Recommendation 1
In hospital care settings the use of any antibiotic should be reviewed within 72 hours of being started.
Evidence/guidance
ARK virtual learning open access via BSAC
Government UK resources on Antimicrobial resistance
International Pharmaceutical Federation (FIP). Fighting antimicrobial resistance: The contribution of pharmacists
Morley G, Wacogne I. UK recommendations for combating antimicrobial resistance: a review of ‘antimicrobial stewardship: systems and processes for effective antimicrobial medicine use’ (NICE guideline NG15, 2015) and related guidance. Arch Dis Child Educ Pract Ed. 2017. pii: edpract-2016-311557.DOI: 10.1136/archdischild-2016-311557.
Ashiru-Oredope D, et al. Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart–Then Focus. J Antimicrob Chemother. 2012;67 Suppl 1:i51-63. DOI: 10.1093/jac/dks202.
Pinder R, et al. Behaviour change and antibiotic prescribing in healthcare settings – Literature review and behavioural analysis. Public Health England, London; February 2015.
Patient information
NHS Choices. Antibiotics
Public Health England. Keep Antibiotics Working
Recommendation 2
People should be advised on and signposted to alternative options by their pharmacist such as self-care, lifestyle changes and non-pharmacological interventions where appropriate.
Evidence\guidance
Taylor DA, et al. 2019. Perceptions of Pharmacy Involvement in Social Prescribing Pathways in England, Scotland and Wales. Pharmacy (Basel), 7(1). pii: E24. doi: 10.3390/pharmacy7010024.
Kellezi B, et al. 2019. The social cure of social prescribing: a mixed-methods study on the benefits of social connectedness on quality and effectiveness of care provision. BMJ Open, 14;9(11):e033137. doi: 10.1136/bmjopen-2019-033137.
Linsky A, et al. 2019. Deprescribing in the context of multiple providers: understanding patient preferences. Am J Manag Care, 25(4):192-198. https://www.ncbi.nlm.nih.gov/pubmed/30986016.
Kaufman G, et al. 2017. Considering patient experience and evidence-based choice of medicines in medicines optimisation. Nurs Stand, 31(42):54-63. doi: 10.7748/ns.2017.e10883.
A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications. University of Westminster, 2017.
Patient information
National voices: Supporting self-management
Recommendation 3
All medicines a person is being prescribed are appropriate for the individual and are optimised in line with personal goals in all care settings. This may involve discontinuing or deprescribing some medicines. This will improve access for people to medicines expertise and making medicines use as safe as possible.
Evidence/Guidance
Linsky A, et al. 2019. Deprescribing in the context of multiple providers: understanding patient preferences. Am J Manag Care, 25(4):192-198.
Molnar F, Frank C. 2019. Problem-based deprescribing: Using your patients’ clinical concerns to guide medication review. Can Fam Physician, 65(4):266. https://www.ncbi.nlm.nih.gov/pubmed/30979758.
Aoki T, et al. 2019. Factors associated with patient preferences towards deprescribing: a survey of adult patients on prescribed medications, Epub ahead of print. Int J Clin Pharm. doi: 10.1007/s11096-019-00797-4.
Turner JP, et al. 2018. Strategies to promote public engagement around deprescribing. Ther Adv Drug Saf, 9(11):653-665. doi: 10.1177/2042098618794165.
Kaufman G, et al. 2017. Considering patient experience and evidence-based choice of medicines in medicines optimisation. Nurs Stand. 2017 Jun 14;31(42):54-63. doi: 10.7748/ns.2017.e10883.
Royal Pharmaceutical Society guidance on polypharmacy (2018)
Patient information/decision aids
NHS. Medicines: Tips for carers
Royal Pharmaceutical Society. Making the most of your medicines
Recommendation 4
Stop the inappropriate use of antipsychotics to manage behaviour that challenges in people with learning disabilities, dementia and other mental health conditions
Evidence/guidance
Nice (KTT19) Psychotropic medicines in people with learning disabilities whose behaviour challenges.
Care Quality Commission. Survey of medication for detained patients with a learning disability. 2016
Deb S., Clarke D. & Unwin G. (2006) Using medication to manage behaviour problems among adults with a learning disability: Quick Reference Guide (QRG). University of Birmingham, MENCAP, The Royal College of Psychiatrists, London, UK. ISBN: 0855370947.
Royal College of Psychiatrists, British Psychological Society and Royal College of Speech and Language Therapists (2007): Challenging behaviour: a unified approach: Clinical and service guidelines for supporting people with learning disabilities who are at risk of receiving abusive or restrictive practices.
Patient information/decision aids
NHS. How to deal with challenging behaviour in adults
Challenging behaviour foundation. The use of medication for challenging behaviour
Recommendation 1
Do use training of psychologically informed practice for clinicians treating patients with sub-acute and chronic low back pain. e.g. Back Skills Training (BeST) intervention
Evidence/guidance
Nice Guidelines (NG59) Low back pain and sciatica in over 16s: assessment and management
Future Learn. Back Skills Training Programme
Lamb et al, Lancet. 2010 Mar 13;375(9718):916-23.doi: https://doi.org/10.1016/S0140-6736(09)62164-4
Cherkin DC, et al JAMA. 2016 Mar 22-29;315(12):1240-9. https://jamanetwork.com/journals/jama/fullarticle/2504811
Patient information/ decision aids
Keele University, Start Back. Your guide to back pain and what you can do about it
Recommendation 2
Do use stratification tools to guide treatment for patients with back pain e.g. include STarT Back in Primary Care.
Evidence\guidance
Nice Guidelines (NG59). Low back pain and sciatica in over 16s: assessment and management
Hill etal. Lancet. 2011 Oct 9802:1560-1571. doi: https://doi.org/10.1016/S0140-6736(11)60937-9
Foster etal. Ann Fam Med. 2014 Mar-Apr;12(2):102-11. doi: 10.1370/afm.1625
Bradbury (2013) A stratified approach to the treatment of low back pain. Staffordshire and Stoke on Trent Partnership
NHS England (2017) National Low Back and Radicular Pain Pathway
Keele University, Start Back. Your guide to back pain and what you can do about it
Patient decision aids
Start Back Your guide to back pain and what you can do about it
NHS. Back pain overview
Recommendation 3
Do offer a structured education and neuromuscular exercise programme for patients with osteoarthritis, to enable self-management and coping with arthritis e.g. ESCAPE- pain
Evidence\guidance
Hurley 2007 Clinical Effectiveness of a Rehabilitation Program Integrating Exercise, Self-Management, and Active Coping Strategies for Chronic Knee Pain: A Cluster Randomized Trial Arthritis & Rheumatism (Arthritis Care & Research) Vol. 57, No. 7, October 15, 2007, pp 1211–1219 doi: 10.1002/art.22995
Jessop 2009 Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain. doi: 10.1016/j.physio.2009.01.005
Hurley 2012 Long-Term Outcomes and Costs of an Integrated Rehabilitation Program for Chronic Knee Pain: A Pragmatic, Cluster Randomized, Controlled Trial Arthritis Care & Research Vol. 64, No. 2, February 2012, pp 238 –247 doi: 10.1002/acr.20642
NICE Guidelines (CG177) Osteoarthritis: care and management
Patient information/decision aids
Escape pain – personal stories
NHS. Osteoarthritis treatment and support
Recommendation 4
Do offer a three-month trail of supervised pelvic floor muscle training as a first line treatment to pregnant women and women experiencing stress or mixed urinary incontinence.
