Introduction

Within NHS Lothian, all nurse practitioners who wish to prescribe must first complete two Masters level modules in patient history taking and clinical examination. Only then may they progress to the third and final module on NMP and be classed as advanced nurse practitioners [1]. This is not true of all health boards but, in terms of professional accountability and liability, if you are to prescribe safely and appropriately, it is logical that you must first be able to establish a working diagnosis.

The Royal College of Nursing [2] defines advanced nurse practitioners as:
“… Educated at Masters Level in clinical practice and have been assessed as competent in practice using their expert clinical knowledge and skills. They have the freedom and authority to act, making autonomous decisions in the assessment, diagnosis and treatment of patients.”

 The complexity of NMP is reflected by the Nursing and Midwifery Council’s Standards for NMP [3] which are summarized in Table 1.

Table 1: Nursing and Midwifery Standards for non-medical prescribing.

Hospital at Night

Within NHS Lothian the HAN team consists of senior and advanced nurse practitioners (ANPs), medical registrars, clinical development fellows, foundation year one and two doctors and, more recently, clinical support workers. Working in the acute hospital setting, HAN is a medical emergency team whose primary remit is to provide out of hours care via planned reviews of unstable patients and by responding to referrals for the review of newly deteriorating patients. The team is also responsible for clerking new admissions across various specialities. As the service runs on a system of telephone triage, a key role within HAN is that of the coordinator who is responsible for the allocation of patient reviews to the appropriate team member within a timeframe that reflects the acuity of the situation.

One non-medically prescribing ANP per night is responsible for providing a remote service to three community hospitals and one rehabilitation hospital in and around Edinburgh. This remote service ranges from telephone advice and the generation of remote prescriptions to travel to these hospitals to assess and treat deteriorating patients either on site or by moving them to an acute site.

Case Study  

Presentation

A referral was made to the HAN team requesting review of a patient with chest pain and a national Early Warning Score (NEWS) of 14. NEWS is an evidence-based score reflecting the level of acuity of a patient’s condition and is an essential requirement for the speedy triage of an acutely unwell patient [4]. The history given by the nurse included the information that the patient was on oral antibiotics for a chest infection but also had a cardiac history. The nurse had administered Glycerol Trinitrate (GTN) spray. When the patient’s pain did not settle she administered a second dose, rechecked his vital signs and noted he was now pyrexial and acutely short of breath. She commenced the patient on oxygen (O2) therapy, recorded a 12 lead electrocardiograph (ECG) and sent bloods for serum biochemistry and hematology.

Examination and Investigation

The patient was hot, flushed, diaphoretic and tachypnoeic with an increased work of breathing and use of the accessory muscles of respiration. He looked frightened and was only able to reply with one word answers. The pain was in the left side of his chest and worse on inspiration. It had been present earlier in the day but had been mild so he did not inform nursing staff until it recurred, waking him from sleep.

On physical examination the patient had a rapid irregular heart rate, no added heart sounds, a capillary refill time of 4 seconds with cool peripheries, no peripheral oedema and his calves were soft and non-tender. Chest auscultation showed decreased breath sounds at his left base with coarse crepitations to the left mid-zone, a few fine crepitations in the right base and scattered wheeze throughout. Deep breathing caused him to cough and to experience pain in his chest. On percussion, his lungs sounded dull at the left base and his lung expansion was equal. Due to his level of dyspnoea it was not possible to lie him flat to perform a full abdominal examination but he had no obvious signs of an acute abdomen on palpation or ausculation. His fluid balance was not recorded. He was not diabetic but a random capillary blood glucose check was slightly high at 11.2 mmols. His vital signs showed a temperature of 38.8 degrees Celsius, a heart rate of 143, blood pressure of 92/46, respiratory rate of 32 and oxygen saturations of 68% on 4 liters of oxygen.

A twelve lead ECG showed sinus tachycardia with atrial ectopic and T wave inversion in the infero-lateral leads. In this context, these changes can indicate a non-ST elevation myocardial infarction (NSTEMI) [5] secondary to organ dysfunction [6]. An arterial blood gas (ABG) was taken on high flow oxygen. Inflammatory markers, a lactate, coagulation screen, troponin and blood cultures were sent to the laboratories. An urgent portable chest x-ray was ordered.

Results

His CXR showed consolidation suggestive of a left sided pneumonia. His blood results showed raised inflammatory markers and a high lactate, an acute-on-chronic kidney injury with a safe potassium level and a positive troponin result. His arterial blood gas showed type two respiratory failure so his high flow oxygen was titrated down, aiming for target oxygen saturations 88-92%. His normal oxygen saturations trended at 87-89%.

