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Nurse/Midwife Medicinal Product Prescribing in Ireland : The benefits Annette Cuddy, Assistant Director Nursing & Midwifery (Prescribing, HSE West) Website: http://www.hse.ie/go/nurseprescribing Irish Model of Nurse Midwife Prescribing Independent, collaborative model Enables a registered nurse or midwife who has completed an approved education programme, has the appropriate clinical experience, is registered with NMBI as a RNP, and has authority from the health service provider that employs them to independently prescribe a range of medicinal products within their scope of practice and in collaboration. Primary Legislation Provisions for nurses & midwives to prescribe Provides for An Bord Altranais to regulate for prescribing Accessible at: www.oireachtas.ie Regulatory Framework for Prescriptive Authority Nursing and Midwifery Board of Ireland: Education Clinical Competence Clinical Governance Registration Documents: Requirements and Standards for Education Programmes for Nurses and Midwives with Prescriptive Authority (2007) Practice Standards and Guidelines for Nurses and Midwives with Prescriptive Authority (2010) Collaborative Practice Agreement (CPA) for Nurses and Midwives with Prescriptive Authority 3rd Edn (2012) Website: http://www.nursingboard.ie Number of RNPs: 550 Nurse Midwife Prescribing: The Benefits: Context and Background 2012: Five years of prescriptive authority 500 Registered Nurse Prescribers Over 140,000 items prescribed Evaluation undertaken 2009 Team looked at benefits for patients and services Literature search undertaken (national and international) Literature Search Improved quality of care Patients and parents (140 respondents) were highly satisfied with care from nurse/midwife with prescriptive authority and felt supported by nurse and midwife (Drennan et al, 2011) Improved relations and communications with patients (Stenner and Courtenay, 2008) Listening, understanding beliefs and concerns about medicines and working in partnership with patients promotes compliance Joint decision-making (Latter, 2011) Nurses prescribe within their own area of expertise and competence (eg. pain, wound care, diabetes and cardiac medicine). Patients value this specialised knowledge and combined with health education and health promotion is much valued (Latter, 2011) Integrated care services – places the patient central to care (Astles, 2006) High levels of satisfaction reported with the consultation process (Drennan et al, 2011) Literature Search Contd. Access and continuity of care Convenience (Latter, 2011; Courtenay et al, 2009; O’Connell et al, 200 Access to medications: easier and quicker (reduced waiting times for treatment) emerged asone of the most beneficial aspects of prescribing. Because of this, the patient will now sometimes see the nurse rather than the doctor in ongoing treatment for both acute and long term conditions (Latter, 2011) Effective use of the nurses and doctors (GPs) time Timeliness: responsive to their needs - assessed and prescription written, therefore begin treatment immediately (Brooks et al, 2001) Efficient ordering of pain medication and tests (Kaasallainen, 2010) Timely follow-up with residents pain concerns (Kaasallainen, 2010) Faster access to treatment (Stenner and Courtenay, 2008) Immediate commencement of treatment (Astles, 2006) Methodology Purposive sample: 406 Registered Nurse Prescribers Accessed through RNP E-Network Requested to “share any information regarding the impact of nurse and midwife medicinal product prescribing in Ireland, with particular emphasis on cost and benefit” Qualitative and quantitative information submitted Reports from Nurse Midwife Prescribing Data Collection System analysed Findings: Midwifery Prescribing Irish Review: Effects on patient care and the organisation of the introduction of the administration of first dose intravenous antibiotic therapy for Group B Streptococcus prophylaxis by midwives following the prescription of this therapy by Registered Nurse Prescribers in the delivery ward. 58 cases were randomly audited Findings: More timely and effective delivery of care to woman and baby Reduction in hospital screening of neonate Reduction in hospital bed days Early transfer home Findings: Midwifery Prescribing contd. Maternity Hospital: Prescribing of Antibiotic Therapy by RNPs: Early Transfer Home 1800 1700 1600 1500 Totals 1400 Pre-RNP Post RNP 1300 1200 1100 1000 2007 2008 2009 Year 2010 Findings: Community Hospital 17 WTE nurses 38 bedded unit 4 Registered Nurse Prescribers 328 occasions residents did not have to wait for GP Cost per call out ?? €80 per call out out of hrs Positive impact on quality of life Resource implications for on-call service “For each episode of prescribing by a nurse, the GP does not have to attend on site. This also means there is no waiting time for a doctor to come. There are currently 328 nurse prescribing episodes since February 2009 within the service so over a period of 3 years the doctor's attendance was not required this many times on site” (RNP, Community Hospital) Findings: Day Hospital RNP-Led Anticoagulant Clinic “In 2010 we introduced Point of Care testing to our anticoagulant clinic so this means we have an instant INR result. There is no wait for laboratory results, which has greatly improved the efficiency of the clinic. This has improved patient safety as immediate action can be taken if an INR is very high” (RNP, Day Hospital) Findings: RNP-Led Anticoagulant Clinic INR Therapeutic