| Four pharmacists at Southampton University Hospitals NHS Trust have
recently started to prescribe. Three are located in Southampton General
Hospital, and are prescribing in acute situations, and the fourth works
at the Royal South Hants Hospital, and is prescribing in an outpatient
clinic. Between them, they are demonstrating just how widely supplementary
prescribing can be used.
Peter Austin prescribing TPN on a ward |
The three pharmacists prescribing in acute care are part of the clinical
nutrition team. All prescribe parenteral nutrition and one additionally
prescribes a number of other drugs in intensive care. “We hope
that the vast majority of patients needing parenteral nutrition will
soon be managed by supplementary prescribing,” says Peter Austin,
senior pharmacist, nutrition support team. The idea is that the pharmacists
take over the management of the patient’s parenteral nutrition
and that any drugs that the patient is on continue to be prescribed by
doctors. “Supplementary prescribing enables us to make decisions
needed on a daily basis,” he says.
“Supplementary prescribing was designed for chronic conditions.
We are pushing the boundaries here,” says Mark Tomlin, critical
care directorate pharmacist. “Patients on the intensive care unit
are acutely and dramatically ill, and I am using supplementary prescribing
in the unit.”
Supplementary prescribing has a role, too, in the care of chronic conditions,
as Annette Fitzsimons proves at an HIV clinic in the trust (see Panel).
Supplementary prescribing in a clinic for HIV patients
HIV pharmacist Annette Fitzsimons |
Demonstrating that supplementary prescribing
works just as well for chronic conditions is Annette Fitzsimons,
lead pharmacist,
HIV, at Royal South Hants Hospital, part of the Southampton University
Hospitals NHS Trust. “We run medication clinics that patients
with HIV come to every three to four months. They allow us to
identify problems with treatment such as with adherence,” she
explains.
“The initial problem in introducing supplementary prescribing
is getting clinical management plans set up for patients. So
I will be using these clinics to target patients.” Which
patients are candidates will probably be agreed with doctors
before the clinic starts.
The CMP that Mrs Fitzsimons uses includes the management of HIV
infection with antiretrovirals, prophylaxis of opportunistic
and recurrent infections, and drugs for the side effects of treatment. “My
first prescription was for Combivir and nevirapine for HIV, and
Septrin for pneumocystis carinii pneumonia prophylaxis,” she
explains.
Bringing the pharmacist’s skills to the medication clinic
is important in improving patient care. At the medication clinic,
Mrs Fitzsimons finds out what over-the-counter medicines patients
are taking, and what their GP has prescribed for them. “Some
patients won’t tell their GP that they are on HIV treatment
if someone in their local community works in the surgery and
the patient is concerned about confidentiality,” she comments. “Pharmacists
will automatically ask about other medicines. Doctors plan to
ask but often forget.”
Mrs Fitzsimons comments: “It has been an exciting challenge
for me to become a supplementary prescriber. I have taken time
off to have a family, so I was pleased to be able to do something
new and innovative.” She adds that she found the reflective
learning required as part of the training quite hard. “And
doing an exam was a challenge after all these years,” she
says. But she stresses that pharmacists need to have a number
of years of experience before becoming supplementary prescribers. “Experience
gives you self-confidence in dealing with patients,” she
comments.
As for the future, she says that becoming an independent prescriber
would not make a difference to the HIV treatment she can offer
now. But it would mean that she could prescribe for conditions
that are not included on the CMP.
|
Clinical nutrition team
The nutrition support team consists of doctors, pharmacists, nurses
and dietitians. Three of the pharmacists (there are seven altogether)
have
become supplementary prescribers: Mr Austin, Mr Tomlin and Peter Rhodes
principal pharmacist, technical services. Two of the team’s nurses
are also training to
become supplementary prescribers.
The clinical nutrition team discusses a patient’s progress |
The approach taken by the hospital is to use all members of the team
to the full and, as they become more and more skilled, their roles are
overlapping. “The patient is under the care of the ward team. The
patient is referred to the team and it is not necessarily the doctor
who will see them. It could be a pharmacist, nurse or doctor,” says
Mr Austin.
Perhaps this explains why supplementary prescribing has been adopted
so easily at the hospital: the team has worked closely together for some
time. “We already had a good relationship with the medical staff
and pharmacists were seen as members of the team,” says Mr Austin. “The
team works now because we discuss everything so we want to continue with
that,” adds Trevor Smith, specialist registrar in gastroenterology.
In parenteral nutrition, the skills of pharmacists in formulation, pharmaceutics
and assessing incompatibilities are key, Mr Tomlin says. This explains
why pharmacists have played an important role in the nutrition team at
the hospital for nearly 10 years. “In a way, we have been prescribing
parenteral nutrition for all that time,” he says. “We used
to write the prescription out and the doctor would sign it. Whenever
parenteral nutrition was initiated, pharmacist involvement was needed.” Supplementary
prescribing, in a sense, is a way of legalising what the pharmacists
did before. “The introduction of supplementary prescribing has
not been a big change to the process,” says Mr Austin.
Mr Tomlin points out that under the old system, pharmacists were still
liable for their decisions. He believes that if a pharmacist is 40 per
cent liable for a prescription when involved in only the dispensing,
then a pharmacist who has written a prescription which was signed by
a doctor might be liable for as much as 80 per cent of the total. “The
old system also put junior doctors in the position of having to sign
prescriptions that they did not know much about,” he says. Mr Austin
adds: “Our posts save junior doctor hours and this is improved
further with supplementary prescribing.”
Medical ward rounds are conducted twice a week on Tuesdays and Thursdays.
