www.consultingroom .com @Consulting_Room

REDUCING THE CHANCE OF

COMPLICATIONSWhat difference can we

make through diet?

DEALING WITH DERMAL FILLER

COMPLICATIONSCould you handle a vascular problem?

STOCKING EMERGENCY MEDICINES

Nurses and prescribing in an emergency

THE WHO, WHAT & HOW OF LEVEL 7

IN AESTHETICSDemystifying the

qualification

IN THIS ISSUE: COMPLICATIONS MANAGEMENT IN AESTHETICS

Consulting Room | Volume 1 : Issue 2 | April - June 2018

Est. 2003

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CLINICAL: STOCKING EMERGENCY MEDICINES

BackgroundA review of how best to marry patient needs with the experience and potential scope of nursing care and provision began with the Cumberlege Report in 1986. By 1999, a review of the systems in use recognised that they no longer reflected the needs of modern clinical practice. Since 1999, legislation has been amended to allow non-medical prescribing, first for nurses in 2002, followed by pharmacists and a range of allied healthcare professionals within their scope of practice.

Prescribers are responsible and accountable for the assessment of patients with diagnosed or undiagnosed conditions and for decisions about the clinical management required, including prescribing. The amendments to the legislation since 1999 enable nurses and pharmacists to prescribe any medication for any condition within their competence/scope of practice; physiotherapists, podiatrists, optometrists and most recently, therapeutic radiographers and dieticians may act as supplementary prescribers. Aesthetic Medicine is not recognised as within scope of their registered practice..

Emergency StockOnly registered doctors, dentists (and vets) can order or hold stock drugs. This is how the legislation stands. The NMC considers the need to ensure, wherever possible, the separation of the activities of prescribing, administration, dispensing and supply.

This part of the legislation is seen as providing an important check, mitigating the risk of prescribing errors. The dispensing pharmacist checking and maintaining a record of the prescription, however, the same risks apply to doctors and dentists. The nature of prescribing errors is documented, but mainly refer to errors made by doctors in acute hospitals, there is a lack of research examining prescribing errors made by NMP’s from any perspective. Despite attempts made by BACN and Save Face to present a case for exception regarding emergency drugs, it seems unlikely any further amendments regarding this position will be made.

This restriction poses legal, professional and ethical challenges for nurses practicing autonomously in medical aesthetics; specifically, where it impacts the accessibility of essential prescription only medicines to

manage complications which require prompt administration to prevent harm or even death. Although the risk of anaphylaxis remains rare, as a known risk, nurses quite rightly, feel they cannot justify practicing without adrenaline to hand in the event of an emergency. A further anomaly in the legislation allows nurses to administer adrenaline in an emergency- without a named patient direction (but not to order it unless for a named patient on a prescription order).

Safe and Professional Navigation

Managing complications remains a hot topic; in order to safely administer cosmetic injectables, dermal fillers in particular, practitioners are advised to have an ‘emergency kit’, which includes adrenaline for anaphylaxis and Hyalase for vascular occlusion, both events which require prompt and competent attention and management.

Nurses mindful and respectful of legislation and professional standards ask the question, ‘what do I do?’. There is no body that can recommend to any practitioner, that they break or bend the law, or that they compromise the professional standards they are

EMERGENCY KITS & NURSES IN AESTHETICSEmma Davies, (RGN, NIP) explores the issues for nurses and prescribing in an emergency in independent practice.

FabrikaSimf/Shutterstock

@Consulting_Room | www.consultingroom .com | Vol 1:2 Apr-Jun 2018 | Page 39

accountable to. Each individual must risk assess themselves, their own practice and their patients and be prepared to defend the decisions they make to their statutory body.

If you choose to prescribe and order adrenaline or hyaluronidase for patient A, and then, in an emergency, administer it to patient B, you will be in theory, committing fraud; however, it is doubtful, providing you can defend your competency and decision to the regulator, that you would be prosecuted or struck off the register. Conversely, if you fail to administer appropriate treatment and care, you would almost certainly face a valid claim, and possibly a fitness to practice hearing.

The NMC considers working as part of a team, audit and having support for your prescribing decisions and actions as important, some nurses choose to engage a medical director, which has value beyond providing the facility to order stock prescription only medicines. Certainly, the role of the medical director should not be limited to this facility.

Some practitioners may be anxious to complete their emergency kits with a range of prescription only medicines. It is not necessary to include medicines which can be prescribed, ordered and administered on a named patient basis, for treatment commencing within a day or two (if not hours) of diagnosis. Neither is it appropriate to dispense pharmacy only medicines, if you are not a licensed pharmacist (premises and practice).Most clinics and patients would have access to local pharmacies nearby to dispense prescriptions for widely available drugs. It is also possible to ask a local pharmacy to hold certain medicines a patient, might require urgently.

Non-prescribing nurses, whether or not they have access to emergency drugs (*adrenaline being the sole exception) and competency to

administer, should not commence treatment without a direction to administer from a prescriber who has assessed the patient and shares the decision and responsibility for the

treatment plan. It is not illegal to prescribe remotely in

these circumstances, but the process

should be well documented and defensible. Patient group directions cannot be used in cosmetic non-surgical

practice (Government

Publication).

Practicing safely, within the law and compliance

with professional standards can be challenging in independent practice, but at the heart of every question and every professional standard is, ‘what is in the patient’s best interests?’

