The use of anti-inflammatory canakinumab could reduce risk of heart attack

My Post (9)Results from a recent trial of the anti-inflammatory drug canakinumab have revealed it could help reduce risk of heart attack and mark the biggest breakthrough in cardiovascular treatment since statins.

The Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS) looked at people who previously suffered from a heart attack and tested whether administration of canakinumab  could reduce inflammation and reduce risk of future cardiovascular events (Ridker et al. 2017).

Speaking at the European Society of Cardiology Congress in Barcelona, where the findings were presented, Professor Paul Ridker of Harvard Medical School, said:

‘These findings represent the end game of more than two decades of research, stemming from a critical observation: half of heart attacks occur in people who do not have high cholesterol. For the first time, we’ve been able to definitively show that lowering inflammation independent of cholesterol reduces cardiovascular risk.’

According to Ridker this has far-reaching implications:

‘It tells us that by leveraging an entirely new way to treat patients—targeting inflammation—we may be able to significantly improve outcomes for certain very high-risk populations, he said.’

Outlining the trial

The trial was conducted by researchers from a wide range of international organisations, including the Center for Cardiovascular Disease Prevention and the Cardiovascular Division at Brigham and Women’s Hospital, Harvard Medical School, Boston; Novartis in East Hanover, NJ, and Basel, Switzerland; the Federal University of São Paulo; Universitätsmedizin Berlin; and the Academic Medical Center of the University of Amsterdam.

Participating centres in 39 countries enrolled patients who had a history of heart attack and an elevated blood level of high-sensitivity C-reactive protein. It is believed raised levels of this protein may lead to further heart attacks.

Participants received doses of 50 mg, 150 mg or 300 mg of either canakinumab or placebo. These were administered subcutaneously every 3 months. Patients were excluded from the study if they had any of the following:

  • History of chronic or recurrent infection
  • Previous cancer other than basal-cell skin carcinoma
  • Suspected or known immunocompromised state
  • History or high risk of tuberculosis or disease related to the human immunodeficiency virus
  • Ongoing use of other systemic anti-inflammatory treatments.

The 10,016 participants recruited to the study were then monitored over the next 4 years. The researchers predominantly wanted to see whether participants suffered from additional heart attacks or stroke, or died from cardiovascular disease during this time.

In total, 1,490 participants experienced the main combined outcome of heart attack, stroke, or death from cardiovascular disease within the 4 years monitored. Within the placebo group, there was an average of 4.5 of these main events per year per 100 people. The treatment groups revealed there was no statistically significant difference between the 50 mg group, compared with placebo. The 150 mg group indicated a 15% lower risk compared with placebo (3.86 events per year per 100 people), while the 300 mg group showed a 14% lower risk (3.90 events per year per 100 people). The researchers concluded that 150 mg of canakinumab taken every 3 months led to a significant reduction in recurrent cardiovascular events compared with placebo.

Considering the results

The potential implications for medicine of this study are considerable, with mainstream media hailing it as a remarkable breakthrough (BBC 2017) and calling canakinumab a ‘new wonder drug’ (Donnelly 2017). For a drug traditionally used in the treatment of arthritis it certainly makes for great headlines. However, there are a number of considerations that must be taken into account before the drug is hailed as the medical advancement some have claimed.

Highlighting limitations

As mentioned, the study only looked at patients who have already had heart attacks. This is something many of the media’s headlines failed to convey (NHS Choices 2017). The effect of the drug, therefore, on reducing inflammation in people who have not had a heart attack, remains unknown. Additionally, many newspapers claimed that canakinumab was ‘better than statins’, but this is unhelpful as it does not reflect the nature of the study. It is thought that if canakinumab was licensed as a preventative medication, it is likely it would be given to people who wouldn’t benefit from taking statins (NHS Choices 2017).

Most importantly, before any changes can be made to the current licensing of the drug, further research is needed to confirm both the beneficial effects and the optimal dose. This was highlighted in an editorial by Dr Robert A Harrington of Stanford University published alongside the study (Harrington 2017), who called the clinical benefit of canakinumab ‘modest’. He argues that ‘a better understanding of the risks and benefits of this form of therapy is needed’ and raised concerns about the fatal infections encountered in the trial and sepsis. He also cites concern over the cost of using canakinumab in patients with a previous heart attack.

Cost matters

Canakinumab is currently licensed in the United States to treat systemic-onset juvenile rheumatoid arthritis at a cost of approximately $200,000 per year (Harrington 2017). While this pricing may be suitable for rare diseases, it is unsuitable for common indications such as coronary artery disease. Given the study was funded by Novartis, the manufacturer of the drug, substantial evidence of its benefit is needed before wider licensing of the drug can be considered.

