Transcript The value of supplementary prescribing

Linda Young
Clinical Specialist Radiographer for Lung
Cancers.
Belfast Health & Social Care Trust.
The value of supplementary
prescribing
Thanks!
Medicines Act
1968
Medical
Prescribers:
• Doctors
• Dentists
• Vets
Dr June Crown CBE
• 2nd Crown Report:
Department of Health.
Review of prescribing,
supply and
administration of
medicines: final
report. London: DH;
1999
Non Medical
Prescribers
1999:
2nd Crown Report
2005:
Supplementary
Prescribing by
Nurses, Pharmacists,
Chiropodists/Podiatrists,
Physiotherapists and
Radiographers
How and Why of the 2nd Crown Report
Recognised changes on the
education and training of other
healthcare professional
• Post graduated education
Within Medicine
• Development of evidence based
practice clinical guidelines and
protocols
• Leading to extended autonomous
practice
• Development of Specialities within
medicine
• Specialist qualifications
• Recognised specialist registers by
GMC
• Highly trained health
professionals using their full
range of skills and able to accept
clinical responsibility for doing so
Recognised changes in Professional
Relationships
• Development of the multiprofessional team
– Advanced healthcare
practitioner
2nd Crown Report: Recommendations
Overall Objective
Any change from current practice should result in improved
health outcomes, or else equivalent health outcomes with
improved patient convenience or more appropriate
professional practice.
Any proposed change should be assessed against the
following criteria:• health outcomes and patient safety
• patient choice
• patient convenience
• professional appropriateness
• effective use of resources
IMPROVING HEALTH AND WELL-BEING
THROUGH POSITIVE
PARTNERSHIPS
A STRATEGY FOR THE ALLIED HEALTH
PROFESSIONS IN NORTHERN
IRELAND
2012 - 2017
“Quotes”
“AHPs will actively
enhance people's lives
through the planning and
delivery of high quality
and innovative diagnostic,
treatment and
rehabilitation services and
practices that are safe,
timely, effective and
focused on the service
user.”
4 Strategic Themes:
• Promoting person-centred
practice and care;
• Delivering safe and effective
practice and care;
• Maximising resources for
success; and
• Supporting and developing
the AHP workforce.
Aims of NMP
• Improve patient care without compromising patient
safety
• Make it easier and quicker for patients to get the
medicines they need
• Increase patient choice in accessing medicines
• Make better use of the skills of health professionals
• Contribute to the introduction of more flexible team
working across the Health Service
Strategic Theme 4-Supporting and Developing the
AHP Workforce : Workforce Planning
• Workforce Planning
–
–
–
–
Right people
Right place
Right time
Right outcome
• Extended roles
&Changing work practices
• Extended Roles
• Changing Work Practices
• Skills and Grade Mix
– Future skill mix to support
strategic shift in how and
where care is delivered
– Clinical AHP Consultant
Grades in Northern
Ireland implemented in
the next 5 years
Strategic Theme 4-Supporting and Developing the
AHP Workforce: Learning & Development
Staff Development
– Current Grade
– Career progression
AHP Support Staff to Advanced Consultant
Practitioners
Strategic Theme 4-Supporting and Developing the
AHP Workforce: Learning & Development
AHP Prescribing in Northern Ireland:
Postgraduate Certificate
in Prescribing for Allied
Health Professionals
• 2010
• 11 AHP
– 3 radiographers
– 2 podiatrists
– 6 physiotherapists
Non Medical Prescribing for AHP’s :
Supplementary Prescribing
Supplementary Prescribing
Supplementary prescribing is a voluntary
prescribing partnership between an independent
prescriber and a supplementary prescriber, to
implement an agreed patient-specific clinical
management plan with the patient's agreement.
The independent prescriber must be a doctor
(or dentist).
IP & SP: The Definitions
Independent Prescriber
• professionals who are
responsible for the initial
assessment of the patient
and for devising the
broad treatment plan,
with the authority to
prescribe the medicines
required as part of that
plan.
• NMP must only prescribe
as IP’s within their scope
of practice
Supplementary Prescriber
• professionals who are
authorised to prescribe
medicines, for patients
whose condition has been
diagnosed or assessed by
an independent
prescriber, within an
agreed clinical
management plan.
