Intensive and Critical Care Nursing
Volume 28, Issue 1 , Pages 1-5, February 2012

A critical care nurse practitioner's prescribing using standing orders and authorised prescribing when performing a critical care outreach role: A clinical audit

Critical Care Complex, Middlemore Hospital, School of Health & Social Services, Massey University, Private Bag 93311, Otahuhu, Auckland, New Zealand

Received 7 July 2011; received in revised form 25 October 2011; accepted 29 October 2011.

Article Outline

Summary 

Objective

This paper assesses the frequency of prescribing and the types of medications prescribed by a New Zealand critical care nurse practitioner (NP) whilst performing a critical care outreach role.

Method

A before and after audit was conducted from June 2006 to July 2008. Audit data were collected prospectively and analysed retrospectively. Data collected between July 2006 and June 2007 when standing orders were used were compared to data collected between July 2007 and June 2008 when the NP was authorised to prescribe. Data were analysed using count, chi-square, the Fisher's Exact Test and Phi.

Findings

The NP completed 1061 patient visits. When compared to using standing orders, the NP prescribed a greater number and a wider range of medications when authorised to prescribe (χ2=9.280, p=.002, Φ=.094). Electrolytes and analgesics were the most common medications prescribed in both audit periods.

Conclusion

The results provide insight into critical care NP prescribing practice to better inform future critical care workforce development.

Keywords: Nurse practitioner, Nurse prescribing, Critical care outreach

 

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Introduction 

New Zealand introduced nurse practitioners (NPs) to increase access to healthcare and improve patient outcomes (Ministry of Health, 2002). Nurse practitioners provide a sustainable solution to doctor shortages (Forde, 2008, Ministry of Health, 2009). They combine advanced nursing practice with skills from medicine to diagnose, assess and manage patients and can order diagnostic tests and prescribe. Historically these roles have been considered exclusive to medicine (Forde, 2008, Ministry of Health, 2009). The number of NPs in New Zealand is now approaching 100, with NPs working in varying areas of practice. The first New Zealand critical care NP registered in 2006 and remains the only NP working in this area of practice.

In New Zealand the title ‘nurse practitioner’ is legally protected. Some countries, such as Australia, have similar NP legislation, however, this is not the case in other countries (Carryer et al., 2007, Coombes, 2008, Pirret, 2008a). New Zealand NPs are expert nurses with a clinically focused Master's degree (or equivalent), who have a minimum of four years experience in a specific area of practice and have passed the Nursing Council of New Zealand's NP assessment (Nursing Council of New Zealand, 2008).

The international variability in NP legislation extends to prescribing practice. Some countries such as New Zealand, Australia, Canada, and the United States, allow NP prescribing and other countries, such as the United Kingdom (UK), allow registered nurse (RN) prescribing (Creedon et al., 2009, Dunn et al., 2010, Pirret, 2008a).

The literature outlines the roles and effectiveness of critical care NPs (Hoffman et al., 2003, Hoffman et al., 2005, Kleinpell et al., 2008, Pirret, 2008a). Minimal literature exists, however, on critical care NP or RN prescribing practice (Bray et al., 2009) due to prescribing historically being a medical role. As nurses take on more prescribing responsibilities, there is a need to fill this knowledge gap. The paper presents the results of a clinical audit measuring the types and frequency of medications prescribed by a New Zealand critical care NP when performing a critical care outreach (CCO) role.

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Method 

The study used a before and after audit design to prospectively collect data between July 2006 and June 2008. Data collected between July 2006 and June 2007 when standing orders were used were compared to data collected between July 2007 and June 2008 when the NP was authorised to prescribe. The standing orders had no limitation on medication dosage and/or frequency. Medications included in these standing orders are outlined in Table 1.

