This presentation by Linda Renfrew looks at evidence for non medical prescribing among allied health professionals, and how prescribing can be integrated into MS physiotherapy practice.
It was presented at the MS Trust Annual Conference in November 2014.
Making a difference: the benefits and challenges of non-medical prescribingMS Trust
This presentation by Dr Nicola Carey looks at the context of non-medical prescribing in the UK as well as its benefits and challenges.
It was presented at the MS Trust Annual Conference in November 2014.
Making a difference - the benefits and challenges of non-medical prescribingMS Trust
This presentation by Nikki Embrey from the North Midland MS Service looks at the benefits of and barriers to nurse prescribing, and whether it can make a difference to patient outcomes.
It was presented at the MS Trust Annual Conference in November 2014.
Prescribing, administration and supply of medicines by allied health professi...MS Trust
This presentation by Helen Marriott, AHP Medicines Project Lead, looks at prescribing and medicines supply mechanisms and the AHP Medicines Project.
It was presented at the MS Trust Annual Conference in November 2014.
Shelagh Morris, Allied Health Professions Officer of the Department of Health, talks about supplementary prescription. COT Annual Conference 2010 (22-25 June 2010)
The Broad Picture - recent developments in long-term condition managmentepicyclops
This lecture was given by Dr Aileen Keel, Deputy Chief Medical Officer for Scotland, to the North British Pain Association Spring Scientific Meeting on Friday 18th May, 2007 and forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Reproduced with permission.
Making a difference: the benefits and challenges of non-medical prescribingMS Trust
This presentation by Dr Nicola Carey looks at the context of non-medical prescribing in the UK as well as its benefits and challenges.
It was presented at the MS Trust Annual Conference in November 2014.
Making a difference - the benefits and challenges of non-medical prescribingMS Trust
This presentation by Nikki Embrey from the North Midland MS Service looks at the benefits of and barriers to nurse prescribing, and whether it can make a difference to patient outcomes.
It was presented at the MS Trust Annual Conference in November 2014.
Prescribing, administration and supply of medicines by allied health professi...MS Trust
This presentation by Helen Marriott, AHP Medicines Project Lead, looks at prescribing and medicines supply mechanisms and the AHP Medicines Project.
It was presented at the MS Trust Annual Conference in November 2014.
Shelagh Morris, Allied Health Professions Officer of the Department of Health, talks about supplementary prescription. COT Annual Conference 2010 (22-25 June 2010)
The Broad Picture - recent developments in long-term condition managmentepicyclops
This lecture was given by Dr Aileen Keel, Deputy Chief Medical Officer for Scotland, to the North British Pain Association Spring Scientific Meeting on Friday 18th May, 2007 and forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Reproduced with permission.
Evidence-based medicine is the system of practicing medicine in such a way that it results in improving outcomes and reduces the overall healthcare cost.
https://www.cognibrain.com/importance-of-evidence-based-medicine-on-research-and-practice/
Introduction of the NZ Health IT Plan enables better gout management - Reflections of an early adopter. Presented by Peter Gow, Counties Manukau DHB, at HINZ 2014, 12 November 2014, 11.37am, Plenary Room
Rajesh Jain1, Sanjeev Davey2, Sangeeta Arya3, Anuradha Davey4, Santosh Kumar5
ABSTRACT: BACKGROUND: In India; the high rate of infant and maternal mortality, may be attributable to rising trend of GDM across Pregnant women. Therefore the study of management of GDM by existing health facilities and Community camps in government and private sector becomes crucial for managing such cases. The present study by prospective evaluation method saught to find out the management of GDM for implementing GDM screening in Kanpur.
Conclusion:Public health system role is management of GDM is more significant as compared to Community level camps. There are potential benefits of actively involving Public health facilities in GDM Management among pregnant women, which needs to be taken care by Government on priority basis.
Course 2 the need for a careful and thorough historyNelson Hendler
The medical literature reports that 40%-80% of chronic pain patients are misdiagnosed. Clearly, misdiagnosis leads to ordering the wrong tests, and thereby obtaining an incorrect diagnosis, or overlooking a diagnosis totally, which results in mistreatment. Many reports in the medical literature indicate the best way to get an accurate diagnosis, is to obtain a complete and thorough history. However, this is a time consuming process, and most physicians don’t spend the needed time with a patient. Therefore, a team of doctors from Johns Hopkins Hospital developed a 72 question test, with 2008 possible answers, available over the Internet. When a patient completes the questionnaire, diagnoses are returned within 5 minutes. These diagnoses have a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This is the highest level of accuracy of any expert system available. The efficacy of this approach is proven by outcome studies, which prove that this approach results in a far higher return to work rate and reduced use of medication and doctors visits, when compared to other techniques. This is similar to the techniques used by Johns Hopkins Hospital to reduce their workers compensation payments by 54%.