References

BBC News. Anti-inflammatory drug ‘cuts heart attack risk’ [Internet]. London: BBC News; 2017 Aug 28 [cited 2017 Sep 7]. Available from http://www.bbc.co.uk/news/health-41071954

Donnelly L. New wonder drug hailed as biggest breakthrough in fight against heart attacks and cancer [Internet]. London: The Telegraph; 2017 Aug 27 [cited 2017 Sep 7]. Available from http://www.telegraph.co.uk/science/2017/08/27/new-wonder-drug-hailed-biggest-breakthrough-fight-against-heart/

Harrington RA. Targeting inflammation in coronary artery disease. N Eng J Med [Internet]. 2017 Aug 27 [cited 2017 Sep 6]. Available from http://www.nejm.org/doi/full/10.1056/NEJMe1709904

Ridker PM, Everett BM, Thuren T et al. Antiinflammatory therapy with canakinumab for atherosclerotic disease. N Engl J Med [Internet]. 2017 Aug 27 [cited 2017 Sep 6]. Available from http://www.nejm.org/doi/full/10.1056/NEJMoa1707914?query=featured_home&#t=articleTop

NHS Choices. Anti-inflammatory drug may help prevent heart attacks [Internet]. 2017 Aug 30 [cited 2017 Sep 6]. Available from http://www.nhs.uk/news/2017/08August/Pages/Anti-inflammatory-drug-may-help-prevent-heart-attacks.aspx

Taken from British Journal of Cardiac Nursing, published December 2017.

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First ESC Focused Update on dual antiplatelet therapy in CHD

My Post (8)The European Society of Cardiology (ESC) has published its first Focused Update on the use of dual antiplatelet therapy (DAPT) in coronary heart disease (CHD) (Valgimigli et al, 2017). Produced in collaboration with the European Society for Cardio-Thoracic Surgery (EACTS), the document addresses recommendations on a medical treatment that has seen conflicting advice over the years.

Conflicting evidence
According to Dr Marco Valgimigli, Chairperson of the ESC/EACTS Task Force, the conflicting evidence surrounding DAPT has resulted in many people calling it a controversial topic:

‘This has led to a great deal of uncertainty in the medical community, particularly regarding the optimal duration of DAPT after coronary stenting,’ he said.

A survey initiated by the European Association of Percutaneous Cardiovascular Interventions sought opinions from the medical community on the evidence relating to DAPT duration after coronary stenting (Valgimigli et al, 2015). It revealed considerable uncertainty over optimal duration of DAPT after stenting and therefore called for updated recommendations for practising physicians to guide treatment decisions.

Neglected populations
Alongside conflicting results in the published literature on DAPT, there is also limited evidence on various patient subsets—such as elderly patients—who may have a greater bleeding risk. Here, the benefits and risks of DAPT may be different to those seen in more selected patient cohorts included in randomised controlled trials. The aim of this Focused Update therefore is to address the current recommendations on DAPT in patients with CHD.

Dual antiplatelet therapy
Being one of the most intensively investigated treatments in cardiovascular medicine, there have been 35 randomised clinical trials of DAPT, including more than 225 000 patients. The first randomised clinical trial to establish the superiority of DAPT over anticoagulant therapy among patients undergoing percutaneous coronary intervention was published in 1996.

Platelets are small particles in the blood that can clump together to form clots; these can go on to cause myocardial infarction or the occlusion of a coronary stent. Antiplatelet agents are a class of drugs that are used to stop platelets from forming these clots. The use of two types of antiplatelet agents to prevent blood clotting is known as DAPT (American Heart Association, 2017).

The number of patients requiring dual antiplatelet therapy consisting of the combination of aspirin and an oral inhibitor of the platelet P2Y12 receptor for adenosine 5’-diphosphate has increased over time. In Europe, it is believed that around 1 400 000 patients per year may have an indication for DAPT after coronary intervention, and 2 200 000 after myocardial infarction.

P2Y12 inhibitors range from safer drugs, such as ticlopidine or clopidogrel, to the more potent and predictable, such as ticagrelor or prasugrel. The decision on when to initiate a P2Y12 inhibitor depends on both the specific drug and the disease.

DAPT reduces the risk of stent thrombosis from occurrences ranging from acute to late events. It also reduces the rate of spontaneous myocardial infarction after percutaneous coronary intervention and myocardial infarction.

