Administration of medicines by emergency nurse practitioners

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					JAccid Emerg Med 1997;14:233-237                                                                                                  233

                             Administration of medicines by emergency nurse
                             practitioners according to protocols in an accident
                             and emergency department

                             Julie Marshall, Carol Edwards, Mike Lambert

                             Abstract                                             result in improved patient satisfaction and
                             Objective-To present the legal and                   ENP job satisfaction.
                             professional issues related to nurse ad-                In December 1995 a working party was
                             ministration of drugs according to proto-            formed to address this issue. The working
                             cols, and describe the implementation and            party reviewed the legal and professional issues
                             initial audit findings of such a scheme.             surrounding the development of nurse admin-
                             Setting-Accident and emergency (A&E)                 istration of drugs. Its recommendations were
                             department of a district general hospital.           then submitted to the Trust Board.
                             Methods-Analysis of legal and profes-                   This paper outlines our interpretation of the
                             sional opinion. Protocols acceptable to the          legal and professional issues, how the adminis-
                             medical, nursing, and pharmacy profes-               tration of drugs by ENPs according to clinical
                             sions were developed across a wide range             protocols was developed and implemented,
                             of drugs appropriate for administration              and our experience of audit of the administra-
                             by accident and emergency nurse practi-              tion of drugs against these protocols.
                             tioners (ENPs). The first six months ofthe
                             scheme were audited. Audit initially ad-             Legal issues
                             dressed general compliance with proto-               The working party obtained written opinion
                             cols and later the specific areas of tetanus         from the United Kingdom Central Council for
                             immunisation and emergency contracep-                Nursing, Midwifery and Health Visiting
                             tion.                                                (UKCC), the Royal Pharmaceutical Society of
                             Results-ENPs assessed 2925 patients in               Great Britain, the General Medical Council
                             six months (10.9% of all new patients); 455          (GMC), and the Medical Defence Union
                             patients (15.5% of the ENP patients) were            (MDU).
                             given drugs according to protocols. There               Section 58 (2) of the Medicines Act 1968'
                             were no breaches of the protocols. Subse-            sets out the relevant statutory position regard-
                             quent audit of tetanus immunisation                  ing nurses giving medicines to patients which
                             showed 94-100% compliance with protocol              have not been directly prescribed for a named
                             standards and 71-100% compliance for                 patient by a doctor. This section of the Act
                             emergency contraception.                             states that "prescription only medicines"
                             Conclusions-There are no legal or                    should only be given by "an appropriate
                             professional obstacles to the development            practitioner, ie a doctor, a dentist, or a vet, or a
                             of protocols for the administration of               person acting in accordance with the directions of
                             drugs to patients by nurses without refer-           an appropriate practitioner".
                             ence to a doctor, providing the protocols               From the various opinions it was understood
Accident and
                             meet all the requirements of the UKCC                that "directions" may be verbal or written (as
Emergency                                                                         in a prescription), and that a protocol may
Department, Norfolk          and have the support of consultant medi-             constitute "directions". We concluded that an
and Norwich Hospital,        cal staff. Such a system must be subject to          emergency nurse practitioner, acting in ac-
Norwich                      regular audit to promote a dynamic
J Marshall                                                                        cordance with a protocol, could give
M Lambert
                             approach to protocols and training. The              prescription-only medicines without that pro-
                             system safely enhanced the quality of care           tocol referring to a specific patient.
Department of                of patients treated by ENPs in A&E.
