2 Introduction of Nurse Prescribing May 2007 The medicinal products (prescription and Control of Supply Regulations and the Misuse of Drugs (amendment) regulations signed into law.Specified the conditions for prescribing of medicinal products by Registered Nurse Prescribers.Nurses rules 2007.
3 Conditions for prescriptive authority Nurse/Midwife must be employed by a health service provider.Medicinal product must be one used in the usual course of service.The prescription is issued in the usual course of the healthcare setting.Successful completion of education programme.Work within scope of practice.
4 Education programme Six month education programme. Level 8 minor award.Pharmacology – exam.Systematic assessment in patient care.Osler exams/Case study.Professional accountabilityReflective portfolio and CPA assignments.Clinical time with Consultant Cardiologist.
5 Collaborative Practice Agreement (CPA) A written agreement between the RNP, medical mentor and employer.Prescribing site coordinator.Contains the details of patient group and health care setting in which the RNP can prescribe.Details medicinal products the RNP can prescribe.Forwarded to An Bord Altranais annually.
6 Nurse Prescribing in Cardiac Rehabilitation Successful completion of course in RCSI.Drawing up of CPA.Patient group and setting identified.Medications identified.Communication pathway with other healthcare professionals.Introduction into CR (SCH) March 2009.
7 Caseload Patients attending Phase III. Formal assessment of Risk factors during week 5.Cholesterol measurement.Medications re evaluated with patient.Titration of medications.Complicated patients refer back to Cardiologist or GP as appropriate.
8 Patient assessment Documentation of patients medical history. Physical exam if required.Recording of blood pressure.Cholesterol measurement.Documentation of risk factors (diabetes, smoking, alcohol, BMI)Current medicationsAllergies.Exercise level.
9 Prescription writing Legible Include patients Name, Address, Date of Birth (triplicate).Allergies.Prescribe generically.Dose and duration of therapy.Signature and pin number of RNP.Explanation of therapy to patient – verbal and written.
10 Communication Drug specific information. (Medicines.ie) Treatment discussed with patient.Individual medication record.Information booklet (medication safety).Nurse Prescribing leaflet.Discharge summary to GP and Cardiologist.Documentation of patient consultation with RNP.Referral to other healthcare professional.
11 Role of prescribing in CR Therapeutic relationship with patient.Continuity in patient care.Opportunity to assess adherence.Information targeted to individual patients.Affords patient opportunity to ask questions.Lifestyle changes discussed.Communication within CR team.Communication with GP enhanced.
12 Case Study one 79 year old female. Cardiac history: STEMI, medical management.Risk factor assessment- Blood pressure 110/70mmHg, no diabetes, non smoker, BMI 26 kg/m².Cholesterol measurement:Total 2.81mmol/l HDL 1.10 mmol/l LDL 1.25mmol/l Trigs 1.02 mmol/l Glucose 5.10 mmol/l
13 …….contd Current medications: Nuseals aspirin 75mg od Clopidogrel 75mg odBisoprolol 2.5mg odRamipril 2.5mg odAtorvastatin 80mg odLiver function test normal.No over the counter drugs.No known drug allergies.
14 ……contd Plan : reduce Atorvastatin to 40mg od. Discussed with patient. Written information.Advised 6 monthly cholesterol and liver function check.Lifestyle factors.Documented in patients record card.
15 DocumentationPatient assessment documented and copy prescription kept.All prescriptions input into HSE Nurse Prescribing data base.Changes in medications documented in patients discharge summary sent to GP and cardiologist.
16 Special considerations Prescribing for elderly patients.Avoiding polypharmacy.Compliance with medical therapy.Level of literacy.Alcohol consumption.Over the counter medications/herbal.
17 Case study two Male 63 years. Cardiac history: Cardiac arrest, medical management.Current medications:Nuseals aspirin 75mg od.Atorvastatin 80mg odMicardis 20mg odLansoprazole 30mg odNo known drug allergies.
18 Current Smoker – 40 cigarettes daily. Blood pressure 130/80mmHg at rest.Heart rate 110 bpm pre exercise.Alcohol > 30 units per week.Cholesterol measurement:Total 3.53mmol/l HDL 1.26mmol/l Trigs 1.12mmol/l LDL 1.76 mmol/l.Glucose 4.31 mmol/l.
19 Training heart rate 120-140 bpm Blood pressure 140/90mmhg.Dyspnoea on exertion.PlanRestart low dose beta blocker.Atorvastatin reduced to 40mg od.
20 Patient consultation Explain rationale for change of medication. Advised re alcohol intake.Smoking cessation offered.Advised re side effects with beta blocker.Written information given.Follow up in Cardiology clinic. Follow up bloods - LFTsGP contacted by phone.
21 National Independent Evaluation of Nurse & midwife prescribing initiative.(2009) BarriersDelays with Drugs & Therapeutics Committees/Medical practitioner in agreeing CPA.Prescribing of unlicensed medications.Antibiotics.RNP/RMP> 10 years experience.Scope of practice.Quality educational experience.Increased workload.
22 Attitudes of patients Highly satisfied with their care. Comprehensive education and advice.Self report intent to comply was high.Reduction in waiting times.Consultation with RNP – time for the patient.
23 Support for prescribing role Other Health professionals supportive.Medical mentorNursing colleagues.Pharmacy colleagues.An Bord Altranais & HSE.Continuing professional development.
24 Conclusion Positive impact on patient care. Avoidance of delays in treatment.Opportunity to enhance compliance.Avoidance of visits to Cardiologist Clinic.Patients at target for risk factor management.Expanded role as CNS-enhanced knowledge.
26 ReferencesDrennan J., Naughton C., Allen D., Hyde A., Felle P., O’Boyle K., Treacy P., Butler M. (2009) Independent Evaluation of the Nurse and Midwife PrescribingInitiative. University College Dublin, Dublin.Irish Society for Quality and Safety in Healthcare (ISQH) (2008). Let’s Talk Medication Safety.Collaborative Practice Agreement for Nurses and Midwives with Prescriptive Authority (December 2007).Practice Standards for Nurses and Midwives with Prescriptive Authority (July 2007).Office of the Nursing Services Director. HSE (2008) Nurse and Midwife Prescribers-How they care for you.WEBSITESMedicines.ieHSE.ie/nurseprescribing