Evidence\guidance
Nice Guidance (NG123) Urinary incontinence and pelvic organ prolapse in women: management
Chochrane Library. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women
Patient information/decision aids
Pelvic Obstetric and Gynaecological Physiotherapy Booklets
Royal College of Obstetricians and Gynaecologists. Pelvic organ prolapse
Pelvic floor exercies (in multi languages)
NICE patient decision aid. Surgery for stress urinary incontinence
NHS Choices. How and when should I do pelvic floor exercises
Recommendation 5
Do offer a programme of supervised pelvic floor muscle training (PFMT), alongside lifestyle modifications and vaginal oestrogen, if appropriate, for a minimum of 16 weeks (continue if effective) to women with symptomatic prolapse, before surgery is considered
Evidence\guidance
Nice Guidance (NG123) Urinary incontinence and pelvic organ prolapse in women: management
Hagen et al (2014) Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial Lancet VOLUME 383, ISSUE 9919, P796-806, MARCH 01, 2014. doi:https://doi.org/10.1016/S0140-6736(13)61977-7
Braekken et al (2010) Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010 Aug;203(2):170.e1-7. https://doi.org/10.1016/j.ajog.2010.02.037
Patient information/decision aids
Pelvic Obstetric and Gynaecological Physiotherapy Booklets
Royal College of Obstetricians and Gynaecologists. Pelvic organ prolapse
Pelvic floor exercies (in multi languages)
NHS Choices. How and when should I do pelvic floor exercises
Recommendation 6
Do offer a strength and balance exercise programme, with a minimum of 50 hours’ dosage, to older people living in the community who have experienced any of the following:
- More than one fall in the last year
- Problems with balance or walking
- Fear of falling or reduced confidence when walking.
Evidence\guidance
NICE Guidance (CG161) Falls in older people: assessing risk and prevention
NICE guidance (QS86) Falls in older people quality standard [QS86]
Public Health England. Falls and fracture consensus statement. Supporting commissioning for prevention
Public Health England. Muscle and bone strengthening and balance activities for general health benefits in adults and older adults
NHS RightCare. RightCare Pathway: Falls and Fragility Fractures
Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2019(1) https://doi.org//10.1002/14651858.CD012424.pub2
Kendrick D, Kumar A, Carpenter H, et al. Exercise for reducing fear of falling in older people living in the community. Cochrane Database of Systematic Reviews. 2014(11) https://doi.org//10.1002/14651858.CD009848.pub2
Centre for Ageing Better. Raising the bar on strength and balance: The importance of community-based provision. London: Centre for Ageing Better; 2019. https://bit.ly/2BwISM3)
Patient information/decision aids
Chartered Society of Physiotherapy. Get up and go – a guide to staying steady
Chartered Society of Physiotherapy. Never too late campaign
Chartered Society of Physiotherapy. Love activity, hate exercise? Campaign
NHS live well. Physical activity guidelines for older adults
1. Day surgery should be considered the default for many elective surgical procedures. Variation in the use of day surgery for these operations should be measured and this information should be available to patients.
Evidence/guidance
- Report by John Appleby from the Kings Fund BMJ2015;351:h4060doi: 10.1136/bmj.h406
- British Association of Day Surgery has a bench marking tool for day surgery
2. With the appropriate preoperative assessment and preparation elective surgical patients do not need to be admitted to hospital the day before their operation.
Evidence/guidance
3. Healthy patients having planned minor or intermediate surgery do not need routine preoperative tests. NICE guideline should be used (NG 45) to help determine which tests are appropriate.
Evidence/guidance
4. Patients choosing surgery who are at a high risk of dying after an elective surgical procedure (predicted 30-day mortality of greater than 1%) should be identified by their age, type of surgery and coexisting medical conditions. They should have a shared decision-making consultation to discuss their individual chance of benefit or harm and to identify their personal preference.
Shared decision aids to use with patients
- The NHS Right Care website details the steps to go through for shared decision making. Use the principles if there is not a specific one to the operation being considered.
Evidence/guidance
- RCOA report: Guidance on the Provision of Anaesthesia Services for Pre-operative Assessment and Preparation 2016
- NCEPOD report: Knowing the Risk A review of the peri-operative care of surgical patients
5. Patients should be helped to stop smoking, reduce alcohol consumption, improve fitness and nutrition and modify weight where possible. This should be in addition to active measures to optimise individual medical conditions before surgery.
Shared decision aid to use with patients
Evidence/guidance
Recommendation 1
Not all patients with simple respiratory tract infection infections will need antibiotics.
Evidence/guidance
English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2017
Antibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study. BMJ. 2017 May 22;357:j2148. doi: 10.1136/bmj.j2148.
Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2013 Jun 4;(6):CD000247. doi: 10.1002/14651858.CD000247.pub3.
Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2017 Jun 19;6:CD000245. doi: 10.1002/14651858.CD000245.pub4.
Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis. 2013 Feb;13(2):123-9. doi: 10.1016/S1473-3099(12)70300-6. Epub 2012 Dec 19.
Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups. Br J Gen Pract. 2014 Feb;64(619):e75-80. doi: 10.3399/bjgp14X677121.
Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD010257. doi: 10.1002/14651858.CD010257.
Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev. 2017 Sep 7;9:CD004417. doi: 10.1002/14651858.CD004417.pub5.
Influenza vaccine effectiveness among high-risk groups: A systematic literature review and meta-analysis of case-control and cohort studies. Hum Vaccin Immunother. 2017 May 8:1-12. doi: 10.1080/21645515.2017.1321722. [Epub ahead of print]
Effectiveness of the 23-Valent Pneumococcal Polysaccharide Vaccine (PPV23) against Pneumococcal Disease in the Elderly: Systematic Review and Meta-Analysis. PLoS One. 2017 Jan 6;12(1):e0169368. doi: 10.1371/journal.pone.0169368. eCollection 2017.
Trends in antibiotic resistance of Streptococcus pneumoniae and Haemophilus influenzae isolated from nasopharyngeal flora in children with acute otitis media in France before and after 13 valent pneumococcal conjugate vaccine introduction. BMC Infect Dis. 2015 Jun 21;15:236. doi: 10.1186/s12879-015-0978-9.
US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016 Nov 22;316(20):2115-2125. doi: 10.1001/jama.2016.16201.
Antibiotics, gut microbiome and obesity. Clin Endocrinol (Oxf). 2018 Feb;88(2):185-200. doi: 10.1111/cen.13495. Epub 2017 Nov 20.
The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda and management guidelines:
Public Health England. Managing common infections: guidance for primary care
NICE. Self-limiting respiratory tract infections – antibiotic prescribing overview
NICE. Managing exacerbations of COPD
National guidelines recommend influenza and pneumococcal vaccination for patients at risk:
Public Health England. National flu immunisation programme for 2017-18
Pneumococcal: the green book, chapter 25
Patient information/decision aids
Adults and children:
Public Health England. Treating your infection leaflets.
Children:
Caring for children with coughs
Recommendation 2
Clinician
Review use of antibiotics for patients with bacteria in their urine who have no, minimal, non-specific, or long-standing urinary symptoms
Evidence\guidance
Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis2005;40:643-54.
Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents? Ann Intern Med1995;122:749-54
Health Protection Agency. English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011
Urinary tract infection in old age: over-diagnosed and over-treated. Age Ageing. 2000 Jul;29(4):297-8
Testing for urinary infection using urinary reagent test strips in unselected acute medical patients. Clin Med (Lond). 2007 Dec;7(6):645-6.
Benefits and Harms of Treatment of Asymptomatic Bacteriuria: A Systematic Review and Meta-analysis by the European Association of Urology Urological Infection Guidelines Panel. Eur Urol. 2017 Dec;72(6):865-868. doi: 10.1016/j.eururo.2017.07.014. Epub 2017 Jul 25.
Benefits and harms of screening for and treatment of asymptomatic bacteriuria in pregnancy: a systematic review. BMC Pregnancy Childbirth. 2016 Nov 2;16(1):336.
Maternal and neonatal consequences of treated and untreated asymptomatic bacteriuria in pregnancy: a prospective cohort study with an embedded randomised controlled trial. Lancet Infect Dis. 2015 Nov;15(11):1324-33. doi: 10.1016/S1473-3099(15)00070-5. Epub 2015 Aug 5.
The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: to treat or not to treat? Clin Infect Dis2012;55:771-7
Prior trimethoprim use and trimethoprim-resistant urinary tract infection: a nested case-control study with multivariate analysis for other risk factors. J Antimicrob Chemother. 2001 Jun;47(6):781-7.
Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care. J Antimicrob Chemother. 2006 Nov;58(5):1000-8. Epub 2006 Sep 23.
