|NHC 2013 |NHC 2013 |NHC 201

Sore Throat Clinics   Workbook - Standing Orders for Registered Nurses in Primary Care

For the treatment of Group A Streptococcal sore throats in Primary Health Care

ISBN: 978-0-473-32154-3

1

Table of Contents Introduction

2

Directions

2

Medico‐Legal/Professional Requirements

2

Pre‐requisites & Learning Resources

3 

Associated Documents and References

3

WORKBOOK:  Standing Orders for Registered Nurses Questions Specific To Standing Orders for Registered Nurses Throat Swabbing Procedure Quick Reference Medication Table Standing orders

4‐ 11            12‐15            16 17  18‐ 20

DATA SHEETS:  NEW ZEALAND DATA SHEET: CILICAINE VK

21‐28

NEW ZEALAND DATA SHEET: OSPAMOX

29‐43

NEW ZEALAND DATA SHEET: E‐MYCIN

44‐53

NEW ZEALAND DATA SHEET: BICILLIN

54‐61 

NEW ZEALAND DATA SHEET: LIDOCAINE CLARIS

62‐ 74

INTRAMUSCULAR INJECTION OF BICILLIN >30KG

75‐76

INTRAMUSCULAR INJECTION OF BICILLIN  30 ml/min. The maximum recommended dose in patients with creatinine clearance between 10 and 30 ml/min is 500 mg twice daily. The maximum recommended dose in patients with a creatinine clearance < 10 ml/min is 500 mg/day. In patients receiving peritoneal dialysis, the maximum recommended dose in 500 mg/day. Amoxicillin may be removed from the circulation by haemodialysis. Renal impairment in children under 40 kg - Creatinine clearance >30 ml/min: No adjustment necessary - Creatinine clearance 10 to 30 ml/min: 15 mg/kg give twice daily (maximum 500 mg/twice daily) - Creatinine clearance 30kg) You will need:     

1.2mu prefilled Bicillin syringe (with Bicillin needle) 2% Lignocaine ampoule X1 1ml syringe 25g 1” needle BUZZY®

Process: Ensure an aseptic non touch technique is used throughout procedure.  2 RNs independently double check the pre-filled Bicillin syringe and Lignocaine ampoule  Administering RN draws up 0.25ml of 2% Lignocaine into a 1ml syringe  Checking RN confirms right volume in syringe  Attach 25g 1” needle to the 1ml syringe containing Lignocaine  Remove cap from pre-filled Bicillin syringe and draw back plunger to allow space for Lignocaine  Add Lignocaine to the pre-filled Bicillin syringe  Discard empty Lignocaine needle/syringe in sharps bin  Push plunger up gently so there is no air in the Lignocaine/Bicillin syringe  Attach Bicillin needle (with needle guard) and warm injection with hands  Locate site for VG injection (see below)  Press activated BUZZY® directly on injection site and leave for 1 minute  Slide BUZZY® 2-5cm proximal to site  Use distraction while administering (non-procedural talk/eye spy/breathing)  Administer Lignocaine/Bicillin to client slowly. Give first portion containing Lignocaine and wait a few seconds then give remaining Bicillin (leave BUZZY® vibrating until needle is removed). Note: Discard unused Lignocaine at the end of the day.

Administration: Gluteus Medius Muscle  This site is recommended in adults and children over seven months old as it is the largest muscle in the young child.  Potential complications are limited as it is free from nerves and major vascular structures.  Site is easily palpable and accessible in both thin and obese patients.  The muscle is accessible in the supine, prone or side lying position.  Subcutaneous tissue is thinner over this muscle and has a consistent thickness of adipose over it ensuring that the needle will penetrate the muscle.

Version 1

Version 1

Intramuscular Injection of Bicillin with Lignocaine added For clients < 30kg You will need:      

1.2mu prefilled Bicillin syringe (with Bicillin needle) 2% Lignocaine ampoule X1 1ml syringe X1 3ml syringe X2 23g 1” needle BUZZY®

Process: Ensure an aseptic non touch technique is used throughout procedure.  2 RNs independently double check the pre-filled Bicillin syringe and Lignocaine ampoule  Using a 3ml syringe pull the plunger back to 1.15ml o Decant the Bicillin from the prefilled syringe into the 3ml syringe using a 23g needle filling from plunger end of 3ml syringe first to avoid air bubbles  Administering RN draws up 0.25ml of 2% Lignocaine into a 1ml syringe  Checking RN confirms right volume in syringe  Attach 23 (or 25)g 1” needle to the 1ml syringe containing Lignocaine  Add Lignocaine to the 3ml Penicillin filled syringe  Discard empty Lignocaine needle/syringe in sharps bin  Push plunger up gently so there is no air in the Lignocaine/Bicillin syringe  Attach Bicillin needle (with needle guard) and warm injection with hands  Locate site for VG injection (see below)  Press activated BUZZY® directly on injection site and leave for 1 minute  Slide BUZZY® 2-5cm proximal to site  Use distraction while administering (non-procedural talk/eye spy/breathing)  Administer Lignocaine/Bicillin to client slowly. Give first portion containing Lignocaine and wait a few seconds then give remaining Bicillin (leave BUZZY® vibrating until needle is removed). Note: Discard unused Lignocaine at the end of the day.