For patients with stable CHD treated with percutaneous coronary intervention, the default P2Y12 inhibitor is considered to be clopidogrel. It is also commonly the default drug for patients with indication to concomitant oral anticoagulation, and in patients with acute coronary syndromes in whom ticagrelor or prasugrel are contraindicated. Ticagrelor or prasugrel is recommended in people with acute coronary syndromes unless drug-specific contraindications exist.

Recommendations for DAPT
A Task Force made up of selected medical experts carried out a comprehensive review of the published evidence for management of CHD according to ESC Committee for Practice Guidelines policy, and approved by the EACTS. A critical evaluation of diagnostic and therapeutic procedures took place, including assessment of the risk–benefit ratio. The level of evidence and the strength of the recommendation of particular management options were then weighed and graded according to predefined scales.

The Focused Update recommends a default DAPT duration of 12 months for patients with acute coronary syndrome. This is irrespective of revascularisation therapy, whether through medical therapy, percutaneous coronary intervention or coronary artery bypass surgery. In patients with high bleeding risk, 6 months of DAPT should be considered. Therapy over 12 months may be considered in patients with acute coronary syndrome who have tolerated DAPT without a bleeding complication.

The Task Force felt that the need for a short DAPT regimen should no longer justify the use of bare metal stents instead of newer generation drug-eluting stents. An assessment of the individual patient’s ischaemic risks versus bleeding risks should be used to establish duration of DAPT rather than the type of stent used.

For patients with CHD being treated with percutaneous coronary intervention who are believed to be stable, the duration of DAPT should be 1–6 months, depending on the bleeding risk. This is irrespective of the type of metallic stent implanted. For patients whose ischaemic risk is thought to be greater than the risk of bleeding, the Focused Update recommends a longer DAPT duration. The Task Force felt that there were insufficient data to recommend DAPT in patients with stable CHD treated with coronary artery bypass graft surgery.

The most controversial issue cited was the need for a prolonged DAPT regimen (anything over 12 months) in patients with acute coronary syndrome treated with percutaneous coronary intervention. This is owing to concern over ensuring benefits while diminishing risks.

‘This is a setting in which one needs to think twice about how to maximise the benefits over the risks,’ said Dr Valgimigli. ‘The most novel and important message here is that DAPT is a regimen to treat a patient, not the previously implanted stent. This is crucial and the community needs to adapt to this new treatment paradigm.’

Differing types and durations of DAPT therapy have not been seen as necessary for male and female patients, instead calling for a similar approach to care. Additionally, no difference in therapy is required for patients with diabetes.

Dr Valgimigli said:

‘The Task Force advocates a personalised medicine approach where each treatment and its duration is individualised as much as possible. The document highlights who should, and should not, receive long-term treatment, while at the same time outlining how to maximise the expected benefits over the risks.’

Conclusion
This year marks the 21st anniversary of the first randomised clinical trial that established the superiority of DAPT over anticoagulant therapy among patients undergoing percutaneous coronary intervention. However, differing advice on optimal duration of DAPT after coronary stenting makes this Focused Update long overdue—though it should go some way to guiding treatment decisions. BJCN

References

American Heart Association. 2017. What is Dual Antiplatelet Therapy (DAPT) [Internet]? Available from http://tinyurl.com/yajb9wmx

Valgimigli M, Costa F, Byrne R, Haude M, Baumbach A, Windecker S. Dual antiplatelet therapy duration after coronary stenting in clinical practice: results of an EAPCI survey. EuroIntervention. 2015;11(1):68-74. https://doi.org/10.4244/EIJV11I1A11

Valgimigli M, Bueno H, Byrne RA et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J; 2017. https://doi.org/10.1093/eurheartj/ehx419. [Epub ahead of print]

Taken from British Journal of Cardiac Nursing, published December 2017.

New cross-specialty guidelines on peripheral arterial diseases

My Post (3)New guidelines on peripheral arterial diseases (PADs) have been jointly published by the European Society of Cardiology (ESC) and European Society for Vascular Surgery (ESVS) (Aboyans et al, 2017). These guidelines mark the first time that ESC recommendations on PADs have been developed as a collaborative effort between cardiologists and vascular surgeons. Management of hypertension is achieved through a combination of medication regimen and lifestyle changes. However, the results of the studies examining the level of adherence among hypertensives indicated that the target was not achieved. Saarti et al (2015) found that the level of adherence for medication regimen is 29.1%.

What are PADs?
Over 40 million people in Europe are affected by PADs (Fowkes et al, 2013)—a term used to describe all arterial diseases except those affecting the coronary arteries and aorta. Peripheral arterial diseases include atherosclerotic disease of the extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries.

