Safe and effective prescribing of nutrition: the impact of dietitian prescribing rights in New Zealand

Transcription

1 Safe and effective prescribing of nutrition: the impact of dietitian prescribing rights in New Zealand Tory Crowder, Clinical Dietitian Christchurch Hospital, Canterbury District Health Board

2 THANKYOU Susannah King Stella Friedlander Barbara Cormack Sophi Buddo Mary-Louise Hannah

3 PRESENTER DISCLOSURE Tory Crowder NZRD AUSPEN registration supported by a grant from Dietitians New Zealand (from Bohringer Ingelheim)

4 ME

5 AIMS Are we safe to prescribe? Are we effective? What has been the impact of prescribing rights by dietitians in New Zealand?

6 NEW ZEALAND HEALTH SYSTEM New Zealand (NZ) dietitians are registered and regulated by the Dietitians Board Scope of Practice Dietitians apply scientific knowledge about food and nutrition to individuals and groups in states of health and disease to promote optimal health outcomes within the social, economic, and cultural context of the New Zealand population. (Health Practitioners Competence Assurance Act 2003 regulates all health professions in NZ) Restricted activities 'Prescribing of enteral or parenteral nutrition where the feed is administered through a tube into the gut or central venous catheter ( Order in Council came into force on 1/8/2005)

7 IN NEW ZEALAND The Dietitians Board is appointed by the Ministry of Health under the HPCA Act 2003 and is mandated by legislation to protect the health and safety of the public Mechanisms which ensure dietitians are qualified, competent and fit to practise All dietitians by law if they wish to practice must be registered and hold a current practising certificate Participate in a competency programme and be subject to audit

8 CURRENTLY IN NZ 649 practitioners with the status Registered practising (current APC) - of which 494 are prescribers 128 practitioners with the status Registered nonpractising (maintenance of registration) - of which 55 are prescribers The current total of prescribers is therefore 564.

9 NZ DIETITIANS Ability to prescribe unique currently

10 PRESCRIBING OF SPECIAL FOODS PREVIOUSLY Community/outpatients Dietitians recommended Special Foods but could not: Apply for Special Food Subsidy Prescribe Special Foods e.g. subsidised supply of an enteral feed from a retail pharmacy Needed to be prescribed by a doctor (usually a specialist) to be subsidised Hospital inpatients Dietitians prescribed on a daily basis i.e. on the fluid balance or enteral feeding prescription and some DHBs special foods on the medication chart

11 HISTORY OF NZ DIETITIAN PRESCRIBING 1993 NZ Dietitians started examining the feasibility of obtaining Special Food Subsidy application and prescribing rights 2009 Dietitians Board and Dietitians NZ made a joint application to the Ministry of Health for dietitian prescribing rights 2010 Ministry of Health and PHARMAC authorised NZ dietitians to prescribe Special Foods - subsidised supply 2011 NZ dietitians able to apply for Special Foods subsidy online applications 2012 Application for dietitians to become Designated Prescribers 3 Aug 2015 Dietitians become Designated Prescribers!! Able to prescribe 3 new prescription only medicines

12 DESIGNATED PRESCRIBING

13 WHAT NZ DIETITIANS CAN PRESCRIBE NOVEMBER 2016 Special Foods enteral, oral supplements and special infant feeds Vitamin products Multivitamins Vitamins A,D,E and K Vitamin A with vitamins D and C Vitamin B complex Pyridoxine hydrochloride Thiamine hydrochloride Ascorbic acid Alpha tocopheryl acetate Folic acid Multivitamin Renal Mineral products Calcium carbonate Sodium fluoride Ferrous fumarate Ferrous fumarate with folic acid Ferrous sulphate Ferrous sulphate with folic acid Potassium iodate (iodine) Oral electrolyte replacement products Compound electrolytes Dextrose with electrolytes Potassium bicarbonate Potassium chloride Sodium chloride liquid Pancreatic enzymes (low dose) Prescription only medicines Pancreatic enzymes (high dose) Zinc Vitamin D (high dose)

14 PREPARATION FOR DIETITIAN PRESCRIBING Course developed with Dietitians Board, University of Auckland School of Pharmacy and PHARMAC To prepare dietitians to prescribe in an ethical, appropriate, safe and efficient manner within the relevant NZ legislation: Module 1: Basis of Prescribing Practice (~10hrs online) Module 2: Therapeutic and Pharmacokinetic Considerations (~ 5hrs online) Module 3: Clinical Decision-making and Prescribing Practice (6 hour workshop) Exam at end of workshop Emphasis on legal, ethical and critical thinking aspects rather than clinical Dietitian Prescribers Workshops run throughout NZ Dietitians who pass are entitled to become a Dietitian Prescriber Annual practising certificate (APC) and Dietitians Board s register endorsed

15 DIETITIAN PRESCRIBING Began April 2011 Must have a Professional Supervisor (mentor) Monitored by the Dietitians Board with a quarterly audit of what each dietitian prescribes From 2012 the prescribing course has been incorporated into the postgraduate masters course of dietitians From 2014 new graduates have been able to prescribe

