Experts call on NICE to review TAVI guidelines for aortic stenosis

Adobe Spark (5)Leading experts have urged the National Institute for Health and Care Excellence (NICE) to review its guidelines on the use of transcatheter aortic valve implantation (TAVI) for aortic stenosis to include intermediate-risk patients.

Speaking at a plenary session of the PCR–London Valves conference, experts delivered a focused summary of the new European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines on valvular heart disease (Baumgartner et al, 2017). This included details of how the guidelines have been updated to lower the threshold for intervention with TAVI to patients at intermediate-risk of surgery. Previous guidance stipulated that TAVI should only be considered for those patients with symptomatic aortic stenosis at high risk of surgery (Vahanian et al, 2017).

Dr Helmut Baumgartner, chair of the taskforce for the European Guidelines, has said the new recommendations mark a profound change to the 2012 guidelines. This is largely owing to the number of randomised controlled trials comparing surgical and transcatheter treatments in the last 5 years. These have looked at intermediate- and low-risk patients treat-ed, not just elderly high-risk patients (Leon et al, 2016). He said:

‘There is much controversy right now over who should undergo surgery and who should undergo per-cutaneous valve implantation, and this is an area in which we have profound changes in what we recommend and have consequently dedicated a large part of the guide-lines to the choice of intervention in symptomatic aortic stenosis.

‘We are now recommending that surgical valve replacement remains the first line of therapy in low-risk patients, and low risk should not only be defined by risk scores, because these have several limitations, but by the lack of frailty and other specific risks for surgery not included in risk scores such as porcelain aorta or sequelae of chest radiation. There are numerous issues that need to be considered before we speak of low-risk patients.’

How NICE guidelines differ

An updated version of NICE’s Interventional Procedures Guidelines (IPG), which considers whether procedures are safe and work well enough for wider use in the NHS, was published a month before the ESC/EACTS guidelines (NICE, 2017). At first glance, it appears not to have revised the indication for TAVI beyond the high-risk patient population, unlike the European guidelines. According to a press advisory from Edwards Lifesciences (2017), NICE said additional trials are needed before TAVI could be considered in patients at inter-mediate risk for surgery:

‘Based on current data, TAVI is recommended in patients with severe symptomatic aortic stenosis who are, according to the heart team considered unsuitable for conventional surgery because of severe comorbidities.

Should NICE guidelines change?

Approximately 1.5 million people in the UK over 65 years suffer from heart valve disease with aortic stenosis (d’Arcy et al, 2016). This represents 2–7% of those over 65 years (Spaccarotella et al, 2011) and 13% of those over 75 years (Nkomo et al, 2006). For many cardiologists, it is believed that expanding the use of TAVI would enable more patients in the UK to have access to the minimally-invasive therapy, rather than have to undergo open-heart surgery.

According to Dr Bernard Prendergast, Consultant Cardiologist at Guy’s and St Thomas Hospital and Course Director/Board Member of PCR London Valves, recent evidence increasingly supports the use of TAVI for intermediate-risk patients. Speaking at the PCR–London Valves conference, he said:

‘There is growing evidence in favour of the use of TAVI for the treatment of intermediate-risk patients with severe symptomatic aortic stenosis. This expanded indication in the ESC/EACTS guidelines paves the way for more patients to receive a true alter-native to open-heart surgery.’

As a result, Prendergast emphasised why NICE should update their guidelines to be in line with the rest of Europe:

‘We are calling for NICE to review their recent IPG in light of these new ESC guidelines in order to address current inequalities in treatment across the UK, and between the UK and most of Europe.’

There is concern that the NICE guidelines leave UK patients at a disadvantage in the treatment of aortic stenosis com-pared with the rest of Europe. Currently, the UK performs far fewer aortic valve implantations than Germany, France, Norway and Sweden.

Clearing up misconceptions

It was hoped in light of the new ESC/EACTS guidelines that this disadvantage would change. However, when NICE was asked if they will be looking into revising their guidelines to recommend TAVI for aortic stenosis for intermediate-risk patients for the writing of this article, they clarified that their guidelines have actually already been extended beyond the high-risk population.

In response to the expert calls for revision and the critical comments quoted in this article, a spokesperson from NICE requested a correction, stating:

‘The new guidance gives standard arrangements for TAVI and does not any longer differentiate between different risk groups. The decision as to which patients are suitable is left to risk assessment by clinicians and the MDT [multidisciplinary team].’

