Prescribing in Specialist Palliative Care Our Journey

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Bertha Jenkins
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1 Prescribing in Specialist Palliative Care Our Journey M A I M U R P H Y C N S R N P M A R Y C O R C O R A N C N S R N P L A O I S / O F F A L Y S P E C I A L I S T P A L L I A T I V E C A R E S E R V I C E

2 A Journey of Two Parts The Early Years Practice Evaluation & Feedback

3 Background Improving patient care is at the heart of this initiative on nurse/midwife prescribing. In particular, I believe that in services such as palliative care, care of the older person and in nurse led clinics, patients will receive earlier interventions and therefore a better service. The basis of our health service should be that patients receive the right care from the right person in the right setting (Mary Harney, Minister for Health and Children) (February 2007)

4 Positive Influences Personal Organisational CNS Role National Coordination Practice Setting Management Support Model of Practice Development Committed Medical Mentorship

5 Preparation Discussion with Multidisciplinary Colleagues (CNS/ GP/ PHN/ Pharmacist) Feedback from Patients and Families Application Process Numerous Strands Offer of Place on Course at RCSI

6 Certificate in Nurse Prescribing Six-Month Course: Three Modules: Professional Accountability Pharmacology and Prescribing Systematic Assessment Clinical Component (Learning Contract / Competencies, Medication Formulary) Site Preparation (Policy / PPPGs / D&TC/ CPA)

7 Challenges One of First NP Site Developments Laois/Offaly Complexity of Community Site Medications for Palliative Care New Roles New Structures Required At times what seemed to be insurmountable hurdles!

8 Foreseen Benefits. Patient / Family: RNP / MDT / HSE: Straight to local pharmacy Timely access to medication Quicker relief of symptoms RNP can explain medication at time of consultation Holistic Encounter Greater job satisfaction Efficient and effective use of CNS role Value for money Saving of resources Generic medications are prescribed Robust system of audit and review

9 Practice Introduction of role to patients and families. Comprehensive patient assessment. Autonomous clinical decision making. Explanation to and agreement from patient re plan of care. Discussion of expected benefit and alerted to special considerations / possible side effects. Issue of prescription.

10 Practice The Primary Care Prescription Pad Original & Copy 1 to Pharmacy Copy 2 to GP Copy 3 retained by the RNP The Drug Administration & Prescription Record

11 Data Collection & Audit RNP Data Collection System Input details of each prescription issued Audit Regular audit and review meetings with the Prescribing Site Coordinator (CNM 3) HSE Quality & Patient Safety Audit Sept Dec 2014 demonstrated a high level of compliance with selected criteria from the National Policy

12 Invitation to Present May Primary Care Conference - Living and dying well in the community (IHF) October 2014 NMPDU HSE Midlands Celebrating Nursing & Midwifery Practice in the Midlands LOLW (3 day conference) November 2014 University of Applied Sciences Saimaa, Finland - Nursing Delegation (INMO)

13 And so to Part 2! A natural evolution emerged. Our roles are now well established within the community We have presented and disseminated on our journey to date We have recently renewed our CPAs and increased the number of GPs collaborating with us and pharmacists processing our prescriptions With the help of Eileen Dunphy (Quality & Patient Safety Researcher) and Margaret Digan (Team Secretary) we set about designing a research study to run from 1st of November 2015 to 30th of April 2016

15 Aim To evaluate the role of two established Registered Nurse Prescribers (RNPs) within the Specialist Community Palliative Care Service in Laois/Offaly

16 Objectives To explore the prescriptive patterns of the RNP through a review of prescribing reports generated on the RNP database. To survey patient and family experience of the service provided to them by a RNP through a semi-structured questionnaire. To survey pharmacists on their experience of processing prescriptions issued by a RNP through a semi-structured questionnaire. To survey GPs in order to gain their views on the introduction and impact of nurse prescribing on their patient care and on their own GP role through a semi-structured questionnaire.

