Transcript What is the contribution of nurse presecribers to medicines

What is the contribution of
nurse prescribers to medicines
optimisation?
Current practice and
challenges ahead
Prof Sue Latter, Health Sciences, University of Southampton
Nurses and medicines optimisation
• 675,000 nurses registered in the UK
• Working in a variety of settings; homes and schools,
workplaces, A and E, hospital wards, nurse-led clinics,
outreach teams, community and primary care, nursing and
care homes
• Contribution to medicines optimisation through: preparing,
supplying, administering and prescribing medicines,
monitoring and review, patient education, multidisciplinary liaison and care interface communication
Nurse prescribers and medicines
optimisation
• 54,000 nurse prescribers in the UK
• Over 20,000 independent nurse prescribers, prescribing
across whole formulary
• Preparation: 3 years post qualification; 26 days in HEI
taught course + 12 days with Designated Medical
Practitioner
• Radical model, comparative to other countries
• Experience, extra training, greater autonomy
Setting
% NIPs
Mean
hrs/wk
% PIPs
Mean
hrs/wk
GP practice
40.8%
26.8
54.5%
5.1
NHS hospital Trust
Home visits
Walk-in Centre
Family planning
clinic
Care homes
Nursing homes
28%
20.9%
6.7%
4.8%
33.9
16.1
24.9
8.2
35%
2.1%
0.7%
-
4
1.3
2.0
-
3.6%
3.5%
6.4
5.5
1.4%
0.7%
1.0
2.0
Sexual health clinic
NHS Mental health
Trust
2.4%
1.0%
11.7
16.7
1.4%
1.4%
8.5
2.7
Scale of NIP and PIP
Hospital / Foundation Trusts:
Mean number of:
NIPs per Trust 21.4
PIPs per Trust 2.0
Primary Care Trusts:
Mean number of:
NIPs per Trust 74.9
PIPs per Trust 1.9
Treatment areas prescribed in most frequently
NIPs
Infections
Asthma
Diabetes
COPD
Family planning
%
15.3%
9.8%
7.9%
6.1%
5.8%
Wound care
Dermatology
Pain
management
Minor injuries
5.6%
4.2%
4.0%
PIPs
Hypertension
Cardiology
Asthma
CHD prevention
Care
of
older
people
Oncology
Diabetes
Infections
%
25.0%
9.6%
6.6%
5.8%
5.8%
3.9%
Drug/subs. misuse 3.7%
Cardiology
3.7%
Gastrointestinal
5.8%
4.4%
4.4%
2.9%
Scope and scale of NMP
66.4% of NIPs and 42.7% of PIPs report prescribing
instead of a doctor in their main treatment area
The average consultation time reported by NIPs for a
prescribing consultation was 21.21 minutes and for PIPs
18.01 minutes.
MAI question
Is there an indication for the medication?
Is the medication effective for the
condition?
Is the dosage correct?
Are the directions correct?
Are the directions practical?
Are there clinically significant medication
/ medication interactions?
Are there clinically significant medication
/ condition interactions?
Is there any unnecessary duplication
with other medications?
Is the duration of therapy acceptable?
Is the drug the least expensive
alternative..?
NIP %
appropriate
PIP %
appropriate
93%
96%
97%
98%
91%
88%
97%
91%
90%
98%
97%
95%
94%
91%
98%
98%
95%
98%
88%
79%
Ireland: national evaluation
• 142 patients, 208 medicines prescribed by 25 nurses
• 95-96% of medicines prescribed were indicated and effective for the
diagnosed condition
• Criteria relating to dosage, directions, drug-drugs or disease condition
interaction, and duplication of therapy were judged appropriate in 8792% of prescriptions
• Duration of therapy received the lowest value at 76%.
• Overall, reviewers indicated that between
69 - 80% of prescribing decisions met all eight criteria.
Naughton et al (2012)
A & E and sexual health prescribing
• 764 case notes from NIPs in 1 London A & E
• Over 53.5% (n = 409) of prescribers’ patients required
medication
• Analgesia was most commonly prescribed in accident and
emergency (31%, n = 85)
• Antibiotics in sexual health (55%, n = 162)
• Safe prescribing practice was evident in 99.4%
Black (2012)
Patients’ experiences and
preferences
Acceptability of IP to patients is high, as evidenced by the
majority of patients reporting that they were ‘very satisfied’
with their visit to the nurse (94%) or pharmacist (87%)
prescriber
Tinelli et al (2013)
Patients’ experience & preferences
Discrete Choice Experiment findings also showed that
patients valued pharmacist and nurse prescribing services as
an alternative to GP prescribing in primary care.
Preference for own doctor, but certain attributes of the
consultation - listening to patient’s views about medicines;
explanation about medicines, were valued more than the
profession of the prescriber.
Gerard et al (2014)
Challenges
• Promoting adherence
• Prescribing for co-morbidities & complexity
• Acute sector prescribing / antimicrobial stewardship
UK guidance on adherence
• RPS (2013) understand patient experience
• NICE (2009) guidance:
– address perceptions and practicalities
– Necessity-Concerns Framework (Horne and Weinmann
1999)
– ‘be aware that patients’ concerns about medicines, and
whether they believe they need them, affect how and
whether they take their prescribed medicines
Are nurses’ promoting adherence?