Administration: Gluteus Medius Muscle  This site is recommended in adults and children over seven months old as it is the largest muscle in the young child.  Potential complications are limited as it is free from nerves and major vascular structures.  Site is easily palpable and accessible in both thin and obese patients.

Version 1

 

Version 1

The muscle is accessible in the supine, prone or side lying position. Subcutaneous tissue is thinner over this muscle and has a consistent thickness of adipose over it ensuring that the needle will penetrate the muscle.



79



Sore Throat Clinics

Appendix

                                       

  |NHC 2013



80



OVERVIEW

 

Around 50 South Auckland children are affected by Rheumatic Fever each year, the largest  number of cases of any DHB in New Zealand. New Zealand children, particularly Māori and  Pacific children, have one of the highest rates of rheumatic fever in the developed world.  Rheumatic fever is a serious illness that is preventable. It mainly occurs in children (aged 5‐19  years) after a Group A Streptococcal (GAS) throat infection. For some children an autoimmune  response will occur where the body will attack its own tissue: heart, brain and joints. In adult  life it may develop into chronic heart disease and require heart surgery.  The Ministry of Health has invested over $40million into reducing the rates of rheumatic fever  in Counties Manukau. Counties Manukau Health (CMH) is committed to reducing Acute  Rheumatic fever rates in the district and acknowledges the complexity of preventing this  disease as well as the wide range of activities and investment which will be needed if a  significant reduction in cases is to be achieved.  An overall reduction in ARF incidence of two thirds is needed in order to achieve the Better  Public Service target by 2016/17.   In order to achieve this goal several interventions have been put in place. Services have been  implemented in primary and intermediate schools as well as primary care clinics.     

SERVICES



  The National Hauora Coalition is the lead contractor for Mana Kidz. This successful  programme is the largest initiative in New Zealand to combat the silent childhood illness of  rheumatic fever. It is spread across four communities; Otara, Mangere, Manurewa and  Papakura covering 61 schools, and 25,000 children.  Each comprehensive clinic has a registered nurse and whānau support worker. These health  teams are based in schools Monday to Friday attending to rheumatic fever prevention  services. Mana Kidz is a proactive initiative, which strives to improve health outcomes for  Tamariki across Counties Manukau.   The National Hauora Coalition has set up these clinics in partnership with the Counties  Manukau District Health Board and with the support of local providers: Kidz First, East Tāmaki  Health Care, Otara Union, Health Star Pacific, Turuki Health Care, Te Hononga O Tāmaki Me  Hoturoa, ProCare and Papakura Marae. 





81

Mana Kidz is not only the largest rheumatic fever initiative in New Zealand, but also an  example of primary health organisations working together in an alliance to improve the health  and wellbeing of tamariki.  

   

   

     



82



What is Mana Kidz?

 

Mana Kidz is the name for the school‐based health service in Counties Manukau.  All school clinics are led  by Registered Nurses from either Health or General Practice with help from skilled Whanau Support  Workers (WSWs).  Mana Kidz is governed by the Child Health Alliance, an alliance forum with a focus on  improving the health of children in South Auckland which includes membership from health providers and  key organisations that fund and/or provide health care to children living in the Counties Manukau area.  Currently, dedicated Mana Kidz teams are working in 61 schools in South Auckland providing  comprehensive school based, nurse led health services for children in identified schools.  This has been  accomplished in conjunction with the rheumatic fever prevention response and has enabled teams to  deliver sore throat checks, skin assessments and treatments five days a week.  The Mana Kidz nurses also  manage school health referrals such as hearing and vision follow up and other child health issues which  have historically been managed by Public Health Nurses. This includes home visiting.   Mana Kidz Nurses are a highly skilled group of nurses with a population health perspective who are able  to deal with a range of health issues.  Enabling these RNs, through extra training and support, to work  independently under standing orders is both empowering for them as a workforce, and for the population  they serve through improved access to much needed health care.  Another key strength is the emphasis on empowering families and individuals by providing them with  knowledge on a myriad of health issues and encouraging, supporting and motivating them to achieve  good antibiotic adherence and positive health outcomes.  The delivery of this aspect of care is  undoubtedly one of the most challenging, but the potential benefits are immeasurable.  The Mana Kidz model of nurse‐led care is easily transferable to primary care response where an  innovative approach is needed to effect change in the RF rates.  The utilisation of specially trained nurses  operating at the top of their scope within primary care is not new, but has not been implemented on a  large scale or with a clear set of guidelines, standing orders, and a dedicated supported training pathway  such as this.    “Sometimes the questions are complicated and the answers are simple.”   ― Dr. Seuss 

             



