history taking, clinical assessment and diagnosis - workshop...professional staff have prompted...
TRANSCRIPT
History taking, clinical assessment and diagnosis - Workshop
ALISON POTTLE - NURSE CONSULTANT IN CARDIOLOGY
ROYAL BROMPTON & HAREFIELD NHS FOUNDATION TRUST
HAREFIELD HOSPITAL
NURSE PRESCRIBING LEADERSHIP SUMMIT 2020 – FEBRUARY 28 TH 2020
Learning objectives
Ensure you have history taking, clinical assessment and diagnostic skills to prescribe appropriately and effectively
Keep prescribing knowledge up to date; accessing education, training and resources
Diagnostic decision making
Case studies
Background
Historically diagnosis and prescribing have been seen as medical roles
Changes in ways of working by both medical and allied health professional staff have prompted nurses and AHPs to take on skills/practices they have not previously undertaken
Aim is to improve patient care and access to treatment whilst maintaining safety
Advanced nursing roles
The past 2 decades have seen a proliferation of new, advanced clinical roles for nurses in the UK
Advanced nursing – an umbrella concept which covers many clinical roles
Advanced clinical practice
Advanced level practice encompasses aspects of education, research and management but is firmly grounded in direct care provision
(DH 2010,p.7)
CNO Ten Key Roles for NursingOrder diagnostic investigations
Make and receive referrals
Admit and discharge patients
Manage caseloads
Run clinics
Prescribe medicines
Resuscitation procedures
Perform minor surgery
Triage patients
Influence provision of local services
4 pillars of advanced practice
What is competence?
Competence may refer to:◦ Competence (biology), the ability of a cell to take up DNA ◦ Competence (geology), the resistance of a rock against either erosion or deformation ◦ Competence (human resources), a standardized requirement for an individual to properly
perform a specific job ◦ Competence (law), the mental capacity of an individual to participate in legal
proceedings◦ Jurisdiction, the authority of a legal body to deal with and make pronouncements on
legal matters and, by implication, to administer justice within a defined area of responsibility
◦ Linguistic competence, the ability to speak and understand language. ◦ Communicative competence, the ability to speak and understand language.
(Wikipedia…)
What is competence?
Competence may refer to: Competence (biology) the ability of a cell to take up DNA Competence (geology) the resistance of a rock against either erosion or deformation Competence (human resources) a standardized requirement for an individual to
properly perform a specific job Competence (law) the mental capacity of an individual to participate in legal
proceedings Jurisdiction the authority of a legal body to deal with and make pronouncements on
legal matters and, by implication, to administer justice within a defined area of responsibility
Linguistic competence the ability to speak and understand language. Communicative competence the ability to speak and understand language.
(Wikipedia…)
Advanced Nurse Practitioners – an
RCN guide to advanced nursing
practice, advanced nurse practitioners
and programme accreditation
This considers the nurse’s levels of competence as a whole. It combines the skills, knowledge and attitudes, values and technical abilities that underpin safe and effective nursing practice and interventions
ICN Nurse Practitioner/Advanced Practice Nursing network - A Nurse Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice
Competency
Why is competency important?
Maintains standards
Measurable
Facilitates good practice
Patient safety
Organisational accountability/liability
Professional accountability
Core competencies in advanced practicePractising autonomously
Making decisions and being accountable
Admitting and discharging patients
Ability to take a clinical history
Ability to physically examine a patient
Ability to determine a diagnosis
Ability to determine when onward referral is required
Ability to prescribe
Autonomous practice
‘Having the authority to make decisions and the freedom to act in accordance with one’s professional knowledge base’
(Skar, Journal of Clinical Nursing, 2010)
Developing clinical skills
Managing patient caseloads
Prescribing medicines and treatments
Carrying out procedures
Running clinics
(C.N.O. 10 key roles for nurses)
(The NHS Plan (July 2000) www.nhs.uk/nationalplan)
Combining theory and practice
Education
Degree
MSc
Physical assessment
History taking
Prescribing
Developing skills
Practice based learning
Practice based assessment
Clinical supervision
Advancing skills
Advanced clinical and academic skills
Robust frameworks
Education and trainingClinical
•Specific clinical competencies
•Ability to prescribe
•Assessment, history taking, diagnostic skills, knowledge when to treat or refer
Leadership
•Ability to manage change
•Ability to bid for, set up and lead services
•Positive role model
Developing practice
•Developing self
•Developing others
• Improving quality and practice
How do you make a diagnosis?
