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Linda RenfrewMS Trust Conference 2014
Fit with current policy Evidence for non medical prescribing Prescribing options for AHPs My prescribing journey Integrating prescribing into MS physiotherapy
practice Case Studies Impact on patient care, clinical practice and
service development Thinking about prescribing: things to consider
Key health care policy drivers call for: a shift from acute, hospital-driven services to
community - treating people faster and closer to home
meeting the needs of the ageing population and rising incidence of long-term conditions
encouraging health improvement and “wellness” by supporting people with long-term conditions to self manage their condition
developing services that are proactive, modern, and safe
Non medical prescribing is about
enabling quick, safe and equitable access to medicines for patients.
increasing the kinds of services accessible health professionals (NMAHPs) can deliver.
improving quality-of-care, reducing health inequalities and opening access to services for all.
improving patients’ experiences of services and contributing to better outcomes.
A safe prescription (Scottish Government, 2009)
Efficiency
Improved speed & convenience of treatment (Ball, 2009; Drennan et al, 2009, jones et al, 2010; Oldknow et al, 2010).
Reduced waiting times & increased efficiency of appointments (Courtenay et al, 2011; 2010; Page et al, 2008).
Doctors make better use of their time to treat more complex patients (Carey et al, 2010b; Daughtry and Hayter, 2010).
Patient Experience
Patients were highly satisfied with, and confident in, NMP’s abilities (Courtenay et al, 2011; 2010 Jones et al, 2010; Watterson et al, 2009).
Safety
Patient safety improved (Carey et al, 2009a; Courtenay et al, 2009a).
Medication errors were significantly reduced in diabetic management with a nurse prescriber (Carey et al, 2008; Courtenay et al, 2007).
Nurse prescribers were cautious in prescribing & recognised budgetary restraints ( Watterson et al 2009).
Only 1 adverse incident reported since 2006 No evidence specifically on AHP prescribing
No prescription required Patient Specific Direction(PSD) Patient Group Direction (PGD)
Prescription required Supplementary Prescribing Independent prescribing
“physiotherapists who have not passed an approved prescribing course must not advise patients to take or stop taking medication, or change their dose or type of painkillers, even paracetamol” (CSP 2006)
Legally we need to demonstrate our competency to give advice about medications and that we are working within scope of practice.
Scope of practice
No automatic transfer to new role Scope of profession Working within clinical governance framework of employer Professionally responsible for own actions Accountable to employers and regulatory bodies for actions Easy access to primary patient record, timely communication
with GP Informed consent No unlicensed medicine, limited prescribing of CD’s “Off license/off label” or mixing of medicines undertaken with
strong justification /evidence given Within own caseload
Using a medicine outside its licensed indications/UK marketing authorisation
Only prescribe ‘off-label’ where it is accepted clinical practice.
Local policies for the use of off-label medicines should be approved
Many drugs used in MS are used off label
e.g Gabapentin, Amitriptyline, Amantadine etc.
No other licensed medicine will meet the patient’s need
If a licensed medicine is not available There is sufficient evidence to demonstrate
safety and efficacy Take full responsibility for prescribing, follow
up and monitoring (or ensure GP does). Patient informed re the unlicensed aspect of
medicine
HCPC registered, minimum of 3 years, identified need & support from employer
Non-medical prescribing programme
Joint NMAHP course
40 credits @ level 9 ( 6 months), 20 credits @ level 11( 5 months)
Funded by Scottish Government
26 theory days or 10 days blended learning(+ 10 study days)
78 hours of supervised practice
Exam, examination of practice & portfolio of competencies
NMC/HCPC register annotated Added to local health board register Part of PDP supported by audit of practice
1986 - BSC physiotherapy 1995 - 2005 Senior Neurological out- patient
physiotherapist 2001 - 2005 MPhil in MS 2006 – 3 year ESP post in MS ( part funded
MS soc). Drive to demonstrate added value & improve patient pathways - NMP
2007/8 – NMP(supplementary prescribing) 2009 – secured permanent post – consultant
physiotherapist in MS SP integral to role
Physio led MS review clinics
AHP rep on NMP group NHS A&A 2014 – SP/IP conversion course 2014 – consultant in rehabilitation medicine
retired ( currently unable to recruit to post)
First AHP prescriber in NHS Ayrshire & Arran. ? other AHP prescribers in MS nationally No national or local AHP prescribing a guidelines Discussions with prescribing leads re prescribing
pathway demonstrate how patient care is enhanced
alleviate concerns re prompt communication with GP
alleviate concerns re inappropriate prescribing Liaised with other AHP prescribers re pathways Undertook audit of prescribing practice
Types of medications Numbers of patients -
where, how often Details Costs
0
5
10
15
20
25
30
35
40
45
50
MS clinic Physio Dom visit Total
Total SP
0
1
2
3
4
5
Numbers ofpatients
Musclerelaxants
NSAID
Neuro pain
AB
Bowel med
Patient Details of prescription Cost ( 4 weeks) (based on BNF March
2007 prices)
1 7 day course of trimethoprin £1.35
2 Increase Tizanadine from 18mg – 36mg Approx x100tabs extra £40.00
3 Increase Baclofen from 10mg to 15mg Approx 14 extra tabs £1.80
4 Increase Lactulose from 30 ml to 75ml Additional 1260ml £10.50
5 Increase gabapentin from 2.1g to 2.7g Additional 56(300mg) tabs £4.00
6 Start gabapentin 300mg day 1, 600mg day
2, 900mg day 3.
