Analysis of a prescribing consultation

Introduction and Consultation

Urinary tract infections are one of the most common presentations encountered by
Healthcare Professionals in primary and secondary care, affecting 50% to 60% of females at
least once in their lifetime within the United States of America (Medina et al., 2019). This
case review will discuss the decision making process of a Paramedic during a consultation
at a walk-in centre (WIC). It will discuss the consultation, professional, legal, ethical and
clinical governance issues around prescribing, and justify the use of the antibiotic
Nitrofurantoin. The author is currently undertaking a prescribing course and therefore any
prescription was authorised and obtained from a qualified medical prescriber. The study
focuses on an 18 year old female who presented to the WIC. The patient shall be
anonymised in line with National Health Service Confidentiality Policy (NHS, 2019).

Patient A was called into the surgery, introductions made, and her details checked against
the records. Patient A consented to the consultation which must not be presumed just by
their attendance and must be documented on their records (Dimond et al., 2009). Consent
must also be obtained to share medical records with other healthcare professionals in order
to prevent duplication of treatment. Common law dictates that all Patient details are
confidential under the Data Protection Act (1968) and agreement to share was approved
(Kalra 2006). Consent is ongoing throughout the consultation and was not taken for granted
when moving onto the examination, thus respecting patients’ autonomy (Kuhse and Singer,
2001).

Open questioning allowed Patient A to express her concerns which were increased urinary
frequency, urgency, dysuria, cloudy urine and suprapubic tenderness over the past four
days. It was important to listen and not interrupt Patient A. Providing reassurance that her
thoughts and feelings were being acknowledged in a friendly environment (Pawlikowksa et
al., 2016). Closed questioning can be seen as clinician led (Silverman et al., 1998) It remains
important to rule out red flags such as, flank pain, vomiting, fevers, vaginal bleeding, itch and
discharge. Affirmation of any of these symptoms would indicate Patient A was systemically
ill, requiring onward referral (Nice, 2018). The Paramedic followed a structured approach to
history taking (Weed, 1968), seen in Appendix1, allowing a safe approach. Not following this
approach can lead to vital information being missed, such as allergies, possibly leading to
consequences for the patient. Blaber and Harris (2016) also see this approach as

1
hypothetically deductive, narrowing down the diagnosis and ruling out more serious
pathology.

Patient A’s urine was dipped which showed positive indication for leucocytes, blood and
nitrates. Sign (2012) demonstrated that this combination of findings on dipsticks are
statistically significant in diagnosing urinary tract infections compared with negative findings
(P=0.001). A test was undertaken to identify whether Patient A was pregnant as this can
guide treatment options. Some drugs are teratogenic and may cause disruption to foetal
development, such as Trimethoprim (BNF, 2020). Summarising allowed Patient A to express
her ideas, concerns and expectations of a urinary tract infection (Neighbour, 2005) and
Nitrofurantoin 100mg modified release tablets, twice daily for three days were prescribed by
the Doctor (BNF, 2020). The consultation can be seen in Appendix1 and observations in
Appendix2.

The Paramedic utilised the Calgary-Cambridge consultation model (Silverman et al., 1998),
The National Prescribing Pyramid (NPC, 1999) and the competencies laid down by the
Royal Pharmaceutical Society (RPS) (2016). Calgary-Cambridge was taught on the
Paramedics advanced clinical assessment course and validated by Gillard (2009) who found
18 out of 20 medical schools taught the model. It does, however, incorporate 70 steps which
the novice prescriber may find challenging. Pawlikowska (2016) suggests communication
skills can deteriorate with time after initial training and clinicians will develop their own
flexible consulting skills. Nuttall-Howard (2016) agrees that all consultation styles are similar,
and the clinician will use a style they are experienced with. The most important thing is to
form a trusting relationship with the patient and build empathy whilst using a rigid structure to
compliment and develop consulting. The RPS (2016) was established by selected esteemed
prescribers and is monitored regularly by chief Pharmacists to maintain its credibility. It
contains ten competency steps. Each must be achieved within 90 observational supervision
hours by experienced medical prescribers. It is taught on independent prescribing courses,
providing standardised training for all prescribers and has been adopted by the College of
Paramedics (CoP, 2018) as the model to be used. It is a structured patient centred
consultation incorporating safe, legal, efficient prescribing within the Paramedics scope of
practice and was relevant in treating Patient A. The Prescribing Pyramid (1999) used by
Nurse Prescribers since 1999 is a credible model. It looks at the Patient, which strategy, the
choice of product, is it safe, negotiation of a contract, reviewing the patient, the importance
of record keeping and reflection within its components (NPC, 1999). Not using these models
would be unsafe. (Blaber and Harris 2016).

