Prescribing safely under COVID-19

It is intended to provide additional principles around working remotely. It applies to all prescribers working within their normal scope of prescribing practice for adults and children.

The advice is that care should, as far as possible, be carried out remotely, and that online and telephone consultations be increased to help increase capacity. In England, a letter from the Medical Director for Primary Care dated 19 March 2020 was sent to all general practitioners and their commissioners, advising that practices move to a total triage system to ensure that all patients are appropriately referred to the right health professional setting. It was also advised that all care that can be undertaken remotely should be done so through appropriate channels and care should be prioritised for those patients at highest risk. 

Guidance 

The RCN recognises at this time of unprecedented demand there is a need for increased use of remote prescribing. This change in practice is essential to limit the spread of the virus and protect patients and staff by reducing the footfall in clinical areas. 

Guidance is already in place across the UK to move towards increased remote prescribing, and mechanisms for remote independent prescribing already exist. However, there are some services who will have less experience in running telephone consultations and will require capacity building support.

Supervision and clear guidance will also be required in the event of practice nurses being required to prescribe outside of their usual clinical area, as a result of staff shortages. 

Recognising these issues, we have developed this guidance to support nurses in prescribing safely under these conditions. 

The following process and the supporting links have been developed to support nurses in the process and help services build capacity. 

Consultation guidelines process

1. Introduction - Establish who you are speaking to and that it is the correct person, within the principles of mental capacity legislation, and introduce yourself. Check that the patient can hear and understand you, and is in a suitable place to talk
2. Presenting complaint - Establish the reason for the telephone consultation
3. History of the presenting complaint - to include symptoms, how long they have had it, any Over the Counter medication, symptoms getting better/ worse. Also check current medication, past medication and past medical history
4. In direct Physical examination - Gain information by asking the patient to describe signs such as breathing and vital signs and rashes. Questions around the signs and symptoms which can include home readings (BP for example) and documentation of patient’s description of symptoms. Use video conferencing if available and needed. In the absence of other cues, the tone and content of speech is important
5. Diagnosis - can you make a diagnosis based on the information you have collated or do you need to see the patient (you may choose to treat with less information than you would do normally to avoid seeing a patient face to face both for their safety and yours) 
6. Treat - Give clear instructions on any treatment recommended including when and how to take medication if you issue a prescription. Prescriptions can be sent to a nominated pharmacy via Electronic Prescribing systems, or if this is not available then sent to the pharmacy via their collection processes to reduce footfall in clinical services
7. Strong Safety netting - When to seek further advice including if symptoms get worse, don’t improve or if any red flag symptoms don’t improve. Remember that a face-to-face consultation or home visit may be needed
8. Remote Prescribing – Independent Prescribers can prescribe based on a telephone assessment if they can assure themselves that they are prescribing within their competence, have made an informed assessment and are safe. Always follow safe practice guidance
9. Follow up - consider if follow up is needed, and when and how the patient will be followed up 
10. Documentation - ensure documentation reflects that this is a telephone consultation and be specific over how information was obtained.