References

Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739–2791.

d’Arcy JL, Coffey S, Loudon MA et al. Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: The OxVALVE Population Cohort Study. Eur Heart J. 2016;37(47):3515-3522.

Edwards Lifesciences Ltd. Leading Experts Call for Adoption of New ESC/EACTS Guidelines on the Management of Valvular Heart Disease to include Intermediate-Risk Patients in National Protocols [Press Advisory]. Berkshire: Edwards Lifesciences Ltd.

Leon MB, Smith CR, Mack MJ et al. Transcatheter or surgical aortic-valve replacement in intermediate risk patients. N Engl J Med. 2016;374(17):1609-20.

National Institute for Health and Care Excellence. Transcatheter aortic valve implantation for aortic stenosis. Interventional procedures guidance [IPG586]. London: NICE; 2017.

Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart disease: a population-based study. Lancet. 2006;368:1005-11.

Spaccarotella C, Mongiardo A, Indolfi C. Pathophysiology of aortic stenosis and approach to treatment with percutaneous valve implantation. Circ J. 2011;75(1):11-19.

Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33(19):2451-96.

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

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More advanced paramedics needed if A&E pressure is to be eased

Adobe Spark (1)The NHS must introduce more advanced paramedics if emergency departments are to meet growing patient demand. The NHS is reaching a crisis point—annual rises in emergency admissions and insufficient resources mean patients aren’t receiving the necessary levels of care. Traditionally, care provided by paramedics has focused on the immediate assessment and management of potentially life-threatening emergencies. This is then followed by transfer to an appropriate receiving unit. However, increasingly, evidence suggests that patients who present to ambulance services with lower acuity presentations could alleviate the need for hospital admission by undergoing assessment and management in the community.

This is highlighted in new draft guidance published by NICE (2017), which should fall on welcome ears to ambulance services. It recommends that the NHS provides more advanced paramedic practitioners (APPs), who have extended training in assessing and treating people with medical emergencies, to relieve pressure on emergency departments.

Evaluating the evidence

In order to make these recommendations, the guideline committee investigated whether enhancing the competencies of paramedics resulted in a reduction in hospital admissions and demand for emergency department services. When considering clinical evidence, three studies were included in the review. Two studies, which came from the same cluster-randomised controlled trial, looked at a paramedic practitioner service in the UK, which gave enhanced training to paramedics.

The first study comprised 3018 people and evaluated the benefits of paramedic practitioners who have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community (Mason et al. 2007). The evidence suggested that enhanced competencies of paramedics may provide benefit for reducing the number of hospital admissions (0–28 days), emergency department attendance (0–28 days), and patient and/or carer satisfaction. There was no effect on mortality.

The second study comprised 2025 people and evaluated the safety of clinical decisions made by paramedic practitioners of older patients contacting the emergency medical services with a minor injury or illness (Mason et al. 2008). Of the 3018 patients recruited into the randomised-controlled trial, 993 were admitted to the hospital at the index episode, which explains why they were excluded from the analysis in this study. The evidence suggested that there was no effect of paramedics’ enhanced competencies on unplanned emergency department attendance.

The final study was a non-randomised (quasi-experimental) study of emergency care practitioners who worked as single responders to ambulance service 999 calls, compared with standard paramedic or technician ambulance responding to ambulance service 999 calls. The study comprised 1107 people and aimed to evaluate the impact of emergency care practitioners on patient pathways and care indifferent emergency care settings.
(Mason et al. 2012). The evidence suggested that enhanced competencies of paramedics may provide a benefit from reduced numbers of patients referred to hospital (emergency department or direct admission to a hospital ward), and increased number referred to primary care.

Additionally, one cost-utility analysis was assessed to consider the economic implications of providing additional advanced paramedics within ambulance services, and found that the paramedic practitioner scheme was cost-effective compared with the standard 999 service (Dixon et al. 2009). This study was assessed as partially applicable with minor limitations.

Points for concern

There are a number of considerations when looking at the evidence in question that could be cause for concern. While evidence exists, it is minimal, with only one
randomised-controlled trial and one non-randomised study evaluated by NICE. Though results from the studies are positive, it would be difficult to generalise them beyond the services assessed. Additionally, the quality of evidence is generally of a low GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The randomised-controlled trial evidence has a moderate-to-low GRADE rating overall, mainly owing to risk of bias and imprecision (NICE 2017). The non-randomised study, although it had large effect sizes, has a very low GRADE rating as a result of high risk of bias and indirectness of the outcomes to the protocol (NICE 2017). The economic evidence was considered high-quality but only partially applicable because the costs were quite dated. Some social care costs were also included, which means that the perspective is not strictly NHS and personal social services (NICE 2017).