Application of relatively simple & rapid test to a large number of apparently healthy people in order to classify them as likely or unlikely to have the disease.
Evidence-based medicine is the system of practicing medicine in such a way that it results in improving outcomes and reduces the overall healthcare cost.
https://www.cognibrain.com/importance-of-evidence-based-medicine-on-research-and-practice/
Introduction of the NZ Health IT Plan enables better gout management - Reflections of an early adopter. Presented by Peter Gow, Counties Manukau DHB, at HINZ 2014, 12 November 2014, 11.37am, Plenary Room
Rajesh Jain1, Sanjeev Davey2, Sangeeta Arya3, Anuradha Davey4, Santosh Kumar5
ABSTRACT: BACKGROUND: In India; the high rate of infant and maternal mortality, may be attributable to rising trend of GDM across Pregnant women. Therefore the study of management of GDM by existing health facilities and Community camps in government and private sector becomes crucial for managing such cases. The present study by prospective evaluation method saught to find out the management of GDM for implementing GDM screening in Kanpur.
Conclusion:Public health system role is management of GDM is more significant as compared to Community level camps. There are potential benefits of actively involving Public health facilities in GDM Management among pregnant women, which needs to be taken care by Government on priority basis.
Course 2 the need for a careful and thorough historyNelson Hendler
The medical literature reports that 40%-80% of chronic pain patients are misdiagnosed. Clearly, misdiagnosis leads to ordering the wrong tests, and thereby obtaining an incorrect diagnosis, or overlooking a diagnosis totally, which results in mistreatment. Many reports in the medical literature indicate the best way to get an accurate diagnosis, is to obtain a complete and thorough history. However, this is a time consuming process, and most physicians don’t spend the needed time with a patient. Therefore, a team of doctors from Johns Hopkins Hospital developed a 72 question test, with 2008 possible answers, available over the Internet. When a patient completes the questionnaire, diagnoses are returned within 5 minutes. These diagnoses have a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This is the highest level of accuracy of any expert system available. The efficacy of this approach is proven by outcome studies, which prove that this approach results in a far higher return to work rate and reduced use of medication and doctors visits, when compared to other techniques. This is similar to the techniques used by Johns Hopkins Hospital to reduce their workers compensation payments by 54%.
Application of relatively simple & rapid test to a large number of apparently healthy people in order to classify them as likely or unlikely to have the disease.
Enhancing Recovery from Critical Care with FESDerek Jones
Post-intensive care syndrome is now recognised as a spectrum of physical, cognitive and emotional problems that can stem from even reletively shorts stays in critical care units.
Over 100,000 patients will be treated in critical care units each year in England and Wales alone. Most are discharged to home but a significant percentage will have persistent problems.
This presentation by Derek Jones describes how motion therapy combined with a form of FES Cycling (Letto2 with FES) can help boost vital signs in even unconcious patients. The FES enhanced exercise preserves muscle mass and improves the speed and quality of rehabilitation.
Switching DMDs and new pipeline therapies - Dr Eli SilberMS Trust
Outline:
Where are we now
Therapies
Uncertainties
Induction v.s escalation v.s. rescue
Modelling outcomes
What is progressive disease, SP &PP
Risk reduction
Why is there a need for new therapies?
When is there a need to switch?
Stroke rehabilitation in the community: commissioning for improvementNHS Improvement
Stroke rehabilitation in the community: commissioning for improvement
provides a comprehensive guide to the development of effective community rehabilitation services. Together with detailed examples of good practice and information about early supported discharge (ESD) service models implemented in England, it explores factors which influence local commissioning, and identifies tools to assist with commissioning and funding rehabilitation. This new publication is particularly relevant to the emerging commissioning landscape, the development of a new outcomes framework, and the positioning of stroke within long term conditions. (Published July 2012)
This presentation by Gail Clayton, Lead MS Clinical Nurse Specialist and Jacki Smee, MS Clinical Nurse Specialist at Cardiff and Vale University Health Board explores setting up an Alemtuzumab service. It includes: patient selection, infusion related and long-term side-effects, ongoing monitoring requirements, potential challenges and case studies.