Nursing Practice             (7Accid Emerg Med 1997;14:233-237)
(Education and                                                                    Professional issues
Development), Norfolk        Keywords: accident and emergency; drug administra-   NURSING
and Norwich Hospital,        tion; emergency nurse practitioners                  There are five key professional issues which
Norwich                                                                           affect the role of nurses giving medicines:
C Edwards
                                                                                  (1) UKCC code of professional conduct2
Correspondence to:           Emergency nurse practitioners (ENPs) were            (2) Standards for the administration of
Mr M A Lambert,              introduced to the accident and emergency                  medicines3
Consultant in Accident and   (A&E) department of the Norfolk & Norwich            (3) The scope of professional practice4
Emergency Medicine,          Hospital in February 1995. The role of the
Accident and Emergency                                                            (4) UKCC, Rule 18 (1)'
Department, Norfolk and      ENP is to assess, diagnose, treat, and advise        (5) Exercising accountability.6
Norwich Hospital, Norwich    patients within defined protocols. We felt the       The UKCC produced Standards for the admin-
NRl 3SR.                     service would be enhanced if the ENPs gave           istration of medicines in October 1992. Para-
Accepted for publication     appropriate medication to patients without the       graph 6.2 sets out the Council's view on the
28 February 1997             need to consult a doctor. We hoped this would        administration of medicines to patients. It
234                                                                                   Marshall, Edwards, Lambert

      states that "Where it is the wish of the profes-       decline any duties or responsibilities unless
      sional staff concerned that practitioners in a         able to perform them in a safe and skilled man-
      particular setting be authorised to administer,        ner.
      on their own authority, certain medicines, a             We therefore concluded that the UKCC rec-
      local protocol [should be] agreed between              ognised that appropriate protocols could be
      medical practitioners, nurses and midwives             developed to support a nurse giving drugs to a
      and the pharmacist."3                                  patient, even though that patient had not been
         The UKCC also states that "... in any situa-        assessed or diagnosed by a registered medical
      tion in which a practitioner may be expected or        practitioner, if all the above conditions and
      required to administer 'prescription only medi-        requirements were met. The development and
      cines' which have not been directly prescribed         implementation of such a protocol would have
      for a named patient by a registered medical            to recognise the nurses' responsibilities under
      practitioner who has examined the patient and          the Scope ofprofessional practice.4
      made a diagnosis, it is essential that a clear
      local policy be determined and made known to           MEDICAL
      all practitioners involved with prescribing and        It was important to determine the accountabil-
      administration. This will make it possible for         ity of medical staff who were clinically respon-
      action to be taken in patients' interests while        sible for a patient who may receive medication
      protecting practitioners from risk of complaint        according to protocols. Advice was taken from
      that might otherwise jeopardise their position"        the GMC and the MDU. It was accepted that
      (Para 35).' It is further stated that a local policy   a doctor, while remaining clinically responsible
      should be agreed and documented which
      makes clear the circumstances under which a            for a patient, is entitled to delegate a task to
      particular 'prescription-only medicine' may be         someone without medical qualifications. The
      given, ensures the relevant knowledge and skill        GMC guidance to doctors makes it clear that
      of those to be involved in administration,             "a doctor who delegates treatment or other
      describes the form, route, and dose range of           procedures must be satisfied that the person to
      the medicines so authorised, and satisfies the         whom they are delegated is competent to carry
      requirements of section 58 of the Medicines            them out", and "that the doctor should retain
      Act 1968 as a "Direction".                             ultimate responsibility for the management of
         Rule 18 (1) of the Nurses, Midwives and             their patients because only the doctor has
      Health Visitors Rules Approval Order No 873,5          received the necessary training to undertake
      states that successful "admission to Part 1, 3, 5      this responsibility."7
      or 8 of the register entails accepting responsi-          We were advised that a consultant proposing
      bility to be able to assess, plan, implement and       to develop protocols for the administration of
      evaluate care, whereas admission to Part 2, 4, 6       drugs by a nurse must be satisfied that the
      entails the nurse being able to plan and imple-        nurse has the appropriate training, skills, and
      ment nursing care". This means that a first            competence to provide the standard of care
      level registered nurse, rather than enrolled           expected of an experienced nurse giving medi-
      nurses, could undertake this role, as the nurse        cines within that clinical area. Therefore,
      must be able to assess and evaluate the care of        providing a consultant is involved in the devel-
      the patient before and after administering             opment of protocols and is satisfied that nurses
      medicines. The UKCC strengthens this posi-             who will be giving the drug according to that
      tion by maintaining that a first level registered      protocol have the appropriate training and
      nurse "must endeavour always to achieve,               experience, there was no professional or medi-
      maintain and develop knowledge, skill and              colegal objection to the development of proto-
      competence to respond to those needs and               cols.