There are notable concerns over the definition of an APP, as there is a national lack of consensus over paramedic roles and scope of practice. This was a contributing factor to why independent prescribing by APPs was not recommended by the CHM and MHRA (Allied Health Professions Medicines Project Team 2016).

The need for unanimity across all ambulance services is a concern the College of Paramedics emphasised inits response to the guidance:

‘There has previously been insufficient attention given to career development and career opportunities and there is currently significant variation across the ambulance services in the definitions, titles, education, and training of specialist and advanced paramedics. To ensure consistency of education, training and qualification, the UK ambulance services would need to adopt the frameworks developed by the College of Paramedics, which provide detailed guidance on education, competencies, and career development’ (College of Paramedics 2017).

The College of Paramedics has a clear definition of the APP role in terms of competencies and education:

‘Advanced paramedics are experienced autonomous paramedics who have undertaken further study and skill acquisition to enable them to be able to deliver a more appropriate level of assessment and indeed care to patients in the community and access many more referral pathways.’

It is essential that this becomes the accepted definition across the NHS, and the private health sector. This will ensure that all advanced paramedics are clinically competent and that patient safety is not at risk. More advanced paramedic practitioners with extended training could alleviate current pressures on A&E services.

From guidance to practice

Consulting on the guidance closed on 14 August, with an expected publication of 20 December. If the guidance is to be put into practice, the most important step is to introduce additional funding for NHS ambulance services to educate their clinicians through advanced practice programmes. NHS England and clinical commissioning groups would then have to provide funding to deliver specialist and advanced paramedics as part of the core workforce. Additionally, regulation is essential to ensure clinical competency and patient safety.

There is no denying that acute and emergency care is a challenge for all health services. This is largely owing to the fact that as populations age, costs rise, and technological developments extend the limits of health care. However, providing acute and medical care in the community can reduce the need for hospital admissions.

The introduction of more advanced paramedics will meet the increasing and changing needs of patients who access 999 emergency ambulance services. Having a higher proportion of emergency patients assessed and treated in the community will cause a reduction in the number of attendances at emergency departments.

References

Allied Health Professions Medicines Project Team. 2016. Summary of the responses to the public consultation on proposals to introduce independent prescribing by paramedics across the United Kingdom. Leeds: NHS England.

College of Paramedics. 2017. College of Paramedics respond to NICE Consultation [Internet]. Bridgwater: College of Paramedics; [cited 2017 29 August]. Available from https://www.collegeofparamedics.co.uk/news/college-of-paramedics-responds-tonice-consultation.

Dixon S, Mason S, Knowles E. 2009. Is it cost effective to introduce paramedic practitioners for older people to the ambulance service? Results of a cluster randomised controlled trial. Emerg Med J. 26(6):446-51. http://doi.org/ 10.1136/emj.2008.061424.

Mason S, Knowles E, Colwell B et al. 2007. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. BMJ. 335(7626):919. http://doi.org/10.1136/bmj.39343.649097.55

Mason S, Knowles E, Freeman J, Snooks H. 2008. Safety of paramedics with extended skills. Acad Emerg Med. 15(7):607–12. http://doi.org/10.1111/j.1553-2712.2008.00156.x.

Mason S, O’Keeffe C, Knowles E. 2012. A pragmatic quasi-experimental multi-site community intervention trial evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways (NEECaP Trial). Emerg MedJ. 29(1):47-53. http://doi.org/10.1136/emj.2010.103572.

National Institute for Health and CareExcellence. 2017. Emergency and acute medical care in over 16s: service delivery and organisation: Draft guidance consultation [GID-CGWAVE0734] [Internet]. London: NICE; [cited 2017 29 August]. Available from https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0734/consultation/html-content.

Taken from Journal of Paramedic Practice, published 8 September 2017.

Royal Pharmaceutical Society updates prescribing competency framework

Adobe Spark (1)The Royal Pharmaceutical Society (RPS, 2016) has published an update to the Competency Framework for all Prescribers to ensure health professionals prescribe safely and effectively.

Originally published in 2012, the framework was developed to offer a common set of competencies for prescribing, regardless of professional background. As a result, it is relevant to all prescribers, including doctors, pharmacists, nurses, dentists, physiotherapists, optometrists, radiographers, podiatrists and dietitians. However, the framework should be contextualised to reflect different areas of practice and levels of expertise.