Multidisciplinary approach
The Task Force was led by ESC Chairperson, Professor Victor Aboyans, and ESVS Co-Chairperson, Professor Jean-Baptiste Ricco. Building on recommendations laid out in the 2011 ESC guidelines (Tendera et al, 2011), it was felt by both societies that a multidisciplinary approach for the management of patients was needed.

Collaboration between specialisms has meant that there is now a single European document on the management of patients with peripheral arterial diseases. Professor Aboyans said:

‘Working together has enabled us to be comprehensive in our recommendations.’

Speaking to theheart.org | Medscape Cardiology, Aboyans stressed the need for multidisciplinary management of patients with PADs. Given the different areas of the body affected by PADs, it is necessary that other specialties beyond cardiovascular medicine and surgery are involved. An example of this would be in the case of carotid disease.

Aboyans said:

‘Talking about the management of carotid disease, we also need the input of a neurologist; the same for nephrologists or gastroenterologists.

‘We cannot think any more about a patient at a consultation and the surgeon says: “Ok, I’ll operate on you, I’ll fix the problem, and then it’s over,” because this is just the beginning of another story, which is the long-term management and reassessment of these patients, as with coronary risk,’ he added.

Complications of PADs
According to Aboyans, patients suffering from PADs often have difficulty walking— particularly those with arterial disease of the extremities. This is owing to insufficient blood flow to the lower limbs brought on by stenoses or occlusions of the peripheral arteries. This can pose a complication, as many patients may be unaware that they have a more serious condition. This is because they do not suffer from common symptoms of circulatory problems, such as shortness of breath, due to being sedentary.

‘They may have heart failure, but they don’t really complain about shortness of breath, just because they don’t walk any more,’ he said.

The benefit of cross-specialty assessment is therefore apparent. This ensures that all possible areas for concern are taken into consideration.

‘It is really mandatory that, if a patient comes to one specialty, to also have the call with other specialties, and this complementary approach is of benefit to the patients,’ he said.

‘It is one thing to fix the local-territory issue, the other is the cardiovascular health of these patients and, in the end, the prognosis.’

Changes to the guidelines
In putting together these guidelines, a comprehensive review of the published evidence was carried out. The Task Force was made up of experts in the field selected by the ESC. It included representation from the ESVS and European Stroke Organisation (ESO). This ensured all professionals responsible for the medical care of patients with this pathology were involved. The Task Force considered published articles on management of a given condition according to the ESC Committee for Practice Guidelines policy. These were then approved by the ESVS and ESO. A critical evaluation of diagnostic and therapeutic procedures for PADs was carried out, including an assessment of the risk– benefit ratio.

A number of changes have been made since the 2011 guidelines were published and new recommendations set out for the management of PADs. A chapter devoted to the use of antithrombotic drugs has been introduced for the first time. There is also a new chapter on the management of other cardiac conditions frequently encountered in patients with PADs. These include heart failure, atrial fibrillation and valvular heart disease. The chapter on mesenteric artery disease has been entirely revisited. Ricco said:

‘We have updated this chapter with new data showing the interest of endovascular surgery in these often frail patients.’

The Task Force has recommended revascularisation of asymptomatic carotid stenosis only in patients at high risk of stroke. This is despite no new major trials on the management of asymptomatic carotid artery disease since the last guidelines were published. However, there are new data on the long-term risk of stroke in patients with asymptomatic carotid stenosis.

‘The previous guidelines recommended revascularisation for all patients with asymptomatic carotid stenosis, so this is an important change,’ said Aboyans.

‘Trials showing the benefits of revascularisation compared to best medical therapy alone were performed in the 1990s but stroke rates in all patients with asymptomatic carotid stenosis have decreased since then— regardless of the type of treatment— so the applicability of those trial results in the current management of these patients is more questionable.’

There is now a strong recommendation against systematic revascularisation of renal stenosis in patients with renal artery disease. This is following the publication of several trials.

WIfI classification
A new classification system (WIfI) has been proposed as the initial assessment of all patients with ischaemic rest pain or wounds. The system takes into account the three main factors that contribute to the risk of limb amputation, which are:

  • Wound
  • Ischaemia
  • foot Infection.

Professor Ricco emphasised the impor¬tance of the new WIfI classification in lower extremity artery disease.

Guidelines into practice
The new guidelines encourage health professionals to consider its recommendations when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies. However, they make clear that they do not override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition. This should be done in consultation with that patient or the patient’s caregiver where appropriate and/or necessary.

