Notes on NICE Guidance CG180 Atrial Fibrillation [AF] : management

1. Notes on NICE Guidance CG180 Atrial Fibrillation [AF] : management Steve Turner is a NICE Medicines & Prescribing Team Associate, who has a special interest in multimorbidity. Steve & Associates develop & deliver Patent Led Clinical Education services. Steve is Head of Medicines & Prescribing for #MedLearn (Medicine Gov). Notes from Steve Turner @MedicineGovSte to subscribe to my email updates on medicines & prescribing send details to info@carerightnow.co.uk (#GDPR complaint) Link to Guidance: https://www.nice.org.uk/guidance/cg180 (accessed 12/3/2018)

2. Notes on NICE Guidance CG180 Atrial Fribrillation : management Notes from Steve Turner @MedicineGovSte Link to Guidance: https://www.nice.org.uk/guidance/cg180 (accessed 12/3/2018)

3. •One prescription from a GP costs (on average) £41.35. •A GP visits costs £45 each for a 11.7 minute consultation. •A telephone consultation with a G.P. costs £27 for a 7.1 minutes. •A home visit from a G.P. lasting 23.4 minutes costs £114. •A 15 minute appointment with a nurse in a GP practice costs £13.

4. Thought provoking healthcare pledges – Hospital staff ‘I will not discharge a vulnerable person in the middle of the night.’

5. Advice for healthcare professionals: be extra vigilant when prescribing and dispensing medicines with commonly confused drug names to ensure that the intended medicine is supplied if pharmacists have any doubt about which medicine is intended, contact the prescriber before dispensing the drug follow local and professional guidance in relation to checking the right medicine has been dispensed to a patient report suspected adverse drug reactions where harm has occurred as a result of a medication error on a Yellow Card or via local risk management systems that feed into the National Reporting and Learning System Source: https://www.gov.uk/drug-safety-update/drug-name-confusion-reminder-to-be-vigilant-for-potential-errors (accessed 18/02/2018)

6. Advice for healthcare professionals: new co-dydramol products are available with a higher dose of dihydrocodeine (co dydramol 20/500 mg and co-dydramol 30/500 mg tablets) when prescribing co-dydramol, clearly indicate tablet strength and dose when dispensing co-dydramol, ensure patients receive the prescribed strength of co dydramol, and, if in doubt, contact the prescriber report suspected adverse drug reactions with opioids, including any harm from medication error, via the Yellow Card Scheme Source: https://www.gov.uk/drug-safety-update/co-dydramol-prescribe-and-dispense-by-strength-to-minimise-risk-of-medication-error?mc_cid=189743028d&mc_eid=dea7794502 (accessed 16/02/2018)

7. ‘Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia1 and its prevalence is increasing. A patient with atrial fibrillation has a 5-fold increase in the risk of stroke and 20–30% of all strokes are attributed to this arrhythmia.’ Source: https://www.nice.org.uk/sharedlearning/safe-and-effective-management-of-stroke-prevention-in-atrial-fibrillation (accessed 16/0220180

8. ‘Managing medicines for adults receiving social care in the community’ is a landmark guideline that will improve the safety of medicines handling in people’s own homes. Source: https://goo.gl/qV4U6E (accessed 5/2/2018)

9. Additional funding, aimed to help the NHS get on a financially sustainable footing, has instead been spent on coping with existing pressures, according to the National Audit Office’s (NAO) report….. Source: https://www.nao.org.uk/press-release/sustainability-and-transformation-in-the-nhs/ (Accessed 21/1/2018)

10. ‘ …NHS England would like to remind all relevant health care professionals of the guidance contained in the BNF and NICE guideline 46…, “Controlled Drugs, Safe Use and Management” that it is considered best practice to include: • clear dosing instructions on the prescription • clear dosing instruction on the corresponding medicine label, such as the individual • unit dose and maximum total daily dose. • To reduce the risk of confusion or misunderstanding at a later date, particularly when terms such as ‘as directed’, ‘when required’ or similar phrases are used…’ • Source: http://www.carerightnow.co.uk/wp-content/uploads/2018/01/Regulation-28-Letter-15-12-17-07519-1.pdf (accessed 2/1/2018)

11. ‘Record high numbers of self-inflicted deaths and incidents of self-harm in prisons are a damning indictment of the current state of the mental health of those in prison and the prison environment overall. ‘ Source: https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/400/400.pdf (accessed 2/1/2018)

