role preparation for nurse advisors handling medicines calls day 1

Role Preparation for Nurse AdvisorsHandling Medicines Calls

Day 1

NAME

Medicines Information Pharmacist

NAME Medicines Information Service

Role Preparation for Nurse Advisors - Day 1

Medicines Training for NursesTraining Duration Trainer

Week 4 Using Toxbase® to support poisons calls ½ day NHSD

Week 5/6 Handling Calls about medicines and the Medicines Algorithm

Trainer evaluation

Further medicines case scenarios

1 ½ days

½ day

UKMI

UKMI + NHSD

Self directed

Week 10 Handling calls about Hormonal Contraception and Emergency Contraception

EC algorithm – further scenarios

½ day UKMI

Self directed

3-6 months Medicines calculations for NAs

e-Toxbase®

One-to-one medicines training on request

Self directed

Self directed

UKMI

6 months Handling calls about medicines during pregnancy and breastfeeding

½ day UKMI


Timetable - Day 1 MorningWelcome & learning outcomes

NHSD policies for medicines calls,

Role of UKMI as a support service to NHS Direct

Workshop 1: Ethical Dilemmas

Baseline knowledge for handling medicines calls

Break

Key information sources on medicines

Workshop 2: Navigating the eBNF, eMC, NetDoctor,

MedicinesChest, Medicines Q&As and Medicines Complete

Lunch


Timetable - Day 1 AfternoonOverview of steps when handling medicines calls

Handling calls about Administration, Dose, Indications

contra-Indications

Workshop 3: Case scenarios on Administration, Dose,

Indications, Contra-Indications, Missed and Double Doses,

Medicines in pregnancy and during breastfeeding

Break

Overview of Community Pharmacy Services

Review and close


Timetable - Day 2 Morning

9.30 Welcome & re-cap

9.45 Handling calls about Adverse Effects & Drug Interactions

Workshop 4: Case scenarios on Adverse Effects and

Drug Interactions

11.15 Break

11.30 Handling calls about analgesia

Workshop 5: Case scenarios on analgesia

1.00 Lunch


Timetable - Day 2 Afternoon

Medicines Algorithm

Workshop 6: Case scenarios using the medicines algorithm

Break

Where are the risks when handling medicines calls?

Examples of common mistakes

Review and close







Break




Lunch


NHS Direct’s Pharmacy and Medicines Services

Why learn about Pharmacy and Medicines?

Research has shown

More than 6% of all calls to NHSD are for advice about medicines

More than 40% of all answers to calls include advice about

medicines



Definition of a medicines call?

Medicines prescribed by the doctor

Homeopathic medicines

Medicines bought at a pharmacy

Food supplements and vitamins

Medicines bought at a general shop

Recreational drugs and drugs of abuse

Herbal medicines Steroids in sport



National Policy for Handling Medicines NP005

Definition of Medicine Calls

Approved Reference Sources

Principles for Handling Medicines calls

Record keeping and Documentation

(Poisons calls) Quality Assurance

Guidance for specific types of calls

Training and Development


• Based on a set of shared beliefs between NHS Direct and the users of the service:

• Everyone is entitled to be involved in decisions about medicines and choose a different option if they prefer

• Everyone will be able to get medicines information they want and need


Principles for Handling Medicine Calls


• Complex calls• Advice to support a therapeutic choice• Advice and information about EC and

unprotected sex• Dental medicines calls• Third party and intermediary calls• Requests for repeat medication


Guidance for specific types of calls



Health Advisors P4 “Quick Calls”: Information on access Locations & opening hours of pharmacies, family

planning clinics, walk-in centres. Where can I get EHC? How do I get a repeat prescription? How do I get a new oxygen cylinder?Interim information on Low Toxicity ingestionsInterim care instructions for dental pain

Health Information Advisors

P4 Calls (M1, M2 or M3): Information about medicines No new or worsening symptoms.

Nurse Advisors P1-4 Calls: Advice or information about medicines Symptoms. No new or worsening symptoms.

Dental Nurse Advisors

Information about medicines for dental conditions


All P4 calls now subdivided into either Medicines (M) calls or Health Information (H) calls

M calls prioritised M1, M2 or M3

H calls prioritised H1, H2 or H3

Identification and prioritisation of medicines calls

Annotating calls



P4QC Quick calls about access to medicines. e.g. “Is there a pharmacy close

to me that is open?”

