Last month, the research round-up provided you with an overview of articles around the subject of paramedics in advanced practice roles and the requirements for practice as well as their impact. This month, we will look at prescribing and medicines management in critical care.
The first article looks at non-medical prescribing in the critical care area to explore the breadth and depth of prescribing activity. The second article looks at the role of a prescribing physiotherapist working with children in a critical/intensive care environment. In our third article we will review the experiences of patients and family members' perceptions of medication management after a critical care stay.
Non-medical prescribing in critical care: a mixed methods study
This article, online ahead of publication in the Journal of Intensive and Critical Care Nursing, sought to explore the breadth and depth of prescribing practice of non-medical prescribers (NMPs) employed in the critical care environment. This UK-based study used an online questionnaire method to gain insight into prescribing by NMPs between 26 October 2021 and 19 November 2021. This study aimed to build on work published and elicit whether prescribing practice by NMPs had evolved with increasing numbers of prescribers across professions. The questionnaire was sent to participants identified via the British Association of Critical Care Nurses who were prescribing during the study period. This was contextualised by accessing data from the relevant professional and regulatory bodies regarding the number of prescribers on their register at that time. The survey wanted to capture activity not only in the critical care unit itself but in other critical care arenas such as A&E and outreach.
The survey elicited 259 responses: 105 respondents identified themselves as non-medical prescribers, and 57 used Patient Group Directions (PGDs) only. In the ICU/HDU, 75 respondents identified as non-medical prescribers, with an additional 45 using PGDs.
The survey suggested that most achieved confidence in their prescribing practice within one year of qualification and many attributed this to regular prescribing needs. The survey also noted a difference in remuneration between professions that was disproportionate to skill.
The research also uncovered that many people working within critical care are interested in becoming non-medical prescribers and that the Future Nurse Curriculum and prescribing readiness may mean a future increase in the number of nurses undertaking prescribing courses earlier than they currently do in their careers.
The authors suggest more research is needed to fully understand the use of prescribing, PGDs and the authorising of blood products in the critical care arena as the number of prescribers increases.
The complex challenge of prescribing as an advanced clinical practice physiotherapist
This article, an e-publication in the International Journal for Advancing Practice, reports on some of the complexities faced by non-medical prescribers as the role evolves.
There is discussion of the role in general and then a focus on complexities in paediatric intensive care settings. This UK-based paper looks at prescribing from the perspective of a Health and Care Professions Council registrant advance clinical practitioner (ACP). There is a robust consideration of the legal frameworks and the differences in prescribing rights by professional background, as highlighted by the restricted controlled drug prescribing permitted by law for independent physiotherapist prescribers compared to their nurse and pharmacist counterparts.
The overview of common areas of prescribing in the paediatric intensive care area reveals a wide range of activities including endotracheal intubation, status epilepticus, neurocritical care, cardiac disorders, respiratory management and postoperative care as well as advanced paediatric life support.
The author discusses the differences in professional background access to certain medications, which means they cannot prescribe equally to peers in some of these roles. This presents a unique problem that can be a source of professional frustration and inequality in the advance practice team. In such situations, this may mean the ACP needs to use the supplementary prescribing framework and formulate a CMP, which, in anticipated situations is workable but in unplanned or emergency needs is unworkable. The paper goes on to discuss how these complexities and nuanced legal aspects are not always well understood by the members of the multi-disciplinary team in practice and require ACPs who are subject to prescribing restrictions to clearly communicate their roles. It is hoped by the author that future evolution in the area of advance practice will remove these differences to present a more unified ACP workforce in prescribing rights.
Qualitative insights into patients' and family members' experiences of in-hospital medication management after a critical care episode
This open access article, published in the journal CHEST Critical Care, posed a research question to elicit the views and experiences of critical care patients (and their families) about their involvement in, communication about, understanding of and decision-making related to their medication after transferring out of critical care.
This research used a qualitative approach including semi-structured interviews to gather data. This was conducted in a single large UK NHS Trust in the north of England with three critical care units included over two hospital sites. Interview topics were derived form the Continuum of Patient Engagement (Bombard et al, 2018). Participants were selected using purposive sampling and then stratified to include patients and their family members. The inclusion criteria ensured that they had received critical care at levels 2 or 3 and were at least 3 days post discharge from critical care to the ward environment. Exclusion criteria ensured that no-one under 18 was involved or anyone non-fluent in English. Potential participants were screened to ensure no delirium affected, aphasic or clinically deteriorating patients were involved.
A family member was defined as a person with a close familial, social or emotional relationship to the patient and was not restricted solely to next of kin. This resulted in 27 participants (15 patients and 12 family members of patients) completing the interviews, which were conducted by one researcher by telephone. Ethical approval was obtained and adhered to. Thematic analysis was used to provide a rich and detailed examination of the views gathered.
The researchers identified five themes and 15 sub-themes, providing an overview of patients' and family members' views on medication management during acute illness and ongoing recovery. These were impact of acute illness and the treatment burden on pre-existing conditions, preexisting knowledge and capability, beliefs about persons roles and expectations, care continuity and individualised information exchange, and engagement in practice.
Each theme was discussed, and examples of patient responses were included to give clarity and context. The participants' views were informed by their pre-existing knowledge and capabilities around medication and their beliefs around their own and health professionals' roles. Patients and family members wanted to be engaged with decisions regarding medications but challenges were present. These included current illness status and recovery progression. Patient participants stated that they felt they were often unable to have an active role in medication decisions and that family advocacy was important at these times.
The authors suggest their findings highlight the importance of communication around medications on transfer out of critical care and take into account the variability in engagement. They suggest that critical care patients want to engage and that clinicians need to adopt a tailored approach to facilitate this.
Conclusion
The area of medication decision making and management in critical care is a complex one. Many factors play a part in ensuring that prescribing is timely, done by the most appropriate practitioner and in the best interests of patients and patient safety. Advancing clinical practice brings a new dimension to prescribing in critical and intensive care, but is not without its drawbacks. This is an active and evolving area of research with much attention still needed.