Sunday, 4 November 2007

Nurse prescribing

Given that there is zero evidence that shows nurse prescribing to be safe, it is extremely worrying when an esteemed Professor of prescribing science writes of his concerns:

• There were more than 20,000 independent nurse prescriptions for the full range of antibiotics and antivirals.

• Amiodarone and cimetidine are being prescribed – both very risky drugs with dozens of potentially fatal interactions.

• A wide range of cardiac drugs is being used by nurses, including digoxin, ACE inhibitors, angiotensin receptor blockers and calcium channel blockers. Many of the digoxin prescriptions were for the higher dose tablet, and there were 98 prescriptions for the calcium channel blocker verapamil – a drug that should only be instigated by a cardiologist and prescribed by a GP.

• There were hundreds of prescriptions for diuretic-hypotensive combinations, including co-amilozide and co-amilofruse, both of which carry a serious risk of plasma electrolyte problems and are major causes of drug-related emergency admissions.

• Nurses were prescribing the full range of anti-diabetes drugs, despite diabetes being the most brittle and treacherous of syndromes, even in specialist hands.

• There were many prescriptions for antidepressants – after antibiotics, the most over-prescribed drugs.

• There were thousands of prescriptions for NSAIDs – the most dangerous drugs of all, accounting for more than 30% of all reported serious adverse drug reactions.

• Nurses had given out about 200 scripts for atypical antipsychotics, whose incorrect use may lead to permanent sequelae.

• There were a host of other drugs prescribed by nurses that are potentially seriously risky. These included more than 1,000 prescriptions for a-blockers, more than 100 of methotrexate and almost 500 prescriptions for erection enhancers.

Most of these drugs are suitable for a nurse to prescribe in a medication plan agreed with a doctor. Given nurses’ entirely inadequate training in diagnosis and therapeutics (which of course is not the nurses’ fault), hardly any of these drugs should be prescribed independently.

Currently, about 5% of emergency hospital admissions are the result of faulty GP prescribing (in the elderly the figure rises to 12%), despite the prolonged training that GPs get and the long period of supervision.

We may expect a marked escalation of preventable prescription-related disease from independent nurse prescribing on the basis of these figures.

However those who back nurse prescribing will cast this aside as it is simple common sense, and they have ways of living in denial and ignoring good old common sense.


Advanced Practitioner said...

Garth! Do you always have to get on the bandwagon?

As has been mentioned previously on my blog, the research mentioned above is both elusive and flawed.

When I undertook the nurse prescribing programme in 2005, we had to concentrate on pharmacology and prescribing for six months. This included two full days of taught content a week, with one day spent with my GP mentor. I was examined by OSCE, had two written exams, one pure pharmocology which had a pass mark of 100%.

As potential nurse prescribers we also had to complete a portfolio of Evidence relevant to our area of practice, mine being general practice. All my training was undertaken under the supervision of my GP supervisor who did not sherk his responsibility and whos’ supervision was extremely rigourous.

How many doctors have this level of input during their training and since qualifying?

I undertake monthly CPD sessions on prescribing and prescribing issues with my advanced practitioner colleagues, but no GPs have ever attened, is this because they don’t feel they need to keep up-to-date once qualifying, I hope not!

The above list of drugs are drugs that have been prescribed by many nurse specialists who have more knowledge of the chronic disease they are treating compared to many GPs. Other conditions have also been prescribed for by practice nurse for years but have needed the signature of the GP, so on them signing has their attention lapsed. Did all GPs read the prescription before signing, I think not!

One thing I know for sure is the nurse prescribers I know do not prescribe outside of remit or their competence, and they are fully aware of the complications of the drugs they prescribe, can we again say the same for all doctors? How many doctors can realistically make this claim?

The learned proffessor acknowledges the amount of hospitalisations caused by faulty GP prescribing, but no mention of that fact in your piece.

As nurse prescribers we would like to see the evidence of harm caused by faulty nurse prescribing.

Advanced Practitioner said...

Sorry! Professor

Garth Marenghi said...

You are entitled to your opinion,

however nurses are so undereducated for prescribing that they will make far more errors than doctors when prescribing,

it's not good enough that we have to wait for evidence to prove the obvious, it should have been proven safe before being inflicted upon the public, and it most certainly has not,

in fact in several other pieces I have linked in the past, nurses have struggled to even prescribe within small fields, so god only knows how they are going to get on prescribing anything in the whole BNF!

The lame duck 'sphere of competence' argument is frankly nothing but pathetic.

It can be used to justify the unjustifiable- ie we'll hand more and more responsibility to less and less trained people and they will as if by magic only practice within their 'sphere of competence'-

it takes a thorough training and years of experience of doctoring to realise when one is out of one's depth, nurses do not have sufficient training or experience of doctoring to be able to realise when they are acting dangerously-

this is why this dumbing down is so dangerous-

the same lame argument is used to justify PAs practising independently after only two years of dumbed down training- and it doesn't cut the mustard

the A&E Charge Nurse said...