This is when the entire clinical nutrition team, including the consultants,
see patients. Non-medical ward rounds take place on Mondays, Wednesdays
and Fridays. “The benefit of supplementary prescribing is that
on these three days we can now make decisions and changes to patient’s
parenteral nutrition,” explains Mr Austin. “Clinical management
plans (CMPs) are agreed and reviewed on the medical ward rounds. If a
new patient comes onto the ward on the other days, we either find a doctor
to sign the plan or carry on under the old system until Tuesday or Thursday
when the patient can be swapped onto supplementary prescribing,” he
says.
Since patients are on parenteral nutrition for an average of seven to
10 days, making the swap is worthwhile because it allows day-to-day adjustments
to therapy to be made. “We can make these adjustments under the
trust policy without supplementary prescribing but only if we confirm
a change with the doctor and endorse the prescription ‘prescriber
contacted’. With supplementary prescribing, we can make changes
immediately without the need to find a doctor,” says Mr Austin.
In order to decide whether to use supplementary prescribing the following
questions are asked. Does the patient need parenteral nutrition? Is supplementary
prescribing appropriate? Does the patient’s condition match the
clinical management plan and does the whole team and patient agree? “Once
it is decided, a CMP is added to their notes. It is broad enough to allow
daily alterations to electrolytes,” Dr Smith explains. “It
was designed to enable more complicated decisions to be made,” adds
Mr Rhodes. The CMP has been kept as simple as possible, stating what
condition is to be treated and that treatment should be according to
the trust’s standard protocols and guidelines.
“
One of the difficulties is that unlicensed medicines are still not approved
for supplementary prescribing. The bags that require a special formulation
and have to be made up from scratch are unlicensed, so prescriptions
for these ones have to be taken back to the doctor for a signature,” Mr
Tomlin explains. “This now seems exceptionally cumbersome. We need
a special exemption to this rule for parenteral nutrition.” Critical care unit
The prescription chart used in the intensive care unit has been specifically
designed and contains a section for drugs with a narrow therapeutic
index that require therapeutic drug monitoring (TDM). These are the
drugs that Mr Tomlin prescribes in addition to parenteral nutrition.
It is all about targeting the pharmacist’s skills to an area
that needs extra input to ensure that the drugs are managed properly.
He has two standard clinical management plans for TDM drugs. The first
is for antibiotics that require TDM: vancomycin,
teicoplanin, gentamicin, netilmicin, tobramycin and amikacin. The second
is for other TDM drugs and covers: digoxin for arrhythmia, phenytoin
for fits, and aminophylline and theophylline for wheeze.
Both CMPs are based around monitoring the condition, interpreting the
results and adjusting the dose of drug as appropriate. The patient is
referred back to the independent prescriber at each consultant ward round,
if the patient’s condition deteriorates or there are difficulties
in achieving treatment targets.
“The greatest challenge appears to be when to intervene and take over
under the supplementary prescribing rules,” Mr Tomlin comments.
If a patient has already been started on a drug when he first assesses
the notes, and the patient is likely to continue on that drug for some
time, then he would take over the prescribing. But if it was shorter-term,
he probably would not. Another situation in which Mr Tomlin takes over
prescribing is where problems with therapy arise that require a pharmacist’s
input.
Taking over the prescribing of a drug that has already been started is
not an ideal arrangement so Mr Tomlin ensures that he is involved in
the ward round every day. “At the ward round I can identify situations
where supplementary prescribing is appropriate and start it straight
away,” he says.
“I have had a particular issue with consent and the rules of necessity,” explains
Mr Tomlin. “Obtaining consent from the patient is explicit in the
CMP yet my patients are unconscious. So I have to take the presumption
of necessity.” What he has done to support this decision is to
test it through a patient involvement forum. Former patients were asked
what they thought about pharmacists prescribing for them. “They
said pharmacists are the experts and had no problem with us acting on
necessity,” he comments.
Marinos Elia, professor of clinical nutrition and metabolism, is happy
with the introduction of supplementary prescribing. He says: “It
is working well on ITU. There are areas where other professionals have
more expertise than ordinary housemen on the wards. In these situations
it seems reasonable to consider prescribing by these other professionals
as long as their level of competence has been established.” Meeting training needs
Julie Osborne, education and development lead for pharmacy, played
a key role in the supplementary prescribers’ training. She arranged
their places on the courses, applied for the funding from the Workforce
Development Confederation, helped the pharmacists put their portfolios
together and provided other training support when it was needed. “Pharmacists
thinking about undertaking the training need to be aware of the time
commitment it requires. It is important to have a realistic view of
that before starting,” she comments.
The team has the support of chief pharmacist Martin Stephens. He comments
that supplementary prescribing provides a formally, legally and professionally
recognised way of using pharmacists’ skills more fully. “For
a chief pharmacist and for the trust board, that gives some assurance
for clinical governance purposes that it is an appropriate system to
use.” He adds: “Supplementary prescribing uses pharmacists
better, it saves junior doctor time, it provides junior doctors with
a good role model for prescribing and the patient gets care from a skilled
practitioner. It is wins all round.” But he warns: “It should
be used where the pharmacist can make an additional contribution that
is effective and to the benefit of the patient.”
Looking to the future, Mr Stephens says that he does not expect all the
pharmacists in the hospital to become supplementary prescribers because
they have got other roles, too. “But I do expect it to be a more
normal part of all clinical pharmacists’ responsibilities.”
Julia Wright, head of clinical pharmacy, says that cystic fibrosis is
the next condition for which she expects a pharmacist to prescribe at
the hospital. She can also see a role in cardiology. “Supplementary
prescribing will only work in acute situations if the pharmacist is a
key member of the team: that is fundamental to it developing,” she
adds.
With four prescribing pharmacists at the hospital now and another in
training, Mr Stephens says that he expects the total will have reached
double figures by the end of 2005. “It is exciting to be part of
a team that pushes forward,” he says. |
The
Pharmaceutical Journal