It was presented at the MS Trust Annual Conference in November 2013.
Current State of Pain Management Services in Primary Care in the UKepicyclops
This lecture was given by Dr Martin Johnson, a General Practitioner from Barnsley, Yorkshire, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. This lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
www.wspg.org.uk
Dra. Naomi A. Fineberg - Simposio Internacional ' La enfermedad de la duda: e...Fundación Ramón Areces
El 14 de noviembre de 2013, la Fundación Ramón Areces organizó y acogió en su sede un Simposio Internacional sobre 'La enfermedad de la duda: el TOC'. El Trastorno Obsesivo-Compulsivo (TOC) es un problema de salud pública, poco conocido, que afecta a un porcentaje de la población en torno a un 1-2% y que la Organización Mundial de la Salud ha situado entre las diez entidades que producen más discapacidad.
Acute neuropathic pain - Stephan Schug - SSAI2017scanFOAM
A talk by Stephan Schug at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
Ems world expo pain management 11112014.handoutMichael Dailey
Acute pain management is one of the keys to quality patient care. Over the course of the last 10 years there has been a steady evolution of prehospital pain management protocols and use of different medications. Currently, we are on the verge of a national standard of care for treatment of pain in ambulances. What has changed over that time? What medications are currently being used across the country? How are these medications being given? Dr. Dailey will discuss a national dataset of pain management protocols and discuss the goals for optimal pain management for the acute pain of medical or traumatic pain in the prehospital arena.
this power point help new clinical pharmacist to start practice ,understand the concepts of clinical pharmacy and give them all the tools to give good care to the patient
Migraine and Tension Headache Diagnosis and Treatment Guideline, 1999–2013 Group Health Cooperative. , https://provider.ghc.org/all-sites/guidelines/headache.pdf
The video for this presentation is available on our Youtube channel: https://youtube.com/allceuseducation A continuing education course for this presentation can be found at https://www.allceus.com/member/cart/index/index?c=
We examine medication assisted therapies for smoking, opiate addiction and alcohol dependence. We also explore the research supporting MAT and approaches that can be taken with clients who abuse drugs for which no MAT is available.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. Fit with current policy
Evidence for non medical prescribing
Prescribing options for AHPs
My prescribing journey
Integrating prescribing into MS physiotherapy
practice
Case Studies
Impact on patient care, clinical practice and
service development
Thinking about prescribing: things to consider
3. Key health care policy drivers call for:
a shift from acute, hospital-driven services to
community - treating people faster and closer to
home
meeting the needs of the ageing population and
rising incidence of long-term conditions
encouraging health improvement and
“wellness” by supporting people with long-term
conditions to self manage their condition
developing services that are proactive, modern,
and safe
4. Non medical prescribing is about
enabling quick, safe and equitable access to
medicines for patients.
increasing the kinds of services accessible health
professionals (NMAHPs) can deliver.
improving quality-of-care, reducing health
inequalities and opening access to services for all.
improving patients’ experiences of services and
contributing to better outcomes.
A safe prescription (Scottish Government, 2009)
5. Efficiency
Improved speed & convenience of treatment (Ball, 2009;
Drennan et al, 2009, jones et al, 2010; Oldknow et al, 2010).
Reduced waiting times & increased efficiency of
appointments (Courtenay et al, 2011; 2010; Page et al, 2008).
Doctors make better use of their time to treat more complex
patients (Carey et al, 2010b; Daughtry and Hayter, 2010).
Patient Experience
Patients were highly satisfied with, and confident in, NMP’s
abilities (Courtenay et al, 2011; 2010 Jones et al, 2010;
Watterson et al, 2009).
6. Safety
Patient safety improved (Carey et al, 2009a;
Courtenay et al, 2009a).
Medication errors were significantly reduced in
diabetic management with a nurse prescriber (Carey
et al, 2008; Courtenay et al, 2007).
Nurse prescribers were cautious in prescribing &
recognised budgetary restraints ( Watterson et al
2009).
Only 1 adverse incident reported since 2006
No evidence specifically on AHP prescribing
7. No prescription required
Patient Specific Direction(PSD)
Patient Group Direction (PGD)
Prescription required
Supplementary Prescribing
Independent prescribing
8. “physiotherapists who have not passed an
approved prescribing course must not advise
patients to take or stop taking medication, or
change their dose or type of painkillers, even
paracetamol” (CSP 2006)
Legally we need to demonstrate our
competency to give advice about
medications and that we are working within
scope of practice.