81 (300mg) tabs £5.40
7 Start ibuprofen 400mg x 3 daily 84(400mg) tabs £6.85
8 Start diclofenac 25mg x 3 daily 84(25mg) tabs £2.42
9 Start clonazepam 1mg increasing to 4mg at
night
56 (2mg) tabs £2.93
10 Start Baclofen 30mg daily 84 (10mg) tabs £2.55
Total £77.80
How? Agreement re prescribing pathway (Nov 2008)
Mirrors traditional out-patient prescribing arrangements in secondary care. Specialist makes recommendations to the GP
Assess, determine need, advise to GP using out-patient notice ( & follow up letter). Personalised stamp
GP writes prescription
Initially as SP within limits of a CMP guiding prescribing
Autonomous prescribing decisions now as an IP
Agreed date for review (in person or phone) and further amendments communicated to the GP
Pt attends physio & needs to start spastcity medicationPt attends physio, assessed & needs to start spasticity medication
Appointment with consultant at clinic
Pt sees consultant & letter sent to GP re medication
Pt makes an appointment with GP & prescription issued
Pt starts medication
Pt reviewed by physio & requires an dose
DELAY 2-6wk
DELAY 2-4wk
DELAY1-3 wk
DELAY
Pt attends physio prescriber , assessed & needs to start spasticity medication
OP advice note issued to GP
GP initiates prescription - pt starts medication
Pt reviewed by physio within agreed timeframe
and dose altered
Final dose of medication notified to GP
Where & when?
Physiotherapy new and review clinics
FES clinic
Domiciliary visits
MS review clinic
Over the phone▪ where initial assessment
has been undertaken
▪ for symptoms such as pain and fatigue
What? Symptomatic treatment
Pain (musculoskeletal and neuropathic)▪ paracetamol, NSAID’s, opiates, compound preparations( co-
codamol), amitryptaline, duloxatine, gabapentin, pregabalinetc
Spasticity( inc management of constipation acting as a trigger factor)▪ baclofen, tizanadine, dantrolene, gabapentin, clonazepam,
sativex (??), movicol, fibrogel, lactulose, anti-biotics Fatigue and management of secondary factors impacting on
fatigue ▪ amantadine
More unusual symptoms▪ tremor▪ hypersalivation
Evidence, local & national guidelines Licencing and legal considerations Local governance and policy arrangements Risks and benefits
Medical History
Drug interactions and side effects
Compliance & concordance▪ Informed consent
▪ Titration & dosing regimes
▪ Impact of psychosocial factors, values & beliefs
▪ Cognition
NICE 2014 – MS pharmacological management Fatigue
Amantadine recommended 8 studies ( 6 Amantadine, aspirin, paroxetine) low to moderate
evidence Spasticity
Ist line baclofen or gabapentin or combine 2nd line tizanadine or dantrolene Benzodiazepines ( nocturnal spasms) Sativex not recommended 33 studies low quality evidence
Tremor 4 studies ( ioniazide, baclofen, botox) evidence inconclusive No recommendations made
NICE 2013 Neuropathic pain
1st line consider amitriptyline, duloxetine, gabapentin ( al off label) or pregabalin
2nd line tramadol for acute rescue therapy
3rd line Capsaicin cream for localised neuropathic pain
Trigeminal Neuralgia
▪ Carbomazapene of phenatoyin
Amantadine Hydrochloride licensed for: Parkinson's disease, antiviral off label for fatigue in MS
Gabapentin licensed for: monotherapy & adjunct treatment for
focal seizures, peripheral neuropathic pain off label prescribing for central neuropathic pain and
spasticity Amitriptyline Hydrochloride
licensed for: depression off label for neuropathic pain
Governance Systems in place to report and respond to "near misses", errors
and adverse drug reactions ( local & national) Rapid access to medical history, current medication and
kidney/liver function to prescribe effectively and safely. Appropriate mentoring, supervision and line management Effective scrutiny of prescribing practice ( audit & quality
monitoring) Strong leadership of non medical prescribing at board level
Policy Local medicines management policy includes NMAHP prescribing NMAHP prescribing policy developed by a multi-disciplinary group
and reviewed regularly
48 year old lady diagnosed with RRMS 10 years ago.
Attending FES review clinic. Is currently taking
copaxone, amantadine (100mg) and co-codamol ( minimal effect on pain).
Ongoing problems with fatigue worse over past 4 months and increased lower limb neuropathic pain affecting sleep. Her mood is low.
Previously tried amytriptyline (25mg) with no effect.
