Nurse Prescribing In Nurse Prescribing In Cardiac RehabilitationCardiac Rehabilitation

Jacinta Caulfield CNS/RNP Jacinta Caulfield CNS/RNP

Cardiac Rehabilitation. Cardiac Rehabilitation.

St Columcilles Hospital.St Columcilles Hospital.

Introduction of Nurse PrescribingIntroduction of Nurse Prescribing

May 2007 The medicinal products May 2007 The medicinal products (prescription and Control of Supply (prescription and Control of Supply Regulations and the Misuse of Drugs Regulations and the Misuse of Drugs (amendment) regulations signed into law.(amendment) regulations signed into law.

Specified the conditions for prescribing of Specified the conditions for prescribing of medicinal products by Registered Nurse medicinal products by Registered Nurse Prescribers.Prescribers.

Nurses rules 2007.Nurses rules 2007.

Conditions for prescriptive authorityConditions for prescriptive authority

Nurse/Midwife must be employed by a health Nurse/Midwife must be employed by a health service provider.service provider.

Medicinal product must be one used in the Medicinal product must be one used in the usual course of service. usual course of service.

The prescription is issued in the usual course The prescription is issued in the usual course of the healthcare setting.of the healthcare setting.

Successful completion of education Successful completion of education programme.programme.

Work within scope of practice.Work within scope of practice.

Education programmeEducation programme Six month education programme.Six month education programme. Level 8 minor award.Level 8 minor award. PharmacologyPharmacology – exam. – exam. Systematic assessment in patient careSystematic assessment in patient care.. Osler exams/Case study.Osler exams/Case study. Professional accountabilityProfessional accountability Reflective portfolio and CPA assignments.Reflective portfolio and CPA assignments. Clinical time with Consultant Clinical time with Consultant

CardiologistCardiologist..

Collaborative Practice AgreementCollaborative Practice Agreement(CPA)(CPA)

A written agreement between the RNP, A written agreement between the RNP, medical mentor and employer.medical mentor and employer.

Prescribing site coordinator.Prescribing site coordinator. Contains the details of patient group and Contains the details of patient group and

health care setting in which the RNP can health care setting in which the RNP can prescribe.prescribe.

Details medicinal products the RNP can Details medicinal products the RNP can prescribe.prescribe.

Forwarded to An Bord Altranais annually.Forwarded to An Bord Altranais annually.

Nurse Prescribing in Cardiac Nurse Prescribing in Cardiac Rehabilitation Rehabilitation

Successful completion of course in RCSI.Successful completion of course in RCSI. Drawing up of CPA.Drawing up of CPA. Patient group and setting identified.Patient group and setting identified. Medications identified.Medications identified. Communication pathway with other Communication pathway with other

healthcare professionals.healthcare professionals. Introduction into CR (SCH) March 2009.Introduction into CR (SCH) March 2009.

CaseloadCaseload

Patients attending Phase III.Patients attending Phase III. Formal assessment of Risk factors during Formal assessment of Risk factors during

week 5.week 5. Cholesterol measurement.Cholesterol measurement. Medications re evaluated with patient. Medications re evaluated with patient. Titration of medications.Titration of medications. Complicated patients refer back to Complicated patients refer back to

Cardiologist or GP as appropriate.Cardiologist or GP as appropriate.

Patient assessmentPatient assessment Documentation of patients medical history.Documentation of patients medical history. Physical exam if required.Physical exam if required. Recording of blood pressure.Recording of blood pressure. Cholesterol measurement.Cholesterol measurement. Documentation of risk factors (diabetes, Documentation of risk factors (diabetes,

smoking, alcohol, BMI)smoking, alcohol, BMI) Current medicationsCurrent medications Allergies.Allergies. Exercise level.Exercise level.

Prescription writingPrescription writing

LegibleLegible Include patients Name, Address, Date of Birth Include patients Name, Address, Date of Birth

(triplicate).(triplicate). Allergies.Allergies. Prescribe generically.Prescribe generically. Dose and duration of therapy.Dose and duration of therapy. Signature and pin number of RNP.Signature and pin number of RNP. Explanation of therapy to patient – verbal and Explanation of therapy to patient – verbal and

written.written.

