Transcript No Slide Title

Nurse/Midwife
Medicinal Product
Prescribing in Ireland :
The benefits
Annette Cuddy, Assistant
Director Nursing & Midwifery
(Prescribing, HSE West)
Website: http://www.hse.ie/go/nurseprescribing
Irish Model of Nurse Midwife Prescribing
Independent, collaborative model
Enables a registered nurse or midwife who has
completed an approved education programme, has the
appropriate clinical experience, is registered with NMBI
as a RNP, and has authority from the health service
provider that employs them to independently prescribe
a range of medicinal products within their scope of
practice and in collaboration.
Primary Legislation
 Provisions for nurses & midwives to prescribe
 Provides for An Bord Altranais to regulate for
prescribing
Accessible at: www.oireachtas.ie
Regulatory Framework
for Prescriptive Authority
Nursing and Midwifery Board of Ireland:
Education
Clinical Competence
Clinical Governance
Registration
Documents:
Requirements and Standards for Education Programmes for Nurses
and Midwives with Prescriptive Authority (2007)
Practice Standards and Guidelines for Nurses and Midwives with
Prescriptive Authority (2010)
Collaborative Practice Agreement (CPA) for Nurses and Midwives
with Prescriptive Authority 3rd Edn (2012)
Website: http://www.nursingboard.ie
Number of RNPs: 550
Nurse Midwife Prescribing: The Benefits:
Context and Background
2012: Five years of prescriptive authority
500 Registered Nurse Prescribers
Over 140,000 items prescribed
Evaluation undertaken 2009
Team looked at benefits for patients and services
Literature search undertaken (national and
international)
Literature Search
Improved quality of care
Patients and parents (140 respondents) were highly satisfied with care from nurse/midwife
with prescriptive authority and felt supported by nurse and midwife
(Drennan et al, 2011)
Improved relations and communications with patients
(Stenner and Courtenay, 2008)
Listening, understanding beliefs and concerns about medicines and working in partnership
with patients promotes compliance
Joint decision-making
(Latter, 2011)
Nurses prescribe within their own area of expertise and competence (eg. pain, wound care,
diabetes and cardiac medicine). Patients value this specialised knowledge and combined with
health education and health promotion is much valued
(Latter, 2011)
Integrated care services – places the patient central to care
(Astles, 2006)
High levels of satisfaction reported with the consultation process
(Drennan et al, 2011)
Literature Search Contd.
Access and continuity of care
Convenience
(Latter, 2011; Courtenay et al, 2009; O’Connell et al, 200
Access to medications: easier and quicker (reduced waiting times for treatment) emerged asone
of the most beneficial aspects of prescribing. Because of this, the patient will now sometimes
see the nurse rather than the doctor in ongoing treatment for both acute and long term
conditions
(Latter, 2011)
Effective use of the nurses and doctors (GPs) time
Timeliness: responsive to their needs - assessed and prescription written, therefore begin
treatment immediately
(Brooks et al, 2001)
Efficient ordering of pain medication and tests
(Kaasallainen, 2010)
Timely follow-up with residents pain concerns
(Kaasallainen, 2010)
Faster access to treatment
(Stenner and Courtenay, 2008)
Immediate commencement of treatment
(Astles, 2006)
Methodology
Purposive sample: 406 Registered Nurse Prescribers
Accessed through RNP E-Network
Requested to “share any information regarding the
impact of nurse and midwife medicinal product
prescribing in Ireland, with particular emphasis on cost
and benefit”
Qualitative and quantitative information submitted
Reports from Nurse Midwife Prescribing Data Collection
System analysed
Findings: Midwifery Prescribing
Irish Review: Effects on patient care and the organisation of the
introduction of the administration of first dose intravenous
antibiotic therapy for Group B Streptococcus prophylaxis by
midwives following the prescription of this therapy by Registered
Nurse Prescribers in the delivery ward.
58 cases were randomly audited
Findings:
More timely and effective delivery of care to woman and baby
Reduction in hospital screening of neonate
Reduction in hospital bed days
Early transfer home
Findings: Midwifery Prescribing contd.
Maternity Hospital: Prescribing of Antibiotic Therapy by RNPs: Early
Transfer Home
1800
1700
1600
1500
Totals 1400
Pre-RNP
Post RNP
1300
1200
1100
1000
2007
2008
2009
Year
2010
Findings: Community Hospital
17 WTE nurses
38 bedded unit
4 Registered Nurse
Prescribers
328 occasions residents did
not have to wait for GP
Cost per call out ?? €80 per
call out out of hrs
Positive impact on quality
of life
Resource implications for
on-call service
“For each episode of
prescribing by a nurse, the GP
does not have to attend on
site. This also means there is
no waiting time for a doctor to
come. There are currently 328
nurse prescribing episodes
since February 2009 within
the service so over a period of
3 years the doctor's
attendance was not required
this many times on site” (RNP,
Community Hospital)
Findings: Day Hospital
RNP-Led Anticoagulant Clinic
“In 2010 we introduced Point of Care
testing to our anticoagulant clinic so this
means we have an instant INR result.
