Aim: To provide a framework of guidelines, standing orders and protocols that informs and directs the day-to-day practice of nursing staff working within Westland Medical Centre. These documents will be updated regularly in order to maintain currency and reflect changes in the field of best practice.

NOTE:These standing orders are to referred as 'The Westland Medical Centre Standing Orders' as all staff at Westland Medical Centre have played crucial parts in their development including the nursing staff.

General Principles

Comments: February 2011: Westland Medical Centre would like to thank everyone that has assisted with the ongoing review and development of these Standing orders.

Some changes:

  1. Roxithromycin can be substituted for erthromycin in adults – at either 150mg bd or 300mg daily
  2. Infective Endocarditis prevention has been updated to current recommendation of a single dose prior to dental surgery etc as per NZ Cardiovascular Guidelines Handbook 2009
  3. The West Coast Community IV cellulitis protocol has been included – Cefazolin and probenecid added to medication list. http://wc.healthpathways.org.nz
  4. Warfarin over anti-coagulation tables have changed.

  5. Sections have been rearranged to hopefully result in better groupings of conditions – give or take, plus or minus!

These guidelines, policies and standing orders have been developed by Westland Medical Centre, Hokitika in accordance with the Ministry of Health Guidelines for the development and operation of standing orders. Also with the help of the Youth Health Centre, Christchurch, Nelson Division of the NZ College of Practice Nurses (NZNO), Roxburgh Medical Centre and St John's Clinical Advisory Group. They represent best practice as is known to date. Medication doses and recommendations are based on BPAC information, BMJ clinical evidence guidelines and other guidelines as referenced. Advice has been obtained from Dr Paul Holt, physician, Coast Health Care, West Coast DHB and Tracey Makinson, Pharmacist, Grey Hospital, Coast Health Care, West Coast DHB. These standing orders are necessary due to the on-going shortage of General Practitioners on the West Coast and are designed to ensure that patients receive appropriate care in a timely manner for emergency and acute conditions. The list of medications and conditions is deliberately restricted. Some antibiotics are restricted to one condition only. This is to reduce the risk of adverse events. The selection of common conditions to include in these standing orders is based in part on audit of after- hours and emergency calls at Westland Medical Centre and discussion with the Practice Nurses at Westland Medical Centre and Rural Nurses in South Westland over 2002 - 2008, with regular input from other rural areas. Ongoing audit and additions occur at least annually. BPAC has reviewed these orders.

These standing orders are issued by Dr Anna Dyzel for practice nurses employed by Westland Medical Centre. Locums employed by Westland Medical Centre Ltd, but not named individually, may also act as issuers on a temporary basis.

Copies of these standing orders will be available in all clinical rooms where nurses or medical practitioners affected by them are operating including an electronic version. They are to be shown to any locum working at Westland Medial Centre as part of their orientation to the facility.

The issuing medical practitioner, commencing from the date on the current standing orders in question, will review this manual annually.

Each individual standing order forms part of a living document. Obsolete or out-of-date standing orders will be removed from each clinical room and replaced with new standing orders on an annual basis after the standing orders are reviewed. Copies of the standing orders stored on the Westland Medical Centre computers will be replaced similarly on an annual basis. Expired copies of standing orders will be retained for medicolegal purposes.

Registered Nurses employed by Westland Medical Centre who have received appropriate instruction in their use, indications and contraindications by an issuing medical practitioner may supply medicines covered by the standing order protocols. In situations where a caution/contraindication is relevant to medication use, nurses should consult with a doctor prior to supplying the medicine. Competence to continue to supply medicines under the standing order policy will be reassessed annually by the issuer. Assessment will take the form of on-going audit of notes pertaining to standing order use.

Nurses using standing orders must accept that they are responsible, accountable and therefore legally liable for their actions. Standing orders cannot cover every clinical ramification and it is expected that the nurses' professional judgement and experience will be used. There is no obligation for practice nurses to use these guidelines and those nurses who conclude that using standing orders is outside their scope of practice are to consult with a medical practitioner before dispensing any treatment. The medical practitioner issuer of these standing orders is responsible for review and updating of the orders to ensure that they remain evidence based. The nurses' liability rests with proper patient assessment and appropriateness of issuing the standing order. Vicarious employer responsibility exists for the employers of both the issuer and the nurses using these orders, but this does not remove or replace personal professional accountability and therefore liability for actions taken.

Nurses supplying medicines according to the standing orders must write up the assessment and treatment of the patients (including any adverse reactions) and, if necessary, any monitoring or follow-up of the patient's treatment. The issuing medical practitioner must be informed ideally within 24 hours but certainly within 96 hours of the medicine being supplied (for example, in the situation of a public holiday). It is good practice to ensure the patient has a follow-up appointment or is contacted by telephone to ensure that the clinical condition is improving and that no side effects have occurred.

Any adverse events associated with these standing orders should be reported to an issuing medical practitioner who will review the individual situation and assess the operation of the standing orders.

The pharmacists are able to clarify concerns about drug interactions. Drug interactions are common - always seek advice from pharmacy or a doctor if you are unsure.

Patients referred to another healthcare provider should be given a full referral letter containing current history, findings and management, past history, medication list, allergies and any other relevant information.

The role of the Practice Nurse is to promote health, provide screening, perform early intervention including acute, emergency and PRIME care, arrange prescriptions and dispense under guidelines such medications as are deemed necessary for maintenance of health e.g. contraception and medication of chronic conditions e.g. asthma, hypertension. Practice nurses are expected to be familiar with the target goals for chronic medical conditions such as diabetes, asthma and hypertension and refer their patients for management review if these targets are not met. Examination templates and guidelines are included for reference. The issurers recommend ongoing reference to updated guidelines e.g. the New Zealand Gudelines group.

August 2011: as per Amendments to Regulations under the Medicines Act 1981

Countersigning will be undertaken on a random monthly basis – not every order will be signed. The nurse continues to inform the issuer of the standing orders used, but not all will be signed. The random assessment of standing order use will include audit of appropriateness and education needs. PRIME trained practice nurses working at Westland Medical Centre for more than 2 years, who have undergone intensive training in standing order use, will be exempt from countersigning of every standing order used.

The monthly audit of standing orders used will include a review of the practices of those working under the order. A full annual review of all standing orders will be undertaken.

Competency to use standing orders will be based on attendance at ongoing education sessions, personal supervision, completion of assessments and discussion with team members.

For any queries discuss with Nigel Ogilvie, Managing Director and Practice nurse

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Anna Dyzel, Clinical Director and general practitioner

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Additional information