ANP “Bugs and Drugs” conference: from hand washing to komodo dragons

April 10, 2009 by admin 

Preventive strategies, good nursing care, appropriate antibiotic prescribing, hospital cleanliness and hand hygiene, fundamental organisational change, and new therapies, were all highlighted at the recent “Bugs and Drugs” ANP conference, held in London in February. Everything from what crocodiles can do for human medicine to how to support organizational change was covered in the talks and a workshop explored some of the trickier issues surrounding antibiotic and other prescribing.

The importance of nurse prescribers as role models and leaders was emphasised throughout the day, starting with Dr June Crown (President of the ANP) in her welcome. If the challenges presented by healthcare-associated infections (HCAI), for example, are to be met, we need organisational change that puts prevention and accountability at centre stage.

One immediate challenge is the advent of the Health and Social Care Act 2008, with Trusts due to hear the outcome of their registrations in March. Tracey Cooper (Vice-President of the Infection Prevention Society and Consultant Nurse, Infection Prevention, Southampton University Hospitals NHS Trust) described the Act’s specific, legal duties on HCAI as “fantastic but challenging”. Infection prevention is now a very clear duty, trusts not meeting the requirements will not be registered by the new Care Quality Commission, and it will be a criminal offence to provide healthcare while unregistered. Organisations will be held to account every day of every year. This all represents a major shift, which may well be painful, but it is about getting things right for patient safety and effective care. Nurses can use the requirements of the code to support and develop their prescribing and other work.

Michael Dickson (Lead Programme Manager, Department of Health, Southern Regions) stressed that tackling HCAI correctly leads to improvements across the board, and that time spent on prevention will not be wasted. When the government targets for MRSA and C. difficile were first announced, they were greeted with great scepticism, but the results are hugely encouraging (although more progress is needed, particularly in community care). The 50% reduction in MRSA is now being sustained and exceeded; for C. difficile, there was a month on month reduction between April 2007 and October 2008 and the October 2008 figures showed a 37% reduction over October 2007.

A culture of zero tolerance and accountability - no shrugging of shoulders - is needed: we need to believe that, “avoidable infection is an insult to our patients”, and to embed HCAI reduction at every level of organizations. Good role models and leaders are needed here - are they all “bare below the elbows”? Appropriate antibiotic prescribing must also be a key expectation for staff. The website http://www.clean-safe-care.nhs.uk/ contains a lot of useful information for healthcare staff, including the latest C. difficile guidance.

Later in the day, a very moving talk was given by Graziella Kontkowski, whose grandmother died after contracting C. difficile during a hospital stay, and who then founded a support group (http://www.cdiff-support.co.uk/index.htm). A former nurse, she had an interesting perspective as she recounted the poor care her grandmother received, highlighting the importance of good practice in hygiene and communication – and of compassion in basic nursing care. This emphasized again how important the developments in tackling HCAI are.

Keeping up to date in the war against microbes is difficult but vital and Omar Ali (Formulary Development Pharmacist, Surrey and Sussex NHS Trust) cantered through some of the latest developments, from gold nanoparticles to medicines from reptiles. Having shown our hand far too early, we will now need to focus on prevention, while still keeping an eye on new therapies. Omar discussed the latest developments in MRSA therapy: linezolid shows very good efficacy but has side effects and is expensive. Usually, people have to be pretty sick to be prescribed this, because of concerns about resistance and cost. Other new agents are even more expensive, highlighting again the need to get back to the basics of ward cleaning. He also discussed: the controversial guidance on antibiotic prophylaxis for people at risk of infective endocarditis; the scare over antibiotics in pre-term labour that hit the headlines last autumn, but for which no change in current practice was recommended; the growing use of maggots in clinical practice; necrotising fasciitis and how it can start from the smallest of triggers and progress astonishingly fast; HIV therapy and how gold nanoparticles seem to offer hope in resurrecting failed HIV therapies by conjugating with the drugs; and Helicobacter pylori and how the link between C. difficile infection and inappropriate prescribing of proton pump inhibitors means that policy needs to be reviewed. Finally, what might nurses be prescribing in the future? Future antibiotics may well come from the blood of reptiles such as crocodiles or komodo dragons so could this audience be talking about crocodillin prescribing at future meetings?

Given the vast size of the medico-legal bill to the NHS and the fact that drug errors are the most common cause of medical mistakes, non-medical prescribers need to face the possibility that they may be sued or called as witnesses, said Omar Ali (Formulary Development Pharmacist, Surrey and Sussex NHS Trust) in his talk on ‘How to sue a nurse prescriber’.

Because all three of the Bolam principles - duty of care; harm and damages; causal or contributory negligence - have to be proved, is quite difficult to win a case. However, many cases are settled out of court for large amounts of money to avoid the consequent hassle and publicity, especially as the latter may open up other cases for prosecution. Some interesting case studies illustrated how the law operates in practice, and how important it is for non-medical prescribers to ensure their job descriptions and policies are up to date so that if the worst happens, their employers are vicariously liable and will provide back up.

What do you do if a teenage girl appears for vaccination in your surgery accompanied by her entire family, or if a young man is demanding antibiotics for a sore throat before he goes away for the weekend? These were some of the scenarios explored in a prescribing workshop run by Molly Courtenay (Professor of Prescribing and Medicines Management, Reading University, and ANP National Prescribing adviser), and Marion Russell (Clinical Development Nurse, Medicines Management, Pharmacy, St Thomas Hospital, London), which generated some good debate, and highlighted the importance of good documentation, not prescribing medicines that are not on the formulary you have been asked to work from, how to get formularies changed, and not prescribing for a patient you have not seen, regardless of what other professionals do and think!

The conference was well attended by practitioners from both community and acute sectors, with many nursing specialities represented, as well as some pharmacists and other professions. There was plenty of opportunity for debate and discussion to find out what other people are doing and how they are doing it. Participants commented on how much they had learned, and on how useful it is to be able to network like this, particularly for those prescribing in more isolated situations, so do keep an eye on the events planned by the ANP (add link) and we hope to see you at future meetings! If you would like to suggest topics for future meetings then we would love to hear from you (at events@anp.org.uk). Lowri Daniels

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