12. ‘The Board has today agreed these treatments should no longer be routinely prescribed: • Homeopathy – no clear or robust evidence to support its use. • Herbal treatments – no clear or robust evidence to support its use. • Omega-3 Fatty Acid Compounds (fish oil) – essential fatty acids which can be obtained through diet, low clinical effectiveness. • Co-proxamol – pain killer which has had its marketing authorisation withdrawn due to safety concerns. • Rubefacients (excluding topical NSAIDS) – warming muscle rub products, limited evidence. • Lutein and Antioxidants – used to treat the eye condition age related macular degeneration , low clinical effectiveness. • Glucosamine and Chondroitin – used for joint pain, low clinical effectiveness. • A joint clinical working group considered the responses to the consultation and agreed that the recommendations for the 18 products consulted on should either remain unchanged (13 products) or be modified or clarified in five cases (Liothyronine, Travel Vaccines, Lidocaine Plasters and Immediate Release Fentanyl).’ • Source: https://www.england.nhs.uk/2017/11/prescription-curbs-to-free-up-hundreds-of-millions-of-pounds-for-frontline-care/ (accessed 4/12/2017)

13. Notes on: Notes from Steve Turner @MedicineGovSte Link to source(s) :

14. Notes of NICE Guidance NG80 Asthma: diagnosis, monitoring and chronic asthma management November 2017 Notes from Steve Turner @MedicineGovSte Link to Guidance: https://www.nice.org.uk/Guidance/NG80 (accessed 7/12/2017)

15. Did you know? • Between 5 and 10% of all hospital admissions are medicines-related • Two thirds of medicines-related hospital admissions are preventable • The overall NHS drugs bill is £16.8 billion a year • The NHS drugs bill is rising by 8% a year which is more than the current annual increase in funding • A 2010 report estimated the national figure for pharmaceutical waste to be £300 million • Source: https://www.england.nhs.uk/medicines/value-programme/ (accessed 21/12/2017)

16. The updated “Orange book’ offers new guidance on: prison-based treatment; new psychoactive substances and club drugs; mental health co-morbidity; misuse of prescribed and OTC medicines; stopping smoking and preventing drug-related deaths, including naloxone provision

17. Funding has been approved for a new specialised service for Stevens-Johnson syndrome, immediate antiretroviral therapy for treatment of HIV-1 in adults and adolescents and bendamustine with rituximab for the treatment of non-Hodgkin’s and mantle cell lymphoma Source: https://www.england.nhs.uk/2017/12/nhs-england-announces-new-specialised-treatments-for-patients/ (accessed 19/12/2017)

18. Related to an alert or safety warning

19. Other info…

21. Other info….

22. We tweet short health and social care stories, from patients, public, staff, carers, relatives. Most are fictional. All are based on real experiences. They are entered without commentfor everyone, including clinical educators, to reflect on/use in teaching/ supervision/ mentoring/ peer support etc. The tweets aim to promote discussion on all points of view, & stimulate learning & actions, by seeing things from all perspectives. They cover all of health and social care. Subjects are prioritised according to their impact on patient safety. Editors: Steve Turner & Sam Williams @SteveMedGov @care_right_now

23. ‘ Sending in the crisis team is more for your benefit than for mine. I have to wait in for them most of the day & don’t feel it benefits me at all.’ User of Community Mental Health services

24. Neurolpetic Malignant Syndrome A serious, potentially life-threatening complication of treatment with antipsychotic drugs or abrupt withdrawal of dopamine agonists. Characterised by a tetrad of altered mental status, muscle rigidity, autonomic instability, and hyperthermia. A diagnosis of exclusion. Common differential diagnoses are sepsis and drug reactions. NMS is a medical emergency. Treatment consists of immediate cessation of the offending medication and provision of supportive measures (hydration and cooling). Additional treatment may be considered if supportive interventions fail. Source: BMJ http://bestpractice.bmj.com/topics/en-gb/990 (accessed 9/11/2017)

25. ‘I’ve fallen off the edge. Every week a different community mental health nurse came to see me. Then nobody came.’ User of Community Mental Health services

26. Mental Health Nursing students’ comment: ‘Think about the person’s needs rather than the target.’ Best practice exercise feedback. Second year students.