Table 1. Standing order medications.
AnalgesicsBronchodilators
MorphineNebulised Salbutamol
TramadolSodium Chloride 0.9%
Paracetamol
Miscellaneous
AntiemeticsSodium chloride 0.9% (intravenous flush)
MetoclopramideLignocaine
Ondansetron
Intravenous fluids
Emergency drugsDextrose 5%
AtropineDextrose 4%/sodium chloride 0.18%
AdrenalineSodium chloride 0.9%
AmiodaronePlasmalyte
Dextrose 50%Gelofusine
FlumazenilPentastarch 10%
Ephedrine
MidazolamElectrolytes
MetaraminolPotassium chloride
Potassium phosphate
Sodium phosphate
Magnesium sulphate

The audit was completed in a New Zealand 750 bed tertiary hospital, which had a 7 bed general intensive care unit (ICU). The ICU provided a tertiary ICU service for the national burns unit and the onsite paediatric facility. The hospital historically has had a 24hour a day, 7 days a week medical emergency team (MET) responding to ward detection of the physiologically unstable patient. This team includes an ICU registrar, a medical registrar and a ward based senior nurse. During the second 12-month period of this study, when the NP was authorised to prescribe, a modified early warning score (EWS) and algorithm were introduced to the wards. This EWS was supported by the ward based senior nursing staff involved in the MET team. These nurses, alerted when the EWS increased to 2, assisted ward nursing/medical staff in providing timely and appropriate care and initiated a MET call for more advanced care when required. An EWS of ≥5, or any patient causing concern, triggered a MET call.

The hospital introduced the CCO NP role in 2006 to further detect and manage deteriorating patients; the NP was not part of the MET team. The NP worked three shifts per week and outside these hours the ICU registrars and intensivists supported the service. As there was no published literature on this type of NP role, the NP collected audit data at each patient visit to capture the type and frequency of NP activities. This paper presents audit data collected to answer the question, how often does medication prescribing occur and what types of medications are prescribed?

Pirret (2008b) previously reported some data collected when the NP used standing orders. Data collected for this study included patient demographics and the number and type of medications prescribed. The study defined prescribing as adding or deleting a medication or altering the medication dosage or frequency on the patient's medication chart. If prescribing occurred during a patient visit it was recorded as a prescribing activity on the audit sheet. The audit sheet also recorded the classification category of the prescribed drug. If a medication had dual actions (such as an antihypertensive or a rate control agent for rapid atrial fibrillation) the NP classified the medication according to the purpose for which it was prescribed. The names of medications classified in the ‘other’ category were recorded.

Collected data were entered into a Microsoft Access data base and exported into Microsoft Excel and Predictive Analytic Software 18 Statistics programmes for analysis. Data were analysed retrospectively. Descriptive data were summarised using count. Chi-square (χ2) and the Fisher's Exact Test (FET) measured differences between variables. A statistical difference was set at a p value <05. Phi (Φ) determined effect size related to the strength of difference between the numbers of medications the NP prescribed when using standing orders and authorised to prescribe.

The hospital deemed formal ethical approval unnecessary as this study collected and analysed audit data. Patient confidentiality and anonymity was maintained throughout the audit process.

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Results 

The NP reviewed 254 patients, 133 patients when using standing orders and 121 when authorised prescribe. Referrals to CCO came from three referral streams: ICU patient discharges at a high risk of deteriorating on discharge to the ward (n=159); ward patients previously reviewed by the ICU registrar and at risk of further deterioration (n=61); and deteriorating ward patients referred by ward medical or nursing staff (n=34). Analysis revealed statistically significant differences in the type of referrals between the two audit periods. More ICU patient discharges referrals occurred when the NP was using standing orders (p=0.002) and more ICU registrar referrals occurred when the NP was authorised to prescribed (p=0.001) (refer Table 2). Referrals originated from predominantly surgical and medical wards. The specialty patient groups were similar across both audit periods (refer Table 3).