Clinical history
Physical examination
Appropriate investigations
Interpretation of results
History taking – the theory
Provides subjective data
In ‘vulnerable’ patients – older, cognitive impairment, language difficulties, need to obtain history from a third party
Over 80% of diagnoses are made solely on the basis of history
Need to ensure you ask the right questions
The stages of the interview1. Greeting the patient and establishing rapport
2. Inviting the patient story
3. Establishing the agenda for the interview
4. Generating and testing hypotheses about the nature of the problem by expanding and clarifying the patient's story
5. Creating a shred understanding of the problem
6. Negotiating a plan (includes further diagnostic evaluation, treatment and patient education)
7. Planning for follow-up and closing the interview
(Bates’ Guide to Physical Examination and History Taking. Bickley. 1999)
The seven attributes of a symptom1. Its location. Where is it? Does it radiate?
2. Its quality. What is it like?
3. Its quantity or severity? How bad is it?
4. Its timing. When did (does) it start? How long does it last for? How often does it occur?
5. The setting in which it occurs, including environmental factors, personal activities, emotional reactions
6. Factors that make it better or worse
7. Associated manifestations
Comprehensive historyDate and time of history
Identifying data – name, age
Source of history or referral – patient, friend, medical record
Reliability if relevant – unable to say when symptoms began
Chief complaint(s) – ideally in the patient’s own words
Present illness – clear, chronological account of problem
Past medical history
Allergies
Family history
Social history
Review of systems
Physical examination
Dependant on where you work and how you work
Head to toe
Focussed on presenting problem
Time constraints
Tips for head to toeBe organised – head to toe
Be thorough – look at everything
Be efficient – but not rushed
Be flexible – adapt to the individual
Be sensitive – to unique situations and needs
Think about normal and abnormal
Aim for an overall flow for the process
Focused clinical examinationUsed in general practice, walk-in centres, by specialist nurses
Concentrates on specific presenting problem
Can cut errors and avoid diagnostic delays and reduce unnecessary and potentially harmful investigations
Sometimes additional systems involved
Physical examination allows you to revisit the history and gain valuable clinical information
Diagnostic funnel
Who can order investigations?
Medical staff
Nurses
AHPs
Local/national guidelines
Legislation (IRMER regulations)
Risk/benefit ratio
InvestigationsECG
Ultrasound
CXR
CT scan
Nuclear perfusion scan
Echocardiogram/stress echo
24 hour ECG
Angiography
Blood tests
Guidelines and evidence
Practice must be evidence based1
Numerous guidelines within cardiology – NICE2, ESC3, SIGN4, local
Guidelines help confidence and competence
Enable the effectiveness of practice to be measured - audit
ESC, European Society of Cardiology; NICE, The National Institute for Health and Care Excellence; SIGN, Scottish Intercollegiate Guidelines Network.1. NMC. 2015. Standards of proficiency for nurse and midwife prescribers. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-
standards-proficiency-nurse-and-midwife-prescribers.pdf. 2. NICE CG108. Chronic heart failure in adults: management. September 2010. Available at: https://www.nice.org.uk/guidance/cg108. 3. Ponikowski et al. Eur J Heart Fail 2016;18(8):891–975. 4. SIGN 147. Management of chronic heart failure. March
2016 Available at: http://www.sign.ac.uk/pdf/SIGN147.pdf.
Nailing the diagnosis
Diagnosis
History taking
Physical examination
Identify red flags
Any further investigations
Any further information
required
Any outstanding
results
Knowing when to refer
‘I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery’.
(The Hippocratic Oath: Modern Version. Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University)
Astin et al (2015) A Core Curriculum for the Continuing Professional Development of Nurses Working in Cardiovascular Settings: Developed by the Education Committee of the Council on Cardiovascular Nursing and Allied Professions (CCNAP) on behalf of the European Society of Cardiology European Journal of Cardiovascular Nursing Vol. 14 (S2) S1-17
Skills required to prescribeAdvanced clinical knowledge
Experience in the field
Clinical examination skills
Ability to interpret investigations
Diagnostic skills
Ability to make decisions and work autonomously
One year on the NMC Register (from January 2019)
Where are we now?A quick tour of the evidence base…
Literature is (still) scarce◦ Prescribing authority increases job satisfaction
◦ Enhances relationships with patients
◦ Improves the quality of care, more choice, more convenient
◦ But…
◦ Increases pressure and workload
Developing confidence in prescribing practice
‘Self reported confidence in prescribing skills correlates poorly with assessed competence in fourth-year medical students’
(Brinkman et al 2015; Clinical Therapeutics Vol 37; e1)
Influences on prescribing‘Prescribing is a complex skill that is high risk and error prone, with many factors influencing its practice, whether contextual of psychological’
(Lewis et al 2014)
Confidence
Time since qualifying
Training
Continuous practice
Multidisciplinary support
Use of formularies or guidelines
ConfidenceNurses – knowledge of pharmacology
Pharmacists – ability to undertake physical examination or to diagnose
(Latter et al 2012)
Prescribing can be scary!!