Working Diagnoses

Sepsis secondary to pneumonia
Positive troponin: potential causes - sepsis, acute kidney injury or Type 2 MI secondary to sepsis.

Initial Management

Following a review of his drug kardex for allergies, current medication and potential interactions, prescriptions were written for intravenous morphine, an anti-emetic, high flow oxygen and a salbutamol nebulizer as well as an initial fluid bolus of 250 milliliters of plasmalyte. His oral antibiotics were escalated to intravenous for a community-acquired pneumonia as per local guidelines. Due to the acuity of the situation, an explanation of the plan was given to the patient but not discussed in any detail.

 How does NMP contribute to patient care?

Education and experience as an ANP provides the necessary knowledge and skill to assess a patient and generate a working diagnosis. Further education and registration as a non-medical prescriber contributes to timely initiation of treatment, meeting sepsis standards of initiating treatment within an hour of diagnosis [7]. If an ANP could not prescribe independently, a doctor would have to review the patient a second time before prescribing the appropriate antibiotics, resulting in a delay to treatment. Given the high morbidity and mortality of sepsis, delay can lead to a poorer outcome. Evidence underpinning current sepsis management guidelines clearly demonstrates the need for early recognition and treatment of patients presenting with sepsis [8].

Factors to be considered when prescribing for an elderly patient

Due to the presence of pre-morbid and co-morbid factors, the elderly are predisposed to sepsis, often presenting atypically [9] with a compromised immune response leading to an increased risk of developing systemic infections and an impaired vascular response [10].

Immunosenescence is the term used to describe immune compromise secondary to aging. Defined as a combination of oxidative stress, altered apoptosis and cytokine mediated inflammatory response and with a profound effect upon survival [11] it can be seen that senescence adds a further layer of complexity to the issue of sepsis in the elderly. In terms of deciding whether to treat a pneumonia as hospital or community-acquired, the length of stay of the patient is relevant (in this case two days) as the causative organisms are different and therefore require different antibiotics [12]. Antimicrobial stewardship is a major and very current factor in terms of trying to avoid antimicrobial resistance [13]. In this instance, the clinical status of the patient dictated the prescription of antimicrobials. The presence of multiple co-morbidities and polypharmacy mean the risk of adverse drug reactions (ADRs) are two to three times more likely in the elderly [14] and the benefit versus risk of treatment should be considered before any prescription is written [15].

As a non-medical prescriber it is your responsibility to ascertain and guide a patient’s expectations about their treatment by forming a partnership with them that takes into account their beliefs about health and medication [16]. Involving the patient in the planning of their care is the guiding principle without which all other aspects of the prescribing process become less effective [17]. These patient centered discussions should also include longer term management considerations such as the wishes of the patient and their family should further deterioration occur [18]. However, as this case study shows, there are situations where clinical need takes precedence and discussions have to wait until the situation has stabilized.

Safety of NMP

At this point it is worth emphasizing the individual nature of each HAN ANP’s prescribing formulary. Starting with a core formulary developed during the NMP Master’s module, this formulary is expanded post registration as a non-medical prescriber to include NHS Lothian’s Drug Formulary. Consequently, ANPs within HAN work with a broad formulary comprising multiple types of medication across many adult specialties rather than the limited formularies used by specialist ANPs who may only be able to prescribe a set group of drugs within their area of expertise.

The following list of drugs prescribed over the course of one HAN night shift illustrates the diversity of our prescribing practice:

Anti-epileptic
Opiates
Antibiotics          
Insulin
Saline nebulizer    
Decision not to prescribe
Anti-arrhythmic drug
Resuscitation fluids
Laxatives

As the legislative barriers to nurses prescribing independently have been removed [24], NMP has become an asset that can be utilized by ANPs working across a broadening spectrum of specialities and healthcare institutions. An evaluation of the safety of NMP found that it compared favorably with medical prescribing with an improved patient experience, antimicrobial stewardship and safe prescribing practice [25]. Prescribing is a complex skill affected by many factors and further research is required on the impact of NMP and rate of prescribing errors [26]. A systematic review [27] found that the level of experience of a non-medical prescriber had a direct effect on confidence to prescribe both in the learning phase and on implementation of NMP in their role. 

Conclusion

 NMP in the acute setting has become an integral part of the care given by ANPs. By providing fast and effective treatment to deteriorating patients it is both safe and well received by patients. A robust and structured system of guidelines and standards of practice supports the autonomy of the role and clinical supervision by a designated medical practitioner provides ongoing support and guidance.