Rheumatic fever:

the neglected disease Key concepts

The problem

■■ New Zealand continues to have high rates of

Pacific peoples have the highest rate of rheumatic fever

rheumatic fever, particularly among Pacific

in New Zealand and one of the highest rates in the world.

peoples

In 2009, there were 53 notified cases of rheumatic fever

■■ 80% of cases occur in young people aged less than 15 years ■■ The majority of areas with a high incidence of rheumatic fever are in the North Island ■■ Acute rheumatic fever can be prevented by

among Pacific peoples in New Zealand, a rate of 23 per 100 000. This is over six times the overall rate for all New Zealanders of 3.5 per 100 000 (a total of 140 cases).1 New Zealand stands out from most other developed countries in continuing to have high rates of acute

effective treatment of Group A streptococcal

rheumatic fever (ARF) and rheumatic heart disease (RHD).

throat infection

It is estimated that 97% of cases of RHD worldwide occur

■■ Management of people presenting with sore throat should be guided by age, ethnicity and

in developing countries and in the indigenous populations of countries such as New Zealand and Australia.2

location ■■ Guidelines have been developed for the diagnosis and management of sore throat and acute rheumatic fever and also for primary and secondary prevention of rheumatic fever

Since 1984, ARF has been a notifiable disease in New Zealand. However, it continues to be under-notified despite increasing rates each year.3, 4 There is significant geographical variation in the rates of ARF in New Zealand, with the highest rates in the North Island, e.g. Tairawhiti, Hawke’s Bay and Northland.1,5 However, clusters of cases occur in a number of communities across New Zealand.   Best Practice Tip: Check the incidence of rheumatic fever in your DHB area. A map of New Zealand showing rates per DHB is available in the Heart Foundation Rheumatic Fever Guidelines (see sidebar). BPJ | Issue 32 | 15

The majority of cases of ARF (approximately 80%) occur

in areas with a high incidence of rheumatic fever, should

in young people aged less than 15 years. The high rates

have a throat swab taken.

1

of ARF in Pacific peoples have been widely attributed to socioeconomic factors such as overcrowding, poverty and

If the child has any of the following clinical features,

poor nutrition, but also to delayed diagnosis and treatment

empirical antibiotics should be prescribed:6

of streptococcal throat infection. Group A streptococcal throat infection Appropriate diagnosis and treatment of streptococcal sore throat in high risk populations is required to reduce the

▪▪ Tonsillar swelling or exudate ▪▪ Anterior cervical lymphadenopathy ▪▪ No cough or coryza (which may suggest viral cause) ▪▪ Temperature ≥38ºC

incidence of ARF. A guideline for the management of sore throats in New Zealand (see sidebar) has been developed

If none of the clinical features are present, wait for the

to assist with targeted treatment of streptococcal throat

results of the throat swab. If the swab is positive for

infection and includes algorithms for individual and

group A streptococcus, a ten day course of antibiotics,

household management.

e.g. penicillin V, amoxicillin or erythromycin, should be prescribed.

Community pharmacists, particularly those in areas of high ARF incidence, can assist by encouraging patients with sore throat to see their GP.

Acute rheumatic fever and rheumatic heart disease ARF arises from an autoimmune response to group A

Approach to treatment of sore throat in high risk groups

streptococcal throat infection. On average there is a

A key message from the Auckland Regional Public Health

latent period of three weeks between the initial infection

Service is to: “Think differently about sore throats in

and the development of symptoms of ARF. The majority

different population groups”.

of people with ARF are very unwell, in considerable pain

6

and require hospitalisation for confirmation of diagnosis All children presenting with sore throat who are of Pacific

and treatment. ARF causes a widespread inflammatory

or Māori ethnicity, aged three years and over and who live

response that affects the heart, joints, skin and brain.

The Heart Foundation Rheumatic Fever Guidelines The Heart Foundation of New Zealand has developed a

The full guidelines are available from the Heart Foundation

three part guideline for rheumatic fever;

website: www.heartfoundation.org.nz Keyword search:

1. Diagnosis, management and secondary prevention 2. Group A streptococcal sore throat management 3. Proposed rheumatic fever primary prevention programme These guidelines provide key information including: ▪▪ A geographical map of rheumatic fever incidence ▪▪ Guidelines for the management of sore throat ▪▪ Clinical features and diagnosis criteria for rheumatic fever 16 | BPJ | Issue 32

Rheumatic fever

The heart (specifically the mitral and/or aortic valves) is

It has been estimated that over 60% of patients with ARF

the only organ that suffers long term damage, particularly

will develop RHD,9 which remains a significant cause of

after recurrent attacks of ARF. In some people ARF may

premature death in New Zealand (responsible for up to

be silent and symptomless, but still affects the heart i.e.

200 deaths each year).10 Adult patients may present with

causing subclinical carditis.4, 7

RHD that is a legacy of ARF from decades previously.