M1 Assess within

20 mins

Caller extremely anxious or distressed. e.g. Caller crying.

e.g. “I have missed my usual dose of medicine. Should I take 2 now?”

M2 Assess within

1 hr

Urgent medicines call - answer needed before the next dose.

Goes to the First Advice Queue after HI service closes at 8pm.

e.g. “My dentist has given me amoxicillin for a dental abscess. Can I take paracetamol?”

M3 Assess within

4 hrs

All remaining medicines calls.

After HI closed, remains in HI Queue until the next day.

Advise caller that HI is closed so will be answered next day.

e.g. “What vaccinations do I need for a trip to Africa in a few months time?”



Annotating H calls

H1 Assessment within 20 minutes

If extremely anxious or distressed

Eg ‘I have just been diagnosed with breast cancer. I don’t want a mastectomy. Will I die?’

H2 Assessment within 1 hour

Urgent HI call Eg ‘I work in a nursing home. My daughter has chicken pox. Should I go to work today?’

H3 Assessment within 4 hours

Non-urgent HI call

Eg ‘ I want to give up smoking. Can you help please?’







Break




Lunch


What is UK Medicines Information?

• UKMI- supports MI needs of NHS health professionals

• >½ million enquiries 2006• 16 regional & 260 local centres• Specialist services -

pregnancy, breastfeeding, liver disease, dental

• Training, websites, QA, drug reviews

www.ukmi.nhs.uk



Alana Adams Wales

Alison Alvey Bristol

Kelly Broad Leicester

Ruth Cheema Leicester

Jane Farris Birmingham

Matt Haggerty Leeds

Wynn Pevreal London

Caroline Riddle Bristol

Paula Russell Newcastle

Jill Rutter Liverpool

Davina Wraight London



Staff• Pharmacists• Pre-registration

pharmacists• Secretarial support

Services to NHS Direct• Complex medicines

calls• MI skills training• Quality Assurance• National work

Mon- Fri 9am - 8.00pmWeekends 9am – 3pmExcept Bank Holidays

Speed Dial 004



• Complex medicines call.

• Difficult to interpret what is being asked.

• No information or it is unclear or conflicting.

• Not within your competency or a second opinion needed.

• When Medicines Algorithm advises referral

Referral to UKMI


Examples of Complex Medicines Calls

Complex drug history • Lots of medicines• Unclear what is taken• Unlicensed medicines

Side effects• Not clear if symptoms due

to medicines

Drug interactions• Narrow therapeutic range

medicines e.g. digoxin

Pregnant• No UKMI Q&A

Breastfeeding • No UKMI Q&A• Baby pre-term / unwell

Uses / choice• Contra-indicated• Doses outside norm








Break




Lunch


Ethical Dilemmas

Medicines calls that may lead to ethical dilemmas

• Age of caller• Third party calls• Refusal of another HCP to supply a medicine• Caller not wishing to disclose information to Dr• Wrong information given to caller by HCP• Caller taking a higher dose than prescribed• Caller wants information about how to obtain a

medicine that is of dubious worth• Caller prescribed two interacting medicines


Ethical Dilemmas

• I found a tablet….• My G.P. says this…. but I’ve read

something different• Does heroin interact with…..?• Could my partner’s tablets cause……?• What are my friend’s tablets for….?


General Guidance• There are often no “right answers”.• Give yourself thinking time.• Second opinion: try to speak to a colleague or to the

Medicines Information Centre.• Conflicts: try not to get caught up in patient conflicts

with other professionals.• All the published information sources that you use are

in the public domain.• Instinct: You may have to do what seems right to you.• You do not have to answer everything that you are

asked!• Document carefully everything that you do.

Ethical Dilemmas


Workshop 1 – Ethical Dilemmas

A woman says she has found some medicines in her son’s room. She reads the labels - lamivudine, zidovudine & saquinavir.

Can you tell her what they are for? Would your answer be different if the call was from his wife?

A man asks how long cocaine stays in the body. He used some cocaine at the weekend but is due to have a drug test tomorrow.

What advice would you give?







Break




Lunch


What is a medicine?

Active Ingredient or Drug

Excipients – vehicle, bulking agent, tablet coating, capsule shell, colours, flavouring, stabiliser, pH adjuster ……

Form – tablet, capsule, suppository, eye drops, cream, patch, inhaler, injection ……..


What is a medicine?