•
Little research on nurses (Stevenson et al 2004)
•
Latter et al NAME papers
•
Evidence on UK nurse prescribers suggests opportunity is not being fully exploited
Sibley et al 2011: 20 NIPs; 59 consultations; 260 medicine discussions
•
most frequently raised themes were:
‘medication named’ (88.8%)
‘usage of medication’ (65.4%)
‘instructions for taking medication’ (48.5%)
‘reasons for medication’ (8.5%)
‘concerns about medication’ (2.7%).
•
‘Instructional’ communication most prevalent
•
Professional development is required to support evidence-based approaches to medicines
optimisation
15
Prescribing for co-morbidities
58% of NIPs agreed / strongly agreed that they have concerns
prescribing for patients with co-morbidities
28.5% of PIPs agreed or strongly agreed with this statement.
Latter et al (2011)
Prescribing for co-morbidities &
complexity
• Greater proportion of community matrons reported less access to
support & supervision to underpin their prescribing (Smith et al 2014)
• Herklots (2013)
– prescribing-related knowledge essential
– the ability to prescribe speeds patient access to medicines and may
be instrumental in preventing hospital admission
– prescribe a limited range of medicines regularly, whilst referring to
GPs for other prescribing outside their competence
– Mostly access their support from GPs and consider this adequate
in supporting them in their prescribing role.
Prescribing for co-morbidities &
complexity
• CMs prescribing a similar range of meds – COPD
exacerbations and infections
• variation in confidence in prescribing for conditions beyond
this core group of drugs:
I’m happy with exacerbations and chest infections… UTIs
and wound infections, but anything that’s going beyond that
I just don’t feel confident in myself to be going out and doing
that, I really feel that to me is a doctor’s job (CM7)
You see I don’t think I have increased my scope over the
years to be frank, I think I have quite a limited range that I
feel confident doing, using and I haven’t gone outside it…I
think the knowledge and skills are there to impart
information and support to the patients.. but I certainly don’t
feel the need to suddenly become an expert in you know,
Parkinsons meds or anything, I just wouldn’t touch it (CM1)
Prescribing for co-morbidities &
complexity
• Enhanced training for prescribing?
• Working with pharmacists
RPS Commission on future models of pharmacy:
examples of multi-disciplinary working to support
complex meds management
Prescribing for co-morbidities
• outreach pharmacists employed by hospitals or community
services, forming part of the care team for frail older people
in particular
• E.g. Guy’s and St Thomas’ Community
Services team have pharmacists as core members, working
with nurses and others to manage complex patients in the
community to avoid unnecessary admissions or readmissions.
Acute sector prescribing
• Main setting reported by 28% of NIPs in 2011 national
survey
• Little robust evidence on current practices and contribution
to key issues:
– Communication between care settings
– Integrated primary and secondary care systems
– Antimicrobial stewardship
Acute sector prescribing
• Kroezen (2014) hospital nurse specialists
– Great variety in prescribing – frequency and type
– Extensive number of protocols, guidelines and
formularies
– Highly frequent, informal consultation between nurse
and medical specialists about nurse prescribing
– Difficulties: new professional power relations; lack of
organisational readiness
•
Local flexibility or lack of strategic thinking?
Acute sector prescribing
• Need for UK data on what areas, what medicines and how
the role is being utilised to achieve key policy objectives
e.g. antimicrobial stewardship
RCN (2014)
• Reduce demand for antibiotics
• Enhance effectiveness of prescribed antibiotics
– Awareness of, and ensuring compliance with, policies
– Ensuring clear and accurate prescription processes
– Dispensing at the right time and correct circumstances
– Educating patients and carers re self-administration
Nurse role in AMS
• Sustained, seamless level of monitoring and decisionmaking (Edwards et al 2011)
• Questioning and highlighting suboptimal drug therapy
• Appropriate therapy is promptly initiated
• Check for allergy status
• Ensure potential for switching from intravenous to oral
therapy is reviewed
• (Ladenheim et al 2013)
Nurse role in AMS
• But still we know very little about nurses and / or nurse
prescribers’ current practice and roles in AMS
• Role of acute care nurse and development of intervention
• Quality and safety and influences on practice nurses’ AB
prescribing
• Intervention for hospital-based prescribers to improve
initial AM prescribing
Conclusions
• Large workforce, practising in variety of settings
• Expanding number of nurse prescribers with autonomy and capacity to
independently manage patient episodes of care
• Prescribing safely within defined areas
• But
– must use evidence-based consultations to promote adherence
– engage with others on complex prescribing for enhanced patient
experience
– use prescribing authority proactively and strategically in all settings
Necessity Concerns Framework
• Higher adherence was associated with stronger perceptions
of Necessity of treatment (p 0.0001) and
• Fewer Concerns about treatment (p 0.0001)
• These relationships remained significant when data were
stratified by study size, country and type of adherence
measure used
• Taking account of patients’ necessity beliefs and concerns
could enhance the quality of prescribing by helping
clinicians to engage patients in treatment decisions and
support optimal adherence to appropriate prescriptions
‘Adherence’ or medicines
optimisation
• Medicines self-monitoring and self-management appear
generally effective to improve medicines use, adherence,
adverse events and clinical outcomes (Ryan et al 2014)
• ‘Some evidence’ for:
– education + skills training, counselling, support, or
enhanced follow-up; information and counselling
delivered together
– practical strategies like reminders, cues and/or
organisers, reminder packaging and material incentives
RCN (2014)
• Electronic systems for prescribing, dispensing and
administering, for accurate data
• Simplified language – ‘prescribers’ so best practice
messages are seen as relevant to all
• Strengthening nurse education on pharmacology associated
with antimicrobial prescribing and AMR