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Supplementary prescribing for the elective surgical patient

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Throughout the UK, nurses have started training in supplementary prescribing. The guidelines for supplementary prescribing, initially referred to as dependent prescribing (Department of Health, 1999), recommend that nurses can prescribe in continuing care by agreement with the patient and the diagnosing doctor.

Abstract

 

VOL: 99, ISSUE: 28, PAGE NO: 30

Pauline Barnes, MSc (Clinical Nursing), RGN, RM, is nurse clinician for surgical services, Surgical Assessment Unit, Whiston Hospital, Prescot, Merseyside

 

Throughout the UK, nurses have started training in supplementary prescribing. The guidelines for supplementary prescribing, initially referred to as dependent prescribing (Department of Health, 1999), recommend that nurses can prescribe in continuing care by agreement with the patient and the diagnosing doctor.

 


 

Supplementary prescribing is defined as a voluntary partnership between an independent prescriber (doctor, dentist or vet) and a supplementary prescriber (a first-level nurse or pharmacist). It will be implemented by the use of a patient-specific clinical management plan (CMP) drawn up by the independent and supplementary prescribers and used with the agreement of the patient. The CMP determines the drugs that may be used, the range and route by which they may be given, the clinical situation for using the drugs and criteria for referral to the doctor (Table 1).

 


 

A nurse clinician for surgical services typifies the role of a nurse who has taken a master’s degree in clinical nursing. This qualification enables the nurse clinician to diagnose, investigate and instigate treatments or refer patients appropriately. Independent extended nurse prescribing, where nurses can prescribe a restricted range of medications, and patient group directions, where nurses can supply and administer a range of medications, have already been established within this role. Supplementary prescribing should be considered for the elective surgery patient population, which includes patients admitted for elective surgery in urology, orthopaedics and general surgery.

 


 

Rationale for a clinical management plan

 


 

Surgical nursing is not necessarily a specialty, but rather a generic discipline in which nurses have a wide range of abilities. However, patients who are admitted for a variety of elective surgical procedures have specific needs in common, whether in orthopaedics, urology, general or any other defined surgical field.

 


 

Thus it is expected by patients and staff that provision will be made for pain relief, hydration and for the prevention of infection and thromboembolic disorder (Box 1). Using supplementary prescribing allows nurses to deliver a holistic package of care to meet the needs of the elective surgical patient. Therefore the basic requirements of elective surgical care formed the basis of our CMP. The existing hospital policies for these requirements were considered and have been incorporated into the CMP.

 


 

The rules for supplementary prescribing ensure that the independent prescriber will assess and make the diagnosis and can agree that the supplementary prescriber continues to prescribe care within a determined CMP.

 


 

The patient admitted for surgery will have a diagnosis before being admitted to hospital. However, despite individual diagnosis, it is expected that one basic CMP for patients having elective surgery could be drawn up for all patients. The CMP becomes patient-specific when the patient details are completed and have been agreed with the patient.

 


 

Rationale for inclusion of medication

 


 

Pain control

 


 

Most patients having surgery may expect some pain. This will range from minimal soreness not requiring analgesia to severe pain after major surgery that requires skilful prescribing to minimise discomfort without giving side- effects. The analgesia ladder ranks analgesics by clinical efficiency, allowing a choice of medication for the severity of pain.

 


 

The CMP for supplementary prescribing will only require consideration of prescription-only analgesia for moderate pain. This is because the supplementary prescriber is also an independent extended prescriber. Analgesics for minor pain can therefore be prescribed without consultation with a doctor. These include paracetamol, ibuprofen and a single prescription medication, nefopam.

 


 

Controlled drugs for severe pain, such as morphine and pethidine, have been excluded from supplementary prescribing and are usually prescribed in theatre by the anaesthetist.

 


 

The only analgesia identified for our CMP was diclofenac sodium, to be administered either as a suppository or for oral administration to a maximum of 150mg per day in divided doses. The intramuscular route was avoided, thus reducing the risk of skin necrosis from repeated injections.

 


 

Hydration

 


 

Patients are fasted for at least six hours before surgery, with sips of water allowed for up to two hours before. Perioperatively, hydration is maintained by intravenous infusion using glucose 5% and/or sodium chloride 0.9% (saline), often in a 2:1 ratio respectively, with three litres given in 24 hours. The glucose solution replaces water and saline maintains the electrolyte balance (British Medical Association and Royal Pharmaceutical Society of Great Britain, 2002). Sodium chloride (0.9%) may be given more rapidly if the patient is showing signs of dehydration postoperatively, that is, thirst, tachycardia and low blood pressure.

 


 

Prophylaxis to prevent thromboembolic disorder

 


 

The trust policy for the prevention of postoperative deep vein thrombosis and pulmonary embolism varies, depending on the type of surgery.

 


 

For general surgery, a low molecular heparin (enoxaparin 100mg/ml) by subcutaneous injection is given to all patients undergoing operative procedures of longer than 20 minutes. In orthopaedics, this policy is followed only when the patient has a previous history of a thromboembolic disorder.