References

Aboyans V, Ricco JB, Bartelink MEL et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extrem¬ity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2017; [Epub ahead of print]. https://doi.org/10.1093/eurheartj/ehx095

Fowkes FG, Rudan D, Rudan I et al. Comparison of global estimates of prevalence and risk fac¬tors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329–1340. https://doi.org/10.1016/S0140-6736(13)61249-0

Tendera M, Aboyans V, Bartelink ML et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(22):2851–2906. https://doi.org/10.1093/eurheartj/ehr211

Taken from British Journal of Cardiac Nursing, published November 2017.

Leading support for those with mental health issues and learning disabilities

Adobe Spark (3)The Chief Nursing Officer has told mental health and learning disability nurses they need to ‘step up and take the lead’ in delivering ambitions set out by NHS England for mental health and learning disability services. Speaking at the NHS Expo in Manchester, Professor Jane Cummings said:

‘Nurses are creative, they’re innovative, they’re leaders, and they can really drive that change that we all want to see.’

Cummings outlined the important leadership role that mental health nurses have in delivering the Five Year Forward View for Mental Health (NHS England, 2016), and that learning disability nurses have in delivering the Learning Disability Transforming Care programme:

‘I think that nurses and midwives should be at the driving edge of change and improvement. I think there is a wealth of knowledge, a wealth of experience. And there’s a huge amount of skill set that nurses can have to really drive the change that everyone wants to see.’

Five Year Forward View for Mental Health

The Five Year Forward View for Mental Health was launched in February 2016 in an attempt to improve mental health outcomes across the health and care system, and includes an additional £1.4 billion of investment in mental health services by 2020/21. The funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services. Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services, and the integration of mental and physical health services for the first time.

Cummings said that improvements to mental health services is one of the ‘national priorities’ for NHS England, emphasising how there is a massive amount of work going on around mental health, with a real focus on improving access to services:

‘We are particularly focusing, through the Maternity Transformation Programme, on perinatal health. As part of that we have a big workstream looking at perinatal mental health and supporting women to cope with any problems they get post birth.’

According to Claire Murdoch, National Director for Mental Health, the priorities of the Five Year Forward View for Mental Health are built on a core set of pre-existing services that are transforming and developing to create an ‘absolute, quiet and steady revolution in mental health care.’

Murdoch echoed Cummings by also calling mental health nurses to ‘step forward and step up.’ However, in order to do this she said nurses need to become vocal about their skills, and experts in co-production and working alongside mental health service users in their own care. As part of plans laid out in the Forward View, Murdoch said the NHS will see an additional 1 million extra patients. This will include 70 000 more children and young people, who will have increased access to specialist eating disorder services within the community.

Murdoch explained how further evidence-based interventions, made earlier in the pathway of illness or distress, will ‘fundamentally change the outcomes for people’s lives so that we don’t create unwittingly long-term patients for the future.’ She added that there will be more tier 4 specialist beds for children and young people suffering from serious mental health problems, particularly in London and the south, where occupancy often outstrips demand. Additional improvements in respite care, crisis houses and home treatment teams were also assured.

According to Murdoch, nurses are leading community mental health teams for children and young people. Working alongside psychologists and doctors, she explained that they are playing a key role in the management of conditions such as eating disorders. Community eating disorders services for young people largely did not exist until last year, and Murdoch commended the mental health nurses, who she said were not only leading those teams, but also breaking new ground in having to work alongside families, the young people themselves, and deliver evidence-based care in completely different settings.

One of the greatest concerns Murdoch highlighted was the current pressure on the mental health crisis care pathway. In particular she stressed the need to prevent beds overspilling into the private sector and long waits in accident and emergency (A&E) departments. However, she announced that nurses have led the way in redesigning the care pathway through the ‘development of intensive current treatment teams’ and the ‘establishment  of the psychiatric liaison teams in A&E and acute hospitals more widely.’

She believes nurses will play a ‘fundamental part’ in ‘bringing an end to inappropriate out-of-area placements.’ An example she cited was in Birmingham, where nurses are working alongside the police to dramatically reduce the use of Section 136 of the Mental Health Act, which allows the police to take a person who appears to be suffering from a mental disorder to a place of safety. She said this has enabled better outcomes for people in distress.

Though she raised concerns that large numbers of nurses are leaving the profession and that recruitment will be an additional challenge, she said ‘there has never been a better time to be a mental health nurse.’ However, she urged mental health nurses to be vocal about their skills, whether that is their skill of assessment or complex working in networks of care.

