Paediatric Nurse Prescribing all or nothing

1
Paediatric Nurse Prescribing all or nothing?

• Professor Terence Stephenson
• Professor of Child Health
• and Honorary Consultant Paediatrician
• Queens Medical Centre, Nottingham

2
Prescribing by nurses in primary care

• 'prescribing by default', in which nurses
  prescribe using FP10 prescription forms
  previously signed by general practitioners (GPs).
  
• 1989 An advisory group recommended that district
  nurses or health visitors should prescribe from a
  limited formulary
• Nurse prescribing was introduced in primary care
  in the U.K. using a limited list of products
  following the 1992 Act of Parliament

3
But no prescribing by nurses in secondary care

• Medicinal Products Act of 1992 relating to nurse
  prescribing stated that the arrangements would
  not extend to nurses working in hospitals
• even though many nurses in specialist departments
  fulfilled the requirements for prescribing
  (suitable level of qualification and adequate
  training)

4
The governments motivation

• 100,000 doctors
• 350,000 nurses
• Pharmacists, physios, radiographers, podiatrists,
  optometrists etc..
• A workforce of all the talents
• 1997 The government established A review of
  prescribing, supply administration of
  medicines chaired by Dr June Crown to make
  greater use of the skills and experience of the
  various professions.

5
Frank Dobson, Health Secretary, 28th April 1998

• The right patient gets the right drug in the
  right quantity at the right time.

6
The benefits

• The experienced AE, neonatal, diabetic, asthma
  nurse vs the newly qualified House Officer
• Data from research

7
Pharmacists do it better

• Journal of Clinical Pathology 199548545-547
• Evaluation of anticoagulant control in a
  pharmacist operated anticoagulant clinic
• AS Radley, J Hall, M Farrow and PJ Carey
  Pharmacy Department, Sunderland District General
  Hospital.
• AIMS--To compare the quality of outpatient
  anticoagulant control before and after the
  transfer of dosing responsibility to designated
  trained pharmacists from rotating junior medical
  staff.
• RESULTS--INR results (n 2219) for 382 patients
  were analysed. For patients in stable therapeutic
  control, there was no significant difference in
  performance between the two staff groups.
  Patients with an INR result "out" of control
  limits were more likely to be returned "in" to
  control at their next visit by the pharmacists
  than by the doctors (plt0.01).
• CONCLUSIONS--The quality of anticoagulant control
  in outpatient clinics benefits from dedicated
  trained staff using standard protocols.

8
Nurses do it better

• British Journal of Dermatology 1995133340-341
• Evaluation of anticoagulant control in a
  pharmacist operated anticoagulant clinic
• AS Radley, J Hall, M Farrow and PJ Carey
  Pharmacy Department, Sunderland District General
  Hospital.
• AIMS--To compare the quality of prescribing for
  eczema psoriasis by nurses with at least 6
  months dermatology experience and GP trainee
  senior house officers.
• RESULTS 100 prescriptions for 48 patients were
  analysed. 20/100 differences between nurse and
  consultant vs 39/100 differences between SHO and
  consultant (plt0.01).
• CONCLUSIONS In many DGHs, the junior medical
  staff are not career dermatologists. Treatment
  choice by nursing staff may be closer to
  recommendations (guidelines).

9
A hierarchy of prescribing

• Standing Orders
• Patient Group Directives (Group Protocols)
• Supplementary Prescribing
• Independent Prescribing

10
1998 The first Crown Report

• Prescribing from group protocols (Patient Group
  Directives)
• Ideally one population, one diagnosis, one drug,
  one dose
• The law should be clarified
• Unlicensed and off-label medicines generally
  excluded
• But e.g NICU and ANNPs
• Paramedics and Nalbuphine

11
Licensing of drugs in the UK

• A pharmaceutical company must have a licence to
  market a drug
• The drug can only be promoted for the indication,
  dose, route and age group for which it is
  licensed
• A licence is not required for a doctor to
  prescribe that drug

12
Unlicensed and off-label use of medicines

• Unlicensed
• e.g. paraldehyde
• Off-label
• different age group e.g. morphine
• different route e.g. vitamin K po
• different indication e.g. cisapride for ileus

13
1999 The second Crown Report

• Extending prescribing to other professions
• Independendent and Supplementary (dependent)
  prescribing
• Unlicensed and off-label medicines again excluded

14
A hierarchy of prescribing

• Standing Orders
• Patient Group Directives (Group Protocols)
• Supplementary Prescribing (some nurses and
  pharmacists who prescribe in partnership with a
  doctor, following diagnosis according to an
  agreed Clinical Management Plan)
• Independent Prescribing (all doctors, all
  dentists and nurses with the Extended Nurse
  Prescribing qualification)
• Extended Supplementary prescribing is now a
  dual qualification

15
A hierarchy of prescribing

• Standing Orders
• Patient Group Directives (Group Protocols)
• Supplementary Prescribing can prescribe
  anything in the BNF
• Independent Prescribing
• Initially minor injuries, minor ailments, health
  promotion palliative care!
• From Feb 2004, the Nurse Prescribers Extended
  Formulary

16
The risks

• Historical separation of
• Diagnosis prescribing (doctors)
• Dispensing (pharmacists)
• Administration (nurse)
• Up to 52 interruptions during one neonatal drug
  dose calculation
• 25 of negligence claims against GPs due to
  errors in prescribing or administering drugs

17
Paediatric medication errors in a UK hospital
Medication errors ()

• 68 prescription errors (cf. admin, supply)
• 2x more with new junior doctor
• 2/3 of errors prevented due to
  nurses/pharmacists

Profession
18
Paediatric Nurse Prescribing all or nothing?

• All the nurses? - no
• All the medicines? - no
• All licensed medicines? - no

19

20
Principles of using unlicensed medicines in
paediatric practice

• Prescribers should choose the best medicine
• Currently, unlicensed medicines are necessary
• Health professionals need access to information
  on all medicines which they prescribe
• The guidelines on consent are the same for
  licensed and unlicensed medicines
• NHS Trusts should support practices advocated by
  a responsible body of opinion

21
Percentage of off label/unlicensed prescriptions
in children

• Primary care 11-33
• General paediatric inpatients 40
• Neonatal intensive care unit 90

22

• Examples of off label drug use
• Fluticasone 250 µg twice daily in 4 year old.
• Maximum dose 100 µg twice daily
• Trimeprazine used as sedative in child with
  pneumonia.
• Licensed for urticaria, pruritus, and
  pre-anaesthetic medication
• Rifampicin used for enzyme induction in infant
  with biliary atresia
• Salbutamol used two hourly (12 times daily).
• Licensed for 4 times daily
• Tobramycin used once daily in neonate.
• Licensed for twice daily

23
Paediatric medication errors in a UK hospital
Number of errors

• 441 errors in 682 children over 5315 days
• 7x more on ICU
• 68 prescription errors (cf. admin, supply)
• 2x more with new junior doctor

Level of harm