      interests" and "must honestly acknowledge any
      limits of personal knowledge and skill and take        PHARMACEUTICAL
      steps to remedy any relevant deficits in order         Advice from the law department of the Royal
      effectively and appropriately to meet the needs        Pharmaceutical Society of Great Britain made
      of patients and clients." (Para 9.2, 9.3.)4            it clear that the Medicines Act of 1968 did not
         Nurses giving medicines are also required to        prohibit the setting of written protocols for the
      have an understanding of the substances used           administration/supply of medicines by nurses.
      for therapeutic purposes, be able to justify any
      actions they undertake, and be prepared to be          It was also stated that protocols could be
      accountable for any action taken.6                     developed for both inpatients and outpatients
         In the exercise of this professional account-       of the hospital.
      ability, the UKCC Code of Professional
      Conduct2 insists that nurses must: (1) act             CONCLUSIONS
      always in such a manner as to promote and              Based on analysis of the legal and professional
      safeguard the interests and wellbeing of               issues the working party concluded that nurses
      patients; (2) ensure that no action or omission        could administer drugs to patients according to
      on their part, or within their sphere of respon-       a clinical protocol, without the doctors, nurses
      sibility, is detrimental to the interests, condi-      or pharmacists being in breach of the law or
      tion, or safety of patients and clients; (3) main-     professional obligations providing certain cri-
      tain and improve their professional knowledge          teria were met. These criteria included the for-
      and competence; (4) acknowledge any limita-            mat and contents of the protocol, and arrange-
      tions in their knowledge and competence and            ments for training, accreditation and audit.
Administration of medicines by emergency nurse practitioners                                                                                235

                               Clinical protocols                                    Table 1 Drugs for ENP administration according to
                               We advised that a clinical protocol for the           protocol
                               administration of drugs must include:                 Paracetamol                 Flucloxacillin
                               * a rationale for the administration of the           CoDydramol                  Chlorpheniramine
                                  drug, including a nursing assessment of the        Ibuprofen                   Loratadine
                                                                                     Diclofenac                  PC-4
                                  patient;                                           Erythromycin                Tetanus toxoid
                               * the circumstances under which the drug will         Penicillin                  Tetanus immunoglobulin
                                  be given;                                          Co-amoxiclav                Lignocaine hydrochloride
                               * the form of the drug to be given, for example
                                  tablet, injection, etc;                            drugs, and be acceptable to the consultants in
                               * the route by which the drug will be given;          accident and emergency medicine who are
                               * the dose of the drug to be given, including         ultimately responsible for patient care, they
                                  the number of doses or length of course;           should undergo additional training. All the
                               * instructions regarding drug contraindica-           ENPs attended a study day on which the con-
                                  tions, precautions, and side effect profile;       sultants gave lectures on the basic pharmacol-
                               * instructions to check for allergies;                ogy of the drugs and their use within the proto-
                               * instruction to check for concomitant                col. The aim of these training sessions was to
                                  medication and for drug interactions.              give the ENPs sufficient understanding of the
                               Since consultants remain clinically responsible       drugs to ensure that they would be given in a
                               for a patients they must be actively involved in      "safe and skilled manner."4
                               the preparation of protocols and satisfy them-           Following the study day, the ENPs were
                               selves that the nurses who would give the drugs       accredited by the department and Trust to give
                               had sufficient understanding, knowledge, and          certain drugs according to protocols.
                               skills relevant to give that drug. It was therefore      Six nurses were trained as ENPs with
                               expected that formal training programmes,             authority to give drugs. None of the nurses acts
                               supervised by the consultants, would be devel-        as a full time ENP. Their general accident and
                               oped.                                                 emergency and ENP skills are used flexibly and
                                  Our overall conclusion was that if all these       appropriately, depending on the demands on
                               requirements were met there was no legal or           the A&E department.
