(CMPs) for all my patients. CMPs are a legal ... ication that was within my compe- tence to prescribe. As care of ... Prescriber December 2007 www.escriber.com.
Nonmedical prescribing
Nonmedical prescribing for patients in long-term care Nina Barnett MSc, MRPharmS Our series Nonmedical prePractice name/location:
scribing gives an overview of
The Denham Unit, Rowanweald Nursing Home, Harrow
the work that can be done by nonmedical prescribers and
Size:
30 beds,
Staff:
what can be achieved. Here, the author describes her role
1 pharmacist (part time).
as a nonmedical prescriber prescribing for older people, including pain management, Parkinson’s disease, bowel management Prescribing competencies:
Funding:
Harrow Primary Care Trust
I
am a consultant pharmacist specialising in the care of older people in acute, intermediate and long-term care settings. In 2003 the law changed, allowing pharmacists to prescribe in partnership with a named doctor, having previously obtained the patient’s consent (pharmacist supplementar y prescribing). Having been involved in medically led multidisciplinary patient reviews for many years, I took this opportunity to explore the benefit of prescribing in the long-term care setting, where I already participated in the weekly ward rounds. When I completed the prescribing course in April 2004, I set about establishing clinical management plans (CMPs) for all my patients. CMPs are a legal requirement for supplementary prescribing, and list the agreed medication (or class of medication) that can be prescribed by the supplementary prescriber. Creating the plans involved reviewing the patients’ long-term 48
in the long-term care setting.
Prescriber December 2007
conditions with the doctor, and agreeing treatment plans for medication that was within my competence to prescribe. As care of older people generally covers most therapeutic areas, we produced 40 CMP templates for long-term conditions that were then used to create individual CMPs for each patient. The individual CMPs also contained any specific drug requirements for each patient, eg recommendations from other medical colleagues. This work took until November 2004 with positive effect, as we were able to review all our patients’ treatment and agree CMPs with the patient, carers and the team. Though not a legal obligation, we introduced nonmedical prescribing to patients and carers as a ‘team prescribing’ approach to reinforce that prescribing decisions were agreed as appropriate by the whole team, irrespective of who wrote, and thus had clinical responsibility for, the prescription.
Examples
My prescribing areas included pain management, Parkinson’s disease and bowel management. An example of my prescribing contribution is as follows. Mrs X had well-controlled type 1 diabetes, with a twice-daily dose of human insulin 24 units in the morning and 10 units in the evening. On one visit the nursing staff alerted me to a rise in her blood glucose levels each afternoon, peaking at about 15mmol per litre at 5pm. Mrs X appeared well, her PEG (percutaneous endoscopic gastrostomy) nutrition had not changed and the doctor could not find an infection or any other reason for her changing insulin requirement. It was decided to incrementally increase her insulin, titrated to her blood glucose level. I did this on a weekly basis, increasing her morning dose by 2-4 units per week according to effect. After four weeks she was stabilised on www.escriber.com
Nonmedical prescribing
32 units in the morning and 10 units in the evening and remains stable. Although most of the medicines that I prescribe are within licensed indications, there are some instances in long-term care where unlicensed medicines, and licensed medicines for unlicensed indications, need to be used. For instance, prescribing for hypersalivation in patients with PEG tubes: one such patient had not responded to hyoscine patches (unlicensed use) and was continuing to suffer from sores around the mouth due to the hypersalivation. The increased secretions were also an aspiration risk. Using palliative care guidelines to support our practice, we devised a protocol for treating PEG-related hypersalivation and the patient was successfully treated with glycopyrronium bromide (unlicensed medicine) administered via the PEG tube. I was able to prescribe this using a CMP, which refers to our local protocol. Progression to independent prescribing
Supplementar y prescribing worked well for long-term conditions but was not responsive enough to allow prescribing for acute conditions (eg chest infections) or drugs on admission. With the advent of nurse and pharma-
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Prescriber December 2007
cist independent prescribing in May 2006, which allows prescribing without a CMP, both the (nurse) ward manager and I undertook independent prescribing training. This has allowed me to prescribe for a small number of acute conditions within my competence where the condition could not be anticipated in time to allow production of a CMP. Even though I do not legally require a CMP to prescribe most drugs now, the general template of the CMPs that we produced (based on PRODIGY, SIGN and expert group/royal society guidelines) is still ver y useful to the team, supporting our prescribing decisions. However, controlled drugs and licensed drugs for unlicensed uses still require CMPs as they may only be prescribed by pharmacists using the supplementary prescribing legislation. Continuing development
My prescribing practice continues to develop as I extend my clinical examination skills in my areas of prescribing, having attended a physical skills assessment course and with the practice guidance of the doctor and ward manager. I have also taught on the nonmedical prescribing course at King’s College London and worked with the London Pharmacy Prescribing project to support pharmacists con-
sidering nonmedical prescribing in their practice. My prescribing practice has recently expanded to support patients in five new PCT-funded intermediate-care beds. With the benefit of both hospital and general practice information about patients’ medication, I am able to review medication with patients, their carers, and medical, therapy and social-care professionals to ensure a multidisciplinary, crosssector, concordant approach to medicine taking. Details of medication issues, including changes and reasons for changes, are communicated to primar y and secondar y care at discharge, recording the changes in each setting. In the near future, patients will be undertaking self-administration of medicines in intermediate-care, supported by the nurses and pharmacists, using the trust self-administration of medicines policy. As a pharmacist, prescribing has become a useful tool that I have integrated into my pharmacy practice within the multidisciplinary team, and one I will continue to develop through intermediatecare work. Nina Barnett is a consultant pharmacist for older people for Harrow Primary Care Trust
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