Naming medicines

Generic Brand

Amoxicillin Amoxil ®

Salbutamol Ventolin ®

Fluoxetine Prozac ®

Omeprazole Losec ®

Mefloquine Lariam ®


What is a medicine?

Legal classification of medicines

General Sales List GSL

May be sold in general shops e.g. Paracetamol in packs of 16 tablets

Pharmacy OnlyP

May be sold in a pharmacy but not a general shop e.g. Piriton®

Prescription OnlyPOM

May only be supplied on prescription e.g. Amoxicillin


What is a medicine?

Controlled Drugs (CDs)

Class A eg heroin, LSD, ecstasy, morphine,

Class B eg amphetamines, barbiturates, codeine,

Class C eg anabolic steroids, cannabis,

Misuse of Drugs Act 1971

CDs are POMs with stricter controls on production, supply or possession


Off LabelUK product licence but

being used for an indication/at a dose/by a route not in the licence

No LicenceNo UK product licence

•Methotrexate for asthma and lupus

•Sodium valproate for prevention of migraine

•Thalidomide

•Melatonin

•Most herbal products

Unlicensed Medicines

What is a medicine?


• Newly licensed

• Monitored intensively by Commission for Human Medicines (CHM) which reports to MHRA

• Black triangle status usually reviewed after 2 years

Black Triangle medicines

What is a medicine?


• Known as the ‘Black List’

• Pricing Prescription Authority (PPA) will not reimburse dispensing cost.

NHS

Medicines that may not be prescribed in the NHS

What is a medicine?







Break




Lunch


Key Information Sourceson Medicines


• Published every six months

• Information on drugs generally prescribed in UK

• Designed for rapid reference

• Less detail on specialist areas

• Appendices at the back


Electronic British National Formulary (eBNF)


• Summary of Product Characteristics (SPC) and Patient Information Leaflets (PILs)

• Updated daily

• Information provided by manufacturers

• SPC - very detailed, written for healthcare professionals

• PIL - written for patients


Electronic Medicines Compendium (eMC)


• Easy to Search

• Layman’s language

• Good for use, side-effects, drug interactions

• Medicines section written by pharmacists

• Updated daily


NetDoctor



• Online version updated daily – book published annually

• Guide to over the counter medicines• Particularly useful for checking active

ingredients• Very little clinical information

MedicinesChestOnline



• A series of questions and answers written by UKMI for NHS Direct

• May be used a single reference source• Topics cover areas commonly asked by

callers• Ongoing project – Q&As added regularly

NHS Direct Medicines Q&As



• MedicinesComplete provides online access to twelve medicines and healthcare resources – published by the Pharmaceutical Press

• NHS Direct have a quick link to MedicinesComplete. No password now needed

MedicinesComplete


When to use each Source

eBNF For all calls unless Q&A available or inappropriate eg OTC medicine

eMC PIL and SPC – manufacturers information

NetDoctor For patient friendly information. Can be read aloud

Medicines Chest

For Over-the-Counter medicines to establish ingredients, licensed dose and licensed maximum daily dose

Q&As Single reference source. Question asked must exactly match Q&A








Break




Lunch


Workshop 2 – Navigating Key Resources


Merits Disadvantages

eBNF Gold standard Some opinion

Care when searchingJargon

eMC Easy to searchComprehensive info

TechnicalUnlicensed / off label Not all medicines

NetDoctor Easy to searchLayman’s termsUse, side effects, drug interactions

PregnancyBreastfeeding

Medicines Chest

Good for details on active ingredients of OTC products

Very little clinical information

Q&As Saves timeDifficult to find info

Limited numberNeed prompt updating








Break




Lunch




Contra-Indications



Medicines in Pregnancy and during Breastfeeding

Break


Review and close




contra-Indications




Break


Review and close



Clarify the question

Plan search strategy& research problem

Evaluate the information

Tailor the answer/advice

Refer to MI

Using Speed

Dial 004

Recordall

stages


THE PERSON

• Age?

• Allergies/disease states?

• Pregnant: no. of weeks, going well, medicine taken already?

• Breastfeeding: baby age, term/pre-term, well/unwell, medicine taken already?

THE MEDICINE

• Name, dose, frequency?

• Who is it for?

• What prescribed for?

• Why asking?

• Other medicines? Name, dose, frequency?

Confirm no new or worsening symptoms



Standard Search Strategies

• Encourage best practice and sharing of expertise

• Are pointers to the best sources available to answer particular types of medicines call.

