Non-medical prescribing by paramedics in emergency, urgent and critical care

Simultaneous prescribing and administration or supply

In contrast to paramedic practice within primary care settings, advanced paramedics practising in emergency departments and in prehospital settings are more likely to encounter patients who require an immediate supply or administration of medication (Bedson and Latter, 2018; Hilton et al, 2019; Dixon, 2020).

Paramedics working in emergency department settings are often employed as advanced clinical practitioners (ACPs) (Hilton et al, 2019). This role embodies the ability to access and treat patients with a wide range of pathologies from life-threatening to self-limiting illnesses (Hilton et al, 2019). Prior to the change in legislation, ACPs discussed their clinical cases with an independent prescriber, making this time-consuming and consequently delaying patient treatment (Hilton et al, 2019).

Within prehospital settings, specialist and advanced paramedics are now also adopting non-medical prescribing. This includes those employed by ambulance trusts, air ambulance charities and urgent care services. Due to the emergency or unscheduled nature of patient presentations in these settings, such people in these roles are likely to encounter patients who will require an immediate administration or supply of a prescribed medication. For example, patients presenting with minor illness or injury are likely to require an immediate supply of analgesia or antibiotics. This often occurs during the out-of-hours period when pharmacies may not be open (Bedson and Latter, 2018; Rovardi, 2019). For these patients, it may be impractical or impossible to access a prescription from a pharmacist. Similarly, paramedics using non-medical prescribing in critical care roles will also need to simultaneously prescribe and administer medication for the treatment of pain, sepsis and for sedation.

However, separating prescribing and dispensing is widely considered to be best practice in reducing prescribing errors and promoting good medicines management.

Under current medicines legislation, all paramedics can administer a range of medicines on their own initiative including morphine sulphate, diazepam and advanced life support drugs in order to provide emergency treatment (Bedson and Latter, 2018; Rovardi, 2019).

However, published literature and anecdotal discussions with ACPs have highlighted that some employers have challenged if these exemptions can be used, or if they are still applicable outside the context of emergency prehospital care (Clarke, 2019).

A further legislative option to facilitate supply or administration of medications is the use of patient group directions (PGDs). These provide a legal mechanism for the supply or administration of a medicine to patients who meet predetermined clinical inclusion criteria detailed within a PGD document. If these criteria are not met, however, the PGD cannot be used to legally supply or administer the medication to a patient (Bedson and Latter, 2018; Rovardi, 2019).

Prior to the introduction of non-medical prescribing, specialist and advanced paramedics were reliant on the use of PGDs to facilitate the supply and administration of a range of medications (Bedson and Latter, 2018). While PGDs were reported to enable successful medication supply on many occasions, they do not cater for all patient presentations and can at times restrict practice which impacts on patient care. For example, specialist paramedics in emergency and urgent care reported being unable to follow local antimicrobial prescribing guidance based on local resistance patterns when reliant on a trust-wide generic PGD (Bedson and Latter, 2018). Furthermore, ACPs have also reported that PGDs are not able to cater for all patient presentations and are not well suited to their role (Hilton et al, 2019).

Previously, guidance from professional bodies regarding simultaneous prescribing and supply or administration by non-medical prescribers has arguably not aligned with practice of advanced paramedics working within emergency, urgent and critical care settings (RPS, 2016; CoP, 2021). Equally, alternative legislative options such as PGDs and paramedic exemptions do not always cater well for paramedic practice in these settings (Bedson and Latter, 2018; Clarke, 2019; Hilton et al, 2019). However, a recent position statement from the Royal College of Nursing (RCN) and the RPS in March 2020 provides more clarity on the issue. This statement outlines that while the published guidance states that simultaneous prescribing and administration should only occur in exceptional circumstances, the context of the prescriber's practice can itself be viewed as the exceptional circumstance. The statement outlines an example of how patients treated by out-of-hours services will often require an immediate supply of medication. The practice of urgent or unscheduled care therefore represents the exceptional circumstance, rather than an individual patient case (RCN and RPS, 2020).

This therefore lends support to the use of simultaneous prescribing and supply or administration, when it is indicated, and paramedic prescribing guidance has now been updated to reflect this. The RCN and RPS guidance outlines how a clear rationale for the same person to prescribe and then supply or administer the medication should exist. Furthermore, it should be noted that this method of prescribing carries more risk and extra precaution should be taken to minimise error. Prescribing should occur from a limited formulary of medication; an appropriately labelled pack should be available; and clear record keeping is essential (RCN and RPS, 2020).

Arguably, this is not dissimilar to the practice of specialist and advanced paramedics working in prehospital settings using PGDs to supply and administer medication. These are supplied under PGD using pre-labelled packs from a restricted formulary, often as a lone responder. While this does present an increased risk in terms of medicines management and the opportunity for error, specialist paramedics have gained experience and proficiency, in safely suppyling or administering a wide range of medication under such circumstances (Bedson and Latter, 2018). This therefore lends further support to the continuation of this practice as non-medical prescribers, when an immediate supply or administration is in the patient's best interests.

