Supplementary prescribing (SP) allows nurses and pharmacists to prescribe ongoing treatments following diagnosis by medical staff. It is “a voluntary partnership between an independent prescriber (IP) and a supplementary prescriber to implement an agreed patient-specific clinical management plan (CMP) with the patient's agreement”. In the case of neonates this is with the mother's consent. SP was implemented in the neonatal intensive care unit (NICU) at the Southern General Hospital, Glasgow in March 2005. Legislation makes provision for the CMP to be electronic and we hold an electronic copy of a generic clinical management plan on the unit, with consent recorded in the patient notes. The CMP covers parenteral nutrition, antibiotics, apnoea, chronic lung disease and reflux. Each treatment is backed with protocols. Unlicensed medicines can be, and are, included in the CMP.
The pharmaceutical care of patients has improved, for example, production of medication plans in patient notes for vancomycin ensure that protocols are followed and appropriate dosage adjustments are made facilitating consistency of treatment during medical staff rotations. Decisions can be made to start treatment should certain clinical conditions be met when no medical staff are available to prescribe the medicine due to attendance at deliveries for example, dobutamine infusion. Having a pharmacist on the unit who can prescribe has allowed treatment to be commenced when required.
The introduction of Non-Medical Independent Prescribing in 2006 has enabled the process to run more smoothly, although the large usage of unlicensed medicines in NICU1 has meant that a hybrid of SP and IP has had to be introduced.
The main hindrance to SP is the large unlicensed medicine usage in NICU. Under current legislation this means that a CMP has to be in place, for example, to allow parenteral nutrition, which is the most common medicine prescribed, to be prescribed by a non medical prescriber, for example, an Advanced Neonatal Nurse Practitioner who may be acting in the role of a junior doctor (who can prescribe all medicines, licensed or unlicensed).
Non-medical prescribing is intended to encourage a team approach to care and management of patients and to make best use of skills of trained healthcare professionals. This team approach mirrors how we work in practice in the NICU and pharmacist prescribing is an important addition to the healthcare of premature infants.
Prescribing further integrates the pharmacist into the multidisciplinary team and helps to enhance the teaching role with junior medical staff, with the pharmacist no longer seen as a ‘prescribing policeman’ telling doctors how to prescribe, but as an experienced prescriber on the team. Medical and nursing staff have fully supported the development of the new role as it frees up time for doctors to work elsewhere and enhances pharmacist patient contact.
The introduction of legislation to allow non-medical independent prescribers to prescribe unlicensed medicines in late 20092 will enable non-medical prescribers to prescribe without the delay required to set up a CMP. The hospital service needs pharmacists who can utilise their prescribing skills within their current service to do so, and demonstrate the patient care benefits.