27. Ready for discharge? Alice (84) is sitting by her hospital bed in the ward waiting to go home. She’s told staff she manages well at home, ‘yes’ she can cook for herself, ‘yes’ she can manage her daily life, ‘yes’ she takes her medicines, and that her daughter visits everyday. She’s going back to an empty flat with no hot water, faulty heating, and partially opened medicines packets strewn around. Her daughter has 3 small children and visits Alice every week. She is unaware her mother has been discharged.

28. Principles that Guide the NHS – from the NHS Constitution 5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population. Source: NHS Constitution for England https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/480482/NHS_Constitution_WEB.pdf (accessed 13/11/2017)

29. Principles that Guide the NHS – from the NHS Constitution 4. The patient will be at the heart of everything the NHS does. Source: NHS Constitution for England https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/480482/NHS_Constitution_WEB.pdf (accessed 13/11/2017)

30. ‘No decision about me without me’ Source: Department of Health 2012 http://ow.ly/clOr30gzmZH (accessed 14/11/2017)

31. ‘I feel safe with the student nurses. If they don’t know something they always ask for a second opinion’ NHS Inpatient, 2017

32. ‘Some of my doctors copy their letters about me to me, some don’t. I thought copying letters was supposed to be standard practice?’ NHS Patient with multiple long term conditions, 2017

33. Medicines and Healthcare Regulatory Agency – [MHRA] Yellow Card Scheme • ‘The Scheme collects information on suspected problems or incidents involving • side effects (also known as adverse drug reactions or ADRs) • medical device adverse incidents • defective medicines (those that are not of an acceptable quality) • counterfeit or fake medicines or medical devices • safety concerns for e-cigarettes or their refill containers (e-liquids) • It is important for people to report problems experienced with medicines or medical devices as these are used to identify issues which might not have been previously known about. The MHRA will review the product if necessary, and take action to minimise risk and maximise benefit to the patients. The MHRA is also able to investigate counterfeit or fake medicines or devices and if necessary take action to protect public health.’ • Link: https://yellowcard.mhra.gov.uk/the-yellow-card-scheme/ (accessed 20/11/2017)

34. Source: https://twitter.com/cockpitmedizin/status/930810018668208128

35. The birth of a man is the birth of his tomorrow. The longer he lives, the more stupid he becomes, because his anxiety to avoid unavoidable death becomes more and more acute. What bitterness! He lives for what is always out of reach! His thirst for survival in the future makes him incapable of living in the present. CHAG TZU

36. “In the beginner’s mind there are many possibilities, but in the expert’s there are few” Shunryu Suzuki

37. ‘Accept that the patient has the right to decide not to take a medicine, even if you do not agree with the decision, as long as the patient has the capacity to make an informed decision and has been provided with the information needed to make such a decision.’ Source: NICE Guidance on Medicines Adherence http://ow.ly/eBx130gKvvg (accessed 22/11/2017)

38. ‘You have the right to be involved, directly or through representatives, in the planning of healthcare services commissioned by NHS bodies, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.’ Source: NHS Constitution for England http://ow.ly/CuiZ30gKzB7 (accessed 22/11/2017)

39. ‘NICE guidance is not mandatory. …recommendations never instruct a GP or healthcare professional to do anything. We are here to support their decisions, not dictate them. We assess the very best, highest quality evidence so that they can trust our advice is reliable, but it is then up to them as to whether they follow what we suggest, or whether they think their patient would benefit from a different approach. We recognise that they are best placed to make this call. They are the people who see, treat and talk to their patients about what they want and need, after all.’ Professor Mark Baker, NICE Source: http://wames.org.uk/cms-english/2017/09/guidelines-not-tramlines-nice-guidance-is-not-mandatory/ (accessed 22/11/2017)

40. ‘The Centre for Health and the Public Interest (CHPI) began operation in June 2013 as a dynamic health and social care policy think-tank committed to the founding principles of the NHS. The primary focus of the Centre is to ensure that the public interest is given paramount importance in the development and discussion of health and social care policy.’ Source: https://chpi.org.uk/about/ (accessed 24/11/2017)

41. Thought provoking healthcare pledges – Hospital staff ‘I will not discharge a vulnerable person in the middle of the night.’

42. Thought provoking healthcare pledges – Healthcare Practitioners (HCPs) ‘When short staffed we prioritise patient care and defer all non-care related activities.’

43. Thought provoking healthcare pledges – Community Staff ‘I will not discharge a vulnerable person if the only reason is to meet a target or because their session limit is reached’