17 Prescriptive Patterns Activity reports were generated from the RNP database: A total of 158 prescriptions inputted from the 1 st November to 31 st March were examined To date: The most commonly prescribed drugs were: Midazolam, Morphine Sulphate, Oxycodone, Levomepromazine, Hysocine Butylbromide The most common routes of drug administration were: Subcutaneous 66% PR 16% PO 14% TD 4% INH 1%

18 Patient & Family Experience A questionnaire was given to a patient or family member on the first issue of a RNP prescription in the home Anonymity was assured Survey continues to 30 th of April 2016 Up to 31/03/16: 27 issued; 20 returned; (Response Rate 74%)

19 Patient & Family Feedback 100% awareness nurses working in the community can prescribe medications. What did receipt of a RNP prescription mean to families? Convenience in getting to the chemist Patient gets to take effective medication more quickly Increased awareness of the use and side effects of medication

20 Patient & Family Feedback Very happy with the service.to go to a GP requires time.the prescription won t be ready on the day which causes delay in the drugs reaching the patient. The Palliative Care Nurse is much more aware and in touch with the patient needs thus better at prescribing effective medications Medication was explained in detail which we found very helpful. The RNP is a great service The service is exceptional, the RNPs are devoted and confident and bring suchcomforttofamiliesattheendoflife No improvements needed. It is just an amazing service from beginning to end Excellent and prompt service

21 Pharmacist Experience 30 questionnaires were sent Anonymity was assured The survey is now complete 30 issued; 17returned; (Response Rate 57%)

22 Pharmacist Feedback 94% aware of the RNP role 94% felt it was a positive development 82% had processed a RNP prescription 100% satisfaction rate with completion of: Demographic patient information Data fields Details of prescribed medication Written requirements for controlled drugs Generic names for medications prescribed RNP signature Recording of the RNP PIN Legibility of the prescription

23 Pharmacist Feedback As a UK trained pharmacist, I am used to RNPs and feel it is very beneficial towards patient care.this new service has a very positive impact on palliative care in our community Much easier as prescriptions are received when the patient requires the medication and less waste Not sure what protocols they follow. Also unsure about the legislation surrounding what they can prescribe

24 GP Experience 33 questionnaires sent Anonymity was assured The survey is now complete 33 issued; 23 returned; (Response Rate 70%)

25 GP Experience 100% aware of the RNP role 87% state RNP regularly prescribes for their patient 95% received timely communication from the RNP: o Copy of Prescription o + / - Telephone update o + / - Letter

26 GP Experience How the RNP role impacts on GP relationship with: Patient (74% positive impact) Very positive, patients happy with the service and know that we discuss their care Family (65% positive impact) Family have peace of mind and more comfortable with action plan RNP (91% positive impact) RNP seems to be enjoying their role and interaction with us

27 GP Experience How has the reduction in face to face contact with the RNP impacted on opportunities to discuss palliative care issues: 74% responded that this had not impacted on them 26% felt the RNP role has reduced GPs opportunity to discuss palliative care issues but positive feedback regarding: Updates Telephone contact Reduced workload 100% of GPs intend to renew their CPA

28 GP Experience I think this is a well thought-out and operated practical response Very positive with timely interventions and appropriate actions Brilliant, very knowledgeable and willing to share her knowledge and expertise The RNP always updates us, always only a phone call away Massively improved and has taken a bit of work from me in this regard Excellent service

29 RNP Service Rating 100% Excellent (Patients) Fair, n=1, 4% Good, n=2, 9% GP Rating Good n=2, 15% Pharmacist Rating Excellent, n=20, 87% Excellent n=11, 85%

30 Recommendations Patient & Family: All nurses should prescribe prescriptions Pharmacist: More RNPs in the community Mobile phone contact for RNP Education re what RNPs can prescribe and for whom they can prescribe

31 Recommendations GPs: Keep GP and RNP working as a team with meetings and updates MIDOC to be provided with mobile phone numbers of the RNPs Instruction from the RNP on how to set up a syringe pump

32 Conclusion to date. We met the aims and objectives of our research study to date. The RNP role is well established and respected within the community. The service is well received by patients and families. There are enhanced professional relationships with pharmacists and GP s. There is affirmation for us of the value of the RNP role. Upon full completion of our study we will examine all recommendations and agree an action plan with our PSC. We will disseminate the findings of this study nationally and internationally.

33 Thank you We appreciate your presence and attention We welcome your questions and comments

Maureen Nolan Director of Nursing National Lead for the Implementation and Audit of Nurse Prescribing of Ionising Radiation and Medicinal Prescribing

Maureen Nolan Director of Nursing National Lead for the Implementation and Audit of Nurse Prescribing of Ionising Radiation and Medicinal Prescribing Dublin Mid Leinster Prescribing Team Clare MacGabhann,