‘We need to become the experts in co-production and working alongside mental health service users in their own care. We need an effort to come up with a care plan that hasn’t been produced at least in partnership, even at times of great crisis. We need to become the experts in that space. Housing, debt, employment, the physical health care, these are the domains of mental health nurses.’

Transforming care for people with learning disabilities

Alongside improvements to mental health services, a national plan to develop community services and close inpatient facilities for people with learning disabilities has meant better care for this patient group. The focus of the Learning Disability Transforming Care programme is on giving people with learning disabilities the opportunity to live in the setting they think is home. It also aims to stop overmedication and improve access to annual health checks.

Vicki Stobbart, a disability nurse and Executive Director of Nursing and Quality for Guildford and Waverley CCG, said that while learning disability nurses may not be as high profile as other areas of nursing, their impact and value in supporting people with learning disabilities should not be underestimated.

‘Learning disability nurses are the only professional group specifically trained to work with people with learning disabilities,’ said Stobbart. ‘This level of preparation, currently provided at degree level, alongside the breadth, competence and knowledge they develop, makes them a unique and critical component on the delivery of comprehensive skills.’

Alongside presentations on the leadership role of mental health and learning disability nurses, Professor Cummings led a panel discussion with healthcare staff and service users on how nurses can play a key role in the care of mental health and learning disability patients. Organised by NHS England, the Health and Care Innovation Expo saw over 5000 delegates learn about developments and innovations taking place across health and social care.

Looking at the progress made since the launch of the Five Year Forward View, it identified a number of key areas of priority, including urgent and emergency care, primary care and general practice, cancer, and mental health.

Taken from British Journal of Mental Health Nursing, published November 2017.

Jeremy Hunt’s plans to reduce prescribing and medication errors

Adobe Spark (2)A new initiative aimed at reducing prescribing and medication errors across the NHS has been announced by Health Secretary Jeremy Hunt.

Hunt said medication-related errors are responsible for 5–8% of hospital admissions. This is due to 1 in 12 prescriptions involving mistakes relating to dosage, course length or type of medication. With just under  150 prescriptions handed out in primary care every second, Hunt has called the potential for errors ‘huge’.

Writing in the Health Service Journal, he said:

‘Up to 1 in 12 prescriptions may include a mistake and whilst we’re lucky most don’t cause harm to patients, there is more we can do to tackle the problem and make the NHS safer…That’s why I’ve launched a new scheme working with the NHS to reduce these errors and protect patients.’

According to Hunt, the scheme will explore a number of areas where he believes the NHS ‘can do better’. This includes improving the way that technology, such as electronic prescribing, is used, to ensure prescriptions are processed more efficiently; re-evaluating the way that patients are informed and educated about their medicines, to look along the pathway from prescribing to administration and monitoring; supporting 7-day clinical pharmacy services, where possible, in acute hospitals; and providing pharmacist support for care homes and GPs.

Hunt also said the programme will look at how the transfer of information about medicines when patients move between care settings might be improved, as it is during these transition points when things can often go wrong.

According to the Department of Health, the programme is likely to be launched later this year or early next year. It is aimed at helping the NHS meet the World Health Organization’s global patient safety challenge, which hopes to reduce severe avoidable medication-related harm by 50% globally in the next 5 years. An expert group is being put together to help scope the programme and establish how to improve patient safety.

Speaking at the Royal Pharmaceutical Society Annual Conference, Steve Brine MP, Parliamentary Under Secretary of State (Public Health and Primary Care), confirmed how Jeremy Hunt will be working with the Chief Pharmaceutical Officer, Keith Ridge, to tackle the challenge of prescribing and medication errors:

‘Studies currently indicate that up to 8% of prescriptions have a mistake in dosage level, course length or medication type—a risk which the WHO identifies as a leading cause of injury and avoidable harm in healthcare systems across
the world.’

How might this affect nurses?

While the initiative is likely to predominantly affect GPs, it will also have an impact on the 70 000 qualified nurse and midwife prescribers. The Nursing and Midwifery Council (NMC) recently launched a consultation on proposals for nurses and midwives to prescribe earlier in their careers.

The proposals, if implemented, would enable nurses and midwives to gain prescribing practice experience as soon as they qualify. They would, therefore, do the prescribing training as part of their degree so that they have more of an understanding when they graduate.

It is unclear how this may affect patient safety or the number of medication errors carried out by nurses. Nurse Prescribing contacted the NMC, but as their proposals are only in the consultation phase, they said they were unable to comment at this time.