                               professional obstacle to the implementation of           It was agreed that there would be an annual
                               clinical protocols for the administration of          review of the protocols with a further study day
                               drugs to patients by nurses without direct            and reaccreditation to ensure that the proto-
                               reference to a doctor.                                cols remain appropriate for our A&E depart-
                                                                                     ment. The consultants and ENPs also under-
                               Implementation                                        took to monitor changes in practice and
                               The report of the Trust working party was sub-        pharmaceutical developments so that the
                               mitted to the drugs and therapeutics                  protocols and available drugs could be revised
                               committee and subsequently to the Trust               as necessary. ENPs started the administration
                               Board through the executive director for nurs-        of drugs according to protocols in February
                               ing and human resources. After consultation           1996.
                               with the Trust solicitors the recommendations
                               were accepted with the proviso that all protocol
                               development should be submitted to the drugs     Audit
                               and therapeutics committee for approval be-      It was felt that audit of this innovative system
                               fore implementation. The Trust accepted          was essential. Initially individual ENPs had all
                               vicarious liability on behalf of the nurses      decisions to give drugs reviewed against the
                               following the protocols.                         departmental protocols by another ENP. In
                                                                                addition audit was undertaken of approxi-
                               DEVELOPMENT OF PROTOCOLS                         mately one in 10 of the ENP cases in which no
                               Within the A&E department there were drugs had been given, to monitor whether
                               discussions between ENPs, consultants, and patients who would have benefited from the
                               pharmacists to identify groups of drugs which administration of drugs were not receiving
                               would be useful to the ENPs, and to identify them.
                               the specific drugs that could be made available.    In the first six months after implementation
                               These discussions identified simple analgesics, the ENPs saw 2925 patients. This is 10.9% of
                               non-steroidal anti-inflammatory drugs, anti- all new patients attending the A&E department
                               histamines, antibiotics, postcoital contracep- in the same period. Four hundred and fifty five
                               tion, tetanus immunisation, and local anaes- patients were given drugs (either single doses
                               thesia as useful and appropriate for ENPs to or a course of treatment) by the ENPs. Two
                               administer (table 1).                            hundred and eighty eight drug courses were
                                  Protocols which met all the criteria were provided to take home and 167 single doses
                               developed, with the A&E consultants, by the were ,given within the department. Therefore
                               ENPs.                                            15.5% of patients assessed and treated by
                                                                                ENPs received drugs according to the depart-
                               TRAINING                                         mental protocols. Details of the drugs given are
                               To be eligible for the ENP role we required a shown in fig 1. Audit revealed no breaches of
                               minimum of three years of full time A&E nurs- the protocols.
                               ing experience, plus successful completion of       The audit highlighted the importance of
                               an appropriate course. It was agreed that for documenting any decision not to give the
                               ENPs to be accredited by the Trust to give medication, as well as thorough documenta-
236                                                                                           Marshall, Edwards, Lambert

                          Drugs given by ENPs, Feb-Jul 1996   Table 2 Audit of tetanus immunisation administration
      Local anaesthetic _                                                                       Records
                                              71              Standard                          audited       Compliance
           Emergency               31                         Documentation of tetanus
         contraception                                          immunisation statistics          50           94%
                                                              Appropriate administration of
            Antibiotics                               108       tetanus toxoid                   50           94%
                                              70              Appropriate administration of
                                                                tetanus immunoglobulin for
             Analgesia..                             1          tetanus-prone wound               8           100%
                          0   20    40   60 80 100 120 140
                                   Number of courses          Table 3 Audit of emergency contraception administration
                                   and single doses
      Figure 1 Breakdown of drugs (both courses and single                                       Records
      doses) given by emergency nurse practitioners (ENPs)    Standard                           audited      Compliance
      between February and July 1996.
