Supplementary Prescribing in a neonatal ICU Peter Mulholland Pharmacy Department, Southern General Hospital

Aims Begin in October 2004 Rationalisation of treatment Consistent care plan for treatment across city (3 units)

Outline Background to supplementary prescribing Supplementary prescribing in a NICU Our practice results Off label use is allowed under current supplementary prescribing legislation, but unlicensed use is only allowed as part of a clinical trial; and well established, but unlicensed, medicines cannot currently be prescribed as part of a CMP. This restriction is presently the subject of a consultation document3, and it is to be hoped that the use of unlicensed medicines, not as part of a clinical trial, will be allowed on CMPs. Otherwise prescribing in neonatology will be severely restricted.

What Does It Mean? “A voluntary partnership between an independent prescriber (IP) and a supplementary prescriber (SP) to implement an agreed patient-specific clinical management plan with the patient’s agreement”

RPSGB/DoH Requirements Named medical practitioner 5 days teaching, 25 days learning in total (=200hrs) 12 days learning in practice Competencies/learning outcomes Diary records Reflection sheets

What Can Be Prescribed? Anything except: Controlled Drugs (amended March 2005) Unlicensed drugs outwith a clinical trial (amended April 2005) Must only prescribe medicines that fall within your area of competence

Clinical Management Plan (CMP) Cannot prescribe without this Is patient specific Can be a ‘generic’ template Certain items are mandatory

Neonatal ICU Supplementary prescribing is not designed for use in a neonatal ICU (MHRA) Prerequisite for SP to occur – CMP agreed by patient! Parent will agree (Mother or husband) Emotion and trauma of premature birth CMP can be electronic

Conditions We Will Treat Neonatal TPN * Antibiotic therapy (inc anti-fungals) * Apnoea Steroids to wean of ventilator Diuretics for CLD * Reflux treatment Inotropes / morphine infusions Eye drops for ROP screening Immunisations Routine supplementation

The initial draft plan will be discussed with colleagues from two other local maternity units with a view to producing a ‘generic’ template for neonatology for our city. This generic template will, therefore, draw on medical and pharmaceutical expertise throughout our city to produce a plan that will lead to consistency of prescribing in our neonatal population.

Antibiotic Supplementary Prescribing Protocol Independent Prescriber (IP) decides antibiotic needs to be prescribed Medical History Factors leading to prescribing Expected duration of antibiotic Supplementary Prescriber (SP) assesses Drug levels (where appropriate) Microbiology results Changes in patient’s weight Clinical Progress Daily review (48 hour review for newborn prophylaxis) Modify treatment Review Course completed Symptoms resolved or no longer attributable to infection Stop Antibiotics

Selecting the Patient Is the patient likely to be suitable Choosing the right time

Situation Pre Supplementary Prescribing TPN – daily attendance at ward round / ward where changes discussed Antibiotics – suggestions to dosage made based on results Diuretics – started by one of three consultants usually without a plan being stated

Results TPN No change! About to implement electronic prescribing

Results Antibiotics No effect on initial prophylactic therapy Plans adhered to for weekend changes following results (Vancomycin / Gentamicin)

Results - Diuretics 4 patients 2 not suitable (Cardiac) 2 CLD patients Both to plan – allow to wean off as weight increases

Standardisation Across the City 3 units (SGH, QMH and PRMH) In place at SGH but training undergoing at other two Discussions with lead consultant at PRMH Discussions with MICU pharmacist at QMH

Conclusions No benefit for TPN only Need for a CMP can be restrictive In NICU are part of a team, not working solo

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