CommunicationCommunication Drug specific information. (Medicines.ie)Drug specific information. (Medicines.ie) Treatment discussed with patient.Treatment discussed with patient. Individual medication record.Individual medication record. Information booklet (medication safety).Information booklet (medication safety). Nurse Prescribing leaflet.Nurse Prescribing leaflet. Discharge summary to GP and Cardiologist.Discharge summary to GP and Cardiologist. Documentation of patient consultation with RNP.Documentation of patient consultation with RNP. Referral to other healthcare professional.Referral to other healthcare professional.

Role of prescribing in CRRole of prescribing in CR

Therapeutic relationship with patient.Therapeutic relationship with patient. Continuity in patient care.Continuity in patient care. Opportunity to assess adherence.Opportunity to assess adherence. Information targeted to individual patients.Information targeted to individual patients. Affords patient opportunity to ask Affords patient opportunity to ask

questions.questions. Lifestyle changes discussed.Lifestyle changes discussed. Communication within CR team.Communication within CR team. Communication with GP enhanced.Communication with GP enhanced.

Case Study oneCase Study one 79 year old female. 79 year old female. Cardiac history: STEMI, medical Cardiac history: STEMI, medical

management.management. Risk factor assessmentRisk factor assessment - Blood pressure 110/70mmHg, no - Blood pressure 110/70mmHg, no

diabetes, non smoker, BMI 26 kg/mdiabetes, non smoker, BMI 26 kg/m².². Cholesterol measurementCholesterol measurement: : Total 2.81mmol/l HDL 1.10 mmol/l LDL Total 2.81mmol/l HDL 1.10 mmol/l LDL

1.25mmol/l Trigs 1.02 mmol/l Glucose 5.10 1.25mmol/l Trigs 1.02 mmol/l Glucose 5.10 mmol/lmmol/l

………….contd.contd Current medicationsCurrent medications:: Nuseals aspirin 75mg odNuseals aspirin 75mg od Clopidogrel 75mg odClopidogrel 75mg od Bisoprolol 2.5mg odBisoprolol 2.5mg od Ramipril 2.5mg odRamipril 2.5mg od Atorvastatin 80mg odAtorvastatin 80mg od Liver function test normal.Liver function test normal. No over the counter drugs.No over the counter drugs. No known drug allergies.No known drug allergies.

…………contdcontd

Plan : reduce Atorvastatin to 40mg od.Plan : reduce Atorvastatin to 40mg od. Discussed with patient.Discussed with patient. Written information.Written information. Advised 6 monthly cholesterol and liver Advised 6 monthly cholesterol and liver

function check.function check. Lifestyle factors.Lifestyle factors. Documented in patients record card.Documented in patients record card.

DocumentationDocumentation

Patient assessment documented and copy Patient assessment documented and copy prescription kept.prescription kept.

All prescriptions input into HSE Nurse All prescriptions input into HSE Nurse Prescribing data base.Prescribing data base.

Changes in medications documented in Changes in medications documented in patients discharge summary sent to GP patients discharge summary sent to GP and cardiologist.and cardiologist.

Special considerationsSpecial considerations

Prescribing for elderly patients.Prescribing for elderly patients. Avoiding polypharmacy.Avoiding polypharmacy. Compliance with medical therapy.Compliance with medical therapy. Level of literacy.Level of literacy. Alcohol consumption.Alcohol consumption. Over the counter medications/herbal.Over the counter medications/herbal.

Case study twoCase study two

Male 63 years.Male 63 years. Cardiac history: Cardiac arrest, medical Cardiac history: Cardiac arrest, medical

management.management. Current medicationsCurrent medications:: Nuseals aspirin 75mg od.Nuseals aspirin 75mg od. Atorvastatin 80mg odAtorvastatin 80mg od Micardis 20mg odMicardis 20mg od Lansoprazole 30mg odLansoprazole 30mg od No known drug allergies.No known drug allergies.

Current Smoker – 40 cigarettes daily.Current Smoker – 40 cigarettes daily. Blood pressure 130/80mmHg at rest.Blood pressure 130/80mmHg at rest. Heart rate 110 bpm pre exercise.Heart rate 110 bpm pre exercise. Alcohol > 30 units per week.Alcohol > 30 units per week. Cholesterol measurement:Cholesterol measurement: TotalTotal 3.53mmol/l 3.53mmol/l HDLHDL 1.26mmol/l 1.26mmol/l TrigsTrigs

1.12mmol/l 1.12mmol/l LDLLDL 1.76 mmol/l. 1.76 mmol/l. GlucoseGlucose 4.31 mmol/l. 4.31 mmol/l.

