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

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

3. 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.

4. 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”

5. 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

6. 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

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

8. 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

9. 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

10. 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.

11. 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

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

13. 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

14. Results TPN
No change!
About to implement electronic prescribing

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

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

17. 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

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

19. Thanks to
NPPG and Special Products