2
Up to date evidence base was used to prescribe Nitrofurantoin for Patient A. (Blaber et al.,
2018). NICE guidelines (2018), Local Formulary (2018) and the Scottish Intercollegiate
Guidelines Network (Sign, 2012) were used to support the decision-making process.
Combined figures from nine studies involving 4.135 women under 50 with symptoms of
urinary tract infection show they are extremely likely to have bacteriuria (Sign, 2012). If the
patient displayed dysuria and increased frequency a lower urinary tract infection is likely in
90% of cases, from this evidence empirical treatment was started (Nice 2018). Three days
treatment with Nitrofurantoin has been shown to be effective in Patient A’s age group (Milo
et al., 2005). Patient A’s urine was also cloudy. Cloudy appearance to urine has a 66.45%
specificity and 90% sensitivity when diagnosing a UTI (Sign, 2012) clinically significant to
start treatment and relevant for Patient A, although visualisation of urine can be prone to
human error (Sign, 2012).

NICE (2018) recommends empirical treatment should be started immediately where three or
more symptoms are present. A urine sample was sent to the lab to confirm the right
treatment plan indicating good antimicrobial stewardship. NICE guidelines are monitored and
validated and monitored by the English Surveillance Programme for antimicrobial utilisation
(Public Health England., 2019) who found resistance more common for Trimethoprim at 35%
and remained low for Nitrofurantoin 3%. The study supported Patient A’s age and
Nitrofurantoin was therefore prescribed. Trimethoprim’s current resistance could lead to
treatment failure. (Sanchez et al., 2016).

O’Grady (2018) found in a randomised controlled study in Cork Ireland looking at all urine
cultures received by the laboratory at Cork University Hospital, over a six-month period
Nitrofurantoin has significant lower resistance than other commonly used antibiotics. The
study looked at 3608 patients matching Patient A’s age group and gender. Nitrofurantoin
resistance was very low at 4.9% within primary care compared again with Trimethoprim at
25%. (Appendix3). Samples did not include clinical details and may have included some
patients with asymptomatic bacteriuria. The studies outcome did however reflect current
NICE guidelines and provided evidence to influence the prescription for Nitrofurantoin in
Patient A.

NICE (2018) looked at the efficacy and safety of a three-day course of nitrofurantoin as
opposed to a longer course duration. A randomised controlled study by Milo et al., (2005),
included 9605 female patients matching Patient A’s age group and population, found no
difference between a three-day course to a five or ten day course in clinical effectiveness.

3
The studies relative risk (RR) was just over 1 (1.6) meaning the probability of the given
duration of treatment being effective was roughly the same in each group of patients slightly
weighted towards the control group with the longer treatment. The study calculated a 95%
confidence interval with a CI between 0.88-1.28 making the result statistically significant for
Patient A (P=0.01). Interestingly, side effects were noted to be higher in longer course
duration. Providing this information to patients improves adherence to the treatment plan
(Neighbour 2005). Side effects were discussed such as gastrointestinal disturbance and skin
reactions. No contraindications were noted (BNF, 2020) and Patient A was given worsening
advice to call back which gives confidence that a contingency plan is in place (Blaber et al.,
2018).

Legal, Ethical, Professional considerations

Following a consultation process by the CoP (2018) the law was changed to allow
Paramedics to be annotated on the HCPC register as independent and supplementary
prescribers who work at an advanced level. Paramedics must have sufficient training and
education to be able to take a thorough history, decide on management or to refer, prescribe
an appropriate product within their scope of practice, advise risks, benefits, monitor and
review and provide lifestyle advice, therefore, making every contact count (Public Health
England, 2016). Paramedics are accountable to their employer, patients and their registered
body (HCPC, 2018).

Paramedics will have prescribing rights and scope of practice agreed with employers
prescribing lead and may prescribe any licensed medication from the BNF within local and
national guidelines, with the exception of controlled drugs (Blaber et al., 2018). The
prescription of Nitrofurantoin would be within the Paramedic’s scope and are regulated by
the Human Medicines Regulation Act (2012) as a prescription only medication (POM). Valid
marketing authorisation for the use of medicines is provided by the Medicines and
Healthcare Regulatory Body (MHRA, 2019).

It is important for the Paramedic to understand the professional, legal, ethical issues and
their accountability around prescribing practice. Beauchamp and Childress (2001) see the
approach to ethics as four main principles. These are respect for; Autonomy, Beneficence,
Non-Maleficence and Justice.