No evidence ?..........oh, you are a wag ferret.

What about;
"Evaluation of extended formulary independent nurse prescribing" [2005].

This study found: "nurses are prescribing frequently and clinically appropriately in a range of pactice settings [p4].
And - "doctors were positive about the development of nurse prescribers in their teams", cited in the same study.

Incidentally Ferret the BNF has not been thrown open to nurses, they have just been given slightly more leeway [compared to PGDs] when it comes to the relatively small range of drugs pertinent to their respective clinical areas, or sphere of competence [such as use of local anaesthetics, analgesics, antibiotics, etc supplied by ENPs working in A&E].

Meanwhile, consultant neonatologist, Dr Richmond, has expressed "delight" in the BMJ that the DoH "has at last seen common sense" with respect to extended prescribing by UK nurses.

Ferret I have no doubt you have great integrity, and I can understand your concerns, change is often unsettling to begin with.

But may I draw your attention to comments made by John Standing a research pharmacist - he notes that Professor Avery and Dr Pringle [cited in the BMJ] oppose the BNF being made available to pharmacists - despite the fact that is is actually pharmacists [rather than doctors] who write and editing the prescribing bible [BMJ 2005].

I stand by my oft-repeated mantra that senior nurses can take care of certain health problems with a fair degree of independence, providing senior medical support is available to them.

Irrespectve of whether you or I like these developments [and clearly you don't] I do not see how we can get the genie back into the bottle, especially since there are no published studies [AFAIK] which have ever demonstrated that nurses are harming patients as a result of quacktitioning.

Garth Marenghi said...

Have a look back at a piece I did which looked at that very weak piece of DoH 'evidence'. It is piss poor.

The evidence of harm will come, just give it time, the politicos will try to suppress it but it well get out eventually.

I have actually heard of a few great audits that show how dangerous NPs are, shame there is a lot of danger for those who try to expose the truth.

the A&E Charge Nurse said...

Thanks Ferret - like you I welcome any data that reflects on standards of care and patient safety. The quacks have been fussing round NHS patients for well over a decade now, plenty of time to gather in a few hard facts wouldn't you say ?

If, as you suggest, studies are finally brewing, which corroborate quack ineptitutude on a grand scale, then I think we need to see them, and sooner, rather than later.

I have also been told on threads dealing with similar issues [such as Dr Crippen] that this information is "already in the post" [to borrow Irving Welsh's immortal phrase from Trainspotting].

In fact I vividly remember one rather excitable medical student who made all sorts of claims about a study carried out in fracture clinic demonstrating that inappropriate orthopaedic referrals by quacks were hitting >30% - yet these shattering statistics never made it to a reputable medical journal [and as you know the student rag doesn't really count].

You have raised the thorny issue of independent prescribing and I think it would have been helpful if it was make clear that nurses prescribe a very narrow range of drugs which are all restricted to their particular sphere of practice [see A&E example above].

If I were you I'd worry far more about the monolithic "statinisation" obsession perpetrated by doctors, especially when there is a growing number of commentators who have gone to great lengths to point out the bogus science underpinning this mutli-million pound embarrasment.

As you know there is also a mass of data concerning the historical misuse/abuse of antibiotics by doctors, although you have already taken issue with my pot-kettle-black comments over on the excellent APs site.

I have already come across reports by microbiologists that the number of quack prescriptions for infections are [virtually] statistically insignificant, 0.6% or something like that.

None of these facts, seem to bother you half as much as a few fussy quacks dishing out the odd script for ABx or pain killers- why is that ?

Garth Marenghi said...

It's not very hard to find the old post, just use google and you'll find it. Keeping to the point, the research is piss poor and didn't make it into any journals.

Do you not think nurse prescribing should have been subject to a rigorous check of its safety before being inflicted upon the public?

Or are you happy with one small piece of DoH propaganda to justify empowering less trained staff?

Garth Marenghi said...
This comment has been removed by the author.
Garth Marenghi said...


an interesting is this poor antibiotic prescribing issue,

I would guess that this is done by more senior doctors in the community who have not kept up to date with developments,

all nurses who prescribe will have just done their recent dumbed down training course,

in twenty years time we will have a major problem as there will be a large cohort of nurse prescribers who do not have a good foundation of basic science knowledge, who may well not have kept up to date with developments, who will be prescribing very innappropriately,

by your logic it would be safe to trial HCA prescibing with no evidence to show it was safe, and this would be ok, and it would be up to the critics to prove it unsafe, not a great approach for the patient I feel

nurses are inadequately trained for their prescribing powers, and your argument only convinces me further