Table 2. Number and types of patient referrals.
Standing orders period (n=133)Authorised to prescribe period (n=121)Total (N=254)χ2p-Value
ICU discharges95641599.2980.002
ICU registrar ward referrals21406110.3530.001
Direct ward referrals171734.0880.767
Table 3. Specialty groups of patients referred to CCO.
Standing orders period (n=133)Authorised to prescribe period (n=121)Total (N=254)Statistical testp-Value
General surgery8173154χ2=.0090.926
General medicine322759χ2=.3670.545
Orthopaedic surgery151227χ2=.1240.725
Burns/plastic surgery437FET1.000
Women's health167FET0.056

The NP completed 1061 patient visits, 529 when using standing orders and 532 when authorised to prescribe. In the standing order period the NP prescribed 156 medications compared to 204 medications when authorised to prescribe. This difference was statistically significant (χ2=9.280, p=0.002). Phi indicates a large effect size between the numbers of medications prescribed by the NP when using standing orders and authorised to prescribe (Φ=0.094). The types and frequency of medications prescribed during these visits are outlined in Table 4.

Table 4. Types and frequency of medications prescribed by the NP.
Medication typeStanding orders period (n=156)Authorised to prescribe period (n=204)Total (N=360)Statistical testp-Value
Electrolytes7882160χ2=0.0930.761
Analgesics554297χ2=1.9990.157
Bronchodilators191332χ2=1.1950.274
Anti-emetics41014χ2=2.5720.109
Diuretics01919χ2=19.23700.000
Anti-arrhythmics088FET0.008
Anticoagulants055FET0.062
Antihypertensives033FET0.249
Antibiotics077FET0.015
Vasodilators022FET0.158
Other01313χ2=13.0870.000
Total156204360χ2=9.2800.002

Electrolytes and analgesics were the most common medications prescribed by the NP when using standing orders and authorised to prescribe. Analysis identified no statistically significant differences in how frequently these medications were prescribed. When compared to electrolytes and analgesics, prescribing of bronchodilators and anti-emetics occurred less frequently; once again analysis revealed no statistically significant differences in prescribing frequency between the two audit periods.

The NP prescribed a wider range of medications when authorised to prescribe. The study highlighted statistically significant increases in the prescribing of diuretics (p=0.000), anti-arrhythmics (p=0.008), antibiotics (p=0.015) and medications categorised as ‘other’ (p=0.000) (refer Table 4). The medications categorised as ‘other’ (n=13) included insulin, loperamide, nicotine patches and vitamin K. Although not recorded as a medication, there was a statistically significant increase in the frequency of intravenous fluid prescribed (χ2=19.775, p=0.000) when the NP was authorised to prescribe (n=76) compared to when using standing orders (n=32).

Both audit periods had similar patient outcomes (refer Table 5). Most patients seen by the NP when using standing orders and authorised to prescribe improved and discharged from CCO (n=226). All patients admitted to ICU when the NP used standing orders (n=7) survived both their ICU and hospital stay. The one patient who died during this period was referred to ICU by the NP but the intensivist deemed the patient not suitable for ICU admission. When the NP was authorised to prescribe, one of the 12 patients admitted to ICU died; the study did not collect information on the reason for the death.

Table 5. Outcomes of patients reviewed by the NP.
Patient outcomeStanding orders period (n=133)Authorised to prescribe period (n=204)Total (N=254)Statistical testp-Value
Clinically improved120106226χ2=0.4440.505
Admitted to ICU71219χ2=1.9830.159
For palliative care527FET0.712
Died112FET1.000

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Discussion 

This study demonstrates the NP prescribed more medications when authorised to prescribe compared to using standing orders. Minimal literature exists on critical care RN or NP prescribing practice hence few comparisons can be made between these results and those of other studies. Pirret (2008b) analysed the same data used in the standing orders period of this study and reported 31% of CCO patient visits required medication prescribing. Fairley (2006), in her role as nurse consultant in a surgical high dependency unit (HDU) in the United Kingdom (UK), used a daily diary to record medications prescribed over 22 days. Fairley identified gelofusin as the most frequently prescribed medication (n=7). Other medications prescribed only once were furosemide, diazepam, diclofenac, naloxone, volpex and actrapid insulin.

The variation in prescribed medications described by Fairley (2006) and in this audit is likely due to a number of factors including differing practice areas, audit timeframes and limits placed on prescribing. Fairley describes her prescribing practice in a surgical HDU whereas this study describes prescribing whilst performing a CCO role; these two areas may have different patient populations and therefore differing prescribing requirements. Fairley's conducted her study over 22 days compared to two years in this audit. Fairley's shorter timeframe limited the amount of data captured and her results may have altered if data were collected over a longer period. Fairley reports prescribing formularies limited her prescribing, as was the case in this study when the NP used standing orders. However when the NP was authorised to prescribe, legislation did not influence the type and frequency of prescribing.