Legal Requirements for Supplementary Prescribing:
• the independent prescriber must be a doctor (or dentist)
• the supplementary prescriber must be an eligible AHP,
pharmacist, optometrist or nurse
• there must be a written or electronic clinical management
plan agreed by all parties including the patient
• the independent prescriber and the supplementary
prescriber must be able to access the common patient
record
Supplementary Prescribing:
The Prescribing Partnership
Patient
CMP
Doctor
Supplementary
Prescriber
CMP hinges on the Doctor/AHP Prescribing Partnership
IP is responsible for determining
conditions the CMP covers, special
considerations inrealtion to the
individual patient and the limits of the
SP’s
SP is autonomously responsible for
clinical assessment and personally
accountable for prescribing decisions
(i.e. drug choice, and dose ) within the
limits of the CMP
CMP
• Must be Patient Specific
– Take into account the patients medical history and any other
conditions they may have.
•
•
•
•
Allergies or sensitivities the patient has
Not a blanket authority to prescribe medicines
May not be suitable for all patients
Must clearly state the limits of prescribing i.e. when
referral back to IP should take place
However
Clinical Management Plans (CMPs) have to be relatively
simple and quick to complete – or supplementary
prescribing will simply not be worth the effort. They
should not duplicate a lot of information that is already
recorded in the shared record.
Regulations specify that the CMP must include the
following:
•
•
•
•
•
•
•
•
the name of the patient to whom the plan relates;
the illness or conditions which may be treated by the supplementary prescriber;
the date on which the plan is to take effect, and when it is to be reviewed by the doctor or
dentist who is party to the plan;
reference to the class or description of medicines or types of appliances which may be
prescribed or administered under the plan;
any restrictions or limitations as to the strength or dose of any medicine which may be
prescribed or administered under the plan, and any period of administration or use of any
medicine or appliance which may be prescribed or administered under the plan;
[NB The CMP may include a reference to published national or local guidelines. However these
must clearly identify the range of the relevant medicinal products to be used in the treatment
of the patient, and the CMP should draw attention to the relevant part of the guideline. Any
guideline referred to also needs to be easily accessible]
relevant warnings about known sensitivities of the patient to, or known difficulties of the
patient with, particular medicines or appliances;
the arrangements for notification of:a) suspected or known reactions to any medicine which may be prescribed or administered
under the plan, and suspected or known adverse reactions to any other medicine taken at the
same time as any medicine prescribed or administered under the plan, and
b) incidents occurring with the appliance which might lead, might have led or has led to the
death or serious deterioration of state of health of the patient
the circumstances in which the supplementary prescriber should refer to, or seek the advice
of, the doctor or dentist who is party to the plan.
Clinical
Management
Plan: CMP
Departmental Protocol
• Protocol for Lung Cancer
Clinical Specialist
Radiographer Review for
Patients with Lung Cancer
• Agreed by Lung Team
Clinical Oncologists,
Radiotherapy Lead
Clinician, Clinical Director
& Professional Lead
Shared Patient
record
CMP hardcopy inserted
to patient notes at the
end of treatment
Potential of Electronic
Version of CMP
BHSCT: NMP Policy
Prescriber details, Date,
Drug, Quantity, Dose,
Frequency, Treatment
duration
• Hardcopy & ‘COIS’ electronic
case notes
• Gained user rights to input
prescribing information
electronically
• Meets statutorily requirements
– Automatically available for IP
and other clinicians
– Meets the trust’s NMP
policy requirement s
– Governance
Scope of Supplementary Prescribing: (NPC 2010)
No restrictions on the clinical conditions SP may treat as CMP in place.
Primarily used to treat chronic conditions or patients with who require long
term care. This includes cancer.
All general sales list (GSL) medicines, pharmacy (P) medicines, appliances
and devices, foods and other borderline substances approved by the
Advisory Committee on Borderline Substances.
Medicines for use outside of their licensed indications (i.e. ‘off label’
prescribing), ‘black triangle’ drugs, and drugs marked ‘less suitable for
prescribing’ in the 'British National Formulary' (BNF).
Medicines for use outside of their licensed indications (i.e. ‘off label’
prescribing), ‘black triangle’ drugs, and drugs marked ‘less suitable for
prescribing’ in the 'British National Formulary' (BNF).
Controlled Drugs except those listed in schedule 1 of the 2001 Regulations .
These drugs are not for use in humans.
Supplementary Prescribing
Let the confusion begin!