US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016 Nov 22;316(20):2115-2125. doi: 10.1001/jama.2016.16201
Antibiotics, gut microbiome and obesity. Clin Endocrinol (Oxf). 2018 Feb;88(2):185-200. doi: 10.1111/cen.13495. Epub 2017 Nov 20.
The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda: Start smart and then focus
Patient information/decision aids
Recommendation 3
Consider stopping antibiotics after 4 days for patients with abdominal infection under control after operation or drain
Evidence/Guidance
English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2017
CABI: A multicentre study of the management and outcomes of complicated intra-abdominal infection.
Association of excessive duration of antibiotic therapy for intra-abdominal infection with subsequent extra-abdominal infection and death: a study of 2,552 consecutive infections. Surg Infect (Larchmt) 2014;15:417–424.
Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015 May 21;372(21):1996-2005.
Patients with Complicated Intra-Abdominal Infection Presenting with Sepsis Do Not Require Longer Duration of Antimicrobial Therapy. J Am Coll Surg. 2016 Apr;222(4):440-6.
The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017 Jan;18(1):1-76.
Low dosage and long treatment duration of beta-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA. 1998 Feb 4;279(5):365-70.
The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda:
Patient information/decision aids
Recommendation 4
Discuss the use of antibiotics with patients who are close to the end of life
Evidence/guidance
English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2017
Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 2016; 28(4): 456–69.
A nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manage 2013; 46(4): 483–90.
Antibiotic use during the last days of life in cancer patients. Eur J Cancer Care 2006; 15(1): 74–9.
Antimicrobial use at the end of life among hospitalized patients with advanced cancer. Am J Hosp Palliat Care 2012; 29(8): 599–603.
Treatment of the dying in the acute care hospital. Advanced dementia and metastatic cancer. Arch Intern Med 1996; 156(18): 2094–100.
Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med 2008; 168(4): 357–62.
Interventions in the last year of life: do they prevent death in hospital in England? In: 8th World Research Congress of the European Association for Palliative Care (EAPC). Spain: Palliat Med 2014:538–913.
Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manage 2003;25(5): 438–43.
Can anti-infective drugs improve the infection-related symptoms of patients with cancer during the terminal stages of their lives? J Palliat Med 2010;13(5):535–40.
Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med 2010;170(13):1102–7.
Infection management and multidrugresistant organisms in nursing home residents with advanced dementia. JAMA. Intern Med 2014;174(10):1660–7.
Bacterial infections in terminally ill hospice patients. J Pain Symptom Manage 2000;20(5):326–34.
US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016 Nov 22;316(20):2115-2125. doi: 10.1001/jama.2016.16201.
End-of-life treatment and bacterial antibiotic resistance: a potential association. Chest 2010;138(3):588–94.
General Medical Council. Guidance: Treatment and care towards the end of life: decision making
NICE Quality Standard 13. End of life care for adults
NICE Quality Standard 144. Care of dying adults in the last days of life
The GMC and NICE provide guidance and quality standards on end of life care (ref. 16 to 18).
The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda:
Patient information/decision aids
Public Health England. Treating your infection leaflets.
Recommendation 5
Review the use of antibiotics for conditions that are not infections
Evidence/guidance
Use of antibiotics for noninfectious dermatologic disorders. Dermatol Clin. 2009 Jan;27(1):85-9.
Systematic review and meta-analysis of the role of metronidazole in post-haemorrhoidectomy pain relief. Colorectal Dis. 2017 Sep;19(9):803-811. doi: 10.1111/codi.13755. Review.
Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis.Curr Med Res Opin. 2013 Sep;29(9):1171-85. doi: 10.1185/03007995.2013.818532. Epub 2013 Jul 11.
Low dosage and long treatment duration of beta-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA. 1998 Feb 4;279(5):365-70.
Evidence-based management of rosacea. Br J Dermatol. 2017 Feb;176(2):300-301. doi: 10.1111/bjd.15277.
Interventions for rosacea. Cochrane Database Syst Rev. 2015 Apr 28;(4):CD003262. doi: 10.1002/14651858.CD003262.pub5.
Systemic Metronidazole May Not Reduce Posthemorrhoidectomy Pain: A Meta-Analysis of Randomized Controlled Trials. Dis Colon Rectum. 2017 Apr;60(4):446-455. doi: 10.1097/DCR.0000000000000792
Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointest Endosc. 2010 Dec;72(6):1138-45. doi: 10.1016/j.gie.2010.08.011.
US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016 Nov 22;316(20):2115-2125. doi: 10.1001/jama.2016.16201.
Antibiotics, gut microbiome and obesity. Clin Endocrinol (Oxf). 2018 Feb;88(2):185-200. doi: 10.1111/cen.13495. Epub 2017 Nov 20.
The recommendation is in keeping with the national antimicrobial stewardship and resistance agenda: Start smart and then focus
Patient information/decision aids
1. Connecting an intoxicated (alcohol) patient up to a drip and providing intravenous fluids will not help them feel better or allow discharge from hospital any quicker.
Evidence/Guidance
- Wiley Online Library – A randomised Controlled Trial
- Bestbets – rapid evidence-based answers to real-life clinical questions, using a systematic approach to reviewing the literature
- St.Emlyns is a collection of people and projects aimed at improving Emergency Medicine through free and open access education
- Rational Evidence Based Evaluation of Literature in Emergency Medicine
2. Children with small fractures on one side of the wrist, ‘buckle fractures’ do not usually need a plaster cast. They can be treated with a removable splint and written information. There is usually no need to put a plaster cast on, or follow these children up in fracture clinic as they will get better just as quickly without this.
Evidence/Guidance
3. Small fractures of the base of the fifth metatarsal, a bone on the outside of the foot, do not usually need to put into a plaster cast as they will heal just as quickly in a removable boot.
Evidence/Guidance
4. Some injuries, such as hip and shoulder dislocations, can be treated with sedation in the emergency department rather than undergoing a general anaesthetic in the operating theatre.
5. Tap water is just as effective for cleaning wounds as sterile saline.
Evidence/Guidance
Recommendation 1
Consider restricting coagulation screens on patients presenting to emergency departments to only those taking anticoagulant drugs, massive haemorrhage or suspected of having a bleeding disorder.
Evidence\guidance
There is no specific recommendation from NICE about this patient groups. Related guidance from NICE about preoperative testing before surgery advocates a similar targeted approach
Recommendation 2
A clinician should discuss the need for a lumbar puncture for a patient suspected of having a sub-arachnoid haemorrhage if a CT is performed within 6 hours of the start of the headache.
Standard investigations for patients suspected of having suffered a sub-arachnoid haemorrhage involve a CT scan and then, if the CT is normal, a lumbar puncture. Lumbar punctures are painful procedures, usually require hospital admission and some people develop worse headaches afterwards.
CT Scanners have become better at detecting blood in the brain. A normal scan performed with 6 hours of onset of a severe headache means that the risk of having a sub-arachnoid haemorrhage is extremely low.
Evidence\guidance
There is a systematic review of five observational studies, showing that the missed rate of sub-arachnoid haemorrhage was 1.46 per 1,000 patients in CT scans performed within 6 hours of onset.
Dubosh NM Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Stroke 2016
Recommendation 3
Review the routine use of urine toxicology tests in patients who are poisoned.
Urine toxicology tests are commonly performed on patients who are suspected of having taken a drug overdose. The results of these tests very rarely change management. There are also several newer recreational drugs which are not picked up by these tests.
Recommendation 4
People who have suffered a first seizure, who have fully recovered, have no headache and have a normal neurological examination do not usually need a CT scan while in the emergency department. They should be offered an MRI as an outpatient instead.
Evidence\guidance
NICE CG 137 ‘Epilepsies: diagnosis and management’
Recommendation 5
Discuss the need for antibiotics for asymptomatic bacteriuria in older people
Many older people have bacteria in their urine normally. A bedside urine dip test will frequently show cells (leucocytes) and many patients are then treated with antibiotics, despite having no signs or symptoms of a urinary tract infection. This means many older people are treated unnecessarily with antibiotics and some people will develop complications of the antibiotic treatment, such as diarhoea.