Deborah Robertson, Senior Lecturer and Programme Leader in Non-medical Prescribing at the University of Chester highlighted how nurse prescribers are very aware of the risk of prescription errors, and that best practice is needed to ensure errors are minimised:

‘Nurse prescribers are already very conscious of the risk of prescription errors and in prescribing education—we spend a good deal of time ensuring that they know the legalities of prescription writing as well as the need for best practice advice to ensure the minimisation of errors.’

‘We always reiterate the benefits of team working in prescribing practice and establishing good relationships between prescribers and dispensing pharmacists to ensure prescribing errors are picked up in a timely manner and how to avoid confrontation. This also highlights the need for ongoing continuing professional development in all areas of prescribing practice.’

Taken from Nurse Prescribing, published November 2017.

New techniques at pilot sites to improve bereavement care for parents

Adobe Spark (1)A new pathway has been launched to improve the quality of care for parents who have lost a baby. The National Bereavement Care Pathway (NBCP) seeks to offer individualised, safe and sensitive care for parents and families at all stages of pregnancy and baby loss up to 12 months.

Led by Sands, the stillbirth and neonatal death charity, it has been produced in collaboration with a core group of charities and professional bodies, comprising the Institute of Health Visiting, the Royal College of Midwives, NHS England, the Royal College of Obstetricians & Gynaecologists, the Royal College of Nurses, Neonatal Nurses Association, Bliss, Antenatal Results & Choices, The Lullaby Trust and Miscarriage Association. It also has the support of the Department of Health and the All-Party Parliamentary Group on Baby Loss.

The first wave of 11 pilot sites has been rolled out across the UK to coincide with Baby Loss Awareness Week and includes Wirral University Teaching Hospital NHS Foundation Trust, Liverpool Women’s NHS Foundation Trust, and Hull and East Yorkshire Hospitals NHS Trust. The sites were chosen to be ‘representative of geography, capacity and specialism’, and will trial the use of new materials, guidelines and training for professionals to help improve the care that bereaved parents receive.

The latest figures show that in 2015 there were over 2,500 infant deaths (that is, deaths under 1 year of age) in England and Wales, with stillbirths and deaths of infants under 7 days accounting for around 6.5 deaths per 1,000 total births (Office for National Statistics, 2017).

Clea Harmer, chair of the NBCP Core Group and CEO of Sands, comments: ‘I am delighted that we have so many enthusiastic partners across the country who want to work with us in improving bereavement care for parents when a baby dies.

‘As a collaboration, we were inundated with offers of support and I am excited by the potential impact that the pathway will have in these 11 sites, in the first instance. We  look forward to learning from their experiences before wave 2 begins and the wider rollout later next year.’

A spokesperson for the Institute of Health Visiting says: ‘The Institute is pleased to be one of the key partners in the project group working to deliver a National Bereavement Care Pathway for England, with the support of the Department of Health and All-Party Parliamentary Group for Baby Loss.

‘We are really keen to support the project group with identification of community health providers [which employ health visitors] that are willing to be included in the second pilot phase. This will ensure that the pathway offers clear, consistent guidance to health visitors and enable them to work confidently alongside parents, providing compassionate and parent-centred care to those affected through use of the pathway.’

Sue Cooper is the bereavement midwife at Hull and East Yorkshire Hospitals NHS Trust. She highlighted the important role that bereavement midwives play in providing support for parents who have lost a child:

‘Losing a child is an incredibly difficult experience and something that no parent should ever have to go through,’ Cooper says. ‘If they do, however, it’s important that we, as health professionals, are able to provide the right advice, information and support for bereaved parents.

‘The quality of care and the empathy shown to parents at a time when they are struggling with a whole range of different emotions is crucial, and our role in guiding bereaved parents through this difficult time is not to be underestimated. How we care for bereaved families when their baby dies can have long-lasting effects. Good care can’t remove parents’ pain and grief, but it can help them through a devastating experience.

Cooper is hoping bereavement care in Hull and East Yorkshire will improve as a result of being one of the pilot sites on the new pathway: ‘We’re really pleased to have been chosen to pilot the new care pathway,’ she says. ‘We’re not only hoping to improve the care we personally provide for bereaved parents, but it will mean a lot to know that what we do here in Hull and East Yorkshire will go on to shape and improve services provided for others right across the country.’

Since the project was initiated, it has engaged with over 200 professionals and 60 parents, completing a gap analysis of current pathways, guidance and research. A number of pregnancy and baby loss pathways have been created, with input from members of the NBCP Parental Advisory Group, which shared their stories to help inform the pathway.