9. Scope of practice
No automatic transfer to new role
Scope of profession
Working within clinical governance framework of employer
Professionally responsible for own actions
Accountable to employers and regulatory bodies for actions
Easy access to primary patient record, timely communication
with GP
Informed consent
No unlicensed medicine, limited prescribing of CD’s
“Off license/off label” or mixing of medicines undertaken with
strong justification /evidence given
Within own caseload
10. Using a medicine outside its licensed
indications/UK marketing authorisation
Only prescribe ‘off-label’ where it is accepted
clinical practice.
Local policies for the use of off-label
medicines should be approved
Many drugs used in MS are used off label
e.g Gabapentin, Amitriptyline, Amantadine etc.
11. No other licensed medicine will meet the
patient’s need
If a licensed medicine is not available
There is sufficient evidence to demonstrate
safety and efficacy
Take full responsibility for prescribing, follow
up and monitoring (or ensure GP does).
Patient informed re the unlicensed aspect of
medicine
12. HCPC registered, minimum of 3 years, identified need & support
from employer
Non-medical prescribing programme
Joint NMAHP course
40 credits @ level 9 ( 6 months), 20 credits @ level 11( 5
months)
Funded by Scottish Government
26 theory days or 10 days blended learning(+ 10 study days)
78 hours of supervised practice
Exam, examination of practice & portfolio of competencies
NMC/HCPC register annotated
Added to local health board register
Part of PDP supported by audit of practice
13. 1986 - BSC physiotherapy
1995 - 2005 Senior Neurological out- patient
physiotherapist
2001 - 2005 MPhil in MS
2006 – 3 year ESP post in MS ( part funded
MS soc). Drive to demonstrate added value &
improve patient pathways - NMP
2007/8 – NMP(supplementary prescribing)
2009 – secured permanent post – consultant
physiotherapist in MS
SP integral to role
Physio led MS review clinics
AHP rep on NMP group NHS A&A
2014 – SP/IP conversion course
2014 – consultant in rehabilitation medicine
retired ( currently unable to recruit to post)
14. First AHP prescriber in NHS Ayrshire & Arran.
? other AHP prescribers in MS nationally
No national or local AHP prescribing a guidelines
Discussions with prescribing leads re prescribing
pathway
demonstrate how patient care is enhanced
alleviate concerns re prompt communication with GP
alleviate concerns re inappropriate prescribing
Liaised with other AHP prescribers re pathways
Undertook audit of prescribing practice
15. Types of medications
Numbers of patients -
where, how often
Details
Costs
16. 50
45
40
35
30
25
20
15
10
5
0
MS clinic Physio Dom visit Total
Total SP
5
4
3
2
1
0
Numbers of
patients
Muscle
relaxants
NSAID
Neuro pain
AB
Bowel med
17. Patient Details of prescription Cost ( 4 weeks) (based on BNF March
2007 prices)
1 7 day course of trimethoprin £1.35
2 Increase Tizanadine from 18mg – 36mg Approx x100tabs extra £40.00
3 Increase Baclofen from 10mg to 15mg Approx 14 extra tabs £1.80
4 Increase Lactulose from 30 ml to 75ml Additional 1260ml £10.50
5 Increase gabapentin from 2.1g to 2.7g Additional 56(300mg) tabs £4.00
6 Start gabapentin 300mg day 1, 600mg day
2, 900mg day 3.
81 (300mg) tabs £5.40
7 Start ibuprofen 400mg x 3 daily 84(400mg) tabs £6.85
8 Start diclofenac 25mg x 3 daily 84(25mg) tabs £2.42
9 Start clonazepam 1mg increasing to 4mg at
night
56 (2mg) tabs £2.93
10 Start Baclofen 30mg daily 84 (10mg) tabs £2.55
Total £77.80
18. How?
Agreement re prescribing pathway (Nov 2008)
Mirrors traditional out-patient prescribing arrangements in
secondary care. Specialist makes recommendations to the GP
Assess, determine need, advise to GP using out-patient notice ( &
follow up letter). Personalised stamp
GP writes prescription
Initially as SP within limits of a CMP guiding prescribing
Autonomous prescribing decisions now as an IP
Agreed date for review (in person or phone) and further
amendments communicated to the GP
19. Pt attendsP pth aytsteion,d ass psehsysseiod & & n neeeeddss t oto s statarrt ts sppaasstctiictyit ym meeddiciacatiotionn