Prescribing of controlled drugs

Pending a change in the Misuse of Drugs Act, advanced paramedics will potentially be permitted to prescribe a limited formulary of controlled drugs (CoP, 2018). These are morphine sulphate, diazepam, midazolam, lorazepam and codeine phosphate (Advisory Council on the Misuse of Drugs, 2019).

However, until this change in the legislation occurs, paramedics working as ACPs and those in prehospital roles are unable to prescribe controlled drugs. These drugs are likely to be needed in these job roles for prescribing pain management, seizure control and sedation. The current inability to prescribe controlled drugs was highlighted as a key challenge by the first cohorts of paramedics adopting non-medical prescribing in a range of settings (Stenner et al, 2019). However, current restrictions in controlled drug prescribing are reported to be of less concern for paramedics working in primary care settings, as they are often able to seek support from another prescriber (Dixon, 2020). In emergency settings, however, having to seek support from another prescriber can lead to a delay in patient care, particularly in situations such as sepsis or severe pain (Hilton et al, 2019). Furthermore, previous research has highlighted that delays and difficulties were reported by specialist paramedics when trying to access remote support from a prescriber within ambulance settings (Bedson and Latter, 2018).

The current situation also prevents paramedics from being able to delegate prescriptive authority for controlled drugs to others. This too can impact patient care as the paramedic may be unable to act as a team leader or undertake other clinical interventions on the patient when they are unable to delegate prescriptive authority to others.

Until legislation is updated to allow paramedics to prescribe a limited formulary of controlled drugs, the continued use of PGDs and support from other prescribers will be required. While the use of PGDs can often be used to facilitate medication supply successfully, some specialist paramedics working in ambulance settings have reported being unable to supply sufficiently strong analgesia to some patients using PGDs (Bedson and Latter, 2018). Furthermore, specialist paramedics also reported long delays accessing prescriber support or obtaining a verbal order, which also cannot be legally given for a controlled drug (Bedson and Latter, 2018). Additionally, paramedic ACPs have highlighted that PGDs are not well-suited to their role and even a restricted controlled drug formulary to prescribe from does not reflect the full range of drugs required for their role (Hilton et al, 2019).

Paramedic prescribing within ambulance settings

A range of additional issues may also impact the prescribing practice of advanced paramedics working within ambulance settings. Currently, ambulance trusts have limited access to patient records. While many trusts are now introducing access to summary-of-care records, specialist paramedics previously described concerns as to whether they would have sufficient access to patient records to support prescribing decision-making (Bedson and Latter, 2018). Specialist paramedics in the Bedson and Latter (2018) study also outlined concerns regarding sufficient access to medical and peer support for prescribing decision-making in ambulance settings.

For paramedics undertaking non-medical prescribing in other settings, it is likely that these issues may not be so applicable. For example, paramedics working within primary care and emergency departments are likely to have access to medical records. Furthermore, support from medical prescribers is often readily available in these settings to support non-medical prescribers in their decision-making (Graham-Clarke et al, 2018; Dixon, 2020).

Barriers to non-medical prescribing by nurses and pharmacists owing to difficulties accessing patient records have been previously reported (Latter et al, 2010; Courtenay et al, 2012; Herklots et al, 2015; Graham-Clarke et al, 2018). These findings further emphasise the need for ambulance trusts to ensure sufficient access to patient records to support non-medical prescribing. Equally, access to sufficient medical support has also been reported as essential in supporting the practice of non-medical prescribers (Latter et al, 2010; Courtenay et al, 2012; Herklots et al, 2015; Bedson and Latter, 2018). Further research is therefore required to establish if paramedics adopting non-medical prescribing within ambulance settings have sufficient access to both patient records and peer support.

Conclusion

While the adoption of non-medical prescribing by advanced paramedics is likely to be associated with a range of improvements to patient care and professional practice, several potential issues currently exist for advanced paramedics working in emergency, urgent and critical care (Bedson and Latter, 2018; Carey et al, 2019; Hilton et al, 2019; NHS England, 2018a).

Recently published guidance on the simultaneous prescribing and supply or administration of medication, now provides more support for this practice, when it is in the best interest of the patient (RCN and RPS, 2020).

At this time, impacts on patient care are probable as a result of restrictions on the prescribing of controlled drugs. Equally, an unrestricted controlled drug formulary will likely be required to support fully autonomous paramedic practice in emergency settings (Hilton et al, 2019).

Further developments within ambulance trusts to ensure sufficient access to patient records and the provision of appropriate medical support for advanced paramedics may be required to support non-medical prescribing in these settings (Bedson and Latter, 2018). Ongoing national strategies to improve digital access to local and summary care records within ambulance trusts have been proposed (NHS England, 2018b. These innovations in digital technology may therefore contribute to ensuring the safe and appropriate prescribing by advanced paramedics in this setting.

Currently, very little empirical evidence has been published on the topic of non-medical prescribing by advanced paramedics. Further research in this field is required to more fully understand whether the anticipated benefits from the introduction of paramedic prescribing are being realised for patients and NHS services. Strengthening this evidence base will identify where improvements can be made, while driving developments in paramedic prescribing policy and guidance, to maximise patient care and NHS service provision.

Key Points

CPD Reflection Questions