ARF is diagnosed clinically because there is no single

The difficulties

diagnostic test available. Diagnosis is based on the Jones

Not all streptococcal throat infections cause symptoms

criteria although these may not be sensitive enough to

and many children with sore throat do not present to

detect ARF in populations with a high incidence such as

primary care. Therefore there should be a low threshold

Pacific peoples.

for swabbing and treating sore throats in people who live

8

in areas of high incidence of ARF. A modified version of the Jones criteria and a full description of the clinical features of the major and minor

Pacific people are often stoical, putting up with a sore throat

manifestations of ARF are detailed in the Heart Foundation

or a sore joint and not presenting for medical care. Pacific

guidelines for rheumatic fever (see sidebar). Criteria for

families may prefer to use traditional health remedies

diagnosing ARF include the presence of two major, or one

rather than visit a doctor. Children may present later, so

major and two minor, manifestations, plus a preceding

in high incidence areas antibiotics should be prescribed

group A streptococcal infection. Major manifestations

empirically rather than waiting for swab results (if the

include carditis, polyarthritis, chorea, erythema

child has a sore throat and clinical features as detailed

marginatum and subcutaneous nodules. In New Zealand,

previously). A sore, swollen joint in a child should never

evidence of subclinical carditis on echocardiogram

be ignored and a possible diagnosis of ARF should always

is also accepted as a major manisfestation. Minor

be considered.

8

manifestations include fever, raised CRP, polyarthralgia and prolonged P-R interval on ECG. If these signs are not

Populations that are transient are likely to be more at

present but there is strong clinical suspicion, ARF remains

risk. There may be a lack of continuity within primary

a possible diagnosis.

care which can result in delayed diagnosis or treatment

8

or stopping antibiotics needed for secondary prevention. Diagnostic certainty may vary according to location and

Irregular school attendance may jeopardise school-based

ethnicity. It is recommended that a lower threshold for

detection programmes. Multiple caregivers may result

diagnosis be applied to people who:

in a child attending multiple GPs. Secondary prevention

8

▪▪ Are in high risk groups (such as Māori and Pacific peoples) ▪▪ Live in lower socioeconomic areas ▪▪ Have delayed presentation ▪▪ Have atypical clinical features at presentation

programmes are also only effective with consistent longterm follow up.

The solutions Targeted interventions are important. New Zealand-wide approaches include: ▪▪ Ongoing awareness and education about the Heart

Refer all patients with suspected ARF to hospital. Clinical

Foundation rheumatic fever treatment guidelines

follow-up of patients and their close contacts, and the

for all medical care staff both at a primary and

ongoing use of prophylactic antibiotics after an attack of

secondary care level. The goal is for a reduced

ARF are important in preventing recurrence of ARF and

incidence of ARF through effective treatment of sore

RHD.

throat. BPJ | Issue 32 | 17

▪▪ Secondary prevention programmes to prevent

Any child who tested positive for group A Streptococcus

recurrence in people who have had confirmed ARF

received a ten day course of antibiotics. This campaign

or RHD. These programmes rely on effective follow

has raised public awareness and has increased the

up to ensure regular administration of prophylactic

number of parents requesting throat swabs for children

antibiotics over a minimum of ten years.

with sore throat.

School-wide regular throat swabbing programmes have

More information is available from:

successfully reduced the incidence of ARF in some

www.toiteorapublichealth.govt.nz/Rheumatic_Fever_

regions. The use of portable echocardiograms to detect

GP

previously undiagnosed RHD in school children has also been initiated in some areas.

The “Say Aah” campaign in Flaxmere, Hawkes Bay, is fronted by All Black Israel Dagg. This campaign aims to

Solutions aimed at improving housing, reducing

obtain parental permission to take throat swabs from all

overcrowding and improving the socioeconomic situation

school children in Flaxmere, an area with a rheumatic

of Pacific peoples will require a longer time frame and a

fever rate of 32 per 10 000.

co-ordinated approach with other sectors, e.g. education, welfare and housing, at both local and national levels.

In 2002, a successful community based primary prevention programme for rheumatic fever was initiated

Some recent regional approaches include:

in Whangaroa, Northland. For more information on

The Opotiki Rheumatic Fever prevention project led

this programme, see “How a community controlled the

by Te Ao Hou PHO was initiated in October 2009. The

Streptococcus”, BPJ 13 (May, 2008).

message was: “sore throats matter”, and the project involved community health workers visiting primary schools, three times a week, to take throat swabs (with parental consent) from children who reported sore throat.

  For further information about rheumatic fever see “Why we still need to think of rheumatic fever”, BPJ 13 (May, 2008).

References 1. ESR. Public Health Surveillance. Notifiable and Other Diseases in

6. Auckland Regional Public Health Service (ARPHS). Sore throats

New Zealand. Annual Surveillance Report. ESR, 2009. Available

and acute rheumatic fever: advice for GPs and Practice Nurses.

from www.surv.esr.cri.nz (Accessed Oct, 2010).

