The idea of using C-reactive protein point-of-care testing for respiratory tract infections was first discussed during one of my regular clinical supervision meeting with one of partners at Attenborough Surgery in Bushey, Hertfordshire.
Conscious of patients demands for antibiotics for often viral infections and with the growing concerns about antimicrobial resistance we were keen to try a new strategy.
Like many surgeries up and down the country, we have antimicrobial awareness posters on the waiting room walls and self-care prescription pads, but we felt the message was simply not getting through to our patients.
We know that our prescribing habits are higher on a Friday and before the holidays, when clinicians consider the ‘what ifs’ or ‘just in case’. We also had anecdotal accounts that if patients are not prescribed an antibiotic they were more likely to re-attend in surgery, out-of-hours or A&E.
The first major challenge in managing patients with an acute cough is determining which patients will benefit from antibiotics treatment and which are self-limiting infections. The second is conveying to your patient that you have made the correct diagnosis and treatment plan. C-reactive protein is a bio-chemical marker of inflammation so CRP testing can help guide clinicians’ decision making.
Keen to ensure that patients received a quality service we decided to explore the use of CRP point-of-care testing further.
We identified two diagnostics companies that marketed CRP point-of-care testing solutions and invited them to demonstrate their equipment.
The company we chose, Alere, provided the initial training to use the equipment, which we were then able to cascade to the other nurses and healthcare assistants.
We also produced a patient information leaflet, which explained why we have used the test and what the results mean.
Who we test and how it works
In line with the NICE clinical guidelines on pneumonia assessment and management, CRP testing is offered to patients aged 18-65, who are not pregnant or immunocompromised, who present to the surgery with a suspected lower respiratory tract infection (with a duration of illness less than three weeks).
We do not test everyone who presents with a productive cough. If they have one systemic and one focal symptom and you would have considered prescribing antibiotics then we offer them a test.
The test involves taking a finger prick sample of blood and putting it in the analyser. The results are ready in four minutes. The test can be carried out either during the consultation while the clinician is assessing the patient, or the patient can wait outside the room while the results are processed, in the meantime the clinician can see the next patient and call the original patient back once the results are ready.
Antibiotics were prescribed following NICE guidelines:
- CRP >100mg/L immediate antibiotics given
- CRP 20-99mg/L delayed antibiotics should be considered
- CRP<20mg/L do not prescribe antibiotics
We were concerned that patients would view this is another tool to fob them off, but we have been pleasantly surprised how accepting patients have been of the test.
We conducted an audit to compare prescribing practice and re-attendance rates for the advanced nurse practitioner clinic from Nov 2014-Jan 2015 (no CRP testing) and Nov 2015-Jan 2016 (when we were undertaking CRP testing).
Results showed that not only have we reduced antibiotic prescribing from 31% to 9%, we had also reduced our unscheduled re-attendance rates from 28% to 13% with no out-of-hours or A&E attendances. It didn’t increase our workload and at times reduced the need for a debate with patients regarding the efficacy of antibiotics for a viral infection.
The costs involved and future uses
Each test costs £4 and the analzyer is £700 per year to rent. One of the barriers to widespread adoption is that the costs incurred are borne by the general practice but the savings are made elsewhere. However, if you factor the saving made by the reduced follow-up appointments and prescription, CRP point-of-care testing is sustainable.
It was surprisingly easy to adopt and the results have made sound clinical and economic sense. Advanced nurse practitioners (ANPs) are frequently the first point of access in GP-based minor illness clinics, out-of-hours services and A&E. Nurses are already used to working with point-of-care diagnostics so I believe that ANPs are perfectly positioned to drive this innovation forward.
Also, given that 70% of patients tested had a CRP <20mg/L if this was implemented as part of a community pharmacy-based minor ailment scheme it could divert the foot fall away from general practice even further.
Judging whether or not a patient’s chesty cough is caused by a viral, self-limiting or bacterial infection often boils down to a subjective assessment. Using an objective measure to augment our clinical assessment gives patients the assurance that we have made the correct diagnosis and treatment plan.
We started this project this project expecting to see a drop in our antibiotic prescribing important to stop the spread of antimicrobial resistance, what we hadn’t expected was that our unscheduled follow up would also drop and that’s where the savings are made; double win for the practice and CCG.
- Liz Cross is an advanced nurse practitioner and non-medical prescriber at Attenborough Surgery, Bushey, Hertfordshire. The surgery won an Acorn award in the NHS Innovation Challenge prize (2015/16)