4
Autonomy

It is important to respect Patient A’s wishes and rights to choose (Gainsford, 2017). Part of
autonomy is gaining consent. It could be suggested Patient A had implied consent by
attending the walk-in centre. However, this must not be presumed, trivialised or overlooked
(Nuttall-Howard, 2016). A chaperone was present during the examination, safeguarding the
patient and the clinician. Dimond (2009) highlights the need for witnesses should any
discrepancy arise, whether or not consent was given. The author agrees it would be the
patients’ word against the clinician in such circumstances. Autonomy can be seen as a
hazard to prescribing when patients expect a prescription for self-limiting illnesses. It is
important, in these situations, to explain fully and to provide evidence to reassure patients
(Nuttall-Howard, 2016).

Beneficence

The ethical principle of doing “good” (Pope et al., 2016). A credible patient centred,
hypothetical, deductive, approach using evidence-based guidance was used to benefit
Patient A. This approach rules out step by step pathologies during the consultation process
and system review. It is, however, dependent on the clinician’s knowledge and experience.
Just using one approach can be flawed. If Patient A was showing signs of systemic illness
an opinion from a senior clinician would be needed (Blaber and Harris, 2016). Any actions or
omissions, deemed unsafe, will need to be explored to ascertain if a reasonable level of care
was adhered to. Prescribing for Patient A could be seen as routine, but safety is paramount
in prescribing practice and must not be taken for granted. The Paramedic must not be
complacent when prescribing for someone with polypharmacy, pregnancy, reduced renal or
hepatic function and seek support where required to avoid legal action being instigated
(Blaber et al., 2018).

Non-Maleficence

The ethical principle, “to do no harm” (Beauchamp and Childress, 2001). By using evidence-
based guidelines and shared decision making, the Paramedic prevented harm to Patient A.
It is ethical to provide details of possible side effects, how and when to take the medication,

5
worsening advice and to review if needed (CoP, 2018). Interestingly Nitrofurantoin was
noted to have fewer side effects in shorter courses (Milo et al., 2005). Failure to provide such
information can lead to harm and possible complaints, or civil action being taken against you
for negligence. (Blaber et al., 2018).

Justice

Is the ethical principle to be equal and fair. It is important to consider cost implications when
prescribing. Advising Patient A to purchase Paracetamol over the counter will help the NHS
save money (NHS England, 2018). The Paramedic will use local and national guidelines to
keep costs down which can be redirected back into patient care and use minimum doses
required (Nuttall-Howard, 2016). However, this must not result in conflict when prescribing
for people who are not in a position to purchase over the counter medications, e.g. in care
homes. It could lead to harm and would therefore be unethical.

By working towards ethical, legal and professional principles around prescribing the
Paramedic will develop from a novice to experienced prescriber and keep themselves and
their patients safe. The Paramedic will be judged by their fellow peers of equal standing. It
is, therefore, essential the AP is covered for Public liability insurance via their employer and
has relevant insurance if working self-employed (HCPC 2017).

Clinical Governance issues.

Clinical Governance frameworks were first introduced in the 1998 Government Policy
document ‘A first class service’ (Nuttall-Howard, 2016). It consists of seven pillars including
clinical effectiveness, risk management, patient experience, patient involvement,
communication, resource effectiveness, strategic effectiveness and learning (Nuttall-Howard
2016). There are clear implications for the Paramedic prescriber to maintain appropriate
training and continuing professional development, supported by their employer. The
Paramedic must consider all risk factors with every prescribing episode for it to be effective
and not harmful (Blaber et al., 2018).

Halligan (2006) sees Clinical Governance as being organisational led. A partnership must
exist between the employing authority and the employee to maintain and improve patient
care based on clear evidenced based practice. Paramedic prescribing can be a challenging

6
environment as evidence is developing every day. It can be difficult to keep up to date
especially if self-employed. It will be important for the Paramedic to audit their prescribing
activity. This will include how many patients prescribed for, deprescribing, patient follow up
and how many times a pharmacist has contacted them regarding a prescription (Blaber et
al., 2018). To ensure continuing professional development the Paramedic will need to attend
and be supported at peer reviews, clinical updates, clinical supervision, online training from
their mentor. CPD should be straightforward but can be difficult, costly. You can lose
confidence if self-employed (Smith et al., 2014).