Ash Soni, President of the RPS, said:

‘Both the number of medicines prescribed and the complexity of medicine regimens are increasing. The challenges associated with prescribing the right medicines and supporting patients to use them effectively should not be underestimated.

‘There’s lots of evidence to show that much needs to be done to improve the way we prescribe and support patients in effective medicines use. This guide will be invaluable and I’m delighted the RPS has coordinated the update.’

The initial framework was published by the National Prescribing Centre and the National Institute for Health and Care Excellence (NICE). For the update, the RPS was approached by NICE and Health Education England to carry out the work on behalf of all prescribing professions. Additionally, the RPS was asked to ensure the framework had UK-wide applicability.

A project steering group of prescribers across all professions and patients updated the framework. This involved a 6-week consultation of the draft policy, where hundreds of organisations and individuals responded.

The framework has been endorsed by the UK’s Chief Pharmaceutical Officers—Keith Ridge, Rose Marie Parr, Andrew Evans and Mark Timoney—who said:

‘The single competency framework provides a means for all prescribers to become equipped to support patients to achieve the best outcomes from their medicines.

‘This update will ensure individuals can continue to benefit from access to resources which help them continually improve their practice and work more effectively.

‘We commend the updated framework and encourage prescribers, professional bodies, education providers and regulators to use it to support their role in delivering safe and effective care.’

How the competencies are separated

The framework comprises 10 competencies split into two areas: the consultation and prescribing governance. Within each of these competency areas, statements describe the activity or outcomes that prescribers should be able to demonstrate.

The consultation

The first competency concerns assessing the patient. It promotes taking an appropriate medical, social and medication history, before undertaking an appropriate clinical assessment.

The second competency involves the prescriber considering the options for the patient. This includes both non-pharmacological and pharmacological approaches to treatment, and weighing up the risks and benefits to the patient of taking medicine.

The third competency is about reaching a shared decision with the patient/carer, so the patient/carer can make informed choices and agree on a plan that respects the patient’s preferences.

The fourth competency is the prescribing itself. The framework states the medicine should be prescribed only with ‘adequate, up-to-date awareness of its actions, indications, dose, contraindications, interactions, cautions, and unwanted effects.’ Where appropriate, medicines should be prescribed within relevant frameworks, such as local formularies or care pathways.

The fifth competency concerns providing information to the patient/carer about their medicines. This includes what the medicine is for, how to use it, possible unwanted effects and how to report them, and expected duration of treatment.

The sixth and final competency in the area of consultation is monitoring and reviewing. Here the prescriber should establish and maintain a plan for reviewing the patient’s treatment. The effectiveness of treatment and potential unwanted effects should be monitored.

Prescribing governance

The seventh competency, and first under the area of prescribing governance, concerns prescribing safely. It highlights that the prescriber should prescribe within their own scope of practice and recognise the limits of their own knowledge and skill.

The eighth competency comprises prescribing professionally, and ensuring the prescriber maintains confidence and competence to prescribe. This includes accepting personal responsibility for prescribing and understanding the legal and ethical implications.

The ninth competency focuses on improving prescribing practice through reflection. It also stresses the importance of acting on feedback and discussion.

The tenth and final competency involves prescribing as part of a multidisciplinary team to ensure continuity of care across care settings. Part of this concerns establishing relationships with other professionals based on understanding, trust and respect.

Putting the framework into practice

The framework can be used for a variety of reasons by prescribers to help them improve their performance and work more effectively. The following examples are highlighted in the framework:

  • To inform the design and delivery of education programmes; for example, through validation of educational sessions (including rationale for need) and as a framework to structure learning and assessment
  • To help health professionals prepare to prescribe and provide the basis for ongoing education and development programmes, continuous professional development and revalidation processes. For example, use as a framework for a portfolio to demonstrate competency in prescribing
  • To help prescribers identify strengths and areas for development through self-assessment, appraisal and as a way of structuring feedback from colleagues
  • To inform the development of education curricula and relevant accreditation of prescribing programmes for all prescribing professions
  • To provide professional organisations or specialist groups with a basis for the development of levels of prescribing competency; for example, from recently qualified prescriber through to advanced prescriber
  • To stimulate discussions around prescribing competencies and multidisciplinary skill mix at an organisational level
  • To inform organisational recruitment processes to help frame questions and benchmark candidates’prescribing experience
  • To inform the development of organisational systems and processes that support safe effective prescribing; for example, local clinical governance frameworks.

