C McCaughey, D McKelvey, J Stewart, C Mallon, P Scullin Introduction of a Piperacillin and Tazobactam Patient Group Direction (PGD) IN haematology C McCaughey, D McKelvey, J Stewart, C Mallon, P Scullin

National Chemotherapy Advisory Group 2009 Background Neutropenic sepsis (NS) is a potentially fatal complication of systemic anti-cancer therapy National Chemotherapy Advisory Group 2009

NS toolkit Regional Policy Care Bundles Care Pathway Staff Education

95% 18%

....but 100% of door to needle breaches out of hours

Patient Group Direction PGDs provide a legal framework that allows the supply and/or administration of a specified medicine(s), by named, authorised, registered health professionals, to a pre-defined group of patients needing prophylaxis or treatment for a condition described in the PGD, without the need for a prescription or an instruction from a prescriber. (NICE, 2013)

Legislation & Guidance Legislation Change PGDs Established 2000 The Human Medicines Regulations 2012 Final Crown Report 1999 Supplementary Prescribing 2002/3 Independent Prescribing 2006 Health Service Circular 2000/026 Evolved to allow flexibility and accessibility to patients NICE - MPG2 stands for ‘Medicine Practice Guidelines’ NICE PGD overview ‘pathway’ published January 2015 This traditional 'medical model' changed in the years after publication of the final Crown report Review of prescribing, supply and administration of medicines in 1999. Legal frameworks were developed that have allowed services to be redesigned and health professionals to work more flexibly for the benefit of patients. In particular, prescribing responsibilities have been extended to enable other health professionals to complete additional training and qualify as non-medical prescribers. In addition, at some key steps in a care pathway, some of these frameworks enable medicines to be supplied and/or administered directly by a health professional, without the need for prescribing. NICE Medicines Practice Guideline 2013 (MPG2) & NICE PGD Pathway (2015) Using a PGD is not a form of prescribing.

PGD proposed, written and authorised Pharmacy Medicine Microbiology Nursing

Criteria for staff utilising PGD Registered nurses who have following training: Venepuncture and cannulation (one of training) Administration of medicines and medicines code update (three yearly update) Anaphylaxis (two yearly update) Resuscitation (in hospital life support two yearly update) PGD training Mandatory training challenge. Ward sister had won Award from Trust to have highest levels of mandatory training attainment despite very challenging staffing vacancies

Patient inclusion criteria 18 years and over Patient must give (verbal) consent to treatment under PGD

Patient EXCLUSION criteria Under 18 years Known allergy to penicillin or any beta lactams or to beta lactamase inhibitors Pregnancy or lactation Patients who do not consent Staff member must ensure Piperacillin and Tazobactam is appropriate in combination with other medication

Standards and guidelines Trust wide implementation

Models of training and assessment Nursing or pharmacy led face to face sessions Self directed E learning module Theoretical knowledge and clinical competence Completion of questions Simulated practice assessment Register

Record keeping Record on patient kardex and on neutropenic sepsis pathway State: date, time, indication, drug, dose/volume, route, print name and sign State “administered under PGD” Document any adverse effects in notes A record must be kept of all patients treated under PGD for audit purposes

Pilot Commenced 24th August 2015 54% of staff trained and training ongoing Since 2011 average 4 patients with NS a month Therefore projected around 24 patients

Eight patients in 6 week period 1/3 of average NS episodes in last 4 years

Results Door to needle time audit - 100% compliance PGD audit - 100% compliance

Conclusions and recommendations Continue with PGD implementation Extra focus on sepsis, secondary to PGD education, has perhaps aided 100% door to needle compliance Continued implementation of PGD has potential to maintain this high standard

Ciprofloxacin PGD (for Penicillin sensitive patients) written and ready for launch once Piperacillin and Tazobactam PGD evaluated Also PGDs for saline flushes, Lidocaine, Chloramphenamine and Hydrocortisone (in event of hypersensitivity reaction) in final stages of development

References NICE (2013) Medicines Practice Guidelines 2 PGDs www.nice.org.uk NICE (2014) Competency framework: For health professionals using Patient Group Directions www.nice.org.uk NICE (2015) PGD overview pathway www.nice.org.uk NHS PGD website: http://www.medicinesresources.nhs.uk/en/Communities/NHS/PGDs/

caroline.mccaughey@qub.ac.uk