Practice with PGDs or protocols can help with preparation
Medical support – engaged DMP
Clinical supervision
Peer supervision; support from other NMPs
The role of the Trust Lead
Aims of non-medical prescribingThe aims of non-medical prescribing in the Trust are to:-
improve patient care without compromising patient safety;
make it easier for patients to get the medicines they need;
increase patient choice in accessing medicines;
make better use of the skills of health professionals;
contribute to the introduction of more flexible team working across the NHS.
The system used to supply medicines must fulfill the above requirements
Non-medical prescribers annual declaration of competence
Area to self-certify YES /
NO
Comments / Evidence/ Action to be
undertaken if required
Reviewed Scope in line with current
role and responsibilities
Scope extension required?
Circumstances impacting upon
prescribing practice over past year
discussed and addressed with line
manager and/or DMP, practice
supervisor and/or NMP Lead
e.g.long-term sickness, maternity
leave, change in role
If circumstances have not been discussed or
addressed an action plan is required.
Participated in prescribing related
CPD activities e.g. in-house forums,
presentations, conference
attendance, literature read or
reviewed, attended medicines
related committee
Applied professionalism to all
aspects of practice in line with
professional code, standards and
guidance
Received clinical supervision or
opportunities to reflect in relation to
prescribing / opportunities to
discuss prescribing decision making
Participated in clinical audit, quality
improvement or service
development activities relating to
prescribing area
I have reviewed my learning and development needs against the ten dimensions of the RPS Competency Framework for all Prescribers (2016) and I have documented one example below per competency
dimension as evidence of competence and/or areas for development. I have reflected on one of these competencies for discussion with my DMP/ Peer Equivalent NMP
The Consultation
1.Assess the patient Evidence of competence / Areas for
development
2.Consider the options Evidence of competence / Areas for
development:
3. Reach a shared decision Evidence of competence / Areas for
development
4. Prescribe Evidence of competence / Areas for
development
Prescribing
Governance
5. Provide information Evidence of competence /
Areas for development
6. Monitor & Review Evidence of competence /
Areas for development
7. Prescribing safely Evidence of competence /
Areas for development
8. Prescribe professionally Evidence of competence /
Areas for development
9. Improve prescribing
practice
Evidence of competence /
Areas for development
10. Prescribe as part of a
team
Evidence of competence /
Areas for development
Declaration
My job description includes a prescribing statement
I have read the Royal Pharmaceutical Society (RPS) publication ‘A Competency Framework for all Prescribers 2016’
I have reviewed my competence and accurately reflected on my on-going development needs
I have discussed this declaration and my reflection with my DMP or peer equivalent non-medical prescriber or practice assessor
I will discuss this declaration at my annual appraisal
I have the knowledge and skills to safely prescribe within the level of my experience and competence, and I will act in accordance with the professional and ethical frameworks described by my professional body
I have read the RBHT Non-Medical Prescribing Policy
I have attended the mandatory minimum of 50% of in house forums / CPD sessions
Prescribers Signature:
Date:
DMP or Peer Name and Signature:
Date:
Acknowledged by Line Manager:
Line Managers Printed Name:
Line Managers Signature:
Date:
My prescribing story
Nurse Consultant June 2000
PGDs
Qualified as non-medical prescriber 2005
Initially supplementary prescribing
Independent prescribing
My prescribing in 2019No.
Apheresis unit RACPC Pre admission clinic Day case unit OPD TAVI pre admission clinic
100 patients prescribed for
Prescribing in the Rapid Access Chest Pain Clinic 2019
0 2 4 6 8 10 12
Aspirin
Bisoprolol
GTN spray
Lansoprazole
ISMN
Atorvastatin
No.15 patients prescribed for
Case study 1
43 year old male
2-month history of central chest pain which occurs every time he walks
Associated with breathlessness and sweating
Relieved by rest
Typical story for angina
Case studyRisk factors for CAD –
Ex smoker – stopped 6 months ago, raised cholesterol (TC 5.97mmol/L)
(Psoriasis)
No family history of heart disease
CXR – normal
Coronary calcification score 243 >90th centile
Case studyPrescribed –
Aspirin 75mg od
Atorvastatin 20mg od
Bisoprolol 1.25mg od
GTN spray
Admitted for angiogram – PCI to RCA
Benefits
Timely prescribing of essential medication
Patient safety/reassurance
Symptom management
Evidence-based prescribing
Case study 265 year old Asian male
Referred to RACPC with breathlessness
No chest pain
3-month history
PMH;
Type 2 diabetes
Hypertension
Clinical observationOverweight – central obesity
Walking to clinic room – patient obviously breathless
Had to stop every 20 meters to rest
Diagnosis?