Nurses practicing in aesthetic medicine, must be familiar with legislation and the competency framework and risk assess:

1. Competency; not just to administer the procedure, but to diagnose and manage complications

2. CPD opportunities3. Experience of colleagues and

associates, not just themselves4. Governance and support5. Written procedure protocols

for adverse events6. Access to

essential emergency first aid tools, drugs and support

7. Referral and follow up protocols

8. Reporting pathways

9. Audit.

What to include in your emergency kit and how to ensure access to the right medicines at the right time and in the right way, will depend upon first considering and addressing all of the above, because

when something goes wrong, the list above will either be your defence or your fatal flaw.

Useful ReadingAshcroft D., Lewis P., Tully M., Farrangher T., Taylor D., Wass V., . (2015) Prevalence, nature, severity and risk Factors for prescribing errors in hospital inpatients: Prospective study in 20 UK hospitals. Drug Saf 39: 833–843.

Cope, L. C., Abuzour, A. S., & Tully, M. P. (2016). Nonmedical prescribing: where are we now? Therapeutic Advances in Drug Safety, 7(4), 165–172. http://doi.org/10.1177/2042098616646726

Government Publications. Patient group directions who can use them. Available at:www.gov.uk/government/publications/patient-group-directions-pgds/patient-group-directions-who-can-use-them

Lewis P., Ashcroft D., Dornan T., Taylor D., Wass V., Tully M. (2014) Exploring the causes of junior doctors’ prescribing mistakes: a qualitative study. Br J Clin Pharmacol 78: 310–319.

NMC Response to RPS consultation single competency framework for all prescribers (2016): Available at: www.nmc.org.uk/globalassets/sitedocuments/consultations/nmc-responses/2016/nmc-response-to-rps-consultation-single-competency-framework-for-prescribers.pdf

NMC Standards for medicines management (2007) https://www.nmc.org.uk/standards/additional-standards/standards-for-medicines-management/

NMC Remote prescribing and assessment (2008) www.

nmc.org.uk/globalassets/sitedocuments/

circulars/2008circulars/nmc-circular-16_2008.

pdf

RCN Accountability and Delegation https://www.rcn.org.uk/professional-

development/accountability-and-

delegation

Royal Pharmaceutical Society (2017) Prescribing

Competency Framework: available at www.rpharms.com/resources/frameworks/prescribers-competency-framework

Medicines Act Part III section 55. Exemptions for doctors, dentists, vetinary surgeons and vetinary practitioners.

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CLINICAL: STOCKING EMERGENCY MEDICINES

Aesthetic Complications Expert Group Emergency Kit An emergency kit is essential for anyone performing aesthetic treatments as in the event of a medical emergency, there is not enough time to prescribe and order the drugs required to treat it. According to Regulation 238 of the Human Medicine Regulations 2012, anybody can inject adrenaline and other drugs listed in Schedule 19 of the Regulations for the purpose of saving a life without breaking any laws, however this does not get around the issue of how to obtain these drugs in the first place.

In the future, the Aesthetic Complications Expert Group would like to facilitate a register of clinics who stock emergency drugs that may be accessed in the case of an emergency by nurses who are unable to stock these drugs and also a register of experienced practitioners who may be able to give advice to others when diagnosis or treatment decisions are in doubt.

The basic Emergency Kit should contain the following items:Adrenaline 1:1000 1ml 2 ampoules

Hyaluronidase 1500 units 2 ampoules

Water For Injection 10ml 2 ampoules

Aspirin 75mg 4

Topical Glyceryl Trinitrate 30g

Normal Saline Steripod Eye Wash 2 x 10ml

Resuscitation Mask Adult x 1

2ml Luer-lok Syringe 2

10ml Luer-lok Syringe 2

1ml Graduated Syringe 3

23G Blue Needles (25-30mm) 4

27G Grey Needles 2

30G Yellow Needles 2

According to the latest guidance from the Resuscitation Council, the administration of chlorphenamine and hydrocortisone should be restricted to practitioners who are experienced in their use and pre-scribe these drugs on a frequent basis. It is unlikely that practitioners who are working solely in aesthet-ic medicine would be considered experienced and therefore the recommendation would be to call an ambulance and carry out Basic Life Support before help arrives.

The Emergency Kit is appropriate for the vast majority of aesthetic practitioners but it is recommend-ed that the clinical lead for each establishment carries out a risk assessment and have facilities and equipment suitable for the treatments offered. Clinics offering surgical treatments or treating high-risk patients, such as the very obese, may require oxygen and a defibrillator on site. There are several other medications that may be useful to have available to prevent or deal with a complication but not re-quired as an emergency so could be held as stock or prescribed on a named patient basis as required:

1. Iodipine 0.5% Ophthalmic Solution (5mg/ml)2. Aciclovir 200mg tablets x 253. Topical antibiotic (e.g. Fucidic Acid)4. Topical steroid (e.g. Hydrocortisone, Clobetasone butyrate, Betamethasone)5. Oral antibiotic (e.g. Flucloxacillin 500mg QDS x 28 or Clarithromycin 500mg BD x 14)6. Oral antihistamine (e.g. Loratadine 10mg)

No-one should be performing cosmetic treatments if they do not have the knowledge, skills and resources to immediately deal with a complication.

Check the emergency kit on a monthly basis for any drugs that have ex-pired and need replacing and replace any used drugs straight away.