Remote prescribing and injectable cosmetic medicinal products
This sets out our position in relation to the remote assessment and prescribing of cosmetic injectable medicinal products, and their supply and administration by nurses and midwives. It is has been developed in consultation with, and is supported by the Royal College of Nursing. It applies to all nurses and midwives who are registered with the Nursing and Midwifery Council (NMC). The NMC sets standards of education, training, conduct and performance so nurses and midwives can deliver high quality healthcare consistently throughout their careers. It is the personal responsibility of each nurse or midwife to ensure they are aware of, and apply, the relevant standards and laws to their specific area of practice.
Any nurse or midwife who is administering injectable cosmetic medicinal products must follow the standards for practice of administration of medicines in Standards for medicines management, and apply the principles of The code: Standards of conduct, performance and ethics for nurses and midwives which states that nurses and midwives must:
- provide a high standard of practice and care at all times
- deliver care based on the best available evidence or best practice
- recognise and work within the limits of their competence
- take part in appropriate learning and development activities that maintain and develop their competence and performance.
This information sheet supports circular 16/2008 Remote assessment and prescribing. Both make it clear that remote prescriptions or directions to administer should only be used in exceptional circumstances, and not as a routine means to administer injectable cosmetic medicinal products. Whilst we have not defined exceptional circumstances within our standards, we advise that this is in situations where the medication or treatment is necessary to save life, avoid serious deterioration in the person’s health or alleviate otherwise uncontrollable pain.
This relates to injectable cosmetic medicinal products such as botulinum toxin (Botox®). Some have a permanent effect and some may only last a few months.
Like all medicines, injectable cosmetic medicinal products can cause side effects and adverse reactions. If a reaction occurs, although the prescriber would be liable for prescribing, the nurse or midwife would be accountable for their assessment of the person and the administration of the medicinal product.
The information below also applies to the administration of prescription-only local anaesthesia for pain relief.
Administration and remote prescribing
A nurse or midwife can only administer an injectable cosmetic medicinal product once they have received a prescription or direction to administer from a prescriber who has completed a comprehensive assessment of the person.
The NMC requirements relating to administering against a remote prescription can be found in standard 11 of the Standards for medicines management, which states:
"In exceptional circumstances, where medication (not including controlled drugs) has been previously prescribed and the prescriber is unable to issue a new prescription, but where changes to the dose are considered necessary, the use of information technology (such as fax, text message or email) may be used. This must confirm any change to the original prescription."
Our guidance around standard 11 states that:
"A verbal order is not acceptable on its own. The fax or email prescription or direction to administer must be stapled to the patient’s existing medication chart. This should be followed up by a new prescription signed by the prescriber who sent the fax or email confirming the changes within a maximum of 24 hours (72 hours maximum for bank holidays and weekends). In any event, the changes must have been authorised (via text, email or fax) by the prescriber before the new dosage is administered. The registered nurse should request the prescriber to confirm and sign changes on the patient’s individual medicines administration record (MAR) chart or care plan. Where a medication has not been prescribed before, a nurse or midwife independent prescriber may not prescribe remotely if they have not assessed the patient, except in life threatening situations. See standard 20 of the Standards of Proficiency for Nurse and Midwife Prescribers.
In exceptional circumstances, a medical practitioner may need to prescribe remotely for a previously unprescribed medicine, for example, in palliative care or remote and rural areas. In such cases the use of information technology (such as fax, text message or email) must confirm the prescription before it is administered. This should be followed up by a new prescription signed by the prescriber who sent the fax/ email confirming the changes within normally a maximum of 24 hours (72 hours maximum – bank holidays and weekends).
The registrant is accountable for ensuring all relevant information has been communicated to the prescriber and s/he may refuse to accept a remote prescription if it compromises care to the patient. In this instance she should document accurately the communication that has taken place. Registrants should note that remote prescribing cannot be undertaken in a care home because they do not have access to a stock of medicines.
A prescription is required when the drug is to be both supplied and administered. For administration only, a direction to administer is sufficient.
It may be helpful to refer to the GMC Good Medical Practice Guide for further information available on the GMC website.
In the above circumstances the nurse or midwife administering the injectable cosmetic medicinal product is accountable for ensuring all relevant information has been communicated to the prescriber. Where a nurse or midwife feels that a remote prescription compromises the care to the patient, he or she may refuse to accept a remote prescription. In this instance the nurse or midwife should accurately document the communication that has taken place.
A prescription is still a remote one, even where the prescriber has undertaken an assessment of the person using information technology media, such as via the telephone or video link. Nurse or midwife independent prescribers also have to meet the requirements set out in standard 20 of the Standards of Proficiency for Nurse and Midwife Prescribers and NMC circular 16/2008 Remote assessment and prescribing.
Patient group directions
Patient group directions (PGDs) are written instructions for the supply or administration of named medicines to specific groups of people who may not be individually identified before presenting for treatment.
Medication which is licensed but used outside its licensed indications (commonly known as 'off label') may be administered under a PGD only where such use is exceptional, justified by best practice and the status of the product is clearly described.
It is suggested that nurses and midwives note that the Department of Health guidance, which mirrors that of the NMC, states:
"products for use outside their licensed indication may be included in PGDs if their use is exceptional and justified by best clinical practice."
The Medicines Healthcare Regulatory Agency (MHRA) view is that this does not apply to the routine use of Botox® for cosmetic treatments.
Administration of injectable dermal fillers
Dermal fillers are medical devices and therefore do not require a prescription. Nurses and midwives who administer treatments by injection that are classified as medical devices should do so according to standard operating procedures and local protocols. They must also make sure that they have received suitable training and are able to carry out the procedures safely and effectively.
The MHRA has produced the document Managing Medical Devices Guidance for Healthcare and Social Services Organisations November 2006 (MHRA, DB2006 (05)) which nurses and midwives working in aesthetic medicine may find helpful.
The MHRA have produced some FAQs relating to the supply, storage and administration of cosmetic injectables.
The MHRA have also produced some information about medicines regulations relating to advertising of medicines.
Treatments You Can Trust is a Department of Health backed register of cosmetic injectable providers managed by the Independent Healthcare Advisory Service.
This information was reviewed in September 2013.
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