We advocate that patients with a urine dip that shows leucocytes should be evaluated by a clinician before antibiotics are offered
Evidence\guidance
NICE Quality Standard ‘Urinary Tract Infections in Adults’ CG90
The Silver Book, published by the British Geriatrics Society
1. When patients are particularly frail or in their last year of life, unless there is a clear preference otherwise by the patient or advocate, discuss with the patient and family/carers the option of decreasing the number of medicines to only those used for control of symptoms.
Evidence/guidance
2. Being alert to the possibility of dementia in patients at risk, with further assessment on an individual basis is good practice, but routinely screening for dementia using structured tools has not been recommended by the UK National Screening Council. It risks false positive diagnoses and has no proven benefit.
Evidence/guidance
- GOV.UK recommendation against national dementia screening
- The UK NSC recommendation on Screening for Dementia
3. When considering risk modifying treatment in primary prevention, for example treatment for blood pressure, cholesterol or bone density, share the option to have treatment or not before prescribing. Decision aids exist to support this process for doctors and patients.
Shared decision aids to use with patients
- Mayo Clinic Shared Decision Aid: Cardiovascular Primary Prevention Choice
- Bone Health Choice Decision Aid to help reduce bone fractures
4. Treating Stage 1 (mild) hypertension in people without any other cardiovascular risk factors may have only small potential benefit for an individual. Consider total cardiovascular risk before initiating drug treatment.
Shared decision aid to use with patients
- NHS Right Care Shared decision aid to use with patients about high blood pressure
- Interactive decision aid that illustrates risk reduction with blood pressure lowering drugs and other interventions
Evidence/guidance
5. Ultrasound has very limited value in making a diagnosis of polycystic ovarian syndrome:
Polycystic ovaries do not have to be present to make the diagnosis, and the finding of polycystic ovaries does not alone establish the diagnosis.
Symptoms and a hormonal profile* will usually be enough to establish a diagnosis.
*NICE recommends: Testosterone/SHBG/LH/FSH/Prolactin/TSH
Evidence/guidance
6. Once a patient being treated with a statin has reached their target level of cholesterol, there is no need to keep measuring it.
The only liver function test which needs monitoring on statins is the ALT or AST at 3 months and 1 year. If it is normal at 1 year, it does not require ongoing monitoring.
Shared decision aid to use with patients
Evidence/guidance
1. Life support for patients at high risk of death or severely impaired functional recovery should not be offered. A discussion with patients and their families should focus on the goals of comfort care.
Shared decision aids to use with patients
- Planning care for critically ill patients in the Intensive Care Unit
- NHS Right Care decision making aid for end of life care
Evidence/guidance
- Choosing Wisely US: Critical Care Societies Collaborative – Critical Care
2. Tests and investigations should only be done in response to answering a specific question rather than routinely.
Evidence/guidance
3. Blood transfusions should only be given when the haemoglobin is less than 70 g/L. Blood transfusions may occur above this level where the patient is haemodynamically unstable or actively bleeding.
Evidence/guidance
4. Patients who are mechanically ventilated may not need to be deeply sedated, and where possible daily trials to lighten sedation should be done.
Evidence/guidance
1. Medicines like aspirin, heparin or progesterone should not be used in a bid to maintaining a pregnancy in a woman who has had unexplained and recurrent miscarriages.
Evidence/guidance
2. Aspirin is not recommended as a way of reducing the chances of pregnant women developing blood clots (thromboprophylaxis).
3. Unless the mother has diabetes, ultrasound scans should not be used to check if a baby is bigger than normal for its gestational age (macrosomia).
Evidence/guidance
4. A simple ovarian cyst less than 5cm in diameter in a woman who has not gone through the menopause does not need to be followed up; nor is there any need for a blood test to check levels of the protein CA-125.
Evidence/guidance
5. Electronic monitoring of a baby’s heart should not be offered routinely during labour unless the mother is at a higher risk of complications than normal.
Evidence/guidance
Recommendation 1
Avoid use of antibiotics for group B Streptococcus carriage until labour starts
Antibiotics should not be given before labour starts or waters break when group B Streptococcus (GBS) is identified simply from a vaginal or rectal swab during pregnancy. Women with GBS urinary tract infection (growth of greater than 105 cfu/ml) during pregnancy should receive appropriate treatment at the time of diagnosis as well as in labour. Information on GBS in pregnancy should be provided to all pregnant women, and any questions answered.
Evidence\guidance
Royal College of Obstetricians & Gynaecologists Guideline: Group B Streptococcal Disease, Early onset
NICE Antibiotics for the prevention and treatment of early-onset neonatal infection (2012)
Patient information\decision aids
The Royal College of Obstetricians and Gynaecologists provides detailed information on Group B Streptococcal infection in pregnancy:
Additional information from charity Group B Strep Support www.gbss.org.uk
Recommendation 2
Endometrial hyperplasia can often be managed without surgery
Hysterectomy should not be considered as a first-line treatment for hyperplasia without atypia as progestogen therapy induces histological and symptomatic remission in the majority of women and avoids the morbidity associated with major surgery. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.
Evidence\guidance
Royal College of Obstetricians & Gynaecologists: Endometrial Hyperplasia, Management of.
Patient information\decision aids
The patient info website provides detailed information on endometrial hyperplasia: https://patient.info/doctor/endometrial-hyperplasia-pro
Recommendation 3
Where possible an external cephalic version should be offered for breech presentation before a planned caesarean section is agreed
In the absence of contraindications, a planned caesarean section should not be carried out for breech presentation before ECV has been offered. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.
Evidence\guidance
Royal College of Obstetricians and Gynaecologists: External cephalic version and reducing the risk of term breech presentation.
Patient information\decision aids
Royal College of Obstetricians and Gynaecologists provide detailed information on this: https://www.rcog.org.uk/en/patients/patient-leaflets/breech-baby-at-the-end-of-pregnancy/
Recommendation 4
Parental karyotyping is not routinely indicated in recurrent miscarriage. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.
Evidence\guidance
Royal College of Obstetricians and Gynaecologists: Recurrent Miscarriage, investigation and treatment of couples
Patient information\decision aids
Royal College of Obstetricians and Gynaecologists provide detailed information on recurrent and late miscarriage
Recommendation 5
Nausea and vomiting in pregnancy is very common and most women are able to manage this by eating and drinking frequently
Outpatient management of nausea and vomiting in pregnancy is suitable for many patients for whom primary care measures have be unsuccessful. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.
Evidence\guidance
The Royal College of Obstetricians and Gynaecologists: The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum
Patient information\decision aids
Royal College of Obstetricians and Gynaecologists provide detailed information nausea and vomiting in pregnancy: https://www.rcog.org.uk/en/patients/patient-leaflets/pregnancy-sickness/
1. Do not review uncomplicated cataract cases on day one post-op
Shared decision making aid to use with patients
Evidence/guidance
- The Royal College of Ophthalmologists Cataract Guidelines
- Randomised control trial published in BMJ
- Prospective study
2. If a child is under 12 months old and has a blocked nasolacrimal duct, do not try to unblock.
3. Do not carry out laser retinopexy for asymptomatic lattice degeneration/atrophic retinal holes.
Evidence/guidance
4. If conjunctivitis is thought to be viral, there is no need to send samples to the laboratory or to treat with antibiotics.
Evidence/guidance
5. The initial episode of unilateral anterior uveitis does not usually need further investigation
Recommendation 1
Referral for cataract surgery should be made based on a shared decision-making process about how it may impact quality of life. It should not be restricted because of visual acuity alone.
The decision to refer a person with a cataract for surgery should be based on a discussion that includes:
- How the cataract affects the person’s vision and quality of life
- Whether 1 or both eyes are affected
- What cataract surgery involves, including possible risks and benefits
- How the person’s quality of life may be affected if they choose not to have cataract surgery
- Whether the person wants to have cataract surgery.
Evidence/guidance
Recommendation 2
Patients and doctors should use shared decision making to decide when to initiate treatment and what treatment to use for wet active age related macular degeneration. This should take into consideration evidence for visual outcomes to make a fully informed choice of treatment.
Evidence/guidance
Recommendation 3
Doctors and patients should discuss the risks and benefits of having cataracts surgery on both eyes on the same day.