Available from: www.arphs.govt.nz/Guidelines/SoreThroats_ARF. asp (Accessed Oct, 2010).

2. White H, Walsh W, Brown A et al. Rheumatic Heart Disease in Indigenous Populations. Heart Lung Cir 2010;19:273-81. 3. Loring B. Rheumatic Fever in the Bay of Plenty and Lakes District Health Boards. A review of the evidence and recommendations

7.

Tubridy-Clark M, Carapetis JR. Subclinical carditis in rheumatic fever: A systematic review. Int J Cardiol 2007;119(1):54-8.

8. Heart Foundation of New Zealand (HFNZ). New Zealand guidelines

for action. Summary Report. 2008. Available from: www.

for rheumatic fever. 1. Diagnosis, management and secondary

toiteorapublichealth.govt.nz/vdb/document/150 (Accessed Oct,

prevention. HFNZ, 2006. Available from www.heartfoundation.org.

2010).

nz (Accessed Oct, 2010).

4. Wilson N. Rheumatic heart disease in indigenous populations – New Zealand experience. Heart Lung Circ 2010;19:282-8. 5. Heart Foundation of New Zealand (HFNZ). New Zealand guidelines for rheumatic fever. 2. Group A Streptococcal Sore throat

9. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis 2005;5(11):665-732. 10. Ministry of Health. New Zealand mortality statistics: 2006-2009.

Management. HFNZ, 2008. Available from: www.heartfoundation.

Ministry of Health. Wellington, 2010. Available from: www.moh.

org.nz (Accessed Oct, 2010).

govt.nz (Accessed Oct, 2010).

18 | BPJ | Issue 32

Standing Order Guidelines 2012

These guidelines are issued by the Ministry of Health and represent the Ministry’s view as to the matters contained in the Medicines (Standing Order) Regulations 2002. They do not constitute legal advice as to the regulations. Users are encouraged to seek their own legal advice on such matters.

Citation: Ministry of Health. 2012. Standing Order Guidelines. Wellington: Ministry of Health. Published in June 2012 by the Ministry of Health PO Box 5013, Wellington 6145, New Zealand ISBN 978-0-478-39329-3 HP 5482 This document is available at www.health.govt.nz

Contents 1

Introduction and purpose

1

2

Exclusions

2

3

Issuer

3

4

People working under standing orders

4

5

Medicines

5

6

Contents of a standing order

6

7

Period for which the standing order applies

7

8

Record keeping

8

9

Competency, including training

9

10 Countersigning and audit of standing orders

10

11

Review of standing orders

11

12

Availability of standing orders

12

13

Enforcement

13

Checklist for use of standing orders

14

Appendix 1: Standing order template guide

18

Standing Order Guidelines

iii

1

Introduction and purpose

1.

A standing order is a written instruction issued by a medical practitioner or dentist. It authorises a specified person or class of people (eg, paramedics, registered nurses) who do not have prescribing rights to administer and/or supply specified medicines and some controlled drugs. The intention is for standing orders to be used to improve patients’ timely access to medicines; for example, by authorising a paramedic in an emergency or a registered nurse in a primary health care setting.

2.

Currently, medical practitioners and dentists are the only prescribers who can issue standing orders.

3.

The purpose of these guidelines is to provide guidance for health professionals working with standing orders, to assist issuers to comply with the regulations when developing a standing order, and to assist people administering and/or supplying under standing orders.

4.

The use of standing orders is governed by the Medicines (Standing Order) Regulations 2002 (Standing Order Regulations). This regulation sits within the broader health regulatory regime that includes:

5.



the Medicines Act 1981 and Medicines Regulations 1984



the Misuse of Drugs Act 1975 and Regulations 1977



the Health Practitioners Competence Assurance Act 2003



the Health and Disability Commissioner (Code of Health and Disability Services Consumers’ Rights) Regulations 1996.

The above legislation can be accessed online at www.legislation.govt.nz. Hard copies can be purchased from Bennetts Government Bookshop (Wellington), phone (04) 499 3433 or by ordering online at www.bennetts.co.nz.

Standing Order Guidelines

1

2

Exclusions

6.

A standing order does not allow a person to generate a prescription and provide it to a patient to take to a pharmacy to be dispensed (with the prescription signed later by the issuer of the standing order). Pharmacies cannot lawfully dispense unsigned prescriptions. Nor does a standing order allow a person to provide a patient with a prescription that has been ‘pre-signed’ by the medical practitioner or dentist who issued the standing order.

2

Standing Order Guidelines

3 7.

8.

Issuer To issue a standing order a person must be one of the following: (a)

an individual practitioner1 in practice

(b)

a practitioner who is an employer of a practitioner or a person permitted to supply or administer a medicine under a standing order

(c)

a practitioner who exercises managerial control over a practitioner or a person permitted to supply or administer a medicine under a standing order

(d)

a practitioner who is authorised by a group of practitioners or a group of people permitted to supply or administer a medicine under a standing order on their behalf.

Standing orders are a significant and specific authorisation from the issuer. It is important to clearly specify the issuer of each standing order within an individual general practice or hospital ward/department. The issuer retains overall responsibility to: 

ensure the legislative requirements for the standing order are met



ensure that anyone operating under the standing order has the appropriate training and competency to fulfil the role



countersign, audit and review the standing order.

NOTE: Many of the duties (eg, countersigning, annual review) can only be performed by the issuer who originally issued the standing order. If the issuer leaves the organisation or goes on leave for an extended period, a new standing order will be necessary.

1

The Standing Order Regulations define a practitioner as a medical practitioner or dentist.

Standing Order Guidelines

3

4 People working under standing orders 9.

A person who is permitted to administer and/or supply medicines under a standing order must be engaged in the delivery of a health service. They may include, for example: 

registered nurses



paramedics



New Zealand Defence Force medical personnel.

10.

To meet regulatory requirements, a person working under standing orders must have the competency and training to be able to make an assessment that the standing order applies to the presenting patient, the competency to administer and/or supply the medicine, and the knowledge to assess the contraindications and/or exclusions. See ‘Section 9: Competency, including training’.

11.

All staff potentially affected by the standing order should be identified in the development of the standing order. It is recommended that the standing order be developed in consultation with the staff who will be expected to work under that standing order, or representatives of those staff.

12.

A standing order permits or empowers people to administer and/or supply medicines; it cannot require them to do so. In every case it will be a matter of professional judgement by the person concerned as to whether to administer and/or supply medicines pursuant to a standing order. This subject is not covered in detail in these guidelines. The employer or health organisation should have a written policy relating to the standing orders that records the agreement of the management, issuers and those who will administer and/or supply medicines under that standing order. Working under standing orders may be part of the person’s duties as an employee or independent contractor, or may be governed by contract.

4

Standing Order Guidelines

5 13.

Medicines The following medicines can be administered and/or supplied in accordance with a standing order: 

prescription medicines



restricted medicines (pharmacist-only medicines)



pharmacy-only medicines



controlled drugs listed in Part 1 of Schedule 2 to the Misuse of Drugs Act 1975 which are exempt under Misuse of Drugs Regulation 22 and Part 3 of Schedule 2 to the Misuse of Drugs Act 1975



controlled drugs listed in Parts 2 to 7 of Schedule 3 of the Misuse of Drugs Act 1975.

Note: the Immunisation Handbook 2011 sets out who can administer vaccines and in what circumstances a standing order is required: www.health.govt.nz/publication/immunisation-handbook-2011 (Section 2.1, page 38). 14.

Medicines and controlled drugs to be administered and/or supplied must be available on-site. Requirements for the labelling, packing, storage and handling of medicines are specified in the Medicines Regulations 1984. The labelling, packing, storage and handling requirements relating to medicines must be understood and complied with prior to issuing a standing order.

15.

If a standing order includes medicines that require reconstitution, the issuer should ensure the availability of the necessary equipment (eg, accurate measuring vessels) and/or training.

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6 Contents of a standing order 16.

The regulations require that the standing order includes: 

an explanation of why the standing order is required



the circumstances in which the standing order applies – for example, a paramedic in an emergency or a registered nurse running a specified school clinic



the class of people able to administer and/or supply under the standing order – for example, paramedics, registered nurses



the competency requirements of the person administering and/or supplying a medicine under a standing order (see ‘Section 9: Competency, including training’ for further information)



the treatment of condition/s to which the standing order applies – for example, urinary tract infection, asthma



the medicines that may be supplied or administered under the standing order



the indications for which the medicine is to be administered and the recommended dose or dose range for those indications



the number of dose(s) of the medicine for which the standing order is valid



the contraindications and/or exclusions for the medicines, the validated reference charts for dose calculation (if required) and the monitoring of a medicine (if required)



the method of administration



whether countersigning is required and, if countersigning is required, the timeframe for countersigning



the clinical documentation to be recorded



the period for which the standing order applies (see ‘Section 7: Period for this the standing order applies’ below).

These requirements are included in ‘Appendix 1: Standing order template guide’. 17.

If a standing order lists more than one medicine for the treatment of a condition, clear guidance must be provided about which medicine is preferred in what circumstances. For example, medication A for children aged 5–12 years; medication B for pregnant women; medication C for non-pregnant adults.

NOTE: It is recommended that the standing order lists a medicine by its generic name rather than the trade name. This will avoid the need to update the standing order every time the trade name of the available product changes.

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7 18.

19.

Period for which the standing order applies The standing order must specify the period for which it applies. If it is not appropriate to state a specific period, then the standing order must state that it is to apply until it is either: 

replaced by a new standing order covering the same subject matter or



cancelled in writing by the issuer.

Whatever the specified period for the standing order, it must be reviewed by the issuer at least annually (see also ‘Section 11: Review of standing orders’). The standing order must specify the required review date. Following review, the standing order should be re-signed and dated.

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8 Record keeping 20.

A person who administers and/or supplies a medicine under a standing order must document the assessment and treatment of the patient (including any adverse reactions) in the clinical record and, if necessary, any monitoring or follow-up of the patient’s treatment.

21.

The name of the person administering and/or supplying under the standing order, and the date and time of administration and/or supply should also be recorded in the clinical record.

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Standing Order Guidelines

9 Competency, including training 22.

The legislation requires the standing order to specify the level of competency, including training, required to administer and/or supply a medicine under a standing order where the registration authority has not set the level of competency (or where there is no registration authority). Generally registration authorities do not set specific competencies required to administer and/or supply a medicine under a standing order. Therefore the required level of competency, including any specific training requirements, should be specified in all standing orders.

23.

The issuer must, at least once a year, review the competency of each person permitted to administer and/or supply medicine under the standing order if the level has not be set by the registration authority.

NOTE: Clearly defining the specific competency and training requirements in a standing order is particularly important where there is the potential for a significant adverse event to occur. For example, the medicine Warfarin can cause serious bleeding. To administer it correctly, a person must calculate the required dose from a range based on blood results. In addition to completing the in-house training on the organisation’s standing order policy and procedures, assessed competency through peer and/or case review could be set as an additional requirement before a health professional can work independently under the standing order.

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10 Countersigning and audit of standing orders 24.

The requirements for countersigning standing orders changed in August 2011. Previously the issuing prescriber was required to countersign every administration and/or supply of a medicine under a standing order. Now, the issuer has the option of either countersigning every administration and/or supply of a medicine or specifying that countersigning is not required. This change means the issuer can specify different countersigning requirements for people administering and/or supplying under standing orders commensurate with the level of competency and expertise of the individuals.

25.

The requirement for countersigning must be clearly described within each standing order. The issuer of the standing order must decide, and specify: 

whether (and under what circumstances) countersigning is or is not required



in cases where countersigning is required, the period within which the issuer must countersign.

26.

If countersigning is not required, or required less frequently than once a month, the issuer must, at least once a month, audit a sample of the records of administration and/or supply under the standing order.

27.

If a single medical practitioner or dentist has issued a number of standing orders for different conditions or medicines, then that issuer will be required to audit a sample from each standing order.

28.

Audit sample sizes should be, as a minimum: 

50 percent of administration and/or supply records if there are 20 or fewer in total



20–30 percent of administration and/or supply records if they are in range of 21–100



15–20 percent of administration and/or supply records if there are over 100.

29.

If any administration and/or supply records are found to be non-compliant with the standing order, it is recommended that the sample size is doubled.

30.

The results of the audit should be recorded along with any required changes or improvements in relation to the standing order documentation, processes or training to be undertaken. Prompt action should be taken to address any issues identified.

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Standing Order Guidelines

11 Review of standing orders 31.

The issuer must review the standing order at least once a year. The issuer must consider whether the standing order continues to be necessary and whether the terms used are appropriate. If the issuer considers that some of the terms of the standing order are no longer appropriate and require either amending or deleting, then any material variations, deletions or additions to the standing order, made as a result of a review, must be dated and signed by the issuer. All staff potentially affected by amendments or deletions should be identified and consulted on the changes.

32.

The issuer must ensure that there is a process in place for monitoring and reviewing the correct operation of the standing order and, in particular, any adverse incidents that occur. The issuer must also ensure that there is a process for document control so that, following a review, all obsolete copies are replaced with new versions of the standing order.

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12 Availability of standing orders 33.

The regulations require that the issued standing order is made available to: 

every person permitted to administer and/or supply a medicine under the standing order



an employer of any practitioner, whether or not he or she is the issuer



any affected practitioner who is not the issuer



any person affected by the standing order



the Director-General of Health, on request.

34.

Standing orders should be made available to anyone on request.

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13 Enforcement 35.

It is an offence to fail to meet the requirements of the Medicines (Standing Order) Regulations. The Ministry of Health may, from time to time, audit any standing order.

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Checklist for use of standing orders 1.

Has the need for a standing order been established?

(a)

Does the standing order explain why the standing order is necessary?

(b)

Has the scope (coverage) of the standing order been specified?

(c)

Do you have processes in place for monitoring and reviewing the standing order?

2.

Has the best person to issue the standing order been identified?

(a)

Is the person you have identified as issuer one of the following: i.

an individual practitioner in practice

ii.

a practitioner who is an employer of a practitioner or a person permitted to supply or administer a medicine under a standing order

or

iii.

a practitioner who exercises managerial control over a practitioner or a person permitted to supply or administer a medicine under a standing order

or

iv.

a practitioner who is authorised by a group of practitioners or a group of people permitted to supply or administer a medicine under a standing order on their behalf

or

(b)

Does the standing order name the issuer?

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Standing Order Guidelines

3.

Has the class of people permitted to administer and/or supply a medicine under a standing order been determined?

(a)

Does the standing order describe the class of people permitted to administer and/or supply a medicine under a standing order?

(b)

Is the class of people you have identified limited to people engaged in the delivery of a health service?

(c)

Has the registration authority of the class of people set any competencies?

(d)

If the registration authority has set levels of competency, including training, for the classes of people administering and/or supplying medicines under the standing order, are there any additional competencies required, including any training to be undertaken?

(e)

If the registration authority has not set any level of competency, or there is no registration authority, does the standing order specify the levels of competency, including training, required of the class of people permitted to administer and/or supply medicines under the standing order?

(f)

Does the class of people you have identified have the required competencies to administer and/or supply?

(g)

Have the people who will work under the standing order, or their representatives, been involved in the development process?

4.

Does the standing order specify the class of people (eg, adults, children aged 5 to 12 years) to whom medicines can be administered?

5.

Does the standing order specify the circumstances in which it applies?

6.

Which treatment/s are included in the standing order?

(a)

Does the standing order specify the treatment/s and condition/s to which the order applies?

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7.

Which medicines will be administered and/or supplied under the standing order?

(a)

Does the standing order list the medicines that may be administered and/or supplied under the standing order?

(b)

For each medicine that is listed, have you recorded all of the following: i.

indications for which the medicine is to be administered

ii.

the recommended dose or dose range for those indications

iii.

the number of doses the standing order allows

iv.

the contraindications and/or exclusions for the medicine

v.

the validated reference charts for calculation of dose (if required)

vi.

the method of administration

vii.

the documentation required in clinical notes.

8.

Does the standing order specify whether or not countersigning is required?

(a)

If countersigning is required, does the standing order specify the period, shorter than a month, within which the issuer will countersign the administration and/or supply of the medicines?

(b)

If countersigning is not required, has a process been established to document, at a minimum, a monthly audit of a sample of the records of administration and/or supply?

9.

Does the standing order define the terms it uses?

10.

Is the standing order in writing?

11.

Is the standing order signed and dated by the issuer?

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or

Processes 12.

Have you developed a process for the issuer to review the competency of any person working under the standing order who does not have levels of competency set by a registration authority for acting under a standing order?

13.

Have you developed a process for at least an annual review of the standing order?

14.

Have you developed a process for monitoring and reviewing the correct operation of the standing order and, in particular, any adverse incidents that occur?

15.

Is a copy of the standing order available to every person operating under the standing order, any person affected by the standing order, an employer of any practitioner, or any practitioner who is not the issuer?

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Appendix 1: Standing order template guide Issued: 00/00/0000

Review date: 00/00/0000

Medicine Standing Order Title Name the condition you are treating under this standing order – eg, urinary tract infection (UTI), scabies. A standing order covers the treatment of a specified condition. This may involve directions for several different medicines with clear indications for the use of each medicine. Rationale

Explain why the standing order is necessary.

Organisation/clinic

Name and address of the organisation where the standing order is being used.

Scope (the condition and patient group)

eg, for the treatment of UTI in females over 12 years of age.

Medicine/s

Name, strength and dose form.

Dosage instructions for each medicine

eg, 300 mg at night for 3 days.

Route of administration

eg, oral, deltoid intramuscular or deep subcutaneous injection.

Indication/circumstances for activating the standing order

eg, to provide post-coital (or emergency) oral contraception to clients in a school clinic or for the treatment of a UTI (with frequency, urgency and/or dysuria and positive dipstick test) without complicating factors.

Precautions and exclusions that apply to this standing order

eg, pregnancy, breastfeeding, allergies, contraindications.

Name or class of health professional (eg, registered nurses). Persons authorised to administer the standing order Competency/training requirements for the person(s) authorised to administer

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Standing Order Guidelines

eg, prior to administering paracetamol under this standing order the registered nurse is required to undergo the inhouse training on the policy, procedure and documentation requirements for standing orders. A record of this training will be kept.

Countersigning and audit

The standing order must specify whether countersigning is or is not required for every administration and/or supply (and under what circumstances). Note: The standing order must be either individually countersigned or included in the monthly audit by the issuer. If countersigning is required, define the timeframe (eg, within 24 hours of administration); if countersigning is not required, define the audit sample (eg, 20% of standing order treatments once a month).

Definition of terms used in standing order

eg, dysuria is pain or difficulty on urination.

Additional information

Documentation (administration/supply information – including validated dose reference charts); initial and ongoing assessment requirements. Note any supporting documents, eg, policy, guidelines or decision support tools, attached to this standing order.

Signed by issuer: Name: Title:

Date: Medical practitioner or dentist

Notes: This standing order is not valid after the review date. The review date is one year after the date that the order was signed by the issuer. The organisational standing order policy and procedure must be signed by management, the issuer and every person operating under standing orders, and attached to the standing order.

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Workbook developed by:

Tracy McKee - Clinical Leader, Mana Kidz [email protected]

027 309 6707

and Liz Pillay – Clinical Nurse Educator, Mana Kidz [email protected]

021 408 669