Collective Prescriptions

What is the difference between a collective prescription and a medical protocol?
The Professional Code (Chapter C-26, Section 39.3) defines the term “prescription” as follows:

“The word “prescription” means a direction given to a professional by a physician, a dentist or another professional authorized by law, specifying the medications, treatments, examinations or other forms of care to be provided to a person or a group of persons, the circumstances in which they may be provided and the possible contraindications. A prescription may be individual or collective.”https://www.inesss.qc.ca/typo3/#_msocom_1

According to the practice guideline of the Collège des médecins du Québec (05/2017) entitled Les ordonnances collectives (p. 1):

“A (collective) prescription is the condition allowing other health professionals to practice certain reserved activities, including dieticians, nurses, nursing assistants, respiratory therapists, pharmacists, medical technologists and medical imaging technologists, or persons authorized by regulation to practice medical activities.” [Translation]

According to this same guideline (p. 2): “The collective prescription to adjust and the individual prescription to initiate must contain a protocol, that is, a description of the procedures, methods, limits, contraindications or standards that are applicable for a specific clinical condition. In some cases, this protocol will be quite simple. Physicians who write a prescription may, if they wish, define the protocol to be applied by the professional or authorized person, or they may refer to an external protocol. The latter is a stand-alone document, separate from the prescription and published by an institution, by a recognized authority or by the Institut national d’excellence en santé́ et en services sociaux (INESSS).” [Translation]

Is it mandatory to use the collective prescription and the medical protocol of the INESSS?
According to the practice guideline of the Collège des médecins du Québec (05/2017) entitled Les ordonnances collectives (p. 7):

“Although INESSS may produce prescription templates (including collective prescriptions) that may or may not refer to a protocol, it must be remembered that these templates are offered to facilitate development work and that it is not mandatory to use them in their entirety.” [Translation]

On the other hand, it is mandatory to use the medical protocol published by INESSS if a collective prescription is used for the targeted indications. Please refer to the Regulation respecting the standards relating to prescriptions made by a physician (Medical Act, R.S.Q., c. M-9, sect. 19, par. 1, subsect. d) which states that: “If the prescription is related to a clinical condition contemplated by a medical protocol published by the Institut national d’excellence en santé́ et en services sociaux, it must refer entirely to the medical protocol published by that agency and a reference includes any later modification made to that protocol.”https://www.inesss.qc.ca/typo3/#_msocom_2

What happens to a collective prescription established and signed by physicians if INESSS revises the associated medical protocol?
According to the practice guideline of the Collège des médecins du Québec (05/2017) entitled Les ordonnances collectives (p. 2): “A reference to an INESSS protocol includes any subsequent changes to the protocol. In other words, a prescription that refers to an INESSS protocol does not have to be revised and signed again each time a change is made to the protocol. The prescription always refers to the latest version of the protocol.” [Translation]

If INESSS revises the associated medical protocol, it is mandatory to use this revised version; however, the collective prescription does not have to be signed again.

Can an institution adapt a collective or individual prescription template and a liaison form template to suit its own practices?
Use of the collective prescription template suggested by INESSS or the Collège des médecins du Québec is not mandatory; however, an individual prescription must contain all the elements stipulated in the Regulation respecting the standards relating to prescriptions made by a physician.

The liaison form templates can also be adapted to meet an institution’s requirements. These documents are not mandatory as long as the required information about the patient is properly forwarded by the treating physician to the authorized professional who will apply the collective prescription.

The only requirement is that INESSS’s medical protocol, which is mandatory, must be applied in its entirety.

Does a new physician coming to a family medicine group (FMG) or an institution systematically apply the collective prescriptions that are already in place?
The practice guideline of the Collège des médecins du Québec (05/2017) entitled Les ordonnances collectives explains the roles and responsibilities of the signing physician in Chapter 3, pages 14-15.

In short, physicians who come to a new group must apply the collective prescription by adding their signature and must ensure that the prescription includes patient management or medical follow-up measures whenever such follow-up is required. It should also be noted, as mentioned in the second paragraph on page 15 of the guideline, that, since collective prescriptions still amount to a direction given by a physician, this latter cannot sign a collective prescription in a clinical situation for which he/she personally lacks the knowledge, training and skills, or which is not linked to this physician’s field of practice.

Within an institution, the collective prescription must be signed by a physician representing the Council of Physicians, Dentists and Pharmacists (CPDP). This physician must be authorized by a resolution of the executive committee. The CPDP may authorize several physicians to sign collective prescriptions.

Once the collective prescription is signed, it must be used by the professionals and authorized persons practicing at the institution, and all physicians must take part in writing it, in accordance with the status, privileges and obligations provided in the Act respecting health services and social services and which are granted to every physician by the institution’s board of directors. Consequently, the CPDP must ensure that the collective prescription is distributed within the institution (p. 26 of the practice guideline of the Collège des médecins du Québec (05/2017) entitled Les ordonnances collectives).

In cases for which no INESSS medical profile exists, can a collective prescription be written based on an optimal use guide for the medication (index cards) published by INESSS?
Yes. The optimal use guides for the drug have been developed using the same process as the medical protocols. However, the optimal use guides are not considered mandatory under the Regulation respecting the standards relating to prescriptions made by a physician (c. M-9, r. 25.1). The purpose of these guides is to provide support to health professionals.

Is it necessary to have a collective prescription for naloxone nasal spray?
Tools for administering naloxone can be found on the same INESSS website page as the medical protocols and related prescriptions. The information about naloxone on the websites of the Collège des médecins du Québec and the Office des professions du Québec [Québec office of professions] points out that it has not been on the list of prescribed drugs since March 2016.

Moreover, since the adoption in September 2017 of the Regulation amending the Regulation respecting the professional activities that may be engaged in within the framework of pre-hospital emergency services and care, the first responders on the scene have been authorized to administer naloxone irrespective of the route of administration.

In the case of institutions, there may be a rule governing the drug’s use that will guide professionals in administering naloxone for defined indications.