Evidence/guidelines
Patient information/decision aids
Patient information on Cataract surgery can be found at NHS Choices, and there is an NHS Right Care shared decision aid
Recommendation 4
Before referring a patient for chronic open angle glaucoma and related conditions and related conditions ensure you have considered the following tests available in the community including:
- central visual field assessment using standard automated perimetry (full threshold or supra-threshold)
- optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy (with pupil dilatation if necessary), and optical coherence tomography (OCT) or optic nerve head image if available
- intraocular pressure (IOP) measurement using Goldmann-type applanation tonometry
- peripheral anterior chamber configuration and depth assessments using gonioscopy or, if not available or the patient prefers, the van Herick test or OCT.
Patients should be referred for further investigation and diagnosis of COAG and related conditions, after considering repeat measures if:
- there is optic nerve head damage on stereoscopic slit lamp biomicroscopy or
- there is a visual field defect consistent with glaucoma or
- IOP is 24 mmHg or more using Goldmann-type applanation tonometry
If these criteria are not met, people with IOP below 24 mmHg are advised to continue regular visits to their primary eye
Evidence/guidance
For background about glaucoma referral see NICE guideline CG81
Patient information/decision aids
Patient information on Glaucoma can be found at NHS Choices, and on the International Glaucoma Association website
Recommendation 5
When considering whether a patient should have cataracts surgery, you should use a validated risk stratification algorithm.
Evidence/guidance
For background about cataract surgery risk stratification see NICE guideline NG77
Blomquist PH, Sargent JW, Winslow HH (2010) Validation of Najjar-Awwad cataract surgery risk score for resident phacoemulsification surgery Journal of Cataract & Refractive Surgery 36 (10) 1753-1757
Muhtaseb M, Kalhoro A, Ionides A (2004) A system for preoperative stratification of cataract patients according to risk of intraoperative complications: a prospective analysis of 1441 cases British Journal of Ophthalmology 88 (10) 1242-1246
Osborne SA, Adams WE, Bunce C, V et al. (2006) Validation of two scoring systems for the prediction of posterior capsule rupture during phacoemulsification surgery British Journal of Ophthalmology 90 (3) 333-336
Tsinopoulos IT, Lamprogiannis LP, Tsaousis KT et al. (2013) Surgical outcomes in phacoemulsification after application of a risk stratification system Clinical Ophthalmology 7 895-899
Patient information/decision aids
Patient information on Cataract surgery can be found at NHS Choices, and there is an NHS Right Care shared decision aid
1. Helmet therapy is not effective in the treatment of positional plagiocephaly in children, other treatment options should be considered and discussed with your patient.
2. Polyethylene Glycol should be used in preference to Lactulose in the treatment of chronic constipation in children.
Evidence/guidance
3. Buccal midazolam or lorazepam should be in the treatment of prolonged seizures in young people and children, as these are the most effective treatments, in preference to rectal and intravenous diazepam.
Evidence/guidance
4. Bronchodilators should not be used in the treatment of mild or moderate presentations of acute bronchiolitis in children without any underlying conditions.
Evidence/guidance
1. Unless a patient is at increased risk of prostate cancer because of race or family history, PSA testing does not necessarily lead to a longer life.
Shared decision making aid to use with patients
Evidence/guidance
- NICE Clinical Knowledge Summary: PSA testing
- Prostate Cancer UK information page on the PSA test
- Public Health England’s Prostate Cancer Risk Management Programme materials
2. Calcium testing is used when there are symptoms of kidney stones, bone disease or nerve-related disorders; but it is not necessary to test less than three months after the previous test except in acute conditions, during major surgery or in critically ill patients when tests should not be made more often than every 48 hours.
3. Only consider transfusing platelets for patients with chemotherapy-induced thrombocytopenia where the platelet count is < 10 x 109/L except when the patient has clinical significant bleeding or will be undergoing a procedure with a high risk of bleeding.
4. Use restrictive thresholds for patients needing red cell transfusions and give only one unit at a time except when the patient has active bleeding.
Evidence/guidance
- NICE Guidance: Blood transfusion
- Chochrane Review: Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion
5. Only transfuse O Rh D negative red cells to O Rh D negative patients and in emergencies for females of childbearing potential with unknown blood group.
Recommendation 1
Avoid unnecessary duplicate genetic testing for inherited variants
Evidence/guidance
Approximately 0.8% of all genetic test requests received for germline mutations were unnecessary duplicate samples from patients who had already been successfully tested (Miller CE et al. Genetic counsellor review of genetic test orders in a reference laboratory reduces unnecessary testing. Am J Med Genet A 2014;164A:1094–1101).
Adverse effects from venepuncture include vasovagal reactions, pain and bruising, and direct and indirect nerve damage (Stevenson M et al. Appendix 8 Diagnostic venepuncture: systematic review of adverse events. Health Technology Assessment 2012;16:4; Kohn D, Bush A, Kessler I. Risk of venepuncture. Br Med J 1976;2:1133).
Patient information/decision aids
Genetic testing can help identify a disease risk or inherited condition. The results can help your doctor decide:
- Which additional tests, if any, are required
- Help to confirm a suspected diagnosis from previous tests undertaken
- Choose ways to prevent or treat a condition.
Genetic testing may also tell you which family members are at risk.
However, sometimes a genetic test is not the best way to identify a disease risk or inherited condition. A routine blood test or procedure might be just as good. Therefore, it is important you discuss and understand the reasons for a genetic test with your doctor before agreeing to have a sample taken for testing.
Repeat testing
Usually you don’t need to repeat a genetic test.
Your genetic information generally doesn’t change over your lifetime. Your doctor should check with you directly to confirm whether you have previously had the test. There is usually no reason to repeat a genetic test unless:
- Your doctor thinks an error may have been made in the laboratory performing the test.
- A new, more accurate test is available
Recommendation 2
Don’t give a patient a blood transfusion without informing them about the risks and benefits (although do not delay emergency transfusions)
Evidence/guidance
There is a lack of high-quality research in this field with largely observational data available. The evidence suggests that patients have a limited understanding of many aspects of transfusion, but that they do want to be part of an informed decision-making process. The evidence also indicates that patients are reassured by the provision of written information.
NICE guidelines on blood transfusion in November 2015
Patient information\decision aids
A number of patient information materials are available through the NHSBT website:
Will I need blood transfusion?
Recommendation 3
Don’t transfuse red cells for iron deficiency anaemia without haemodynamic instability
Evidence\guidance
NICE guidelines on blood transfusion in November 2015
Royal College of Surgeons of England. 2007; 89(4):418-421; Luporsi E, Mahi L, Morre C, Wernli J, de Pouvourville G, Bugat R.
Evaluation of cost savings with ferric carboxymaltose in anemia treatment through its impact on erythropoiesis-stimulating agents and blood transfusion: French healthcare payer perspective. Journal of Medical Economics. 2012; 15(2):225-232)
Patient information\decision aids
Leaflets are available through the NHSBT website
Anaemia patient Information leaflet October 2016
Recommendation 4
Use statins in appropriate patients
Evidence\guidance
NICE Clinical Guideline CG181 – Cardiovascular disease: risk assessment and reduction, including lipid modification
SIGN 149: Risk estimation and the prevention of cardiovascular disease.
Collins R et al. Interpretation of the evidence for the efficacy and safety of stain therapy. Lancet 2016;388:2532–2561
Mancini GB et al. Diagnosis, Prevention, and Management of Statin Adverse Effects and Intolerance: Canadian Consensus Working Group Update. Can J Cardiol 2016;32:S35–65.
Patient information\decision aids
NICE CG181 patient decision aid
1. In the treatment of depression, if an antidepressant has been prescribed within the therapeutic range for two months with little or no response, it should be reviewed and changed or another medication added, which will work in parallel with the initial drug that was prescribed.
Shared decision making aid to use with patients
2. When adults with schizophrenia are introduced to treatment with long-term anti-psychotic medication, the benefits and harm of taking oral medication compared to long-acting depot injections should be discussed with all relevant parties.
Evidence/guidance
3. Women who are planning a pregnancy or may be pregnant should not be prescribed valproate for mental disorders except where there is treatment resistance and/or very high risk clinical situations.
