Sarah-Joe Harper is an RN(NP) and is prescribing off-label use of Quinine for nocturnal leg pain for a few of her clients because a colleague at a private clinic she works at has been prescribing it for years. It is not Health Canada approved for nocturnal leg pain because it lacks strong evidence to support its use for this indication, especially since the side effect profile demonstrates more risk than the potential benefits.
When looking at the evidence to inform this care-provider, how will she make decisions about the treatment options? What will the provider’s advice be to their clients about the risks verses the benefits? How can the prescriber be certain that this drug is not causing more harm than good?
The Drug and Health Product Register from Health Canada is a good way to check the use of drugs and to review all adverse events noted on the drug monograph. Just because a medication can be prescribed, doesn’t mean it ought to be. Evidence informed practice that has been reviewed by peers and colleagues has been verified by clinical trials and experience. If your practice is using evidence that your peers are not using, ask yourself why. What is your understanding of the credibility and accuracy of evidence? You will want to share with your colleagues to determine whether or how to put this evidence into practice.
Meeting your practice expectations involves demonstrating accountability for your decisions along with the use of current evidence from nursing science, other disciplines, or pertinent sources of data. Other sources of data can be found on Rx Files, a Canadian Pharmaceutical reference, see the resources section for more details. Another resource is PEER, patient experience evidence research from the College of Physicians and Surgeons of Alberta practice tool resources.
Sarah’s co-worker, Ian Suarez RN, approaches her and brings some of the concerning side effects and symptoms of the Quinine prescription to Sarah’s attention regarding a mutual client. This client reported heart palpitations, dark urine, nausea, and vomiting. Ian also pointed out a new online resource from Health Canada that could demonstrate why using this drug off-label is not the best choice. After looking at the client’s list of medications, Ian found that quinine was most likely the cause. Bringing this back to the ordering prescriber and having a conversation between these two providers led to a better outcome for the client and this changed Sarah’s practice as she stopped prescribing this drug for nocturnal leg pain.
When supporting yourself or a colleague in decision making, consider assessing evidence that will inform your practice from peer-reviewed sources and critically apply this information in the care planning for your client (s). To do this, use evidence-based resources to ensure sufficient knowledge of
- benefits of the intervention within the context of the client diagnosis and the plan of care.
You must be able to determine the ongoing appropriateness of performing the activity (i.e. treatment) and must be competent to assess, perform, and evaluate the effectiveness of the intervention in relation to client outcome. Documenting the client’s informed consent, their questions, or concerns and what your response was to their inquiries will demonstrate how you integrated this evidence into your decision making with your client. Nurses [(RN, RN(NP), RN(AP)] must be able to identify when additional skill, knowledge, or expertise is needed and ensure a plan is in place to manage potential adverse events. They must also manage client expectations to help mitigate those adverse events.
Sarah’s prescription is just one example of the need to appraise current evidence. We have opportunities everyday to look at our own decisions when care planning with clients we can always use another set of eyes.
Questions are welcome by submitting them to firstname.lastname@example.org and a practice consultant will speak with you about your concerns.
CRNM Practice Expectations for RN, RN (AP) and RN(NP):
Health Canada (2022) The Drug and Product Registrar:
Patient’s experience evidence research (2022) Alberta College of Family Physicians Practice Tools (PEER):
- RxFiles is an excellent Canadian resource that is focused on Academic detailing (so it essentially distills down the information from clinical trials into “bottom lines”), and it is done by a group of pharmacists and clinicians out of the University of Saskatchewan https://www.rxfiles.ca/rxfiles/
- You can purchase the resource in a variety of formats, but it is available in an app format as well, and comes in a variety of sizes and also has a geriatric version https://www.rxfiles.ca/RxFiles/modules/products/products.aspx
- They update it once every 1-2 years, so you know that it has the most up to date references and information.
- RxFiles has a bunch of free resources on their website as well, and sometimes you might find ones that are relevant to your practice. For example, see this comparison chart: https://www.rxfiles.ca/rxfiles/uploads/documents/members/cht-OAT-colourcomparison.pdf
- CPS is another excellent Canadian reference that has numerous clinical information by topic, and also all of the drug monographs https://www.pharmacists.ca/products-services/
- Also updated regularly, and available online.
- Can be accessed for free with a UofM Library login.
- The clinical information section sometimes also refers to “off-label” uses of medications for certain conditions.
- UpToDate is excellent for a review of information on clinical trials and evidence based medicine, but it is an American Resource.