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1. Nurse Prescribing In Cardiac Rehabilitation Jacinta Caulfield CNS/RNP
Cardiac Rehabilitation.
St Columcilles Hospital.
2. Introduction of Nurse Prescribing May 2007 The medicinal products (prescription and Control of Supply Regulations and the Misuse of Drugs (amendment) regulations signed into law.
Specified the conditions for prescribing of medicinal products by Registered Nurse Prescribers.
Nurses rules 2007.
3. Conditions for prescriptive authority Nurse/Midwife must be employed by a health service provider.
Medicinal product must be one used in the usual course of service.
The prescription is issued in the usual course of the healthcare setting.
Successful completion of education programme.
Work within scope of practice.
4. Education programme Six month education programme.
Level 8 minor award.
Pharmacology exam.
Systematic assessment in patient care.
Osler exams/Case study.
Professional accountability
Reflective portfolio and CPA assignments.
Clinical time with Consultant Cardiologist.
5. Collaborative Practice Agreement (CPA) A written agreement between the RNP, medical mentor and employer.
Prescribing site coordinator.
Contains the details of patient group and health care setting in which the RNP can prescribe.
Details medicinal products the RNP can prescribe.
Forwarded to An Bord Altranais annually.
6. Nurse Prescribing in Cardiac Rehabilitation Successful completion of course in RCSI.
Drawing up of CPA.
Patient group and setting identified.
Medications identified.
Communication pathway with other healthcare professionals.
Introduction into CR (SCH) March 2009.
7. Caseload Patients attending Phase III.
Formal assessment of Risk factors during week 5.
Cholesterol measurement.
Medications re evaluated with patient.
Titration of medications.
Complicated patients refer back to Cardiologist or GP as appropriate.
8. Patient assessment Documentation of patients medical history.
Physical exam if required.
Recording of blood pressure.
Cholesterol measurement.
Documentation of risk factors (diabetes, smoking, alcohol, BMI)
Current medications
Allergies.
Exercise level.
9. Prescription writing Legible
Include patients Name, Address, Date of Birth (triplicate).
Allergies.
Prescribe generically.
Dose and duration of therapy.
Signature and pin number of RNP.
Explanation of therapy to patient verbal and written.
10. Communication Drug specific information. (Medicines.ie)
Treatment discussed with patient.
Individual medication record.
Information booklet (medication safety).
Nurse Prescribing leaflet.
Discharge summary to GP and Cardiologist.
Documentation of patient consultation with RNP.
Referral to other healthcare professional.
11. Role of prescribing in CR Therapeutic relationship with patient.
Continuity in patient care.
Opportunity to assess adherence.
Information targeted to individual patients.
Affords patient opportunity to ask questions.
Lifestyle changes discussed.
Communication within CR team.
Communication with GP enhanced.
12. Case Study one 79 year old female.
Cardiac history: STEMI, medical management.
Risk factor assessment
- Blood pressure 110/70mmHg, no diabetes, non smoker, BMI 26 kg/m.
Cholesterol measurement:
Total 2.81mmol/l HDL 1.10 mmol/l LDL 1.25mmol/l Trigs 1.02 mmol/l Glucose 5.10 mmol/l
13. .contd Current medications:
Nuseals aspirin 75mg od
Clopidogrel 75mg od
Bisoprolol 2.5mg od
Ramipril 2.5mg od
Atorvastatin 80mg od
Liver function test normal.
No over the counter drugs.
No known drug allergies.
14. contd Plan : reduce Atorvastatin to 40mg od.
Discussed with patient.
Written information.
Advised 6 monthly cholesterol and liver function check.
Lifestyle factors.
Documented in patients record card.
15. Documentation Patient assessment documented and copy prescription kept.
All prescriptions input into HSE Nurse Prescribing data base.
Changes in medications documented in patients discharge summary sent to GP and cardiologist.
16. Special considerations Prescribing for elderly patients.
Avoiding polypharmacy.
Compliance with medical therapy.
Level of literacy.
Alcohol consumption.
Over the counter medications/herbal.
17. Case study two Male 63 years.
Cardiac history: Cardiac arrest, medical management.
Current medications:
Nuseals aspirin 75mg od.
Atorvastatin 80mg od
Micardis 20mg od
Lansoprazole 30mg od
No known drug allergies.
18. Current Smoker 40 cigarettes daily.
Blood pressure 130/80mmHg at rest.
Heart rate 110 bpm pre exercise.
Alcohol > 30 units per week.
Cholesterol measurement:
Total 3.53mmol/l HDL 1.26mmol/l Trigs 1.12mmol/l LDL 1.76 mmol/l.
Glucose 4.31 mmol/l.
19. Training heart rate 120-140 bpm
Blood pressure 140/90mmhg.
Dyspnoea on exertion.
Plan
Restart low dose beta blocker.
Atorvastatin reduced to 40mg od.
20. Patient consultation Explain rationale for change of medication.
Advised re alcohol intake.
Smoking cessation offered.
Advised re side effects with beta blocker.
Written information given.
Follow up in Cardiology clinic. Follow up bloods - LFTs
GP contacted by phone.
21. National Independent Evaluation of Nurse & midwife prescribing initiative.(2009) RNP/RMP
> 10 years experience.
Scope of practice.
Quality educational experience.
Increased workload.
Barriers
Delays with Drugs & Therapeutics Committees/Medical practitioner in agreeing CPA.
Prescribing of unlicensed medications.
Antibiotics.
22. Attitudes of patients Highly satisfied with their care.
Comprehensive education and advice.
Self report intent to comply was high.
Reduction in waiting times.
Consultation with RNP time for the patient.
23. Support for prescribing role Other Health professionals supportive.
Medical mentor
Nursing colleagues.
Pharmacy colleagues.
An Bord Altranais & HSE.
Continuing professional development.
24. Conclusion Positive impact on patient care.
Avoidance of delays in treatment.
Opportunity to enhance compliance.
Avoidance of visits to Cardiologist Clinic.
Patients at target for risk factor management.
Expanded role as CNS-enhanced knowledge.
25. Thank you
26. References Drennan J., Naughton C., Allen D., Hyde A., Felle P., OBoyle K., Treacy P., Butler M. (2009) Independent Evaluation of the Nurse and Midwife Prescribing
Initiative. University College Dublin, Dublin.
Irish Society for Quality and Safety in Healthcare (ISQH) (2008). Lets Talk Medication Safety.
Collaborative Practice Agreement for Nurses and Midwives with Prescriptive Authority (December 2007).
Practice Standards for Nurses and Midwives with Prescriptive Authority (July 2007).
Office of the Nursing Services Director. HSE (2008) Nurse and Midwife Prescribers-How they care for you.
WEBSITES
Medicines.ie
HSE.ie/nurseprescribing
