The Point Of Care (POC) C-Reactive Protein (CRP) testing project was a pilot programme which aimed to support antimicrobial prescribing behaviour change. The NICE Guidance on Pneumonia (CG191) and Antimicrobial Stewardship (QS121) have advocated the use of POC CRP testing to reduce antimicrobial prescribing for respiratory tract infections (RTI), many of which are self-limiting but are known to attract prescriptions for antimicrobials. However, challenges exist in the implementation and integration of such new diagnostic technologies.
The project aimed to integrate POC CRP testing into a real-world general practice setting, led by the SCCG Medicines Optimisation (MO).
Four GP practices participated in an initial pilot programme, with list sizes ranging from 2,100 to 14,000. Training on the use of the machines was provided by the manufacturer and the MO team provided an overview of antimicrobial stewardship and the aims of the pilot programme.
Supporting documentation was also produced by SCCG MO team to facilitate implementation. This included a testing pathway for clinicians to follow and a patient information leaflet to explain the test and the rationale for its use (see supporting evidence).
Data was collected for each test completed, and prescribing data followed up for two years following the pilot. A sample of patients were also requested to complete a feedback form about their experience of having a CRP test.
Feedback from the pilot GP practices highlighted that once in use, confidence in prescribing decisions around antimicrobials increased. It was felt that using CRP testing would likely have a ceiling effect, and that the newly acquired confidence could persist without continued access to the diagnostic equipment. As a result, SCCG have initiated a programme of re-locating the machines into new practices every 6 months. It is hoped that this will be sufficient to embed behaviour change and allow maximum access to the diagnostic technology across all 40 GP practices within Sunderland. Evaluation of this novel strategy is currently on-going.
The beneficiaries of the project included prescribers, patients and the CCG. Prescribers benefitted through increased confidence around their antimicrobial prescribing decisions.
Common across all participating sites was the impact of a negative POC CRP test on the prescribing decision of the clinician. Of a total of 180 negative tests, clinicians recorded that this result influenced their prescribing decision on 140 occasions. No prescription was issued in 125 of these cases (69% of negative tests).
“The CRP machine has proven useful in times of clinical uncertainty (e.g. those with COPD or asthma who have a suspected URTI or LRTI) and with patient education. We have a broad range of clinicians who find it helpful and certainly the trainees are encouraged to use it.”
GP at pilot practice
Patients have benefitted through the avoidance of unnecessary antibiotic prescriptions. 92 patient feedback responses were received during the course of the pilot programme (32% response rate). 99% of patients thought that the CRP test was useful, and although only 20% of patients had received an antibiotic prescription, 95% of patients were happy with the prescribing decision.
“I think this was a very clever test and saved time on other tests and me not taking antibiotics when I didn't need them”
Patient who had received a POC CRP test
Sunderland CCG has benefitted from a reduction in antimicrobial prescribing, and practices participating in the pilot went from all being above the NHS England Quality Premium target for antimicrobial prescribing (range 1.167 to 1.454) to three practices achieving below the target in the first year (range 1.025 to 1.364) and all achieving the target in the second year (range 0.968 to 1.16) despite no longer having the CRP testing machine available in the practice. This represented an average reduction of 0.135 in the first year and 0.167 in the second year.
The project was successfully able to:
