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Prescribing for wound care: the role of the nurse

Una Adderley
DN RGN MSc BSc BA
Community Tissue Viability Prescribing Nurse
Scarborough, Whitby and Ryedale PCT

Prescribing for wound care is generally thought of in terms of dressings, topical agents and bandages, and since the introduction of nurse prescribing in 1994, many community nurses have taken responsibility for this area of prescribing. However, recent legislation enabling nonmedical independent and supplementary prescribing means that nurse prescribing for wound care may now include a much wider range of items.
In 1994, following years of campaigning, legislation was introduced to enable nurses with a district nursing or health visiting qualification to undertake educational programmes that allowed them to prescribe from the Nurse Prescribers' Formulary.(1) This formulary is relatively restricted, but does include wound management products, such as the dressings, bandages and emollients available on the Drug Tariff plus a limited selection of simple analgesics.(2)
Although this was a significant step forward, it still meant that nurses without a district nursing or health visiting qualification were unable to prescribe. The second Crown report in 1999 recommended that other groups of clinicians should also be able to access education to enable them to prescribe, and that the formulary itself should be extended for these prescribers.(3) Subsequent legislation enabled nurses to qualify as extended formulary nurse prescribers or supplementary prescribers.  Supplementary prescribing is defined as "a voluntary prescribing partnership between an independent prescriber (doctor) and a supplementary prescriber (SP) (nurse or pharmacist) to implement an agreed patent-specific clinical management plan (CMP) with the patient's agreement."(4) This type of prescribing was primarily for patients with long-term medical conditions (eg, diabetes) and unlike independent prescribers, supplementary prescribers can prescribe all medications except controlled drugs, off-label medicines and unlicensed drugs.
In May 2006 the extended formulary was discontinued. Extended formulary nurse prescribers are now known as nurse independent prescribers and are able to prescribe any licensed medicine for any medical condition, including some controlled drugs.(1)
It is important not to confuse the original nurse prescribers with independent nurse prescribers or supplementary prescribers.  Nurse prescribers may still only prescribe from the Nurse Prescribers' Formulary, unless they have undertaken the additional education required to become independent nurse prescribers. 
Independent prescribing "means that the prescriber takes responsibility for the clinical assessment of the patient, establishing a diagnosis and the clinical management required, as well as for prescribing where necessary and the appropriateness of any prescription."(5) The educational preparation for this role covers consultation and clinical decision-making with regard to therapy and possible referral, influences and the psychology of prescribing, prescribing within a team context, clinical pharmacology, evidence-based practice, law, policy and ethics, professional accountability and prescribing in a public health context.(6)
The principles of prescribing for wound care, whether as a nurse prescriber, supplementary prescriber or as an independent nurse prescriber are the same; to establish the health needs of the patient and to prescribe appropriately with regard to the nurse's level of prescribing responsibility. In addition, although prescribing can only be undertaken by nurses with the appropriate qualifications, many community nurses, while not possessing these qualifications, still influence the prescribing of their medical colleagues. Any advice they give their medical colleagues should be in line with the principles underpinning responsible prescribing.
In prescribing for wound care, there may be several aspects of care that need addressing, for example, if the patient has a venous leg ulcer, the wound bed may require debridement, compression therapy may be required to reverse venous hypertension, analgesia may be required to enable compression therapy to be tolerated, and an adjuvant therapy, such as pentoxifylline, may promote healing. When deciding on an appropriate therapy, it is useful to structure decision-making using an evidence-based approach, which considers research evidence, clinical expertise, resources and patient preferences.(7)

Research evidence
When prescribing, a clinician is seeking to offer a medication or dressing that is going to be clinically effective and cost-effective. This means that ideally the patient will gain some clinical benefit from the prescribed item and the cost to the NHS will represent value for money. Consequently, when seeking research evidence, the clinician should be seeking research designs that are sufficiently rigorous to detect treatment effects such as randomised trials or case-controlled studies, which ideally include a cost-benefit analysis evaluation. 
Such information may be very difficult to find.  Medicines are only required to have evidence of safety, quality and efficacy in order to be licensed for use.(8) Efficacy is when it can be proved that a drug has a greater pharmacological effect than a placebo, but this may not translate into meaningful clinical outcomes.  For example, a drug may be proven to improve venous return in the legs but this may not translate into faster healing. This drug, while efficacious, is not clinically effective. Another drawback is that high-quality cost-benefit analyses are rarer than hen's teeth! 
Consequently, the most useful information about the clinical and cost-effectiveness for a prescribable intervention may come from a good quality systematic review where all the relevant evidence of adequate quality has been systematically considered to answer a therapeutic question.  Inevitably systematic reviews do not exist for all clinical situations and even when they do, they may simply report that there is insufficient evidence to guide practice. Despite these limitations, such reviews do allow prescribers to be fairly confident that their clinical decisions are based upon reasonably up-to-date research of adequate quality.
Unfortunately, the situation is even more difficult for prescribing decisions regarding dressings which, since they are classified as devices, only need to be safe and fit for the intended purpose to receive a licence.The evidence for effectiveness with regard to dressings is almost nonexistent and certainly insufficient for prescribers to use when making prescribing decisions. 

Clinical expertise
Alongside whatever robust research evidence may or may not exist, the prescriber needs to consider the available clinical expertise. For example, a Cochrane review may state that multilayer compression bandaging is the most effective intervention for healing a leg ulcer. However, if the patient does not have access to a clinician with the appropriate skills to apply such a bandage, it might be irresponsible to prescribe such care as it may result in harm to the patient. The prescriber may decide to prescribe compression hosiery instead, which would require less skill in application, even though the evidence with regard to healing rates is significantly less robust than that for bandaging.
Alternatively, in the absence of robust research evidence, the prescriber may have to rely on their clinical judgment. For example, the prescriber may have used a certain dressing in similar situations with good results and therefore decide to prescribe this dressing.  Although this is reasonable, it is important to remember that previous experience will never be as robust as high-quality research evidence; it is possible that previous positive outcomes may have been due to a factor other than the dressing. Consequently, the prescriber should always be seeking emerging evidence and be prepared to question their personal experience in the light of new evidence.

Resources
Cost is always an issue and while a prescriber should be prepared to fight the cause on behalf of their patients for an intervention that has proven clinical and cost benefits, they also have a duty to the public to spend NHS resources in a responsible manner. Dressing selection presents particular challenges in this respect. Cost per item can vary significantly and yet there is no robust evidence to suggest that certain dressings lead to better outcomes for patients, such as faster healing or pain reduction. In fact, it is reasonable to assume that there may be little significant difference between the makes of dressings within a certain dressing category (eg, foams, alginates, hydrocolloids). If there were clinically significant differences, one would assume that the manufacturers would be carrying out randomised controlled trials to prove these.
There are approximately 600 dressings available on prescription; maintaining up-to-date knowledge about all of these is unrealistic. Therefore, if a prescriber's organisation does not already have a wound care formulary, it may be helpful to take a formulary approach and select one make of dressings from each category of dressings as listed in the BNF to create a list of commonly used dressings.1 The prescriber then can focus on what type of dressing is required rather than attempting the impossible task of comparatively evaluating all the dressing possibilities. Selecting an appropriate dressing of adequate quality that will permit as long a wear time as is clinically appropriate should result in both cost minimisation and clinical effectiveness.

Patient preferences
The patient's preferences are a key factor in any prescribing decision. Achieving concordance at the time of prescribing is vital, particularly if the patient is going to be self-medicating or applying the prescription themselves. For example, compression hosiery may prevent recurrence of venous leg ulceration, but only if the stockings are on the patient's legs, rather than sitting in a drawer.
It is also important to consider the general health of each individual patient. For example, neurological wound pain can be effectively relieved by gabapentin, but may not be tolerated by patients with renal impairment, such as many elderly patients.
Prescribing for wound care is a complex, multi-faceted subject for which this article can only provide a broad overview. Every patient will require care that is individual to their needs. Using a framework to evaluate the patient's needs and reach a prescribing decision will help promote high-quality care.

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References

  1. British National Formulary. London: BMJ Publishing Group Ltd and RPS Publishing; 2006.
  2. Drug Tariff. 2006 Available from: http://www.drugtariff.com
  3. Department of Health. Review of prescribing, supply and administration of medicines (Crown report). London: DH; 1999.
  4. Department of Health. Supplementary prescribing. London: DH; 2002.
  5. Department of Health. Supplementary prescribing by nurses and pharmacists within the NHS in England. A guide for implementation. London: DH; 2003.
  6. Courtenay M, Griffiths M. Independent and supplementary prescribing. An essential guide. Cambridge: The Cambridge University Press; 2004.
  7. DiCenso A, Cullum N, Ciliska D. Implementing evidence-based nursing:  some misconceptions. Evid Based Nurs 1998;1:38-40.
  8. The Medicines and Healthcare products Regulatory Agency (MHRA). Available from: http://www.mhra.gov.uk


Resources

The Cochrane Library
For high-quality systematic reviews of clinical interventions
W: www.nelh.nhs.uk/cochrane.asp

The Drug Tariff Online
For up-to-the-minute information on all products that can be prescribed in the UK
W: www.ppa.org.uk/ppa/edt_intro.htm

The BNF online
Up-to-date information for all prescribers and those influencing prescribing
decisions
W: www.bnf.org/bnf/