There is no wait for laboratory results,
which has greatly improved the
efficiency of the clinic. This has
improved patient safety as immediate
action can be taken if an INR is very
high”
(RNP, Day Hospital)
Findings: RNP-Led Anticoagulant Clinic
INR Therapeutic Range Pre and Post RNP Led Clinic
85%
80%
75%
70%
65%
60%
55%
50%
INR Therapeutic Range Pre RNP
INR Therapeutic Range Post RNP
Nurse-led diabetes and renal impairment clinics
An effective disease management strategy was established resulting in an ANP renal and diabetic
service being set up with the aim of improving clinical outcomes
Patient (n=78) Activity within ANP Diabetic and Renal Impairment Services
1,285 visits – represented 10% increase in activity (2011)
Non-attendance reduced from 16% to <1%
Audit confirmed that lower blood pressure targets were all met
Prescriptions issued by RNP = 495
Patients valued continuity of care which was personalised to their own needs
98.5% stated they would prefer to remain in ANP-led diabetes care rather than return to standard
medically-led standard care
New CKD Stage 3 transferred to the ANP service directly from main diabetic clinic:
Kilkenny 67
Carlow 26
(Blanchfield and McGurk, 2012)
Nurse-led diabetes and renal impairment clinics
An effective disease management strategy was established resulting in an ANP renal and diabetic
service being set up with the aim of improving clinical outcomes
Patient (n=78) Activity within ANP Diabetic and Renal Impairment Services
1,285 visits – represented 10% increase in activity (2011)
Non-attendance reduced from 16% to <1%
Audit confirmed that lower blood pressure targets were all met
Prescriptions issued by RNP = 495
Patients valued continuity of care which was personalised to their own needs
98.5% stated they would prefer to remain in ANP-led diabetes care rather than return to standard
medically-led standard care
New CKD Stage 3 transferred to the ANP service directly from main diabetic clinic:
Kilkenny 67
Carlow 26
(Blanchfield and McGurk, 2012)
Findings: Other
Advanced Nurse Practitioners:
Prescriptive authority is an essential pre-requisite for role expansion,
capitalising on nurses’ knowledge and expertise with improved
patient outcomes.
Extended role of RNP results in autonomy, empowerment advanced
practice assessment
Improved ability to manage patient care more completely
Reduced dependence on the medical team
Emergency Department Advanced Nurse Practitioner:
Patient receives total episode of care from one professional.
Timeliness: Patient receives appropriate medication in a more
efficient and timely manner as the RNP prescribes medication as
necessary and appropriate.
RNP’s time as a resource is used more effectively. Medical
colleagues are free to be used more effectively in the delivery of care.
“I no longer need to call medical colleagues away from other
patients to care for my patients”.
Practice Nursing:
Collaborative working between General Practitioner,
Nurse/Midwife, patient/client
Continuity of care, e.g. for patients with chronic diseases
Delivery of direct patient care by Registered Nurse
Prescriber, eg treatment and prescribing for conditions
such as Urinary Tract Infection, COPD, administration of
childhood and travel vaccinations.
Reduced workload for General Practitioner as RNP can
issue prescription within their scope of practice.
RNP can support the work of the multidisciplinary team
by assessing patients and treating them appropriately,
thus ensuring an efficient and timely service.
Findings: Prescribing Activity
In 5 years ..
Jan ’08 to January 2013
RNPs reported writing:
 95,692 Prescriptions for;
 74,137 Unique Patients
 140,240 Medicinal Products
1 From Jan 2012 to 31 December 2012
RNPs reported prescribing for:
 30,682 Prescriptions for;
 25,320 unique Patients
 46,393 Medicinal Products
Most Frequently Prescribed Medicines
Medicinal Product
Nos
Paracetamol
11067 Lidocaine/Fluorescein
1482
Diclofenac
7059
Morphine Sulphate
1443
Ibuprofen
5864
Proxymetacaine
1403
Diphtheria, Tetanus
4494
Tramadol
1346
Lidocaine
4007
Fusidic Acid
1370
Benzylpenecillin
3156
Flucloxacillin
1301
Measles, Mumps, Rubella Vaccine (live)
2288
Metformin
1296
Amoxicillin/Clavulanic Acid
2147
Prochlorperazine
1244
Fluorescein Sodium
2103
Insulin Aspart (Novorapid)
1128
Paracetamol/Codeine (Solpadol/Tylex)
1968
Diclofenac Sodium
1122
Chloramphenical
1783
Pethidine
1066
Warfarin
1621
Paracetamol/Codeine (Solpadeine)
1003
1545
Diphtheria, Tetanus, Pertussis, Inactivated
Poliomyelitis
923
Mefenamic Acid
Medicinal Product
Total Items Prescribed 28 January 2008 – 31 March 2013: 103,051
Nos
Benefits of Nurse Prescribing
Continuity of care for patients
Delivery of direct patient care by RNP
Reduced workload for medical practitioner
Patients value continuity of care
RNP’s time as a resource is used more effectively
Medical colleagues are free to be used more
effectively in the delivery of care
Extended role results in autonomy,
empowerment, and advanced practice
assessment
Conclusion
Further research required
Survey of Clinical Nurse Midwife Specialist
RNPs currently underway
Contact Information
Clare MacGabhann
Interim Director of Nursing and Midwifery
Office of the Nursing Services Director
HSE South
E-mail: [email protected]
Office: 021-4927471
Phone: 087 9317025
Ina Crowley
A/Assistant Director of Nursing and
Midwifery
Office of the Nursing Services Director
HSE Dublin Mid Lenister
E-mail: [email protected]
Office: 061 464007
Phone: 086 3851729
Annette Cuddy
Assistant Director of Nursing and Midwifery
Office of the Nursing Services Director
HSE West
E-mail: [email protected]
Office: 091-775845
Phone: 087 9317039
Rose Lorenz
Assistant Director of Nursing and Midwifery
Office of the Nursing Services Director
HSE Dublin North East
E-mail: [email protected]
Office: 041-6858131
Phone: 087 2864075