Appointment with consultant at clinic
Pt sees consultant & letter sent to GP re medication
Pt makes an appointment with GP & prescription issued
Pt starts medication
Pt reviewed by physio & requires an dose
DELAY 2-6wk
DELAY 2-4wk
DELAY1-3 wk
DELAY
20. Pt attends physio prescriber , assessed & needs to start spasticity medication
OP advice note issued to GP
GP initiates prescription - pt starts medication
Pt reviewed by physio within agreed timeframe
and dose altered
Final dose of medication notified to GP
21. Where & when?
Physiotherapy new and
review clinics
FES clinic
Domiciliary visits
MS review clinic
Over the phone
▪ where initial assessment
has been undertaken
▪ for symptoms such as pain
and fatigue
22. What?
Symptomatic treatment
Pain (musculoskeletal and neuropathic)
▪ paracetamol, NSAID’s, opiates, compound preparations( co-codamol),
amitryptaline, duloxatine, gabapentin, pregabalin
etc
Spasticity( inc management of constipation acting as a trigger
factor)
▪ baclofen, tizanadine, dantrolene, gabapentin, clonazepam,
sativex (??), movicol, fibrogel, lactulose, anti-biotics
Fatigue and management of secondary factors impacting on
fatigue
▪ amantadine
More unusual symptoms
▪ tremor
▪ hypersalivation
23. Evidence, local & national guidelines
Licencing and legal considerations
Local governance and policy arrangements
Risks and benefits
Medical History
Drug interactions and side effects
Compliance & concordance
▪ Informed consent
▪ Titration & dosing regimes
▪ Impact of psychosocial factors, values & beliefs
▪ Cognition
24. NICE 2014 – MS pharmacological management
Fatigue
Amantadine recommended
8 studies ( 6 Amantadine, aspirin, paroxetine) low to moderate
evidence
Spasticity
Ist line baclofen or gabapentin or combine
2nd line tizanadine or dantrolene
Benzodiazepines ( nocturnal spasms)
Sativex not recommended
33 studies low quality evidence
Tremor
4 studies ( ioniazide, baclofen, botox) evidence inconclusive
No recommendations made
25. NICE 2013 Neuropathic pain
1st line consider amitriptyline, duloxetine,
gabapentin ( al off label) or pregabalin
2nd line tramadol for acute rescue therapy
3rd line Capsaicin cream for localised neuropathic
pain
Trigeminal Neuralgia
▪ Carbomazapene of phenatoyin
26. Amantadine Hydrochloride
licensed for: Parkinson's disease, antiviral
off label for fatigue in MS
Gabapentin
licensed for: monotherapy & adjunct treatment for
focal seizures, peripheral neuropathic pain
off label prescribing for central neuropathic pain and
spasticity
Amitriptyline Hydrochloride
licensed for: depression
off label for neuropathic pain
27. Governance
Systems in place to report and respond to "near misses", errors
and adverse drug reactions ( local & national)
Rapid access to medical history, current medication and
kidney/liver function to prescribe effectively and safely.
Appropriate mentoring, supervision and line management
Effective scrutiny of prescribing practice ( audit & quality
monitoring)
Strong leadership of non medical prescribing at board level
Policy
Local medicines management policy includes NMAHP prescribing
NMAHP prescribing policy developed by a multi-disciplinary group
and reviewed regularly
28. 48 year old lady diagnosed
with RRMS 10 years ago.
Attending FES review clinic.
Is currently taking
copaxone, amantadine
(100mg) and co-codamol (
minimal effect on pain).
Ongoing problems with
fatigue worse over past 4
months and increased lower
limb neuropathic pain
affecting sleep. Her mood is
low.
Previously tried
amytriptyline (25mg) with
no effect.
PMH: mild heart arrhythmia
29. Assessment : lower limb & spinal examination, VAS for pain,
FIS & HAD
Diagnosis : neuropathic pain and low mood impacting on
sleep contributing to increased fatigue
Considerations: PMH, drug interactions, off label
prescribing, concordance
Possible options:
increase dose of amantadine ( from 100mg to 100mg bd)
restart amitriptyline and titrate dose from 25mg up to
75mg (depending on response). Caution due to heart
arrhythmia.
trial gabapentin if no/partial response to amitriptyline .
Titrate dose slowly and monitor response
Discuss mood with GP/refer to MS psychologist
discuss fatigue management strategies
30. 46 year old man with MS and
spinal problems. Wheelchair user
but usually independent.