The Prescribing Umbrella
Medical
Prescriber
INDEPENDENT
PRESCRIBER
Non-Medical
Prescriber
SUPPLEMENTARY
& INDEPENDENT
PRESCRIBER
Non Medical
Prescribers
Nurses
Pharmacists
Radiographers
Physiotherapists
Chiropodists/
Podiatrists
Optometrists
Non Medical Prescribers
INDEPENDENT
PRESCRIBER
SUPPLEMENTARY
PRESCRIBER
Non Medical Prescribers
INDEPENDENT
PRESCRIBER
NMP: Independent Prescribers
Some
Controlled Drugs
ANY Medicine
SCOPE of PRACTICE
NMP: Independent Prescribers
Controlled Drugs
ANY Medicine
SCOPE of PRACTICE
NMP: Independent Prescribers
Controlled Drugs
Licensed Medicine
Ocular Condition Only
SCOPE of PRACTICE
MNP: Supplementary Prescribers
Controlled
Drugs
ANY Medicine
CMP
SCOPE of PRACTICE
SUPPLEMENTARY
PRESCRIBER
The BHSCT AHP
Supplementary Prescribing
Experience.
BCH
AHPISP’s
Linda Young
Lung Cancer Specialist
Jenny Keane
Head & Neck Cancer
Specialist
Helen Vennard
Breast and Gynae
Specialist.
CSR
• Clinical specialist radiographers
– Principle Radiographers
• 6-8 years in current posts
• Work in disease specific teams
• MSc level Postgraduate
Education modules
• Expert knowledge in the clinical
management and treatment of
cancer relevant to our specialist
disease site
Patient Centered Care Levels Matched Against Current Roles And
Responsibilities.
Level 1
Level 2
Level 3
Providing appropriate specialist information and knowledge to patients
and careers. Giving guidance and support around the diagnosis and
treatment options.
Ensuring seamless transfer from diagnosis to treatment and onward
referral where appropriate.
Core Member of the MDT.
Functioning as a member of the multidisciplinary team, where decisions
about the optimum treatment options to offer to each patient.
Provide specialist knowledge to the lung cancer multi-professional team
meeting.
Participate at Lung Cancer Regional Network level.
Play a lead role in development of radio-therapeutic practice pertaining to
the treatment of lung cancers.
Responsibility for the co-ordination of care across the radiotherapy
pathway.
Responsible for managing treatment related toxicities.
CSR On-treatment and post treatment review
The NHS Cancer Plan and the New NHS: Providing a patient centered service (2004), DH
Clinical Navigation
Radial intent
Palliative intent
Managing treatment
related toxicity
Gaining optimum
control of symptoms
of disease
Appropriate onward
referral
Lung Cancer Team
Clinical
Oncologists
Medical
Oncologists
Lung Cancer
Radiographer
Lung Cancer
Nurse
THE POSTGRADUATE CERTIFICATE
IN PRESCRIBING FOR ALLIED
HEALTH PROFESSIONALS FEB 2010
Designated Medical Practitioners
Postgraduate Certificate Prescribing
There’s life Jim but
not as we know it
Postgraduate Certificate Prescribing
Portfiolo……it was unending!!!!!!!
Postgraduate Certificate Prescribing
Portfolio of Prescribing
Competencies
Postgraduate Certificate
Semester 2
• Pharmacotherapeutics in Prescribing
February 2010
Semester 3
June 2010
• Clinical Experience & Case Study “Scouting”
Semester 1
• Prescribing in Practice
October 2010
Jan 2011
Results Feb 2011
Register with HPC April 2011
Graduate June 2011
Paperwork July 2011
September 2011 Clinical Protocols in place
October application to Register
??????? Legislation in Place
January 2010 AHPISP
End Result! 14 months later
Prescribing in Practice
Lessons learnt in the first week at UU
• All drugs are poison!
•All drugs are poison!
DR MARK CROSS
Drug Drug Interactions
Importance of Drug Historys & Allergies
Co-morbidities, e.g renal disease
Patients don’t tell the truth about taking their medication!
THE BROWN BAG PHENOMEN!
CSR links to the Patient’s Journey
MDT
New patient
Clinic
Radiotherapy
Follow-up
Clinic
Radiotherapy
Planning Clinic
Radiotherapy On
Treatment Review
(urgent & weekly for
duration of treatment
CSR links to the Patient’s Journey
MDT
New patient
Clinic
Radiotherapy
Follow-up
Clinic
CMP
Radiotherapy
Planning Clinic
Radiotherapy On
Treatment Review
(urgent & weekly for
duration of treatment
• ROUTINE CASE
Case 1
• Radical NCSCL 66Gy in 33 fractions
• SUCRALFATE 1g PO TDS from start of treatment until for 4
weeks post +/- PPI
• Oramorph 2.5mg PO 4-6 hrs PRN
• Fluconazole 50mg PO 14 days
Normal
Grade 2
Grade 3 with candidiasis
Cautions!!!!!!!
• ALL DRUGS ARE POISONS!!!
• FLUCONAZOLE:
– Caution in patients with renal impairment
• EGFR <50 reduce dose by half after 1st dose
• Rare cases of hepatic failure!