Evidence/guidance
4. When a diagnosis of psychosis is made, CT or MRI head scans should only be used for specific indications where there are signs or symptoms suggestive of neurological problems.
Evidence/guidance
Recommendation 1
Cognitive testing alone does not diagnose dementia.
In order to establish an accurate diagnosis of dementia it is recommended to obtain a full history, collateral information from key family members and a cognitive assessment.
Evidence\guidance
Patient information\decision aids
Recommendation 2
Aim to use non-drug treatments for the management of behavioural and psychological symptoms of dementia.
If there are significant risks that make treatment with an antipsychotic necessary, this should be discussed with the patient and their family, and the lowest possible dose used.
Evidence\guidance
NICE (CG42) states this is best practice
In March 2004, the Medicines and Healthcare products Regulatory Agency’s Committee on Safety of Medicines issued a safety warning about the atypical antipsychotic drugs risperidone and olanzapine, advising that these drugs should not be used for the treatment of behavioural symptoms of dementia.
Brodaty H, Arasaratnam C. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 2012;169(9):946-53.
“Nonpharmacological interventions were effective in reducing behavioral and psychological symptoms, with an overall effect size of 0.34 (95% CI=0.20-0.48; z=4.87; p<0.01)”
Patient information\decision aids
Treatments for different types of dementia
Drugs to relieve behavioural psychological symptoms
Recommendation 3
Do not forget pain as a common cause of agitation in patients with dementia.
50% of people with dementia are estimated to experience regular pain. Despite this, current assessment and treatment of pain in this patient group are inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioural symptoms, which can lead to inappropriate. Consider prescribing regular analgesia such as paracetamol if there is clinical suspicion that pain is a relevant trigger.
Evidence\guidance
Achterberg WP, Pieper MJ, van Dalen-Kok AH, De Waal MW, Husebo BS, Lautenbacher S, Kunz M, Scherder EJ, Corbett A. Pain management in patients with dementia. Clinical interventions in aging. 2013;8:1471.
Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial BMJ 2011;343:d4065
More information\ decision support material
Common pain behaviours in cognitively impaired elderly persons according to the AGS Panel on persistent pain in older persons.
Recommendation 4
Antipsychotics can cause serious side effects in patients with Lewy Body Dementia. They should only be used under expert guidance.
Severe sensitivity to both typical and atypical antipsychotic medication occurs in approximately 50% of individuals with Lewy Body Dementia.
Evidence\guidance
McKeith IG, Dickson DW, Lowe J, Emre M, O’brien JT, Feldman H, Cummings J, Duda JE, Lippa C, Perry EK, Aarsland D. Diagnosis and management of dementia with Lewy bodies third report of the DLB consortium. Neurology. 2005 Dec 27;65(12):1863-72.
Patient information\decision aids
Recommendation 5
Anticholinergic drugs can be detrimental to cognition in later life and have other serious side effects.
Careful consideration of the risks to patients, including the use of an anticholinergic burden scale, should be undertaken prior to initiation.
Evidence\guidance
It has been estimated that 20–50% of older people have been prescribed at least one medication with anticholinergic activity. Medications with anticholinergic properties recognized by the anti-cholinergic burden scale have been recently correlated with an additional 0.33 point decline in Mini-Mental State Examination score over 2 years, a 2-fold increase in cognitive impairment with as little as 60–90 days of use, and ∼50–80% increase in the risk of incident cognitive impairment over 6 years.
Fox C, Smith T, Maidment I, Chan WY, Bua N, Myint PK, Boustani M, Kwok CS, Glover M, Koopmans I, Campbell N. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review. Age and ageing. 2014 Jul 19;43(5):604-15.
Patient information\decision aids
Recommendation 6
Do not refuse patients access to a service, investigation or treatment solely on the basis of their age.
Decisions should be based on need
Evidence\guidance
Patient information\decision aids
Recommendation 7
Management of older adults with mental problems should be guided by Old Age specialists, who are able to manage the complex needs of this population.
There is a transition towards ‘ageless services’ across many trusts in the UK whereby many patients in later life are being managed on mixed wards and are often neglected in these settings.
Evidence\guidance
Royal College of Psychiatrists
Patient information\decision aids
Recommendation 8
The care of frail older adults with complex needs who need an inpatient admission, is best managed in an older person’s specialist ward environment.
There is a transition towards ‘ageless services’ across many trusts in the UK whereby many patients in later life are being managed on mixed wards and are often neglected in these settings.
Evidence\guidance
Royal College of Psychiatrists
Royal College of Psychiatrists
National Centre for Biotechnology Information
Patient information\decision aids
Mental Health in the Community
Recommendation 9
Do not use physical restraints in older adults in hospital settings with delirium except as a last resort.
There is little evidence to support the effectiveness of physical restraints to manage people with delirium who exhibit behaviours that risk injury. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Restraints should therefore be used as a last resort and should be discontinued at the earliest possible time, particularly given that effective non-pharmacological alternatives are available.
Evidence\guidance
Flaherty JH, Little MO. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. Journal of the American Geriatric Soc 2011;59(S2):S295-300.
Lach HW, Leach KM, Butcher HK. Evidence-based practice guideline: changing the practice of physical restraint use in acute care. Journal of Gerontological Nursing 2016;42(2):17-26.
Mott S, Poole J, Kenrick M. Physical and chemical restraints in acute care: their potential impact on the rehabilitation of older people. Int J Nurs Pract 2005;11(3):95-101
Patient information\decision aids
Recommendation 10
If benzodiazepines or antipsychotics drugs have been initiated during an acute care hospital admission, make sure there is a clear plan to review their use, ideally tapering and discontinuing prior to discharge.
Both benzodiazepines and antipsychotics have serious side effects in the elderly, in particular, addiction, falls, worsening cognition, infections, stroke and death.
Evidence\guidance
Yokoi Y, et al. Benzodiazepine discontinuation and patient outcome in a chronic geriatric medical/psychiatric unit: a retrospective chart review. Geriatr Gerontol Int. 2014 Apr;14(2):388-94. PMID: 24666628.
Gill SS, et al. Atypical antipsychotic drugs and risk of ischaemic stroke: population based retrospective cohort study. BMJ. 2005 Feb 26;330(7489):445. PMID: 15668211.
Patient information\decision aids
Recommendation 1
Patients with suspected migraine mostly don’t need brain imaging
When managing patients with migraine only perform neuro-imaging where there are atypical features. It is essential to clarify patient expectations and provide education and explanation about the differential diagnosis of migraine. Patients with new onset headaches should have a neurological examination (including fundoscopy) and assessment of ‘red flags’ as per NICE guidance. Where, based on clinical need and imaging is required, unless in a history of trauma or suspected subarachnoid, MRI rather than CT is the preferred modality.
Evidence\guidance
NICE guidance- headaches in over 12-diagnosis & management
Recommendation 2
Patients with low back pain do not routinely need imaging
Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica. Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging. Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management.
Evidence\guidance
NICE guidance on back pain in adults
Metastatic spinal cord compression in adults
Recommendation 3
When managing patients with transient loss of consciousness (TLoC), investigations should be performed only after an appropriate neurological and cardiological assessment.
If the person with suspected transient loss of consciousness (TLoC) has sustained an injury or they have not made a full recovery of consciousness, use clinical judgement to determine appropriate management and the urgency of treatment. Getting a good witness account is vital. The guidance of NICE is excellent https://www.nice.org.uk/guidance/cg109/chapter/1-Guidance#further-assessment-and-referral and is not to be replicated, but in essence:
Older people (aged >50 years) with a new onset of epileptic seizures do not need an EEG, unless they are having very frequent or continuous seizures.
Repeated standard EEGs may be helpful when the diagnosis of the epilepsy or the syndrome is unclear. However, if the diagnosis has been established, repeat EEGs are not likely to be helpful (as per NICE guidance).