 


 

For all other patients, aspirin (150mg once daily) is given before surgery and continued for five weeks. This decision is based on evidence detailed in the Pulmonary Embolism Prevention Trial (2000) indicating that aspirin reduced the risk of pulmonary embolism and deep vein thrombosis by at least one-third in periods of increased risk. Orthopaedic patients who are unable to tolerate aspirin can be offered mechanical foot pumps as a non-pharmacological alternative. All patients are given thromboembolic stockings.

 


 

Enoxaparin is also given when conversion from a long-term anticoagulant (warfarin) to a low-molecular heparin is required to prevent haemorrhage in the perioperative period. The drug is continued after surgery until the patient is again stabilised on long-term medication. Enoxaparin is considered an essential medication for perioperative care and is included in the management plan. Aspirin can be prescribed independently and, therefore, has not been added to the CMP.

 


 

Prophylaxis to prevent joint infection

 


 

With the increase in multi-resistant bacteria, care must be taken to ensure not only that the antibiotic prescribed is appropriate but also that it is necessary. Evidence-based hospital policies have therefore been developed to indicate the appropriate antibiotic for each infection or for prophylaxis.

 


 

The morbidity associated with joint infection after joint surgery is such that prophylactic antibiotic therapy is warranted. Cefuroxime is the drug of choice. This is usually prescribed in theatre; however, occasionally only the first dose is prescribed. Because it is essential that three doses are given it is sensible for the supplementary prescriber to include cefuroxime in the CMP so that it can be prescribed if the need arises.

 


 

Hypovolaemia

 


 

Hypovolaemia is a recognised complication of surgery and the nurse should be able to instigate treatment of symptomatic hypovolaemia by administering a plasma expander if required. This will be in conjunction with a full assessment of the patient for haemorrhage and either administration of blood (prescribed by a doctor) or referral to a doctor for further treatment. The plasma substitutes Gelofusine and Haemaccel have therefore been added to the CMP.

 


 

Implementation of the CMP

 


 

Nurse clinicians in our unit work with the patient throughout the hospital episode, replacing the junior doctor. The CMP could be discussed at the pre-operative clinic and the patient’s agreement sought for its use. Because the CMP has been drawn up in agreement with the consultant, it can be attached to the notes for the consultant to decide whether or not it is appropriate for that specific patient and to sign for its use during the patient’s admission.

 


 

Supplementary prescribing is one of the ongoing developments regarding nurse prescribing. Although a nurse may qualify as a supplementary prescriber, the employers must agree prescribing practice within the role. If patient group directions are already established, it should follow that there is a committee (DoH, 1999) to maintain standards (National Prescribing Centre, 2001), audit practice and ensure continued competencies. This committee is ideally placed to offer support to independent and supplementary prescribers.

 


 

Reflection and analysis

 


 

If a CMP is to work effectively it must be simple. Our CMP for elective surgery covers five areas (Box 2) and includes only eight drugs, omitting the medications that can be independently prescribed.

 


 

The mechanism for instigating the CMP complies with the implementation guide (DoH, 2003):

 


 

- The CMP has been drawn up with the agreement of the independent prescriber; - The doctor (independent prescriber) will have made the diagnosis before the patient’s admission; - The CMP will be discussed with the patient before it is used; - The CMP will be signed in theatre for use in the postoperative period.

 


 

On reflection, other medications could have been included in the CMP. No allowances have been made for pre-medication, the intravenous glucose-potassium-insulin régime for patients with diabetes, or for other prophylactic antibiotics.

 


 

The decision to use pre-medication to reduce anxiety, or for a glucose-potassium-insulin régime, is made by the anaesthetist. The technical difficulties of including these medications in this CMP include involving the anaesthetists as additional independent prescribers and not being able to agree the CMP in time for its use.

 


 

With regard to antibiotics, although there are other indications for administration of prophylactic antibiotics in surgery, as most are given in a single dose on induction of anaesthesia in theatre, they were not considered necessary for supplementary prescribing.

 


 

This basic CMP appears to be all that is required for our situation and it will be revised as necessary. Its strength is in its simplicity because it is written for carrying out the basics of surgical care with no complicating factors. However, it is possible that problems will arise once it has been implemented.

 


 

The CMP is designed to be patient-specific, but is it to be specific to supplementary or independent prescribers? At present, two supplementary prescribers work together, and arrangements can be made to include both prescribers on the CMP. However, will this work in future as more nurses qualify to prescribe? This is something that will need to be addressed if supplementary prescribing is to work in a secondary care setting.

 


 

Conclusion

 


 

Patients admitted for elective surgery have common medication needs that can be incorporated into a CMP. The present CMP encompasses five areas of care: analgesia, hydration, prevention of thrombosis, prevention of infection and treatment of hypovolaemia. It complies with the regulations specified by the Department of Health, and a system for its implementation is suggested.

 


 

Our CMP for the elective surgical patient is simple, yet effective. The difficulties are foreseen in implementing it in secondary care because in this area teams of independent and supplementary prescribers all look after the same patient.

 


 

The CMP consists of only eight medications. Because nurses are able to prescribe these, there should be fewer delays in patients receiving their medication. Furthermore, using a CMP allows nurses to deliver a comprehensive package of surgical nursing care.
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