1. NURSE PRESCRIBING MY JOURNEY PRESENTATION BY VALERIE M WOOD Drug & Alcohol Liaison Nurse Specialist Doncaster & Bassetlaw Hospitals NHS Foundation Trust

2. MY ROLE & RESPONSIBILITIES AN OVERVIEW Senior clinical specialist practitioner in substance misuse Responsible for ensuring continuity of care for those patients with substance misuse presenting in treatment in the acute hospital setting; or those who are identified as having a drug or alcohol concern and require treatment. OTHER RESPONSIBILITIES INCLUDE: Direct responsibility for the development, delivery and continuity of the nurse led service in which I am the lone practitioner. Full autonomy as there is no medical consultancy attached to the service Seamless transfer of care to and from the community Ensure exit prescribing and follow up care for those patients whose treatment has been initiated during their hospital admission

3. DRUG & ALCOHOL NURSE SPECIALIST SERVICE Through the formulation of a treatment / care plan the service is able to provide a comprehensive range of interventions that endeavors to achieve optimal well being in those patients presenting with either drug or alcohol concerns. The service promotes the enablement of the patient by client centered approaches’ which endorses health promotion, abstinence and harm reduction strategies that facilitates the patient to abstain or minimise damage to them selves, their families and the wider community.

4. DRUG & ALCOHOL NURSE SPECIALIST SERVICE Offers a broad choice of care packages ranging from health promotion to managing severe alcohol / drug dependency. Psychosocial approaches are the mainstay of treatment as pharmacological treatments currently have a limited application Hazardous drinkers Harmful drinkers Patients suffering from acute alcohol withdrawal syndrome are treated appropriately [unplanned alcohol detoxification], supported by psychosocial interventions.

5. PATIENT GROUP Medical emergency due to severe alcohol withdrawal Alcohol related seizure Delirium tremens Medical condition Cardio myopathy Gastric bleed Chronic obstructive airway disease Surgical emergency Pancreatitis Surgical elective admission

6. NURSE PRESCRIBING – PRIOR TO COURSE Try and see the patient first ‘Mad Monday Run’ Full reduction regime written up immediately by Drs Direct discussion with the medical and nursing team. Written recommendation in patients notes Direct management of patient care supported by the medical and nursing team Includes : Initiation of treatment Reduction regimes Alteration of existing treatments

7. WHY BOTHER To determine scope of practice. Improve knowledge and skill base Identify accountability and responsibility within my role specific to prescribing El- facto prescribing v independent prescribing Gain some kind of control and consistency with the medication regime that was appropriate the individual needs of the patient Utilise the service consultant champion as my supervisor to the course

8. INDEPENDENT PRESCRIBING The prescriber takes responsibility for the: clinical assessment of the patient, establishing a diagnosis the clinical management plan (CMP) required prescribing where necessary the appropriateness of any prescription. (Department of Health, (DOH), 2005)..

9. BEING AN INDEPENDENT PRESCRIBER DISADVANTAGES Complicated systems of working within the structure of the Trust to have all individual consultants to subscribe Inequality of care – those consultants who agree v those who don’t Clinical management plan - too time consuming to be practical Increase in capacity Need to reconfigure the existing role

10. DISADVANTAGES Less time for psychosocial interventions Increased autonomy Greater responsibility and accountability No financial or promotional incentive to take on the challenges that this presents to the practitioner No obvious supervision structure in place

11. INITIAL REATION AFTER QUALIFICATION Uncertain My ‘gut’ reaction - not to take up the challenge Needed time to determine a model of prescribing that I could trust and feel confident in delivering Write an alcohol policy that addresses the unplanned admission for acute alcohol withdrawal syndrome. Policy to be include management of Wernicke's encephalopathy

12. MODEL OF PRESCRIBING To promote nurse prescribing by the Drug &Alcohol Liaison Nurse Specialist within the acute medical setting using a multidisciplinary approach. INDEPENDENT SUPPLEMENTARY ADVISOR

13. MODEL OF PRESCRIBING Ascertain permission to prescribe from all consultants. Prescribe for those patients admitted the ward having previously assessed by the appropriate clinical team. Work in conjunction with the team and any other health professional to determine a clinical management plan required. Plan entered into patient notes.

14. CRITERIA FOR INDEPENDENT PRESCRIBING Uncomplicated alcohol withdrawal [no other diagnosis] Uncomplicated alcohol withdrawal - [compensating liver] After initial prescribing of chlordiazepoxide by medical team Vitamin replace therapy for dependant alcohol misuse Symptomatic alcohol withdrawal relief Symptomatic opiate withdrawal relief.

15. MEDICATION Chlordiazepoxide Diazepam Vitamin B supplements Anti-emetic

16. BEING AN INDEPENDENT PRESCRIBER ADVANTAGES Increase in professional knowledge and skill base Consistency of care for those patient who regularly attend Increase referral rate Early interventions Easier and quicker access to treatment Informed consent

17. BEING AN INDEPENDENT PRESCRIBER ADVANTAGES More user/care involvement Specialist monitoring Review of care – more frequent Training / learning opportunities for staff working along side specialist

18. PRESENT DAY All the consultants agreed to the model. I attend the post-take ward round. The consultants and senior doctors sign post the junior doctor to the service Direct discharge by the service Development of the alcohol liver disease out-patient clinic Fast track patient into hospital Order blood tests Referral onto other hospital services.

19. QUESTIONS Thank you