This study did not measure the appropriateness of NP prescribing. In New Zealand the Nursing Council of New Zealand assesses competence in identifying medical diagnoses/problems, action planning and prescribing prior to approving NP prescribing. Hence New Zealand NPs cannot prescribe unless they demonstrate competency in these areas.

The NP prescribed more medications when authorised to prescribe compared to using standing orders. Medications prescribed by the NP when using standing orders and authorised to prescribe were prescribed in similar amounts. Statistically significant differences in the numbers of medications prescribed related to those only allowed to be prescribed by the NP when authorised to prescribe. These results support literature suggesting NP prescribing enables timely response to patient needs (Dunn et al., 2010).

The statistically significant increase in prescribing of intravenous fluids when the NP was authorised to prescribe may be due to organisational factors. The EWS and the algorithm may have resulted in ward staff identifying more deteriorating patients. This could have resulted in sicker patients being referred to CCO. No severity of patient illness data was collected making it difficult to assess the effect the NP, when authorised to prescribe, had on patient outcome.

In this audit, electrolytes and analgesics were the most frequent medications prescribed by the NP when using standing orders and authorised to prescribe. The frequency in prescribing of these may be related to the CCO patient population and the preventative nature of the NP role in identifying patient problems and intervening early. Changes in vital signs and biochemistry are well accepted signs of a deteriorating patient (Devita et al., 2010, McGaughey et al., 2007). Electrolyte imbalances, if not treated, cause dysrhythmias. Pain affects both the respiratory and cardiovascular systems and needs considering when interpreting vital signs (Pirret, 2009).

The nursing literature agrees prescribing by adequately prepared nurses provides more timely and comprehensive patient care (Dunn et al., 2010, Latter, 2008, O’Connell et al., 2009). Unfortunately, the standard of RN prescribing varies (Creedon et al., 2009, Latter, 2008, Offredy et al., 2008). Research demonstrates RNs do not fully prescribe after completing prescribing education (Bray et al., 2009). Many prescribing RNs view their prescribing preparation as inadequate and research suggests RNs have poor prescribing knowledge (Creedon et al., 2009, Latter, 2008, Offredy et al., 2008). Avery and James (2007) propose nurse prescribing would improve if incorporated within a NP role. The results of this study demonstrate most CCO prescribing is related to responding to patient problems, such as pain and electrolyte imbalance, rather than treating diagnoses. This suggests adequately preparing CCO RNs to prescribe may enable timely management of these patient problems and prevent patient deterioration.

The decreased number of ICU patient discharge referrals when the NP was authorised to prescribe reflected the increased role senior nursing staff, responding to EWS triggers, had in reviewing these patients. The increase in ICU registrar referrals during this same period reflected the increase in MET calls triggered from the EWS. The ICU registrar attending these calls recognised the need for these patients to have further reviews by the CCO service.

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Limitations 

This paper presenting clinical audit results has a number of limitations. The NP collected audit data on her own practice and NP bias could have influenced the results. This bias was minimised by retrospectively analysing the data at the end of each of the two audit periods to reduce the effect of the data on NP prescribing. Organisational changes, such as the EWS and algorithm, may have impacted on the results found in this study. The audit presents the prescribing practice of one critical care NP working in a CCO role in one hospital; audit of another critical care NP's practice may provide different results.

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Conclusion 

This paper reveals the NP prescribed a greater number and a wider range of medications when able to prescribe. Electrolytes and analgesics were the most common medications prescribed when the NP used standing orders and was authorised to prescribe. Sharing the results of this audit provides insight into critical care NP prescribing practices to better inform future critical care nursing workforce development.

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Conflict of interest 

None.

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PII: S0964-3397(11)00107-8

doi:10.1016/j.iccn.2011.10.008

Intensive and Critical Care Nursing
Volume 28, Issue 1 , Pages 1-5, February 2012

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