                                                              Documented negative pregnancy
                                                                test                             21            95%
      tion of patients' current medication, allergies,        Unprotected intercourse < 72 h
      and any contraindications.                                previously                       21           100%
         In addition to the general audit of drug             Documented relevant past
                                                                medical history                  21            71%
      administration, the use of some specific drugs          Documented possible interactive
      has undergone audit. The first was the admin-             medication                       21            71%
      istration of tetanus toxoid and tetanus immu-
      noglobulin by the ENPs. The audit reviewed              Discussion
      documentation of tetanus immunisation sta-              Shortly after the introduction of ENPs we
      tus, the appropriate use of tetanus toxoid, and         became aware that their activities were limited
      tetanus immunoglobulin in tetanus-prone                 by the requirement to find a doctor to
      wounds. Results are shown in table 2.                   prescribe drugs required by patients. This led
         This audit resulted in minor changes to the          to further delays for the patient, frustration for
      protocol, for example an acknowledgement                the ENPs, and inappropriate use of the
      that it was acceptable practice to refer patients       doctor's time, who invariably felt they should
      who thought they had received tetanus immu-             re-evaluate the patient personally before pre-
      nisation within the previous 10 years but were          scribing.
      unsure of the exact date back to their general             In tackling this issue there were three main
      practitioner for review of their records.               areas to be addressed: first, the legality of a
         The second specific audit we undertook was           nurse giving a drug against a protocol; second,
      of the administration of postcoital contracep-          the professional acceptability to nurses, doc-
      tion to patients attending the A&E depart-              tors, and pharmacists of such an arrangement;
      ment. The specific standards which were                 and finally, the local attitudes of doctors,
      audited were documentation of unprotected               nurses, pharmacists, and the Trust Board, par-
      intercourse less than 72 hours previously,              ticularly in relation to vicarious liability. Exten-
      documentation of a negative urine pregnancy             sive consultation showed that there were no
      test, documentation of no contraindications in          obstacles to a nurse giving a drug to a patient
      the medical history, and documentation that             according to a clearly defined protocol provid-
      the patient was not taking any drugs which may          ing that protocol met all the requirements of
      interact with the postcoital contraception.             the UKCC.
      These standards reflect only part of the                   We recognise that others have reservations
      department protocol which includes the re-              about the legality of schemes such as ours.89
      quirement to give advice concerning vomiting,           The legal and professional opinion we have
      follow up appointments, etc. There is a                 received is that it is reasonable to interpret
      requirement for the patient to receive, read,           "directions", as required by Section 58 (2) of
      and understand a postcoital contraception               the Medicines Act 1968, as covering "group
      advice sheet before they leave the department.          protocols."9 Others take a different view; how-
         This audit showed good compliance with the           ever, a debate as to which interpretation is right
      protocol (table 3). However, one ENP required           will remain one of "opinion" until the argu-
      further guidance in the appropriate documen-            ments are tested in the courts. In the meantime
      tation, particularly in relation to past medical        we have concluded that current legislation does
      history and potential drug interactions.                not prohibit nurse administration of drugs
         Audit has shown the value of ENPs having             according to protocols.
      authority to give drugs to patients without ref-           The whole A&E team has found the
      erence to a doctor. In addition we have                 implementation of the system beneficial. Our
      highlighted areas where the protocols required          ENPs can deliver holistic care to the patient
      clarification and where individuals required            appropriate to their role as independent practi-
      further advice in interpretation of the protocol.       tioners. This has increased the job satisfaction
      Thus the audit process supports a dynamic               of the nurses who perform this role. Further,
      approach to our protocols and training.                 the delays patients experienced in receiving
                                                              medication and care have been reduced, and
      Patient acceptability                                   the ENPs feel they are no longer waiting for
      No patients have refused to accept medication           doctors to be available to evaluate patients and
      from the ENPs, although the option to see a             sign prescriptions. The doctors are able to con-
      doctor is always available.                             centrate on those patients who require their
Administration of medicines by emergency nurse practitioners                                                                                      237

                               particular skills and expertise without the           we shall explore extending the drugs available
                               distraction of writing unnecessary prescrip-          to include eye preparations and the intramus-
                               tions.                                                cular administration of some non-steroidal
                                  Clinicians involved in such schemes must be        anti-inflammatory drugs. Second, we wish to
                               aware that in the view of the GMC they remain         extend the scheme to level 1 nurses who
                               ultimately responsible for the care delivered. It     undertake triage, so that patients can receive
                               is therefore essential that the consultants and       certain drugs, for example simple analgesia,
                               nurses work together and are actively involved        immediately after triage.