• As a causal relationship with fluconazole cannot be excluded,
patients who develop abnormal liver function tests during
fluconazole therapy should be monitored for the
development of more serious hepatic injury. Fluconazole
should be discontinued if clinical signs or symptoms
consistent with liver disease develop during treatment with
fluconazole.
Cautions!!!!!!!
• ALL DRUGS ARE POISONS!!!
• SUCRALFATE:
– Bezoars (an insoluble mass formed with the gastric lumen)
– Caution in patients with renal impairment due to increased
aluminium absorption
– Concomitant administration may reduce the bioavailability
of certain drugs including tetracycline, ciprofloxacin,
norfloxacin, ketoconazole, digoxin, warfarin, phenytoin,
theophylline, thyroxine, quinidine and H2 antagonists. The
bioavailability of these agents may be restored by
separating the administration of these agents from
SUCRALFATE by two hours.
• COMPLEX CASE
Case 2
• Radical NCSCL 64Gy in 32 fractions
•
•
•
•
3rd fraction described Pain in the left thorax
Open and close surgery
No brachial plexus neuropathy
No clinical indication for pain
• Described Pain with neuropathic element
Pain Control:
Adjuvants
10mg
Case 2
• Radical NCSCL 64Gy in 32 fractions
• 2nd Week Nausea
–
–
–
–
METOCHLOPRAMIDE
CYCLIZINE
ONDANSETRON
Added in Steroid
• Friday night at 5pm
• Nausea and vomiting ? Admission
– LEVOMAPROMAZINE 6mg Nocte
DRUG DRUG INTERACTION!
LEVO with Amitriptylline
Case 2
DRUG DRUG INTERACTION!
LEVO with Amitriptylline
Contacted GP who after discussion felt that the drug combination was
justified and she took responsibility for the prescription
GP issued the script to local pharmacy
Patient collected on way home
Nausea and vomiting was resolved by Monday. Pain remained controlled.
• Medicine Reconciliation
Did this meet the aims of NMP
• No inpatient bed stay
Do we consider SP to be of value?
Patient’s: Yes!
Doctors: Definate Yes
“I get the same care, the
same medicines, I just
don’t have to wait so long
to get them.”
“Can I head off to
planning now? sure you
can mange the clinic this
morning, give me a shout
if you need me. Any
problems , I’ll come down
asap. “
Why has Supplementary Prescribing
appeared to fail in Nursing Models ?
The reasons!
• Available for Nurses since 1999
• Over 50% of the nurses surveyed
could use NMP in their area of
practice.
• Due to difficulties implementing
NMP in practice only 22.7% were
prescribing in practice.
• unavailability of prescription pads
• awaiting prescribing code
• impracticalities due to trust-wide
remit
• not working in an area of
practice that lends itself to
extended independent or
supplementary nurse prescribing
•
GRIBBEN, L., 2004. Meeting The Educational Needs of
Independent and Supplementary Nurse Prescribers – An
Interim Evaluation. MSc Learning & Teaching. University of
Ulster Jordanstown
• At a local level NMP uptake was
initially high within Northern
Ireland however it is reported
that within the Belfast Trust only
25% of nurses trained as nonmedical prescribers actually
practice.
V Hall Consultant Nurse.
• Pharmacist NMP’s
• only 47% of them were actively
prescribing
•
BISSEL, P., COOPER,R., GUILLAUME, L., ANDERSON, C., AVERY,
A., HUTCHINSON, A., JAMES, V., LYMN, J., MARSDEN, E.,
MURPHY, E., RATCLIFFE, J., WARD, P., and WOOLSEY, L.,
2008. Nurse and Pharmacist Supplementary Prescribing in the
UK - a systematic Review of the Literature. London: DH
CAUTION!!!!!
AHP’s Will Follow The Same Path If
Candidates Are Not Able To
Meaningfully Prescribe In Practice
Why has
implementing
supplementary
prescribing
worked for us?
Why has
implementing
supplementary
prescribing
worked for us?
Why has
implementing
supplementary
prescribing
worked for us?
Why has
implementing
supplementary
prescribing
worked for us?
Why has
implementing
supplementary
prescribing
worked for us?
Why has
implementing
supplementary
prescribing
worked for us?
Why has
implementing
supplementary
prescribing
worked for us?
Why has
implementing
supplementary
prescribing
worked for us?
Why has
implementing
supplementary
prescribing
worked for us?
How
supplementary
prescribing will
work your you!