Cathy Warwick, chief executive at the Royal College of Midwives, says: ‘This is important work because it is about giving bereaved families better care following the sad loss of a baby and we need to get it right. Learning from parents and the results of the work at the pilot sites will mean care can be better tailored to meet the needs of families.’

According to Carmel Bagness, Royal College of Nursing’s professional lead for midwifery and women’s health, it is the responsibility of healthcare staff to support bereaved parents: ‘The loss of a baby is an absolute tragedy and it is up to healthcare staff to provide the best care possible for bereaved parents and families,’ she says. ‘This pathway could really help to improve the care they receive during this difficult time. We hope this pilot is just the first step towards better care throughout the country for parents and families suffering from this terrible loss.’

Caroline Lee-Davey, Chief Executive of Bliss, adds: ‘Bliss is proud to be partnering on this project to improve bereavement care for pregnancy and infant loss. We know that being supported in the right way can help grieving parents and families at this heart-breakingly difficult time, and we look forward to working with the pilot sites to deliver consistent, high-quality and parent-centred care.’

A second wave of pilot sites is planned for April 2018, with a national rollout expected later in October.

References

Office for National Statistics. Childhood mortality in England and Wales: 2015. London: ONS; 2017.

Taken from Journal of Health Visiting, published November 2017.

Not enough ‘safe care’ for maternity service users, warns NHS England

Adobe Spark (8)The chair of the Maternity Transformation Programme in England has warned that not enough is being done to ensure safety within maternity services. Speaking at the NHS England Health and Care Innovation Expo, Professor Sarah-Jane Marsh, said:

‘There are too many families […] who have not had safe care, who we have let down, and we need to do better.

‘Safety has to be at the heart of everything that we do in our maternity services. We have got to get it right. We know how to get it right, [but] often we just don’t do that consistently.’

In Better Births (NHS England, 2016), NHS England emphasised the need for safer, personalised, professional, family-friendly maternity services, realised through Local Maternity Systems, the maternity element of Sustainability and Transformation Plans (STPs). Here, providers, commissioners and organisations work at a local level to oversee and develop health care issues.

While Marsh called the vision ‘clear’, she cautioned that it was not ‘what is being talked about in every maternity unit in the country at the moment.’

Since the Maternity Transformation Programme was launched in July, 44 Local Maternity Systems have been set up to plan the design and delivery of services to populations of 500 000–1 500 000 people. Marsh claimed that these are making headway, and are looking towards the future of maternity services ‘with a ruthless focus on safety and personalisation.’ Although services are becoming safer, she warns that performance, when benchmarked against maternity staff, ‘is not as it should be’.

Marsh also raised concerns that boards are not as focused on maternity services, saying:

‘We need to have people, at board level, who really understand maternity safety, who understand how to get it right as well as to investigate when things go wrong.’

Marsh stressed that, while visions and national programmes are important,

‘The change that really matters is that which is made by clinical teams on the ground, coming together to want to make a difference for the patients, the families, the women they care for. And the women and families themselves having every opportunity to be able to participate, feedback their experience and work with professionals to improve services.’

Marsh also highlighted the importance of multiprofessional working, saying,

‘We need to see ourselves as one big maternity team […] We have got to move away from the idea that maternity care is purely about the midwives and the obstetricians, because there is so much more to it than that. […] Those who work together and train together ultimately go on to do even more personal and safe care.’

This sentiment was also emphasised by Professor Jacqueline Dunkley-Bent, head of maternity, children and young people for NHS England, who said:

‘We are working really hard and we will continue to work hard to ensure that avoidable death is reduced in this country. We have a commitment at the moment on the table from the Department of Health: £8 million has been allocated to support education and training. This fund has been awarded to maternity services to help them develop multidisciplinary training.’

Matthew Tagney, director of the Maternity Transformation Programme, agreed that progress was being made, but warned that the NHS was still far from its target of halving stillbirths, maternal and neonatal deaths, and brain injuries during or soon after birth by 2030:

‘I think there is a tremendous amount happening both nationally and locally.We are on track for 2020 but there is a huge amount more to do.’

While progress is being made on the delivery of better maternity services, there is still a long way to go. This was accepted by Marsh, who apologised to the hundreds of families who had lost babies:

‘You have my commitment and the commitment from the team at NHS England that we will work tirelessly every day to do the things that we know work in patient safety, and to make sure there are no baby deaths in this country that are avoidable.’

References

NHS England. National Maternity Review: Better Births—Improving outcomes of maternity services in England—A Five Year Forward View for maternity care. Leeds, NHS England: 2016

Taken from British Journal of Midwifery, published November 2017.