16 WHAT THIS MEANS FOR OUR PROFESSION Recognition that dietitians are the best qualified health professionals to prescribe nutritional products Enables dietitians to practise at the top of their scope of practice Innovation in health workforce efficiencies A much better service for patients Comes with increased risks - and monitoring costs Future potential for expanded prescribing

17 APC ENDORSEMENT & ANNUAL UPDATE Up to date knowledge of the use of Special Foods Must complete an online prescribing update yearly to maintain prescribing rights If inactive for > 3 years must attend the Prescribing course again, have prescribing supervision including goals and evidence as part of the CCP

18 COMPLIANCE The HPCA Act contains strong sanctions to prevent HP from practising outside their scopes of practice If a dietitian is found to prescribe outside the boundaries of their APC will be investigated and could be prosecuted before the Health Practitioner Disciplinary Tribunal under the provisions of section 100 of the Act

19 AUDIT Ministry of Health send the Dietitians Board a list of all scripts written by dietitians each quarter Especially interested in high risk items eg metabolic products these are checked against a list of named metabolic dietitians If a Notice of Competence is received then looking at the individuals scripts become part of the investigation

20 EXAMPLE OF AUDIT Creon Creon Total scripts for all products by dietitians st 5 n/a nd n/a 3rd 6 n/a th st nd

21 IMPACT? scripts for the first 6 months of this year NOT being written by Specialist Doctors and GPs Dietitians prescribers are more likely to prescribe accurate and realistic quantities and reduce/manage the patients prescriptions

22 HAS ANY OBJECTIVE RESEARCH BEEN DONE IN NZ? Very Little to date but we are in early stages Sophi Buddo a dietitian at Auckland Hospital conducted a prescribing survey last year

23 THE DIETITIANS PRESCRIBING SURVEY 2015 Identify what and how Dietitians are routinely prescribing in the following settings: Hospital Community Public Health Private Practice/Aged Care Facilities Food Industry To identify any barriers to prescribing

24 RESULTS n = 128 out of 414 registered prescribers in NZ (30%) 60% Distribution of respondents 50% 40% 30% 20% 10% 0%

25 BARRIERS TO PRESCRIBING Special Foods: 96% of dietitians reported no barriers PHARMAC special authority criteria Vitamins and minerals: A lack of confidence or limited experience (31/101) Lack of knowledge around side-effects, interactions and dosing (28/101) Unable to request nutritional bloods (5/101) Not relevant or routine to my practice (4/101) Limited need as can get Doctor s to prescribe (15/101)

26 CONCLUSIONS 96% of survey respondents are prescribing Special Foods Dietitians who responded were the primary prescribers of Special Foods in their clinical setting Prescribing enteral feed practices vary throughout New Zealand and can even vary within a hospital due to different charting policies Potential safety concerns if intravenous fluids and enteral feeds are charted on separate documents 30% of survey respondents reported not being confident in routinely prescribing vitamins and minerals most commonly due to a lack of knowledge and confidence

27 OWN REFLECTIONS Enhanced my practice With my CF patients All nutrition related Special Authorities and scripts Prescribe all ONS and enteral feeds As well as prescribing fat soluble vitamins I can now prescribe all pancreatic enzymes and adjust accurately to their diet, as well high dose vitamin D for patients with deficiency More timely process/in real time no delays in clinic or in their own home Supervisor/mentor

28 CASE STUDY Mr B 63 years old lives in Kaikoura 2 hours drive away CF & borderline pancreatic sufficient 2013 faecal elastase 136 μg/g stool Nov μg/g stool Symptoms of RLQ pain, bowel urgency and reflux March 2016 Vitamin A 341 μg/l (range μg /l) Vitamin E 19μmol/l (range 23-70μmol/l) Vitamin D 60 nmol/l on high dose vit D

29 CASE STUDY Provide education via telehealth Zoom To start on Pancreatic enzymes Creon 25,000 adjusting dose to gms of fat in his meals based on food diary/food recall Apply for special authority for VITABECK Prescribe fat soluble vitamins & Vitamin D Fax script to his pharmacy Follow up phone calls and support Follow up Blood 3 months

30 OWN REFLECTIONS Has had no impact on salary or recognition within our pay scales Dietitians still seem to be hesitant to prescribe outside of Special Foods Dietitians still appear to fly under the radar with prescribing

31 SO. Are NZ dietitians safe to prescribe? I ll let you decide but I would say yes! Are we effective? Yes to Special Foods but we have to step up and take courage in our prescribing ability and knowledge Have we had impact? Yes with Special Foods, starting to with other vitamins and minerals/enzymes

32 WHERE TO NOW E-meds and electronic prescribing Ongoing education and confidence building to prescribe Reflection in salary remuneration Expansion of medicines

33 FINALLY The dietitian is often the right clinician in the right place, at the right time to assess and treat a nutrition diagnosis and prescribe appropriately The challenge is to get out of our comfort zone and prescribe nutrition! Dietitians are the Nutrition Experts!

34 GO FOR IT AUSTRALIA!

35 USEFUL LINKS