Long history of neuropathic pain
and lower limb spasticity( 20 years)
Referred to physiotherapy because
his legs feel stiffer,he is falling to
the right and forward and now
unable to self propel or feed self.
Current medication:60mg
baclofen, 36mg tizanadine, 150mg
dantrolene and 1800mg
gabapentin for past 4 years. GP
recently stopped Acupan for pain
and started dihydrocodine.
PMH: ↑BP- minoxidil
31. Assessment: lower limb spasticity ( Ashworth 1/2), L/L ROM -
reduced muscle length hamstrings and gastrocnemius. Poor posture,
reduced trunk tone and poor control in sitting. U/L tone low with
muscle weakness
Diagnosis: anti spasticity medication is causing additional muscle
weakness in upper limbs and trunk
Considerations: PMH, drug interactions, avoid abrupt withdrawal
Options
gradually reduce & stop one of her AS meds & review impact on
L/L spasticity and trunk stability
refer to physio to address trunk stability and reduced muscle
length
refer to bioengineering clinic for review of wheelchair
refer to OT to review U/L function and additional aids to assist with
eating
32. 38 year old man with
advanced MS. Poor
cognition, wheelchair
bound, poor swallow,PEG
fed, marked upper limb and
trunk tremor, requiring 24
hour care.
Attended the MS review
clinic with mum and carers-main
issue is excessive
drooling causing him to
choke on saliva.
Medication –hyoscine
hydrobromide patches
changed every 3 days and
propranolol (60mg)
33. Diagnosis: progression of condition requiring management of excessive salivary secretions
Considerations: capacity and compliance, drug interactions, scope of practice, withdrawal
of meds
Options:
increased frequency of change of patches
amitriptyline
glycopyrrolate– required further information from MIU on unlicensed application for
use via enteral feeding
botox into salivary gland
Outcome
no additional benefits noted changing patches daily & significant respiratory side
effects noted.
following reaction it was decided not to start glycopyrrolate due to possibility of similar
serious side effects.
amitriptyline started (25mg) – no response therefore gradual titration to 75mg.
Increased drowsiness and negative affect on transfers noted. Titrated down and
stopped.
referral to head and neck surgeon made for consideration of Botox injection
CMP set, close liaison with consultant , GP and mum/carers
34. Improved patient pathway
avoiding multiple appointments with consultant and GP
avoiding delays in starting and titrating medication
Optimal symptomatic management
optimising combined use of medication and physical
treatments
limiting use of medication where not necessary
Seeing the right person with the right skills at the right
time
The MS physiotherapist has expert knowledge and skills to
assess and prescribe for pain and spasticity and to evaluate the
impact of treatment
Improved concordance
Physiotherapists spend more time with the patient allowing
opportunities for discussion, improving adherence and patient
safety, reducing waste and improving outcomes (NICE 2009)
35. AHP led MS review clinic
rehab consultant only sees pts requiring medical
review
freeing up time for rehab consultant to focus on
other areas of service development
longer appointment slots for review
appointments
patients as satisfied/more satisfied with new clinic
targets for annual review now being met
36. Comprehensive initial assessment
Consider impact of prescribing decisions &
accountability
Independent & joint decision making
Extending treatment options & refinement of
treatment combinations
Insight into professional strengths of other
disciplines ( nursing, pharmacy 7 medicine)
Understanding the bigger picture
37. Symptom management clinics
spasticity ( combine with botox)
Pain
Relapse management
Medicines management at ward review
Clinical lead role?
38. Would prescribing enhance patient care?
Within a service
▪ what, how often and where would prescribing be done?
▪ Are there other professions within the team who would/could take this role on?
As an individual
▪ what is your role & function within the service/team?
▪ is there a need for you to initiate new medications, titrate & alter medications?
Where is your service based and is this likely to change ?
Primary or secondary care
Cost codes linked to prescriptions
Communication with GP & access to up to date prescribing summary essential
What is the impact of IP training on service delivery and how would thi be managed within
the service
What are your clinical governance structures to support prescribing?
39. A safe prescription ( Scotland) (2009)
http://www.scotland.gov.uk/Resource/Doc/286359/0087194.pdf
National Prescribing Centre: A single competency framework for all
prescribers (2012)
http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single
_comp_framework_v2.pdf
HCPC Standards for prescribing ( 2013)
http://www.hpc-uk.org/assets/documents/10004160Standardsforprescribing.pdf
Practice Guidance for Physiotherapist Supplementary and/or Independent
Prescribers in the safe use of medicines (CSP, 2013)