JCPSLP Vol 20 No 2 July 2018

Development of a service model. This document outlines the service context and need, the benefits and rationale for the proposed service and an outline of the supervision and governance procedures which will be put in place. The document was drafted in consultation with the project’s medical supervisor and included a detailed outline of supervision and training structures, as well as risk mitigation and monitoring strategies. Risk mitigation strategies. To minimise risk a comprehensive case history prior to medication administration. The case history ensures the identification of contraindications and precautions which prompt the SLP to avoid administration of CoPhenylcaine Forte nasal spray. To ensure appropriate access to medical support the service model also outlined the need for SLP led administration to occur only in the setting of the integrated specialist ENT service. Medication order/prescription. Currently the role of the SLP does not include medication prescription; therefore in order to administer CoPhenylcaine Forte nasal spray requires a written order by a medical officer. To increase service effectiveness and eliminate the need for a medical officer to write an individual order for each patient, an overarching medication order was developed in consultation with the supervising medical officer and the hospital medication safety committee.

Risk Reporting (a) the notification of nursing staff or a medical officer immediately in the case of an adverse event (b) the completion of the appropriate HHS risk reporting tool (via local risk reporting software) (c) an event report on the department risk register following any adverse event. The medication order outlines specifically the purpose and scope of medication administration, the indications for administration and any contraindications or precautions which must be considered prior to administration. The order also outlines the correct medication, dose, route and frequency of administration. “Section 18 Application” includes the (a) service model described above, (b) information regarding the storage and use of the medication and (c) information regarding the applicant (i.e. the SLP). The application also includes the submission of the overarching medication order, the training outline and completion records and a medical letter of endorsement from the project’s medical supervisor. To comply with the state’s requirements for the administration under a research framework, ethical approval from the HHS human research and ethics committee for the project was also obtained prior to Section 18 submission.

State legislative approval. As per the Health (Drugs and Poisons) Regulation (1996) in order for an SLP to obtain, process, administer, prescribe or supply medications in the state of Queensland under a research framework, an approval is required from the Chief Executive of Queensland Health.

Hospital and Health Service credentialing. The HHS requires AHPs engaging in duties not traditionally performed by their profession (for example medication administration) to obtain ‘credentialing’ for their service and the individual. The credentialing application, which included all of the documents submitted to the Chief Executive of Queensland Health, was submitted to the HHS allied health credentialing committee for final approval.

Figure 1. Approval process

Results There were no contraindications (as per Table 2) identified for 95 patients. Five (5) individuals did not receive a dose of Co-Phenylcaine Forte nasal spray as precautions (as per Table 2) were identified during the case history, which were deemed to increase the risk of an adverse event. These precautions included respiratory co-morbidities and patients with multiple co-morbidities in four instances. In one instance the SLP did not administer Co-Phenylcaine Forte nasal spray due to patient’s level of anxiety. For 95 patients, Co-Phenylcaine Forte nasal spray was administered. There was one adverse event observed which required only a brief nursing consultation and was classified as mild in nature. While not having any identified risk factors during the case history, the patient developed high blood pressure and tachycardia (as measured by nursing staff), sweating and anxiety following administration of Co-Phenylcaine Forte nasal spray. Nursing management protocols were initiated and following a rest period of 30 minutes the patient was able to go home. As per risk reporting guidelines, the SLP clearly documented the event in the medical record and nil further action was required. Clinician 1 (advanced SLP) completed administration with 74% of patients, while clinician 2 (senior SLP) administered 21% (no administration was completed in 5 cases). Clinician confidence ratings were documented for all patients, even if Co-Phenylcaine Forte was not administered in order to capture concerns regarding administration decision-making and case

history taking. When combined the SLPs reported feeling “Very confident” in 80% of cases (n = 80), and “Confident” in 19% (n = 19) of cases (Figure 2). In one case the SLP reported feeling “Somewhat confident”; however, this did not relate to the presence of an adverse event following administration. Later examination of this case revealed that this rating related to risk factors being identified during case history, and Co-Phenylcaine Forte nasal spray was not administered due to concerns regarding precautions. Discussion As the SLP role extends into areas of practice such as independent nasendoscopy, the need for medication administration (such as Co-Phenylcaine Forte nasal spray) is likely to increase. This study provides an outline of the approval process our site was required to meet, as well as demonstrating that the SLP can safely administer Co-Phenylcaine Forte nasal spray to low-risk patient populations with dysphagia and dysphonia. Over the course of the data collection period there was only one mild adverse event, requiring only brief nursing intervention. While limited data exists regarding the usual rate of adverse events when Co-Phenylcaine Forte nasal spray is administered by a nurse or medical officer, the medication is considered largely safe (Georgalas, Sandhu, Frosh, & Xenellis, 2005; Myers & Iazzetta, 1982) therefore, adverse events are likely to be mild and infrequent. Furthermore, the low-risk nature of Co-Phenylcaine Forte nasal spray is supported by its

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JCPSLP Volume 20, Number 2 2018

Journal of Clinical Practice in Speech-Language Pathology