Patient group directions. Dietitians prescribing.

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Patient group directions.Dietitians prescribing.

• Sarah Illingworth
• Dietetic Education Placement Tutor
• London Metropolitan University
• s.illingworth_at_londonmet.ac.uk

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Aim of presentation.

• To give an overview of the current legislation
  surrounding medicines management and how
  dietitians can effectively use this to improve
  patient care.

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Objectives.

• Understanding medicines legislation.
• Define and give examples of common terms used
  such as
• Independent prescriber.
• Supplementary prescriber.
• Exemptions under medicines legislation.
• Patient group direction (PGD.)

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Objectives.

1. Provide guidance on producing a PGD and protocol.
2. Give examples of dietitians currently managing
   medicines.
3. Describe to work of the BDA prescribing group.

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Prescribing.

• The NHS Plan emphasised the importance of
  organising services around the needs of patients.
• Healthcare professionals are developing methods
  of working more flexibly.
• Changes have occurred in the management of
  medicines.

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Medicines management.

• The Medicines Act (1968) regulates the use of
  medicines in the UK.
• This requires a medicine to have a marketing
  authorisation.
• When authorisation is granted medicines are
  placed into one of three classifications.

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Classification of marketing authorisation.

• Prescription only medicine (POM).
• Can only be obtained on prescription through a
  pharmacy.
• Pharmacy medicine (P)
• Sold in pharmacies under the supervision of a
  pharmacist.

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Classification of marketing authorisation.

• General sales list
• Sold in general shops as well as in pharmacies

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Mechanisms.

• Patient group directions
• Patient specific directions
• Exemptions under medicines legislations
• Supplementary prescribing
• Independent prescribing

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Independent prescribing.

• Takes responsibility for the clinical assessment
  of the patient, establishing a diagnosis and
  clinical management plan, as well as a
  responsibility for the prescribing where
  necessary and the appropriateness of any
  prescription.
• National Prescribing Centre (2004) Patient
  Group Directions www.npc.co.uk

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Supplementary prescribers.

• Forms a voluntary partnership with an
  independent prescriber.
• A clinical management plan is agreed for an
  individual patient.
• The supplementary prescriber manages the
  clinical condition, including prescribing,
  according to the clinical management plan

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Exemptions under medicines legislation.

• The Prescription Only Medicines Human Use Order
  (1997) contains some specific exemptions which
  allow for the sale or supply and administration
  of certain POMs directly to patients without the
  directions of a prescriber.

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Exemptions under medicines legislation.

• Ambulance paramedics can use a range of
  injectable medicines to provide emergency
  treatment.
• Examples are
• Benzylpenicillin meningococcal septicaemia.
• Metoclopramide anti-emetic.
• Streptokinase as a thrombolytic.

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Patient specific direction

• Used once a patient has been assessed by a
  prescriber and that prescriber instructs another
  health care professional in writing to supply or
  administer a medicine directly to the patient.

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Example patient specific direction.

• Opthamologists can give opthalmic technicians a
  written patient specific direction to administer
  eye drops so that the patient has local
  anaesthesia prior to seeing the opthamologist for
  a scheduled procedure or examination.
• National Prescribing Centre (2004) Patient
  Group Directions www.npc.co.uk

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Patient group direction (PGD).

• Allows a range of specified health care
  professionals to supply and/or administer a
  medicine directly to a patient with an identified
  clinical condition without them necessarily
  seeing a prescriber.

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Example patient group direction.

• Following day-case foot surgery, podiatrists
  can use a PGD to give patients a supply of
  non-steroidal anti-inflammatory drugs for
  post-operative pain
• National Prescribing Centre (2004) Patient
  Group Directions www.npc.co.uk

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Who can use PGDs ?

• Dietitians across the UK are authorised to use
  PGDs.
• Professionals must be registered and act within
  the professional code of conduct.
• Professionals must be fully competent, trained
  and qualified to use PGDs.

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Producing and authorising PGDs.

• Produced by a multi-disciplinary group involving
  a doctor, a pharmacist and a representative of
  the professional group expected to give medicines
  under the PGD.

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Producing and authorising PGDs.

• Approved by local drug and therapeutic
  committees.
• Authorised by the organisations it is to be used
  within.

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Producing and authorising a PGD.

• The PGD should be signed by the doctor and
  pharmacist involved in developing the PGD and
  authorising authority for the organisation in
  which it is being used.

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Dose adjustment.

• This is allowed in a PGD as long as the dosage
  range is specified.
• A PGD does not give a legal framework to adjust a
  dose of medicine already in a patients
  possession.

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Dose adjustment.

• Written protocols may be used to adjust
  medication.
• The principles of writing a protocol reflect
  those required for a good PGD.

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Who should I be talking to ?

• Multi-disciplinary team start with the lead
  clinician and pharmacist.
• Drugs therapeutics committee.
• Quality teams clinical governance, clinical
  audit and lead for user involvement.

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Improving the patient experience.

• Audit the use of the PGD and protocol.
• Include patient stories.
• Consider how to evidence an improvement in
  patient experience.

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Dietitians working with PGDs.

• Renal dietitians in Newcastle have been working
  under PGDs to streamline the processes involved
  in managing patients bone biochemistry.
• More timely changes to patients medications are
  made.
• G. Hartley (2006) Prescribing for dietitians.
  Working under patient group directions.
  Dietetics Today. Volume 41, Number 6 (June)

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Management of Total Parenteral Nutrition (TPN).

• A pilot study was completed to determine the
  competencies of a dietitian and pharmacist
  required to manage TPN.
• Interventions were assessed independently and
  separately by a consultant surgeon and
  gastroenterologist.

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Management of TPN.

• Twenty two consecutive patients completed the
  study and the team made a total of 181
  interventions.
• 40 of interventions were classified as safe.
• 53 were of significant clinical benefit.
• 7 were very significant.

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Management of TPN.

• Concluded that a dietitian and pharmacist can
  competently manage TPN.
• May be clinically and cost effective and improve
  patient care.
• Farrer K.M., Harper L., Shaffer J.L., Anderson
  I.D., Scott N.A., Carlson G.L., (2003)
  Management of TPN, Does is require a medical
  practitioner ? Clinical Nutrition 22 (Supplement
  1) S49.

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BDA Prescribing Group.

• Reviewing current PGDs and protocols
• Producing guidance to support the development of
  new PGDs and protocols.
• Considering the possibility of working under the
  exemptions framework.
• Liaising with specialist groups.

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BDA prescribing group.

• Producing a portfolio of evidence to show that
  patient care could be improved if dietitians were
  able to become supplementary prescribers.

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Conclusions.

• Work under the current legislation in medicines
  management.
• Develop PGDs and protocols within your teams.
• Audit your work.
• Let the prescribing group know.