Physical examinationNormal heart sounds
Chest clear
BP 145/85
No oedema
No carotid bruits
Peripheral pulses present
Abdomen – soft non tender
InvestigationEchocardiogram
Chest CT scan
Results and final diagnosis
Hb 5.8mg/dl
Anaemia!!
Ward rounds
Year March 2010-April 2011
April 2011-March 2012
2012 2013 2014 2015 2016 2017 2018 2019
Number of patients reviewed
1070 833 807 669 591 459 548 325 269 91
CNS 112 136
Total 427 405
Results
60
8 7
Number of patients who were prescribed for
Primary Elective ACS
Total of 133 medication changes made for 69 patients
Main changes to medicationDrug New
prescriptionDose titrated ↑
Dose titrated ↓
Stat dose Drug stopped
ACEi 4 13 2 1 1
Bisoprolol 5 5 1 5
Atorvastatin 2 4
Enoxaparin 28
GTN spray 9
NRT 9
Lansoprazole 2 7
Rosuvastatin 1
ISMN 2 2
Amlodipine 1 1 2
Regular meds 3
Case study – group workWork in groups to discuss the case study
Consider the history – what questions do you need to ask the patient?
What is/are the potential diagnosis/es
What tests might you want to do?
What else would you include in your consultation?
Case studyJohn is a 55 year old man who had a heart attack in January 2019
His past medical history includes arthritis and raised cholesterol
He is active and walks every day
He has just joined a gym and goes 2-3 times a week
Medication:
◦ Aspirin 75mg od
◦ Ticagrelor 90mg bd
◦ Ramipril 2.5mg od
◦ Bisoprolol 2.5mg od
◦ Atorvastatin 80mg od
◦ GTN spray PRN
Reason for appointmentJohn has come in for his annual review
He has noticed that his legs have been aching a lot more in the last few weeks
He reads the Daily Express and has read several bad articles on statins
His neighbour had muscle aches which he told him was due to taking statins
He is sure the Atorvastatin is the cause of his muscle pains and so he has stopped it
Group activity
Consider the history – what questions do you need to ask the patient?
What is/are the potential diagnosis/es
Are there any tests you might want to do?
What else would you include in your consultation?
10 minutes for discussion
'Do YOU have two or more children? You're at risk of heart disease -
because they are so expensive to look after'
Keeping up to dateShort update sessions
Peer review
Informal multi-disciplinary meetings
Audit
Protected time for professional reading
Performance appraisal
Organised Prescribing courses
Critical incident analysis
Clinical visits to other professionals involved in prescribing
Electronic updates & alerts
Professional Journals
Clinical Supervision
Publish articles
Conference presentations
Appraisal
Study days
Local prescribing network meetings
Trust prescribing lead
Peer support and supervision
Mentoring/coaching
Measuring impact
Don’t need to justify role
Don’t need to provide a list…
Audit measures the potential benefit of non-medical prescribing
Adherence to guidelines can be measured
Evidence for expansion in advanced nursing roles and non-medical prescribing
Impact on the nursing role
Autonomy
Facilitates total patient management
Affect on workload
Improvement in knowledge
Medicines adherence
Drugs will only work if they are taken!
Informing and empowering
Patients believe what they read in the newspapers
Must take patients view into account
Partnership between the prescriber and the patient
The value of nursing
Goes beyond the medical model
Nurse with your hands, head and heart
Develop a partnership with the patient
Value the individual’s perspective, hopes and aspirations
Enables us to provide holistic care and support to our patients
Advanced nursing care changing nursing
Advanced practice changes every aspect of nursing
If we get it right then nursing and patient care moves forward and we provide expert life-enhancing care
Advanced practice contributes to the continuing development of nursing
Conclusion
Advanced nursing skills including non-medical prescribing improve the quality of care given to patients
Facilitates running of a seamless service
Quality and safety need to be maintained and monitored
Need to ensure we only work within our scope of competence/expertise