700,000 deaths have resulted from antimicrobial resistance, estimated to cost the us
economy £3Billion a year in health and social care costs (Who 2018). Bacteria once killed by
antibiotics have evolved and modified by changing its cell wall permeability, genetic
modifications and developing enzymes to destroy them (McCleod et al., 2019).
Inappropriate use, increased prescribing and lack of new antibiotics since the 1980s have
contributed to the problem. Optimising the usage of antibiotics is a priority for the Paramedic
Prescriber (Blaber et al., 2018).

A commitment to a global action plan to tackle antimicrobial resistance and stewardship by

the UK started in 2013 with its five-year action plan (HM Government, 2019). The plan
incorporates investments in continuing improvements in data collection, surveillance,
research, infection prevention control procedures, reduction in antibiotic use, development of
near side testing for patients, new diagnostic tests and optimising resistant patterns thereby
controlling infections and optimising treatments for more serious infections.

The report from PHE, (2019) looked at trends of resistance in urine isolates between 2015-
18. 6,146,663 urine cultures analysed across the country were reported to the PHE
Antimicrobial resistance module of which 3,503,425 (57%) were caused by E-Coli. A
reduction in resistance to Trimethoprim was noted from 34.9% to 31% (PHE, 2019). This
reduction was due to Nitrofurantoin being moved to first line treatment for most urinary tract
infections and the outcome was relevant in treating Patient A. However, the data did not
include clinical details or age groups. Standardised methods used within each laboratory
give the study credibility. Urine samples were sent from medically trained general
practitioners from primary care. The samples show positive urine infections and more
importantly resistance patterns.

Nitrofurantoin had a resistance pattern from 4% in children up to 14% in the elderly (PHE
2019). This supports current Nice guidelines in putting Nitrofurantoin as first choice empirical

7
treatment and good antimicrobial stewardship for Patient A (NICE, 2018). This was
supported by Sanchez et al., (2016) who found resistance to Trimethoprim above 23% and
Nitrofurantoin consistently below 3%. 305,749 urine isolates from 200 laboratories across
the United States from female Patients using approved standard analysis, matching Patient
A’s age were used. Cortes Penfold, (2016) supports the study and agrees resistance above
20% should not be used for empirical treatment due to high risks of treatment failure and
highlights the need to prevent, track and trace the use of antibiotics. The report from PHE,
(2019) shows a reduction in prescribing Trimethoprim from 2013-18 by 40% and an increase
in Nitrofurantoin by 27%. Total antibiotic prescribing reduced by 15% in Primary Care and a
further 31% was noted for broad spectrum antibiotics like Co-Amoxiclav. This reduction
equates to 1.3 million less broad-spectrum antibiotics prescribed which also corresponded
with a reduction in community acquired clostridium-difficile infections (Sanchez et al, 2016).
Clinical pharmacists supporting Primary Care in driving HM Government, (2019) AWare
programmes whilst supporting responsible evidence-based prescribing locally within its
stewardship programmes will keep antibiotic prescribing under control . The AWare has
three components, Access, Watch and Reserve. The access group includes 48 antibiotics
showing lowest resistant patterns, with reserve being used only as last resort for the most
serious cases. (PHE 2019).

AWare index for antibiotics within the UK (HM Government, 2019).

NICE guidelines (2018) Sanchez et al., (2016) are evidenced based and validate the use of
narrow spectrum antibiotics, Nitrofurantoin for lower urinary tract infections for Patient A
whilst supporting appropriate stewardship. NICE Guidelines (2018) now suggest only giving
broad spectrum antibiotics following culture results where narrow spectrum shows resistance
8
and you have limited options. The Paramedic prescriber will keep updated as part of a team
working alongside clinical pharmacist’s to continually drive best practice forward and
promote antimicrobial stewardship whilst becoming antibiotic champions.

If Patient A had two or less symptoms a delayed prescription approach would be used.
Then, if symptoms worsen or urine cultures dictate, a change of antibiotic can be made, thus
indicating good stewardship (McLeod et al., 2019). The report from PHE, (2019) produced
evidence that 69% of 26,242 hospital patients antibiotics had an expert and timely review
within 72 hours of admission and a change in antibiotics where needed, indicating good
stewardship. The target antibiotic toolkit will support the Paramedic and patients in
optimising the use of antibiotics. It provides evidence-based guidelines, leaflets, videos and
diagnostic templates for antibiotic stewardship. The five-year forward plan from HM
Government (2019) will continue to invest in stewardship building on improving data
collection, improving infection prevention control, investment in creating new antibiotic
products and diagnostic near side patient testing to optimise and guide care. Point of care
testing and development of new antibiotics are expensive and will need investment from the
world economy. However, it is recognised a one Health Approach is needed and incentives
will be available to support these ( McLeod et al., 2019). By using up to date evidenced
based guidelines the Paramedic used the right drug, the right course, for the right duration.
Inappropriate prescribing can be defined as “Prescribing an antibiotic in the absence of a
bacterial infection for self-limiting illnesses” and “prescribing a broad-spectrum antibiotic
without clear evidenced based rational” and “continuing antibiotics beyond its evidence-
based duration” (Blaber et al., 2018).