Limit use of 24 hour ambulatory ECG recording in TLoC, and use long-term implanted loop ambulatory ECG recording where a cardiac cause is suspected in recurrent TLoC of unclear cause
Evidence\guidance
NICE guidance on Transient Loss of Consciousness
Recommendation 4
Atraumatic lumbar puncture needles are preferred for lumbar puncture to reduce the risk of post LP headache
Evidence\guidance
Nath et al. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis Lancet 2017
Recommendation 5
When managing patients with fleeting sensory symptoms, investigations should not be performed unless clinically indicated
Transient sensory symptoms are extremely common and often have a benign cause. When managing patients with fleeting sensory symptoms, investigations should not be performed unless clinically indicated and are directed by taking a neurological history, examining the patient and having a differential diagnosis. Patients should be referred or investigated where there is clinical uncertainty of the diagnosis. It is essential to clarify patient expectations, and provide education and explanation about the differential diagnosis of fleeting sensory symptoms.
Evidence\guidance
NHS Choices on peripheral neuropathy
https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0800
Recommendation 6
When managing patients with suspected carpal tunnel syndrome (CTS) requiring surgery, a neurophysiological assessment should be performed
It is essential to clarify patient expectations and provide education and explanation about the differential diagnosis of carpal tunnel syndrome. It is essential that all patients being considered for surgery have a neurophysiological assessment
Evidence\guidance
Recommendation 7
Do not use MRI head imaging in patients with suspected Parkinson’s disease
Do not use structural MRI to diagnose Parkinson’s disease.
Structural MRI may be considered in the differential diagnosis of other parkinsonian syndromes.
Evidence\guidance
1. In advanced cancer, the use of chemotherapy that is unlikely to be beneficial and may cause harm should be minimised
2. In cases of a minor head injury, imaging is not likely to be useful
Evidence/guidance
- NICE Guidance: Head injury: assessment and early management
- SIGN guidelines – Early management of patients with a head injury. A national clinical guideline
3. Back pain which is uncomplicated, that is not associated with ‘red flags’ or radicolupathy usually does not require imaging
Evidence/guidance
- Institute for Clinical and Economic Review: Imaging for non-specific low back pain
- NICE Clinical Knowledge Summaries: Back pain – low
4. Where there is suspicion of a pulmonary embolus, imaging should be guided by clinical scoring systems.
Evidence/guidance
5. After treatment for cancer, the use of routine scanning should only be used where this is beneficial to the patient.
Recommendation 1
MRI Is indicated only in specific circumstances. Clinical features will often be sufficient to guide management without the need for imaging.
Evidence\guidance
Nice guideline: Knee pain – assessment (last revised in March 2011)
ACR APPROPRIATENESS CRITERIA: Nontraumatic knee pain (last review date: 2012)
Chan KK,Sit RW, Wu RW et al. Clinical Radiological and Ultrasonographic findings related to knee pain in osteoarthritis. PLoS One 2014;9:e92901-[LEVEL II/III]
Recommendation 2
Morton’s neuroma is essentially a clinical diagnosis and investigations are generally unnecessary.
If the diagnosis of forefoot pain is uncertain, use XR to assess forefoot bones, joints and alignment. In experienced hands, US with dynamic assessment can confirm a diagnosis of Morton’s neuroma and guide injection treatment if required. It is helpful when clinical suspicion is high and conservative measures have failed
Evidence\guidance
Nice guideline: Morton’s neuroma – Last revised in June 2010
Recommendation 3
US is the investigation of choice in the assessment of rotator cuff and surrounding soft tissues.
It may be used to guide injection. It is reserved for cases with unresponsive to first line treatment and clinically guided injection. It is indicated preoperatively if the surgeon requires assessment if rotator cuff integrity
Evidence\guidance
ACR Appropriateness Criteria: Acute shoulder pain
Recommendation 4
Imaging is not normally required for Parkinson’s disease (PD)
MRI is useful for differentiating PD from vascular parkinsonism and atypical parkinsonism syndromes in the differential diagnosis of parkinsonian syndromes (progressive supranuclear palsy, multiple system atrophy and corticobasal degeneration). CT is the alternative when MRI is contraindicated. NM imaging with dopamine transporter is recommended in difficult cases to differentiate true PD and the parkinsonian syndromes from essential tremor and other movement disorders.
Evidence\guidance
NICE Guideline: Parkinson’s Disease: Diagnosis and management in primary and secondary care
SIGN guideline: Diagnosis and pharmacological management of parkinson’s disease
Recommendation 5
Routine follow up imaging is not always appropriate. IREFER guidelines are available, which help you determine what is best for your patients
XR may be required by specialists to assist management decisions; e.g. for instituting and modifying drug treatment and referral for joint replacement. Routine follow up is otherwise not appropriate.
Evidence\guidance
SIGN Guideline: Management of early rheumatoid arthritis. 2011
Recommendation 1.
Testing ANA and ENAs should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA and ENAs should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly.
Evidence\guidance
Solomon DH, Kavanaugh AJ, Schur PH. Evidence-based guidelines for the use of immunologic tests: Antinuclear antibody testing. Arthritis Rheum 2002;47(4):434-44.
Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med 2000;124(1):71–81.
American College of Rheumatology Ad Hoc Committee on Immunologic Testing. Guidelines for immunologic laboratory testing in the rheumatic diseases: an introduction. Guidelines..Arthritis Rheum. 2002 Aug; 47(4):429-33.
Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, Piazza A, Pradella M, Rizzotti P. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117(2):316-24.
Yazdany J., Schmajuk G., Robbins M., et al. Choosing wisely: the American College of Rheumatology’s Top 5 list of things physicians and patients should question. Arthritis Care Res. (Hoboken) 2013;65:329–339
Fitch-Rogalsky C, Steber W, Mahler M, Lupton T, Martin L, Barr SG, et al. Clinical and serological features of patients referred through a rheumatology triage system because of positive antinuclear antibodies. PLoS One. 2014;9(4):e93812.
Gundín S, Irure-Ventura J, Asensio E, et al. Measurement of anti-DFS70 antibodies in patients with ANA-associated autoimmune rheumatic diseases suspicion is cost-effective. Auto-Immunity Highlights. 2016;7(1):10.
Lee AY, et al. The concordance of serial ANA tests in an Australian tertiary hospital pathology laboratory. Pathology. 2016;48(6):597-601.
Satoh M., Chan E.K., Ho L.A. Prevalence and sociodemographic correlates of antinuclear antibodies in the United States. Arthritis Rheum. 2012;64:2319–2327.
Sharp, CA, Bruce, IN, Efficiency in follow-up immunology testing for patients with connective tissue disease and vasculitis, Clinical Medicine, 2010;10(3):632-4
Tonutti E, Bizzaro N, Morozzi G, Radice A, Cinquanta L, Villalta D, et al. The ANA-reflex test as a model for improving clinical appropriateness in autoimmune diagnostics. Autoimmunity Highlights. 2016;7(1):9.
Wandstrat AE, Carr-Johnson F, Branch V, Gray H, Fairhurst A-M, Reimold A, et al. Autoantibody profiling to identify individuals at risk for systemic lupus erythematosus. Journal of autoimmunity. 2006;27(3):153-60
Patient information\decision aids
Arthritis Research UK: Lupus (2011)
Recommendation 2
Patients with suspected inflammatory arthritis should be referred to Rheumatology without delay. Rheumatoid factor and CCP/ACPA are important, but should be avoided as screening tests. A negative result does not exclude rheumatoid arthritis, nor does a positive result equate to a diagnosis of rheumatoid arthritis. Repeat testing is not normally indicated.
Evidence\guidance
NICE clinical guideline CG79: rheumatoid arthritis in adults: management (2015) https://www.nice.org.uk/guidance/cg79
Burr. M. L., Viatte, S., Bukhari, M., Plant, D., Symmons, D. P., Thomson, W., & Barton A. 2012. Long-term stability of anti-cyclic citrullinated peptide antibody state in patients with early inflammatory polyarthritis. Arthritis research & therapy 2012; 14: R109
Sharp, CA, Bruce, IN, Eficiency in follow-up immunology testing for patients with connective tissue disease and vasculitis, Clinical Medicine, 2010, 10 (3): 632-4
Patient information\decision aids
Information for primary care physicians:
Royal College of General Physicians: Inflammatory arthritis toolkit (2017)
Arthritis Research UK: Rheumatoid Arthritis (2014)
National Rheumatoid Arthritis Society (NRAS): Getting an early diagnosis
NRAS: What is RA? (2014)
NRAS: Inflammatory Arthritis Patient Pathway
NRAS: Managing CVD risk in RA – Love your heart
NRAS: Have you got the S factor? (2011)
NRAS: Laboratory tests used in the diagnosis and monitoring of rheumatoid arthritis (2013)
Recommendation 3
Everyone should consider Vitamin D supplementation during winter.
