The Prescribing Pyramid Pyramids – The pyramids at Giza http://www.flickr.com/photos/nburrows/4818784763/ Under a CC BY-NC-SA 2.0 license http://creativecommons.org/licenses/by-nc-sa/2.0 Facilitators notes This activity has 2 sections: This presentation on the prescribing pyramid (1 hour) The activity (1.5 hours) Target audience Nurses Midwives Pharmacists Chiropodists Physiotherapists Junior doctors or medical students Good prescribing is not easy I hope that this session will help you with you prescribing decisions. The process of writing a prescription starts a chain reaction that will have an impact on the patient, possibly their family, the prescriber and the NHS. Kimberley Tordoff

Aim of the session To appraise the use of the prescribing pyramid in relation to non medical prescribing decisions

Learning Outcomes By the end of the session learners will be able to Knowledge Describe the seven principles of good prescribing Describe the concept of the prescribing pyramid Skills practice using the prescribing pyramid challenge other members of the multi-disciplinary group on decisions Attitudes Continue to build up relationships with their peers through group work

The prescribing pyramid Reflect Record Keeping Review Negotiate a contract Choice of product Which strategy Consider the patient The process to prescribe or not to prescribe is a complex one that needs many factors considering before that all important piece of paper is given to the patient, the prescribing pyramid is a process that may help you so that you are sure all the bases have been covered.

1. Consider the patient… The Consultation Prepare as much as you can & establish rapport Identify reasons for consult Explore the patients Ideas, Concerns and Expectations of the problem (ICE) Obtain essential information Impact of problem of the problem Differential diagnoses Re evaluate information, ensure shared understanding, consider more tests, and interpret results for diagnosis Decide treatment options discuss with patient, Q&A Summarising, terminating the consultation, writing-up In 70% of cases the diagnosis will be evident just from a clinical history alone before tests or examination takes place. A good history facilitates good prescribing. Each consultation should have a structure bit it shouldn’t be like a straitjacket These are the vital elements that need to be covered Rapport..observe the pt s demeanour, put at ease, convey warmth and confidence. In reality we don’t take a history we make a history as it is a two way process.

1. Consider the patient WWHAM! What's Wham got to do with it? Who is it for What are the symptoms How long have the symptoms been present Any action taken Medication What information would you want to know about the patient/symptoms NMC picked up on this mnemonic as it had been used by pharmacists when helping them advise people buy medications. It isn’t robust enough to use in isolation, but if incorporated into the assessment it makes sure that medication history is taken; POMs, OTC, Herbal, allergies, patients tend not to tell you about these as they don’t think that they are important. Examine the holistic needs of the patient looking at the determinants of health. Patients will often omit to tell you about OTC preps or herbal meds, but need to know for contraindicated drugs. Discuss illegal drug meds

The determinants of Health Age, sex, hereditary factors Lifestyle factors Social & community networks Living & working conditions Socio-economic, cultural & environmental conditions Dahlgren & Whitehead 1991 The pts medical and social history needs to be taken, a thorough needs assessment may show that non drug therapy may be indicated. Allergies need to be identified and recorded

Medications Drug History and Allergies Ask patient to list medications they are on, or show their repeat prescription, or bring in their meds. Ensure you have a written record in your notes of the name, dose, frequency and route. Are they actually taking them as prescribed? Enquire about Over The Counter (OTC), herbal and illicit…you may be shocked! Any allergies or reactions to meds or foods or environmental factors and record them and any treatment given. Really important part of prescribing Patients symptoms may be as a result of the medications they are on! Women often do not volunteer the pill as they don’t see it as medication They may also not include inhalers, creams, patches or pessaries, eye drops….ask specifically

2. Strategy Is diagnosis established? Is there a need to prescribe? Is referral elsewhere indicated? What does the patient expect? A prescription should only be given when there is a genuine need. When the patient presents it is important to bear in mind that other treatment options need to be considered. Only prescribe when there is a genuine need, patients may want to have a prescription for other reasons…legitimate a sick role, a friend recommended it, gain attention, give or sell to someone else. Patient expectations for medication. Could there be alternative treatments… TENS Has the pt presented with serious or sinister signs that need attention from another person

3. Choice Appropriate Effective Safe Cost Acceptable “Sign," © 2011 Adam Williams, Used under a Creative Commons Attribution-Non-commercial-ShareAlike 2.0 Generic license: http://creativecommons.org/licenses/by-nc-sa/2.0/deed.en_GB

Safety Issues For any given therapeutic intervention, the potential benefits of the treatment must always be balanced against the known safety concerns. ADRs account for 5% of all hospital admissions and are associated with significant M and M risks

Avoiding Adverse Drug Reactions Use as few concurrent drugs as possible Use the lowest effective dose Check if patient pregnant or breast feeding Is the patient at extremes of life? Do you know all of the drugs that the patient is taking Check for Over The Counter medicines Drug allergies or previous reactions to medications

4. Negotiate Concordance Compliance Medicines adherence DANCING NOT FIGHTING! Enables the pt to have a role in the decision making process. . It is a shared contract between the prescriber and patient. It replaces the term compliance which is seen as a negative concept where the patient simply does as they are told. For concordance to occur the patient needs to know what the drug is for, side effects, how long it takes to work, efficacy, when to get advice and from where, potential problems and what to do needs to be talked through with the patient. Patient leaflets. Add image of handshake and dancers

Review Where When How Who Regular review of the patient will establish whether the meds prescribed is safe and effective and acceptable. Always have a plan B Policy on repeat prescriptions variable, repeat prescribing without review will be wasteful and potentially dangerous. make sure the pt knows who to contact and when

Record Why is it important What are the barriers to this in practise Good records are essential, a professional requirement from the NMC enter prescription details into records asap in the appropriate records, best practice 24 hours in community to amend gp records Include date, name of prescriber, name of drug, in fact everything that is on the script plus a record of the consult. Your records need to support your decision making process in case of legal comeback, but also to help fellow clinicians in future evaluation of the patient.

Record Keeping Guidelines Accurate Legible Unambiguous Contemporaneous Relevant Enough to enable other professionals to provide effective care Dated, timed and signed Practitioners must not tamper with original records in any way Electronic records are clearly attributable Kept securely (NMC,2008) Integral part of professional practice Is not an optional extra to be omitted if you are short of time Is a reflection of your standard of practice

Reflect On your prescribing decision On the episode as a whole Discuss with colleagues Code of conduct states that we should maintain and improve our professional knowledge and competence and by reviewing and reflecting we can do this almost on a subliminal level after a while. Periodic review with co workers, discuss with pharmacy, pact data prescribing analysis and cost…allows the individual to compare with others and whether you adhere to local policies

References Dahlgren & Whitehead (1991) Social Model of Health www.nwci.ie/download/pdf/determnants_health_diagram.pdf Nursing & Midwifery Council ( NMC) (2008) The code: Standards of conduct, performance and ethics for nurses and midwives May London NMC www.nmc.org.uk

Note for facilitator Divide the class into inter-professional groups Now proceed to Activity on prescribing pyramid

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