                               in the development of protocols for the admin-          We have improved the quality of service to
                               istration of drugs.                                   patients in our A&E department by the devel-
                                  We would suggest that consultants are              opment of ENPs with the authority to give a
                               involved in the training and accreditation of the     wide range of drugs according to protocols. We
                               nurses who will give the drugs. If consultants        believe that our careful analysis of the legal and
                               are to remain responsible for care, we believe it     professional issues in this area has been worth-
                               is essential that they participate jointly with the   while. Our multidisciplinary A&E team, in-
                               nurses in a continuing audit programme to             cluding pharmacy colleagues, is involved in the
                               ensure that the protocols are followed, and           development of protocols and audit. We have
                               cooperate in any revisions or alterations to          safely enhanced the quality of care given to
                               those protocols.                                      patients attending our A&E department.
                                  We would not support consultants abdicat-
                               ing responsibility for the appropriate adminis-       This work would not have been possible without the efforts of
                               tration of drugs once the protocol has been           the Norfolk & Norwich Health Care NHS Trust drugs and
                                                                                     therapeutics committee and particularly Rick Adams (head of
                               agreed, although some have argued that if a cli-      clinical pharmacy), David Carrington (director of pharmacy),
                               nician and nurse develop an acceptable proto-         Richard Drew (director of administration), Susan Henry (then
                                                                                     nursing development manager), and Dr Magdi Naguib
                               col, and the clinician is satisfied that the nurse    (chairman). We are grateful to Bruce Finlayson and Keith Wal-
                               has undergone appropriate training and under-         ters (consultants in accident and emergency medicine), for their
                                                                                     work in developing the protocols and in training. Finally, this
                               stands the protocol, then the nurse is solely         initiative would not have been successful without the enthusi-
                               accountable if he or she departs from that pro-       asm and commitment of the emergency nurse practitioners
                                  We should have a dynamic approach to pro-           1 Medicines Act 1968. London: HMSO, reprinted 1986.
                               tocols. Ambiguous areas and the need for revi-         2 United Kingdom Central Council for Nursing Midwifery
                               sion and review become clear when the proto-              and Health Visiting. Code of professional conduct. London:
                                                                                         UKCC, 1992.
                               col is in use. Problems will only be revealed by       3 United Kingdom Central Council for Nursing, Midwifery
                               regular audit. Further, review of individual              and Health Visiting. Standards for the administration of medi-
                                                                                         cines. London: UKCC, 1992.
                               knowledge and understanding must continue              4 United Kingdom Central Council for Nursing, Midwifery
                               to ensure there are no differences in                     and Health Visiting. The scope of professional practice.
                                                                                         London: UKCC, 1992.
                               interpretation or misunderstandings of the             5 United Kingdom Central Council for Nursing, Midwifery
                               protocols.                                                and Health Visiting. Rule 18 (1) of the Nurses, Midwives &
                                                                                         Health Visitors Rules Approval order No 873. London:
                                  The success of the scheme in the A&E                   UKCC, 1983.
                               department has prompted other clinical areas           6 United Kingdom Central Council for Nursing, Midwifery
                                                                                         and Health Visiting. Exercising accountability. London:
                               within our Trust to explore nurse administra-             UKCC, 1989.
                               tion of drugs according to protocol. Schemes           7 General Medical Council. Professional Conduct and Disci-
                                                                                         pline. Fitness to practise. Guidance from the General Medical
                               have been successfully implemented within                 Council. London: GMC, 1993.
                               ophthalmology and family planning. Nurses on           8 Peysner J. Nurse prescribers. J Med Defence Union
                               our coronary care unit are hoping to develop               1996;12(2):38-9.
                                                                                      9 Royal College of Nursing. Supply and administration of
                               protocols for fast track thrombolysis with                prescription only medicine. London: RCN, 1996.
                               streptokinase. Within the A&E department we           10 Dowling S, Martin R, Skidmore P, Doyal L, Cameron A,
                                                                                         Lloyd S. Nurses taking on junior doctors' work: a confusion
                               see the scheme developing into two ways. First,           of accountability. BMJ 1996;3 12:1211-4.

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