People who have restricted access to sunlight (e.g. those living in institutions or who cover their skin), or have dark skin, should consider supplementation all year round. Vitamin D testing should be reserved for people at high risk from deficiency and avoided as part of routine investigation of widespread pain alone. Repeat testing is not normally indicated in those taking supplements.
Evidence\guidance
NICE: Clinical Knowledge Summary – Vitamin D deficiency in adults – treatment and prevention (2013)
Patient information\decision aids
National Osteoporosis Society patient leaflet – Vitamin D supplements and tests (2016)
Public Health England: Health England: Vitamin D- All you need to know (2014)
Recommendation 4
Bisphosphonate therapy should be reviewed with every patient after 3-5 years, and a treatment holiday considered. This should follow a shared-decision making conversation which includes the risks and benefits of continued treatment.
Evidence\guidance
NICE technology appraisal guidance 464: Bisphosphonates for treating osteoporosis (2017)
Vitamin D and bone health: A practical clinical guideline for patient management (2013)
Patient information\decision aids
Recommendation 5
The use of intra-articular and soft-tissue steroid injections for non-inflammatory musculoskeletal conditions should be preceded by consideration of non-invasive alternatives such as exercise and physical therapy. Consent to any invasive procedure such as this must arise from a shared-decision making conversation with every patient, which includes assessment of the risks and benefits.
Evidence\guidance
NICE Guideline CG177 (2014) Osteoarthritis: Care and Management https://www.nice.org.uk/guidance/cg177
National Safety Standards for Invasive Procedures (NatSSIPS) (2015)
https://improvement.nhs.uk/uploads/documents/natssips-safety-standards.pdf
American College of Rheumatology, Guidelines on use of pharmacologic and non-pharmacologic therapies in osteoarthritis of the hand, knee and hip 2012; Arthritis Care & Research, 2012; 64(4): 465-74
Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. Fleckenstein J, editor. PLoS One 2017;12(6):e0178621
Brennan KL. J Orthop Sports Phys Ther. 2017;47(4):232-239
Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, et al. Intra-articular corticosteroid for knee osteoarthritis. In: da Costa BR, editor. Cochrane Database of Systematic Reviews Chichester, UK: John Wiley & Sons, Ltd; 201
Kim et al. Pain Physician. 2013;16(6):557-68
Manchikanti et al. Pain Physician. 2014;17(4):E489-501
Mandel S, Schilling J, Peterson E, Rao DS, Sanders W. A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections. J Bone Jt Surg 2013;95(11):961–4.
Mardani-Kivi et al. Arch Orthop Trauma Surg. 2013;133(6):757-63
Mohamadi A, et al. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017;475(1):232-243
Nguyen C et al. Intradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active Discopathy. A Randomized Trial. Ann Intern Med. 2017;18;166(8):547-556
Scott A, Khan KM. Corticosteroids: short-term gain for long-term pain? Lancet. 2010;376(9754):1714–5.
Steuri R, Sattelmayer M, Elsig S, Kolly C, Tal A, Taeymans J, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med. 2017;51(18):1340–7
Wang W, Shi M, Zhou C, Shi Z, Cai X, Lin T, et al. Effectiveness of corticosteroid injections in adhesive capsulitis of shoulder. Medicine. 2017;96(28):e7529
Patient information\decision aids
NHS Right Care – Shared Decision Making: Osteoarthritis of the knee (2017)
Recommendation 6
C3, C4 and dsDNA are important tests to help in the diagnosis and assessment of disease activity in lupus. They should be reserved for specialist monitoring of disease activity and should be avoided as screening tests.
Evidence\guidance
Gordon, C., et al for the British Society for Rheumatology Standards, Audit and Guidelines Working Group (2018) The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology. 2018;57(1) e1-e45.
Bertsias G, Ioannidis JP, Boletis J, Bombardieri S, Cervera R, Dostal C, et al. EULAR recommendations for the management of systemic lupus erythematosus: report of a task force of the EULAR Standing Committee for international clinical studies including therapeutics. Ann Rheum Dis 2008;67:195–205
López-Hoyos M, et al. Clinical disease activity and titers of anti-dsDNA antibodies measured by an automated immunofluorescence assay in patients with systemic lupus erythematosus. Lupus. 2005;14(7):505-9.
Nasiri S, Karimifar M, Bonakdar ZS, Salesi M. Correlation of ESR, C3, C4, anti-DNA and lupus activity based on British Isles Lupus Assessment Group Index in patients of rheumatology clinic. Rheumatol Int. 2010;30(12):1605-9
Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, Piazza A, Pradella M, Rizzotti P. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117(2):316-24.
Patient information\decision aids
Arthritis Research UK: Lupus (2016)
1. If a woman has abnormal vaginal discharge that is likely to be caused by thrush (also known as candida) or Bacterial vaginosis (BV) and she is at low risk of having a sexually transmitted infection, a vaginal swab is not usually necessary.
Evidence/guidance
2. A woman who is thought to be having recurrent thrush should have an examination of the skin around her vagina to exclude other conditions such as lack of vaginal estrogen, allergies or other skin conditions rather than be given another course of thrush treatment.
Evidence/guidance
3. If a woman over the age of 45 years with typical symptoms of menopause, such as hot flushes and sweats and if her periods have become irregular, much lighter or have stopped, further bloods tests to check hormone levels are not usually necessary.
Evidence/guidance
4. Women who have a copper intrauterine device (IUD) or the hormonal intrauterine system (IUS) fitted only need to seek professional advice when they cannot feel the threads which hang from the device. Women should be taught how to feel for these threads.
Recommendation 1
Women can have routine cervical smears taken if they are due at the time that they are attending for other sexual health issues.
Evidence\guidance
Marlow LAV, Chorley AJ, Haddrell J Eur J Cancer. Understanding the heterogeneity of cervical cancer screening non-participants: Data from a national sample of British women. 2017 Jul;80:30-38.
NHS Choices: One in three women don’t attend cervical screening because of ’embarrassment’
NHS Digital. Cervical Screening Programme, England 2016-2017
Patient information\decision aids
NHS Choices. Cervical Screening
Recommendation 2
Women without medical problems can be routinely given a repeat 12-month prescription of oral contraception rather than 3 or 6-month supplies.
Evidence\guidance
Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-4):1–66.
Steenland MW, Rodriguez MI, Marchbanks PA, Curtis KM. How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review. Contraception. 2013 May;87(5):605-10.
White KO, Westhoff C. The effect of pack supply on oral contraceptive pill continuation: a randomized controlled trial. Obstet Gynecol. 2011 Sep;118(3):615-22.
Foster DG, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol. 2006 Nov;108(5):1107-14.
Foster DG. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011 Mar;117(3):566-72
Combined hormonal contraception. Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Healthcare 2011.
Recommendation 3
Women requesting intrauterine contraception can attend for a one-stop consultation and insertion appointment provided they have access to high quality local guidance on the procedure and its risks and benefits e.g. online website resources including a check-list.
Evidence\guidance
Gunn C, Gebbie A, Cameron S. ‘One-stop’ visits for insertion of intrauterine contraception using online resources. J Fam Plann Reprod Health Care. 2015 Oct;41(4):300-2.
Stanek AM, Bednarek PH, Nichols MD, et al. Barriers associated with the failure to return for intrauterine device insertion following first-trimester abortion. Contraception. 2009 Mar;79(3):216-20.
Goodman S, Hendlish SK, Benedict C, et al. Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion. Contraception. 2008 Aug;78(2):136-42.
Cook L1, Fleming C. What is the actual cost of providing the intrauterine system for contraception in a UK community sexual and reproductive health setting? J Fam Plann Reprod Health Care. 2014 Jan;40(1):46-53.