Non-Medical
Prescribing
A Pharmacists’
Perspective
Haifa Lyster
Consultant Pharmacist –
Transplantation & VADs
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Aims
• Non-medical Prescribing – my
experience as a pharmacist
• Prescribing as part of a Multidisciplinary Team
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
My journey…
• Supplementary Prescribing @ Kings
College University in 2004
– Clinical Management Plans
• Post-transplant drug review
• Homecare
• Hypertension
Prescribing as part of a MDT clinic
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Limitations of supplementary prescribing
• Overly bureaucratic
– Initial assessment and diagnosis by
independent prescriber
– Periodic joint reviews (min. annual)
– Individual CMPs
• Lacks sufficient flexibility and
freedom
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
My journey continued…
• Independent Prescriber conversion
course @ LSBU in 2006
• “may prescribe autonomously for any
condition within their clinical
competence”
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
My journey…
• Trust Non-Medical Prescribing Group
– Initially to register:
• Risk assessment
• Scope of Practice
– Inc ‘off-label’
– Unlicensed since Dec 09
– CDs?
– Thereafter:
• Annual Prescribing Audit
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
My first prescription
I remember clearly the day I wrote my first
prescription. It was for ramipril 2.5mg
capsules for a lung transplant recipient with
hypertension.
– The increased responsibility dawned on
me!
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Ward Rounds
• Prescribing as part of a MDT
• On transplant wards & ICU
– Stopping and starting medicines
– PO→IV or IV→PO
– Reviewing doses e.g. renal, drug
interactions
– Medication counselling
– Discharge
• Pharmacy clinical screen
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Integral member of Transplant MDT
• New Transplants
– Immunosuppression regimen
– Anti-infective prophylaxis
– Other prophylactic medication
• New / Changeover of junior doctors
– Prescribing errors
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Integral member of Transplant MDT
• Antimicrobial stewardship
– Micro ward round
– Choice of anti-infective
– Review course duration
• Renal dosing
• Converting to IV if not absorbing
• Anticoagulation in VAD patients
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Integral member of Transplant MDT
• Daily immunosuppression ward
rounds @ 3pm
– Review IS doses as per target levels
– Minimise adverse effects
• Managing Drug Interactions
– Starting AND stopping plans
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Homecare delivery
• Currently 200 patients enrolled, however
numbers increasing ++
• In 2013-14 change in NHS England
commissioning possibly 1300+ patients
• Lifelong Immunosuppressant & courses
of other Transplant related medicines e.g.
anti-infectives
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Homecare delivery
• Immunosuppressants – delivered every 3
months, however doses change!
– Ensure brand prescribing: Prograf
(Tacrolimus) & Neoral (Ciclosporin)
– Assess appropriate dose & target level
– Monitor (and minimise) drug adverse effects
– e.g. SCr, WCC
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Homecare delivery – Anti-infectives
• Anti-infectives (e.g. voriconazole,
posaconazole, valganciclovir) delivered monthly
– Assess continued need
– Manage drug-drug interactions
• Intravenous Anti-infectives @ home
– IV antibiotics e.g. meropenem, daptomycin
– IV antifungals e.g. caspofungin, ambisome
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Transplant & ITU partnership
•Electronic
Prescribing – ICIP in
ITU & HDU areas
•Cross-cover
•6 day clinical
service since Jan 13
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Transplant MDT - future
• Clinics – to restart
– Post-transplant drug review clinics
– IS & Drug Interactions
– Young Adult Clinic (Transitioning
paediatric transplant patients)
• Adherence
• ? Change IS regimen to once daily
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
At Royal Brompton & Harefield
Nurses,
Pharmacists &
Physios
Number of Prescribers
(tot=26)
Pharmacists
Nurses
Annual audit
Physiotherapists
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Cardiology NMP Discharge W/R – since 2010
• Consultant Nurse & Pharmacist – joint daily discharge ward
round
– Different strengths
– The aim to expedite the discharge of patients following
angioplasty
– Patients identified on the morning board round, post-PCI
• Consultant Nurse – physical assessments
• Joint – review of bloods, ECHO, ECG, BP, HR
• Pharmacist
– drug review and optimisation e.g. uptitration of ACE,
reviewing statin doses, smoking cessation
– medication counselling to aid adherence
– Write up TTA to facilitate timely discharge
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Cardiology Discharge W/R
• Nine month evaluation of the service was
accepted for an oral presentation at ESC
2011
– Total 807 patients reviewed Mar 10-Dec 10
– 464 (57%) discharged on the same day, 65 (8.1%)
referred back to medical staff for further assessment
– Total of 522 medication changes
– Concluded: facilitated earlier discharge and improved
consistency of care and medication is optimsed in a
more timely manner.
– Positively evaluated by members of the medical and
nursing team and now part of routine practice.
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Other NMP Clinics
• Pharmacist-led AF clinic
– Patients referred via EP consultant / arrhythmia nurse, hence
still part of the wider MDT
– Optimisation of rate- or rhythm- control (or in pre-ablation
setting)
– Monitor: ECG (esp QT-interval), symptom control, bloods,
ECHO, 24hr tape
– Assessment of anticoagulation (stroke risk)
– Follow-up: when clinically stable and adequately
rate/rhythm controlled then discharged back to EP
consultant or arrhythmia nurse for further long-term
management, patients have pharmacist contact details if any
queries
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Other NMP Clinics
• Pre-admission Clinics
– Surgery – pre-CABG
– Cardiology – pre-angioplasty, pre-ablation
• MDT clinics
– Nurse: assesses med Hx, ECG, bloods etc
– Pharmacist:
• Drug history: 30-35% of pharmacist interventions
due to incorrect drug history on admission
• Starting dual antiplatelets pre-angioplasty,
optimising anti-anginals, commence PPI 1 week
pre-ablation, optimise anti-arrhythmics
• Writing up drug charts ready for hospital admission
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Take home message
• There is no and never should be any competition
between the professions as each of us has much to
offer the other and the patient.
• Medics, nurses and pharmacists can form good
collaborative and complementary relationships in
the provision of patient care.
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE
Any questions??
Harefield Hospital
Imperial College
Royal Brompton & Harefield NHS Trust
OF SCIENCE TECHNOLOGY AND MEDICINE