The RPS is liaising with the professional bodies and organisations of the other prescribing professions to encourage uptake of the framework, which will be reviewed again in July 2020.

References

Royal Pharmaceutical Society (2016) A Competency Framework for all Prescribers. http://www.rpharms.com/support-pdfs/prescribing-competencyframework.pdf (accessed 1 August 2016)

Taken from Nurse Prescribing, published 12 August 2016.

Dental Nursing News February 2016

DN News FebPatients test positive for Hepatitis C

dental nurse who spoke out about hygiene conditions at a dentist’s surgeries in Ayrshire—sparking an HIV scare for 5600 patients—was told by the practice manager: ‘no one has caught anything yet,’ a disciplinary hearing has heard.

The nurse, who remains anonymous and is identified only as ‘Dental Nurse One’, contacted the NHS Ayrshire and Arran health board on 16 September 2013, after she was told of the routine reuse of equipment in an area known for high drug dependency.

Dentist Alan Morrison is accused at a General Dental Council Committee of failing to sterilise instruments between treating patients and reusing dirty gloves at his clinics in Cumnock and Drongan.

An investigation was launched into the dentist’s practices after the nurse blew the whistle, sacrificing her new job. At a hearing in London, the nurse recalled how she was offered a job on the spot, but was told by the practice manager, Lorraine Kelly, of procedures that put patients at risk.

‘She then told me that, “We would do things a bit differently here”…She proceeded to tell me that the practices reuse gloves and matrix bands and did not sterilise aspirators.’

The nurse said that she was shocked at Mrs Kelly’s remarks but that the manager replied in a ‘flippant manner’ that ‘no one’s caught anything yet.’ The whistleblower went on to say: ‘Both practices are in areas of high levels of drug use and therefore are likely to have contact with patients with blood-borne viruses. Although Mr Morrison was not present in this conversation, it was obvious he was aware of procedures and practices as owner of the practices and a practising dentist.’

Many patients underwent testing as a result of being sent a letter. No patients had contracted HIV, however four adult patients tested positive for Hepatitis C. Of these, three had evidence of chronic infection and one showed signs of a previous infection.

It emerged at a health board meeting that two of the patients had received dental treatment on the same day.

However, it could not be established whether the infection was picked up from the practice or from outside their dental treatment.

Mr Morrison has admitted falsifying invoices for medical supplies handed to NHS investigators, which showed phoney purchases of single-use equipment, including matrix bands, but denies the rest of the allegations.

Morrison and Kelly are accused of failing to adhere to infection control guidelines and of being dishonest during the health investigation.

NHS England guide to unscheduled care

NHS England has published a quick guide to unscheduled dental care to help provide practical tips for dental providers and commissioners, and relieve pressure on frontline services.

Within the guide, dental health professionals are advised to ensure accessibility of services by keeping their NHS Choices profile and Directory of Services profile up to date, and ensuring their answerphone provides correct details for signposting to 111 for urgent dental care.

To relieve winter pressures on services, it is recommended that patients are encouraged to seek oral care early. Winter campaign materials should be used to promote oral health and seek early advice for oral symptoms, social media and practice websites should be used to provide information about oral health and access to services, and patients should be advised about taking good care of their own oral health.

The guide goes on to say that self-care advice and management of pain is essential during times when dental treatment services are not available. The dental case mix should be managed by suitably trained dental care professionals (DCPs), who should have the capability to book treatment slots directly with dental providers. Where DCPs cannot provide advice, it is recommended that there should be a mechanism for them to refer to a pharmacist or seek additional clinical advice.

The effective triage of patients with dental problems is also emphasised within the guide. It is noted there are a number of options for triage that could be used and the configuration will depend on local requirements, such as the Dental Nurse Triage service that is being procured in London. This service will receive patient information via NHS 111; return calls and carry out a clinical telephone triage using established dental algorithms; and provide information, reassurance and advice to callers and allocate patients to same day, next day treatment slots or signpost to an NHS dental service.

The service will be delivered by trained and experienced dental care professionals, and is planned to operate between 6pm and 8am during the week. It is also planned to operate 24 hours during weekends and bank holidays. The service will have a phased implementation from 1 April 2016 and align with NHS providers in London.

BDA suspends strike action

The British Dental Association (BDA) suspended industrial action planned for 26–28 January in support of the British Medical Association (BMA), as it seeks to rekindle talks to resolve the differences over the proposed new contract for hospital juniors in England.