• A Trustwide Non Medical
Prescribing policy reflects the
prescribing rites of your
profession
• Departmental Prescribing Policy/
AHP role specific clinical protocol
• Appropriate identification of
applicant
 Right person
 Right place
 Right time
 Right outcome
How
supplementary
prescribing will
work your you!
• AGREED Core Formulary: Which
Which reflects Prescribers level
of clinical management, skill and
knowledge of medicine will be
reflected in the classes of
medication listed in the SP’s core
formulary and referral back to IP
trigger points.
• Close team working built on a
mutual trust and respect for
each prescribers role
• Access to the shared patient
record
• A WORKABLE SYSTEM for
implementing the CMP!
Head & Neck CSR Core Formulary
1Gastro-intestinal system
1.1Agents for dyspepsia and gastrooesophageal reflux disease
1.2Antispasmodics and other drugs and
mucosal protectants
1.3Antisecretory drugs and mucosal
protectants
1.4 Acute diarrhoea
1.6 Laxatives
1.7 Local preparations for anal and
rectal disorders
3.Respiratory system
3.6 Oxygen
3.9 Cough preparations
3.10 Systemic nasal decongestants
4 Central nervous system
4.1 Hypnotics and anxiolytics
4.6 Drugs used in nausea and vertigo
4.7Analgesics controlled drugs listed
below
5 Infections
Antimicrobials:
5.1Antibacterial drugs
6 Endocine system
9 Nutrition and blood
9.1 Agents used for anemias and
some other blood disorders
9.2 Fluids and electrolytes
9.5 Minerals
9.6 Vitamins
10 Musculoskeletal and joint
disease
10.1.1 Non-steroidal antiinflammatory drugs
11 Eye
11.8 Tear deficiency, ocular
lubricants, and astrigents
12 Ear, Nose and oropharynx
12.2 Drugs acting on the nose
12.3 Drugs acting on the
oropharynx
13 Skin
13.2 Emollent and barrier
preparations
13.4 Local anaesthesia
15 Anaesthesia:
15.2 Local anaesthesia
Controlled Drugs schedule 2,3
& 4:
BUPRENORPHINE
CODIENE PHOSPHATE
FENTANYL
MORPHINE SALTS:
SEVREDOL
MST CONTINUOUS
OXYCODONE HYDROCHLORIDE
OXYNORM
OXYCONTIN
TARGINACT
TRAMADOL HYDROCHLORIDE
Off Label drugs
OXCETACAINE in ANTACID:
LEVOMEPROMAZINE:
Head & Neck CSR Core Formulary
1Gastro-intestinal system
1.1Agents for dyspepsia and gastrooesophageal reflux disease
1.2Antispasmodics and other drugs and
mucosal protectants
1.3Antisecretory drugs and mucosal
protectants
1.4 Acute diarrhoea
1.6 Laxatives
1.7 Local preparations for anal and
rectal disorders
3.Respiratory system
3.6 Oxygen
3.9 Cough preparations
3.10 Systemic nasal decongestants
4 Central nervous system
4.1 Hypnotics and anxiolytics
4.6 Drugs used in nausea and vertigo
4.7Analgesics with the exceptions of
controlled drugs listed below
5 Infections
Antimicrobials:
5.1Antibacterial drugs
6 Endocine system
9 Nutrition and blood
9.1 Agents used for anemias and
some other blood disorders
9.2 Fluids and electrolytes
9.5 Minerals
9.6 Vitamins
10 Musculoskeletal and joint
disease
10.1.1 Non-steroidal antiinflammatory drugs
11 Eye
11.8 Tear deficiency, ocular
lubricants, and astrigents
12 Ear, Nose and oropharynx
12.2 Drugs acting on the nose
12.3 Drugs acting on the
oropharynx
13 Skin
13.2 Emollent and barrier
preparations
13.4 Local anaesthesia
15 Anaesthesia:
15.2 Local anaesthesia
Controlled Drugs schedule 2,3
& 4:
BUPRENORPHINE
CODIENE PHOSPHATE
FENTANYL
MORPHINE SALTS:
SEVREDOL
MST CONTINUOUS
OXYCODONE HYDROCHLORIDE
OXYNORM
OXYCONTIN
TARGINACT
TRAMADOL HYDROCHLORIDE
Off Label drugs
OXCETACAINE in ANTACID:
LEVOMEPROMAZINE:
How
supplementary
prescribing will
work
REGIONALLY!
• Have some ACTIVE prescribers
as members of committees at
strategic level to inform at
regional level!
How AHP
strategy will be
implemented
REGIONALLY!
Commissioners, don’t be a
stranger!
THANK YOU FOR YOUR ATTENTION