Range Pre and Post RNP Led Clinic 85% 80% 75% 70% 65% 60% 55% 50% INR Therapeutic Range Pre RNP INR Therapeutic Range Post RNP Nurse-led diabetes and renal impairment clinics An effective disease management strategy was established resulting in an ANP renal and diabetic service being set up with the aim of improving clinical outcomes Patient (n=78) Activity within ANP Diabetic and Renal Impairment Services 1,285 visits – represented 10% increase in activity (2011) Non-attendance reduced from 16% to <1% Audit confirmed that lower blood pressure targets were all met Prescriptions issued by RNP = 495 Patients valued continuity of care which was personalised to their own needs 98.5% stated they would prefer to remain in ANP-led diabetes care rather than return to standard medically-led standard care New CKD Stage 3 transferred to the ANP service directly from main diabetic clinic: Kilkenny 67 Carlow 26 (Blanchfield and McGurk, 2012) Nurse-led diabetes and renal impairment clinics An effective disease management strategy was established resulting in an ANP renal and diabetic service being set up with the aim of improving clinical outcomes Patient (n=78) Activity within ANP Diabetic and Renal Impairment Services 1,285 visits – represented 10% increase in activity (2011) Non-attendance reduced from 16% to <1% Audit confirmed that lower blood pressure targets were all met Prescriptions issued by RNP = 495 Patients valued continuity of care which was personalised to their own needs 98.5% stated they would prefer to remain in ANP-led diabetes care rather than return to standard medically-led standard care New CKD Stage 3 transferred to the ANP service directly from main diabetic clinic: Kilkenny 67 Carlow 26 (Blanchfield and McGurk, 2012) Findings: Other Advanced Nurse Practitioners: Prescriptive authority is an essential pre-requisite for role expansion, capitalising on nurses’ knowledge and expertise with improved patient outcomes. Extended role of RNP results in autonomy, empowerment advanced practice assessment Improved ability to manage patient care more completely Reduced dependence on the medical team Emergency Department Advanced Nurse Practitioner: Patient receives total episode of care from one professional. Timeliness: Patient receives appropriate medication in a more efficient and timely manner as the RNP prescribes medication as necessary and appropriate. RNP’s time as a resource is used more effectively. Medical colleagues are free to be used more effectively in the delivery of care. “I no longer need to call medical colleagues away from other patients to care for my patients”. Practice Nursing: Collaborative working between General Practitioner, Nurse/Midwife, patient/client Continuity of care, e.g. for patients with chronic diseases Delivery of direct patient care by Registered Nurse Prescriber, eg treatment and prescribing for conditions such as Urinary Tract Infection, COPD, administration of childhood and travel vaccinations. Reduced workload for General Practitioner as RNP can issue prescription within their scope of practice. RNP can support the work of the multidisciplinary team by assessing patients and treating them appropriately, thus ensuring an efficient and timely service. Findings: Prescribing Activity In 5 years .. Jan ’08 to January 2013 RNPs reported writing: 95,692 Prescriptions for; 74,137 Unique Patients 140,240 Medicinal Products 1 From Jan 2012 to 31 December 2012 RNPs reported prescribing for: 30,682 Prescriptions for; 25,320 unique Patients 46,393 Medicinal Products Most Frequently Prescribed Medicines Medicinal Product Nos Paracetamol 11067 Lidocaine/Fluorescein 1482 Diclofenac 7059 Morphine Sulphate 1443 Ibuprofen 5864 Proxymetacaine 1403 Diphtheria, Tetanus 4494 Tramadol 1346 Lidocaine 4007 Fusidic Acid 1370 Benzylpenecillin 3156 Flucloxacillin 1301 Measles, Mumps, Rubella Vaccine (live) 2288 Metformin 1296 Amoxicillin/Clavulanic Acid 2147 Prochlorperazine 1244 Fluorescein Sodium 2103 Insulin Aspart (Novorapid) 1128 Paracetamol/Codeine (Solpadol/Tylex) 1968 Diclofenac Sodium 1122 Chloramphenical 1783 Pethidine 1066 Warfarin 1621 Paracetamol/Codeine (Solpadeine) 1003 1545 Diphtheria, Tetanus, Pertussis, Inactivated Poliomyelitis 923 Mefenamic Acid Medicinal Product Total Items Prescribed 28 January 2008 – 31 March 2013: 103,051 Nos Benefits of Nurse Prescribing Continuity of care for patients Delivery of direct patient care by RNP Reduced workload for medical practitioner Patients value continuity of care RNP’s time as a resource is used more effectively Medical colleagues are free to be used more effectively in the delivery of care Extended role results in autonomy, empowerment, and advanced practice assessment Conclusion Further research required Survey of Clinical Nurse Midwife Specialist RNPs currently underway Contact Information Clare MacGabhann Interim Director of Nursing and Midwifery Office of the Nursing Services Director HSE South E-mail: [email protected] Office: 021-4927471 Phone: 087 9317025 Ina Crowley A/Assistant Director of Nursing and Midwifery Office of the Nursing Services Director HSE Dublin Mid Lenister E-mail: [email protected] Office: 061 464007 Phone: 086 3851729 Annette Cuddy Assistant Director of Nursing and Midwifery Office of the Nursing Services Director HSE West E-mail: [email protected] Office: 091-775845 Phone: 087 9317039 Rose Lorenz Assistant Director of Nursing and Midwifery Office of the Nursing Services Director HSE Dublin North East E-mail: [email protected] Office: 041-6858131 Phone: 087 2864075