the conditions they manage, however, little is known about the conditions community practitioner nurse prescribers manage. DESIGN AND METHODS: A modified Delphi approach comprising three on-line surveys delivered to a national Expert Panel of 89 qualified community practitioner prescribers. Data collection took place between January-March 2017. RESULTS: Panelists reached a consensus, with consistent high levels of agreement reached, on nineteen conditions for which it is believed community practitioner nurse prescribers should be able to prescribe. Conditions identified by school nurses (N = 12) and health visitors (N = 7) were mainly acutely focused, whereas those identified by district nurses (N = 9) and community staff nurses (N = 6) included both long-term and acute conditions. CONCLUSION: Given the high degree of consensus, this list of conditions should influence any decisions about the items community and public health nurses should be able to prescribe. The findings should also influence the education and training of these nurses.

Cost-effectiveness analysis of add-on pertuzumab to trastuzumab biosimilar and chemotherapy as neoadjuvant treatment for human epidermal growth receptor 2-positive early breast cancer patients in Singapore.

OBJECTIVES: The Asian PEONY trial showed that add-on pertuzumab to trastuzumab and chemotherapy significantly improved pathological complete response in the neoadjuvant treatment of patients with human epidermal growth factor receptor 2-positive (HER2+) early breast cancer (EBC). This study evaluated the cost-effectiveness of pertuzumab as an add-on therapy to trastuzumab and chemotherapy for neoadjuvant treatment of patients with HER2+ EBC in Singapore. METHODS: A six-state Markov model was developed from the Singapore healthcare system perspective, with a lifetime time horizon. Model outputs were: costs; life-years (LYs); quality-adjusted LYs (QALYs); incremental cost-effectiveness ratios (ICERs). Sensitivity/scenario analyses explored model uncertainties. RESULTS: The base case projected the addition of pertuzumab to be associated with improved outcomes by 0.277 LYs and 0.271 QALYs, increased costs by S$1,387, and an ICER of S$5,121/QALY. The ICER was most sensitive to the pCR rate, and the probabilistic sensitivity analysis showed that add-on pertuzumab had an 81.3% probability of being cost-effective at a willingness-to-pay threshold of S$45,000/QALY gained. CONCLUSIONS: This model demonstrated that the long-term clinical impact of early pertuzumab use, particularly the avoidance of metastatic disease and thus avoidance of higher costs and mortality rates, make neoadjuvant pertuzumab a cost-effective option in the management of patients with HER2+ breast cancer in Singapore.

Emergency treatment of anaphylactic reactions--guidelines for healthcare providers.

*The UK incidence of anaphylactic reactions is increasing. *Patients who have an anaphylactic reaction have life-threatening airway and, or breathing and, or circulation problems usually associated with skin or mucosal changes. *Patients having an anaphylactic reaction should be treated using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. *Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines. *The exact treatment will depend on the patient's location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction. *Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. *Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline. *Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use. *All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy. *Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline auto-injector and receive training and support in its use. *There is a need for further research about the diagnosis, treatment and prevention of anaphylactic reactions.

Taking and giving.

A code of practice sets out how parmaceutical companies can promote medicines to health professionals and give information about prescription-only medicines to the public.

Supply and demand.

A 28-day supply of medicines is not an absolute figure, but it is generally accepted as best practice as it enables medicines to be dispensed in sensible quantities.

Ruling out antibiotics.

Most upper respiratory tract infections are viral. As antibiotics are only effective if the infection is caused by bacteria, they are not recommended in most cases. However, prescribing for respiratory tract infections in primary care is not an exact science, and deciding whether an infection is viral or bacterial is often down to individual clinicians.

Changing the drug rules.

As part of its overhaul of education, the Nursing and Midwifery Council is considering allowing newly qualified nurses to prescribe from a limited formulary. When I first heard this, I was concerned. I have pushed for nurse prescribing to be developed over the years, and was fearful of opening the floodgates to many more junior staff becoming prescribers.

Future-proof powers.

The community nurse formulary for v100 and v150 prescribers is being reviewed by Cardiff University and the British National Formulary (BNF). They are undertaking research into the clinical requirements of district nurses, health visitors and school nurses who prescribe using this formulary, to see what medicines they are prescribing and if any areas for expansion can be identified.

Sharing our knowledge.

There are more than 70,000 nurse prescribers in the UK, many of whom have years of experience that should be shared with trainee prescribers. In November, the General Pharmaceutical Council launched a consultation on whether pharmacist independent prescribers (PIPs) should be able to mentor trainee PIPs. This discussion, which closes on 1 February, should be expanded to our own and other professional groups, because we could all gain so much from each other.

Boarding school rules.

Ofsted inspects and regulates services that care for children and young people, including boarding facilities. Medication management is an integral part of caring for children in boarding schools, and robust systems must be in place to pass inspection. These systems must cover how medicines are dispensed, administered and stored at the facility, risk assessments, identifying which pupils can manage their own medicines and the individual health needs of boarders, so that care plans can be put in place for children with specific needs.

How can we reduce excessive prescribing?

Modern prescribing can be very easy. In many cases, we don't even have to write a prescription - just a few clicks can start a chain of events, affecting patients' lives more than we can imagine. Although it is easy to look for a quick pharmacological fix, consider carefully whether the patient really needs the medication you are prescribing.

Should patients complete the course?

In a recent article in the British Medical Journal (BMJ), a group of experts including infectious disease specialists and microbiologists discussed whether patients should stop taking antibiotics when they feel better.

Standards help to keep nurses and patients safe.

The proposed withdrawal of the standards for medicines management is potentially detrimental to nurses and patients. Medicines legislation is extremely complicated. The standards help practitioners understand what is legal and what is illegal, as well as legislation on licenced, off-licence and unlicensed medicines and the impact this could have on them.

Fair blame, not no blame.

All nurses have a professional responsibility to report medication errors, and patients must be made aware of any incident involving them. I have been involved in investigating medication errors, and emotions often run high for the patients and staff involved, but you should never try to hide an error. Not only is this dangerous for patients, it can have serious consequences for your career, as you may be reported to the Nursing and Midwifery Council and face a disciplinary panel.

Beware of 'lookalikes'.

In 2014, health staff who were vaccinating children in rebel-held northern Syria accidentally administered a muscle relaxant, atracurium, to up to 75 children, killing 15 of them. An investigation found that the drug was given to the children instead of a solution used to mix measles vaccines because the packaging was similar.

Medication reviews are best for minimising waste.

Most patients are responsible on an ongoing basis for ordering their own medicines, sometimes with help from family and carers. Ordering a 28-day supply is the norm in today's NHS - a practice that has been encouraged to ensure medicines are not wasted or over-ordered.

Medicine management.

I have a patient who would benefit from a medicine not available on the NHS. Is there any advice I can give?

Medicines management.

How can I ensure my patient in primary care gets the right medication to relieve their pain?

Who should have the MenACWY vaccine?

Meningitis strain W cases are on the rise in England. In 2009, there were 22 cases, increasing to 117 by 2014. The number is expected to rise again this year unless more vaccinations take place.