References

1.         Taylor P. Change, for the better (2015) Royal College of Nursing Scotland. Edinburgh.

2.        Royal College of Nursing (2018) RCN Credentialing for advanced level nursing practice, United Kingdom.

3.        Nursing and Midwifery Council (NMC) (2015) Standards of proficiency for nurse and midwife prescribers.

4.        Royal College of Physicians (2017) National early warning system (NEWS 2) Standardizing the assessment of acute-illness severity in the NHS, United Kingdom.

5.        Bangalore S, Owlia M. Non-ST elevation myocardial infarction (2017) BMJ Best Practice, BMJ Publishing Group, United States.

6.        Landes U, Bental T, Orvin K, Vaknin-Assa H, Rechavia E and et al., Type 2 myocardial infarction: A descriptive analysis and comparison with type 1 myocardial infarction (2016) J Cardiol 67:51-56. https://doi.org/10.1016/j.jjcc.2015.04.001

7.        National Institute for Health and Clinical Excellence (2016) NICE 51 Sepsis: Recognition, diagnosis and early management. Secton 1.7, United Kingdom.

8.        Daniels R. Surviving the first hours in sepsis: getting the basics right (an intensivists perspective) (2011) J Antimicrob Chemother 66:11-23. https://doi.org/10.1093/jac/dkq515

9.        Murdoch I, Turpin S, Johnstone B, MacLullich A and  Losman E. Geriatric Emergencies (2015) Wiley Blackwell, Chichester, England.

10.      Martin S, Perez A and Aldecoa C. Sepsis and immunosenescence in the elderly patient: A Review (2017) Front Med 4:1-10. https://doi.org/10.3389/fmed.2017.00020

11.      Ventura MT, Casciaro M, Gangemi S and Buquicchio R. Immunosenescence in aging: Between immune cells depletion and cytokines up-regulation (2017) Clin Mol Allergy 15. https://dx.doi.org/10.1186%2Fs12948-017-0077-0

12.      Morgan AJ and Glossp AJ. Severe community acquired pneumonia (2016) BJA Education 16:167-172. https://doi.org/10.1093/bjaed/mkv052

13.      National Institute for Health and Clinical Excellence (2016) Quality standard 121 antimicrobial stewardship, United Kingdom.   

14.      Greenstein B. Drugs in pregnancy and extremes of age (ed)  Greenstein B (2009b) Trounces Clinical Pharmacology for Nurses, Churchill Livingstone, Edinburgh 413 - 420.

15.      National Institute for Health and Clinical Excellence (2017) Multimorbidity and Polypharmacy, United Kingdom.

16.      Healthcare Improvement Scotland (2012) Working together to improve the use of medicines, NHS Scotland.

17.      McKinnon J. Towards prescribing practice (2007) John Wiley and Sons Ltd, Chichester, England 35-57.

18.      Scottish Intercollegiate Guidelines Network (2014) Care of the deteriorating patient SIGN 139, Scotland. 

19.      Croskerry P and Nimmo G. Better clinical decision making and reducing diagnostic error (2011) J R College of Physicians Edinburgh, Scotland 41: 155-162. https://doi.org/10.4997/JRCPE.2011.208

20.      Petty D. Ten tips for safer prescribing by non-medical prescribers (2012) Nurse Prescribing 10: 251-256.

21.      Stewart D, MacLure K and George J. Educating non-medical prescribers (2012) Br J Clin Pharmacol 74: 662-667. https://doi.org/10.1111/j.1365-2125.2012.04204.x

22.      Nursing and Midwifery Council (NMC b) (2015) The Code, Standards of Conduct, Performance and Ethics.

23.      Scottish Government (2016) Transforming Nursing, Midwifery and Health Professions (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland, Advanced Nursing Practice Scottish Government. 

24.      Rideout A. Non-medical prescribing in Scotland (ed) Franklin P (2017) Non-medical prescribing in the United Kingdom, Springer International Publishing.

25.      Scottish Government (2009) An evaluation of the expansion of nurse prescribing in Scotland, Scottish Government.

26.      Cope L, Abuzour A and Tully M. Nonmedical prescribing: Where are we know?? (2016) Ther Adv Drug Saf 7:165-172. https://dx.doi.org/10.1177%2F2042098616646726

27.      Abuzour A, Lewis P and Tully M. Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom (2017) Res Socio Admin Pharm 14: 6-17. https://doi.org/10.1016/j.sapharm.2017.02.002

^*Corresponding author: 

Jayne RW. Advanced Nurse Practitioner, NHS Lothian, Royal Infirmary of Edinburgh, Scotland, Tel: 01312423888, E-mail: jayne.worth@luht.scot.nhs.uk

Citation: 

Worth JR. Non-medical Prescribing in the Acute Setting: A Case Report (2018) Nursing and Health Care 3: 42-44

Keywords

Advanced nursing practice, Non-medical prescribing, Elderly, Sepsis