Training heart rate 120-140 bpmTraining heart rate 120-140 bpm Blood pressure 140/90mmhg.Blood pressure 140/90mmhg. Dyspnoea on exertion.Dyspnoea on exertion.

PlanPlan

Restart low dose beta blocker.Restart low dose beta blocker.

Atorvastatin reduced to 40mg od.Atorvastatin reduced to 40mg od.

Patient consultationPatient consultation

Explain rationale for change of medication.Explain rationale for change of medication. Advised re alcohol intake.Advised re alcohol intake. Smoking cessation offered.Smoking cessation offered. Advised re side effects with beta blocker.Advised re side effects with beta blocker. Written information given.Written information given. Follow up in Cardiology clinic. Follow up Follow up in Cardiology clinic. Follow up

bloods - LFTsbloods - LFTs GP contacted by phone.GP contacted by phone.

National Independent Evaluation of National Independent Evaluation of Nurse & midwife prescribing initiative.Nurse & midwife prescribing initiative.

(2009)(2009)

RNP/RMPRNP/RMP > 10 years > 10 years

experience.experience. Scope of practice.Scope of practice. Quality educational Quality educational

experience.experience. Increased workload.Increased workload.

BarriersBarriers Delays with Drugs & Delays with Drugs &

Therapeutics Therapeutics Committees/Medical Committees/Medical practitioner in practitioner in agreeing CPA.agreeing CPA.

Prescribing of Prescribing of unlicensed unlicensed medications.medications.

Antibiotics.Antibiotics.

Attitudes of patientsAttitudes of patients

Highly satisfied with their care.Highly satisfied with their care. Comprehensive education and advice.Comprehensive education and advice. Self report intent to comply was high.Self report intent to comply was high. Reduction in waiting times.Reduction in waiting times. Consultation with RNP – time for the Consultation with RNP – time for the

patient.patient.

Support for prescribing roleSupport for prescribing role

Other Health professionals supportive.Other Health professionals supportive. Medical mentorMedical mentor Nursing colleagues.Nursing colleagues. Pharmacy colleagues.Pharmacy colleagues. An Bord Altranais & HSE.An Bord Altranais & HSE. Continuing professional development.Continuing professional development.

ConclusionConclusion

Positive impact on patient care.Positive impact on patient care. Avoidance of delays in treatment.Avoidance of delays in treatment. Opportunity to enhance compliance.Opportunity to enhance compliance. Avoidance of visits to Cardiologist Clinic.Avoidance of visits to Cardiologist Clinic. Patients at target for risk factor Patients at target for risk factor

management.management. Expanded role as CNS-enhanced Expanded role as CNS-enhanced

knowledge.knowledge.

Thank youThank you

ReferencesReferences Drennan J., Naughton C., Allen D., Hyde A., Felle P., O’Boyle K., Treacy P., Butler M. (2009) Drennan J., Naughton C., Allen D., Hyde A., Felle P., O’Boyle K., Treacy P., Butler M. (2009)

Independent Evaluation of the Nurse and Midwife PrescribingIndependent Evaluation of the Nurse and Midwife Prescribing

InitiativeInitiative. University College Dublin, Dublin.. University College Dublin, Dublin. Irish Society for Quality and Safety in Healthcare (ISQH) (2008). Let’s Talk Medication Irish Society for Quality and Safety in Healthcare (ISQH) (2008). Let’s Talk Medication

Safety.Safety. Collaborative Practice Agreement for Nurses and Midwives with Prescriptive Authority Collaborative Practice Agreement for Nurses and Midwives with Prescriptive Authority

(December 2007).(December 2007). Practice Standards for Nurses and Midwives with Prescriptive Authority (July 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 Office of the Nursing Services Director. HSE (2008) Nurse and Midwife Prescribers-How

they care for you.they care for you.

WEBSITESWEBSITES Medicines.ieMedicines.ie HSE.ie/nurseprescribingHSE.ie/nurseprescribing