Conclusion

This case review discussed a Paramedic prescribing consultation whilst undertaking a

recognised independent prescribing course supported by a Medical Practitioner. It discusses
the consultation, legal, ethical and clinical Governance issues around prescribing and using
a step by step approach to the consultation in order to keep Patient A safe whilst working
within the Paramedics scope of practice. It also provides evidence base relevant to the
prescription of Nitrofurantoin for Patient A.

9
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13
 APPENDIX 1

Patient A Medical History and Consultation (Weed, 1968).

Presenting Complaint: 18yr Female presented with urinary symptoms 4/7.

History of Presenting Complaint: Four-day history of increased urine frequency, painful,
stings and burns, suprapubic tenderness and cloudy urine, had tried OTC Medications but
symptoms are getting worse.
Past Medical History: Nil
Drug History: Contraceptive Pill
Allergies: no known allergies or OTC medication
Social History: Non-smoker, Regular sexual partner, receptionist, social alcohol.
Family History: nil of note
Review of Systems: No flank pain, rigors, vomiting, discharge or itch, no SOB, bowels open
normally, chest clear, no lymphadenopathy, tummy soft, mild tenderness over bladder, no
distension, no rebound, not pregnant, no bleeding, no retention.
Ideas, Concerns and Expectations
Ideas: patient believes she has developed a urinary tract infection and consented to
assessment and appropriate treatment, review.
Concerns: She would get worse without treatment.
Expectations: She expected antibiotics and to see an improvement very soon.

14
 APPENDIX 2

Patient A vital signs

Set 1 – 1013am Set 2 – 10.18am

Heart rate 76 74

Respiratory rate 16 16

Blood pressure 118/62 122/75

Oxygen saturations 98 98

Temperature 37 37

Capillary blood glucose 6.4 NR

GCS 15(4,5,6) 15(4,5,6)

NEWS2 Low NR

Pain 2/10 2/10

15
 APPENDIX 3

Antimicrobial resistance rates among urine Enterobacteriaceae categorized by patient age

and patient type. Origin Cork University Hospital Ireland. (O’Grady et al 2018).

17–65 years old (n =

Enterobacteriaceae

resistance, patients

resistance, patients

resistance, patients
<17 years old (n =

>65 years old (n =

resistance, all
Percentage

Percentage

Percentage

Percentage
3608)

4118)
629)
Antimicrobial
agent Patient type

Ampicillin all patients 58.5 55.2 53.0 64.0

NH patients 56.8 55.0 52.8 61.4

hospital
inpatients 65.2 56.8 55.8 68.4

LTCF patients 75.0 NA 63.4 76.0

Amoxicillin/
clavulanate all patients 22.6 20.7 18.2 26.8

NH patients 20.6 20.7 17.8 23.6

hospital
inpatients 31.1 20.5 25.6 33.4

LTCF patients 40.5 NA 29.3 41.5

Ciprofloxacin all patients 12.8 4.2 8.0 18.2

NH patients 11.0 4.3 7.6 15.8

16
 17–65 years old (n =
Enterobacteriaceae

resistance, patients

resistance, patients

resistance, patients
<17 years old (n =

>65 years old (n =

resistance, all
Percentage

Percentage

Percentage

Percentage
3608)

4118)
629)
Antimicrobial
agent Patient type

hospital
inpatients 18.3 2.3 16.3 20.3

LTCF patients 31.1 NA 17.1 32.3

Cefalexin all patients 11.8 8.2 8.3 15.3

NH patients 10.3 7.9 7.9 13.5

hospital
inpatients 18.2 11.4 17.8 18.9

LTCF patients 22.7 NA 12.2 23.6

Nitrofurantoin all patients 8.5 9.6 5.2 11.2

NH patients 7.4 9.6 4.9 9.8

hospital
inpatients 13.5 9.1 12.4 14.1

LTCF patients 16.8 NA 12.2 17.3

Trimethoprim all patients 30.8 26.7 25.8 36.2

NH patients 29.2 27.4 25.3 33.9

hospital
inpatients 33.9 15.9 33.2 35.6

LTCF patients 48.5 NA 34.2 49.8

17