The BDA has been following the BMA’s lead in disputing the proposed contract, and supporting hospital junior dentist members to ensure a safe and fair junior contract is put in place. BDA junior hospital dentists took action on 12 January, protesting against the erosion of patient safety and the potential impact on dentists’ working lives.

An announcement from the BDA on the proposed contract, said: ‘We feel it removes vital safeguards for both dentists and their patients. We want to ensure dentists are protected from being required to work excessive hours in a week. We oppose the plans for the extension of standard time from the current 7am to 7pm, Monday to Friday to 7am to 10pm, Monday to Saturday, as we don’t feel this values dentists’ time appropriately.

‘We also object to the proposals on pay progression, which may mean some dentists are discouraged from entering specialist training, due to the plans to increase pay only when a trainee moves to the next stage of training and responsibility. We feel this particularly disadvantages those with families, because of the financial worries of taking time out of training for maternity leave or to work part time. It will also discourage those already in training from undertaking research or retraining in a preferred specialty, to the long-term detriment of the NHS.’

Further action for a full withdrawal of labour is still planned for Wednesday 10 February 2016.

Sound bites

Parliament calls for ‘complete overhaul’ of the General Dental Council (GDC). Members of the House of Commons debated the Section 60 Order which, if laid, will allow the GDC to introduce case examiners into its fitness to practise (FTP) process. This followed a debate in the House of Lords on the same subject, during which Shadow Health Minister Lord Hunt repeatedly called for resignations within the GDC.While the debates in both Houses were held to discuss these changes to the Dentists Act 1984, the main focus of the discussions was the performance, and the fitness to regulate, of the GDC. Shadow Health Minister Justin Madders raised the need for a ‘complete overhaul’ of the GDC, calling it the most expensive and least efficient of the health regulators, and noting the lack of confidence the profession has in the GDC.

The National Institute for Health and Care Excellence (NICE) has published new guidelines on oral health promotion in general dental practice, placing a focus on giving patients the ability to make an informed decision about their care. The guidelines cover how general dental practice teams can give advice about oral hygiene, the use of fluoride, as well as how areas such as diet, smoking, smokeless tobacco and alcohol intake affect oral health in order to help patients make informed decisions about their own care and encourage preventive treatments. Dr Ben Atkins, a dentist and Trustee of the British Dental Health Foundation, was a member of the committee for the NICE guidelines. Dr Atkins said: ‘These guidelines outline a patient-centred approach to ensure patients who are using the services are actively involved in discussions and able to make informed decisions about their care.’

Taken from Dental Nursing, published 29 January 2016.

DN_Feb_2016_News_DPS

NICE issues new draft guidelines on heart attack treatment

The National Institute for Health and Care Excellence (NICE) is updating its guidance on the care of people who have survived heart attacks, including new advice on the secondary prevention of myocardial infarctions.

The draft guideline, which was published on June 13 for public consultation, contains a number of important new recommendations aimed at improving the care given to hundreds of thousands of people in England and Wales who have survived heart attacks.

The guidelines were first issued in 2007 and recommended that patients took part in cardiac rehabilitation programmes to increase the chances of a healthy recovery, but because the uptake of these courses was low, the new guidelines call for interventions to ensure more patients benefit from the programmes.

Among the new recommendations issued by the organisation include a focus on the use of interventional procedures such as using stents rather than drugs as a means of widening blocked or narrowed coronary arteries.

Another notable revision to the guidelines is its removal of the advice that patients eat oily fish, or take omega-3 fatty acid capsules or omega-3 fatty acid supplemented foods in the hope of preventing further heart attacks.

It is felt that the impact these foods would have had on preventing heart attacks would be minimal when compared to new treatments that are now available.

Instead, the guidelines call for a more Mediterranean style diet. Some of the products this would encompass, include more bread, fruit, vegetables and fish, and less meat, while replacing butter and cheese with products based on plant oils.

The draft guidelines also includes recommendations on the use of drugs following a heart attack that reflect new findings on treatments to prevent blood clots (antithrombotic therapy) and on the use of drugs to reduce blood pressure and control heart rhythm and rate such as angiotensin-converting enzyme (ACE) inhibitors and beta-blockers.

Professor Mark Baker, director of the centre for clinical practice at NICE, said: ‘Healthcare professionals should ensure that a programmed of education and activity to help people recover from a heart attack and lead their lives as normally as possible, is designed to motivate people to attend and complete it.’

Taken from Journal of Paramedic Practice, published 25 June 2013.