PMH: mild heart arrhythmia
Assessment : lower limb & spinal examination, VAS for pain, FIS & HAD
Diagnosis : neuropathic pain and low mood impacting on sleep contributing to increased fatigue
Considerations: PMH, drug interactions, off label prescribing, concordance
Possible options: increase dose of amantadine ( from 100mg to 100mg bd) restart amitriptyline and titrate dose from 25mg up to
75mg (depending on response). Caution due to heart arrhythmia.
trial gabapentin if no/partial response to amitriptyline . Titrate dose slowly and monitor response
Discuss mood with GP/refer to MS psychologist discuss fatigue management strategies
46 year old man with MS and spinal problems. Wheelchair user but usually independent.
Long history of neuropathic pain and lower limb spasticity( 20 years)
Referred to physiotherapy because his legs feel stiffer,he is falling to the right and forward and now unable to self propel or feed self.
Current medication:60mg baclofen, 36mg tizanadine, 150mg dantrolene and 1800mg gabapentin for past 4 years. GP recently stopped Acupan for pain and started dihydrocodine.
PMH: ↑BP- minoxidil
Assessment: lower limb spasticity ( Ashworth 1/2), L/L ROM -reduced muscle length hamstrings and gastrocnemius. Poor posture, reduced trunk tone and poor control in sitting. U/L tone low with muscle weakness
Diagnosis: anti spasticity medication is causing additional muscle weakness in upper limbs and trunk
Considerations: PMH, drug interactions, avoid abrupt withdrawal Options
gradually reduce & stop one of her AS meds & review impact on L/L spasticity and trunk stability
refer to physio to address trunk stability and reduced muscle length
refer to bioengineering clinic for review of wheelchair refer to OT to review U/L function and additional aids to assist with
eating
38 year old man with advanced MS. Poor cognition, wheelchair bound, poor swallow,PEGfed, marked upper limb and trunk tremor, requiring 24 hour care.
Attended the MS review clinic with mum and carers-main issue is excessive drooling causing him to choke on saliva.
Medication –hyoscine hydrobromide patches changed every 3 days and propranolol (60mg)
Diagnosis: progression of condition requiring management of excessive salivary secretions Considerations: capacity and compliance, drug interactions, scope of practice, withdrawal
of meds Options:
increased frequency of change of patches amitriptyline glycopyrrolate– required further information from MIU on unlicensed application for
use via enteral feeding botox into salivary gland
Outcome no additional benefits noted changing patches daily & significant respiratory side
effects noted. following reaction it was decided not to start glycopyrrolate due to possibility of similar
serious side effects. amitriptyline started (25mg) – no response therefore gradual titration to 75mg.
Increased drowsiness and negative affect on transfers noted. Titrated down and stopped.
referral to head and neck surgeon made for consideration of Botox injection CMP set, close liaison with consultant , GP and mum/carers
Improved patient pathway avoiding multiple appointments with consultant and GP avoiding delays in starting and titrating medication
Optimal symptomatic management optimising combined use of medication and physical
treatments limiting use of medication where not necessary
Seeing the right person with the right skills at the right time The MS physiotherapist has expert knowledge and skills to
assess and prescribe for pain and spasticity and to evaluate the impact of treatment
Improved concordance Physiotherapists spend more time with the patient allowing
opportunities for discussion, improving adherence and patient safety, reducing waste and improving outcomes (NICE 2009)
AHP led MS review clinic
rehab consultant only sees pts requiring medical review
freeing up time for rehab consultant to focus on other areas of service development
longer appointment slots for review appointments
patients as satisfied/more satisfied with new clinic
targets for annual review now being met
Comprehensive initial assessment Consider impact of prescribing decisions &
accountability Independent & joint decision making Extending treatment options & refinement of
treatment combinations Insight into professional strengths of other
disciplines ( nursing, pharmacy 7 medicine) Understanding the bigger picture
Symptom management clinics
spasticity ( combine with botox)
Pain
Relapse management Medicines management at ward review Clinical lead role?
Would prescribing enhance patient care?
Within a service
▪ what, how often and where would prescribing be done?
▪ Are there other professions within the team who would/could take this role on?
As an individual
▪ what is your role & function within the service/team?
▪ is there a need for you to initiate new medications, titrate & alter medications? Where is your service based and is this likely to change ?
Primary or secondary care
Cost codes linked to prescriptions
Communication with GP & access to up to date prescribing summary essential What is the impact of IP training on service delivery and how would thi be managed within
the service What are your clinical governance structures to support prescribing?
A safe prescription ( Scotland) (2009) http://www.scotland.gov.uk/Resource/Doc/286359/0087194.pdf
National Prescribing Centre: A single competency framework for all prescribers (2012) http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single_comp_framework_v2.pdf
HCPC Standards for prescribing ( 2013) http://www.hpc-uk.org/assets/documents/10004160Standardsforprescribing.pdf
Practice Guidance for Physiotherapist Supplementary and/or Independent Prescribers in the safe use of medicines (CSP, 2013)