• Not a definitive list of sources. You should check other sources as appropriate.

• No need to check every source in the search strategy for every call.



Reasons for Documentation

• Patient record in case of ongoing enquiry.

• Risk management.• In case of query in the future.• Record/evidence of how you arrived at the

answer.

• Training.



What should be documented?• Website e.g. eBNF, eMC, NetDoctor

including URL

• All places looked including those where no information was found.

• Brief detail of information found.

• Brief detail of what was said to caller.



Example documentation

Is warfarin safe in the 1st trimester of pregnancy?

eBNF: Malformations. eMC: No monograph.NetDoctor: Do not use in pregnancyToxbase: Malformations.

Advised to speak to GP by end of day.





contra-Indications




Break


Review and close


Handling medicines calls

• How do I take?• When do I take?• What condition (indication) is this

medicine used to treat?• When should I not take this medicine?



• Is it OK to crush these tablets as I have difficulty swallowing?

• I missed my tablet this morning. Should I double-up tomorrow?

• My Dr has given me new tablets. Will they work like the old ones?

• The leaflet says not to take if you have asthma. Why is this?

• I’m going to Barbados. At what time of days should I take my contraceptive pill?

Examples


Medicines in Pregnancy • 35% of women will take medicines at least

once during pregnancy• All medicines should be avoided in pregnancy

unless they are essentialMedicines whilst Breastfeeding• Unnecessary drug use should be avoided• Assess benefit/risk ratio for both mother and

infant





contra-Indications




Break


Review and close


Workshop 3 – Case Scenarios




contra-Indications




Break


Review and close


• No appointment necessary• 6 million people visit community pharmacies daily. • 94% of population visit at least once per year• Care can be sought on behalf of others• Role of pharmacist is as medicines

expert – advise on the treatment of illness and how to take medicines




What services do community pharmacies offer?Dispensing prescriptions

Emergency supplies of Prescription only Medicines

Health Promotion campaigns

Advising on medicines Sale or supply of the ‘morning after pill’

Needle exchange schemes

Blood pressure monitoring

Pregnancy testing Disposal of unwanted medicines

Selling over-the-counter medicines

Supervised administration of medicines

Advising on minor ailments

Incontinence supplies Stoma care Care Home support

Patient records Smoking cessation Truss fitting


Staff in a community pharmacy

Sales assistants Trained to work in shop but not to sell or advise on medicines

Counter assistants Healthcare assistants

Trained to sell and advise on medicines – supervision by pharmacist

Dispensing technicians Trained to dispense and check prescriptions

Pharmacist Responsible for all sales and Rx of medicines



NHS Prescription Charges

£6.85 for each NHS Prescription from 1st April 2007

• Irrespective of cost to NHS of medicine

• Irrespective of quantity

• Same drug and form is one charge

• Various charges for combination products

• Pre-payment certificates – forms from community pharmacies or buy online



• Aged under 16• Aged 16, 17 or 18 years in full time education. • Aged 60 or over.• Has a Maternity Exemption certificate.• Has a Medical Exemption certificate.• Has a War Pension exemption certificate.• Has a Prescription Prepayment certificate. • Named on a NHS Charge certificate (HC2).• Prescribed free of charge oral contraceptives.• Gets Income Support or Income Based

Jobseekers Allowance.• Entitled to / named on, NHS Tax Credit

Exemption certificate.• Partner gets Pension Credit Guarantee Credit.

Exemptions from prescription charge


.



May be possible when

• Inadvertently run out of medicines at a weekend or surgery closed

• On holiday and forgotten medicines

Pharmacist will check that not run out of through overuse eg inhaler for asthma

There will be a charge to patient as not an NHS service

Emergency Supply by a pharmacist



• Pharmacist must interview the person

• Supply up to five days treatment

• Controlled drugs may not be supplied

•Not an NHS Service so will be a charge




• Patient must go to pharmacy in person• Take evidence of medicine eg empty

box, repeat slip• Take ID

The pharmacist makes a professional judgement and may decline to supply



Emergency Hormonal Contraception (EHC)

Pharmacists may

•Supply EHC (free to patient) subject to pharmacist training and according to local guidelines (PGD or prescription)

•Sell EHC (cost to patient) subject to certain restrictions e.g.age of patient





contra-Indications




Break

What is a Medicine? revision


Review and close

role preparation for nurse advisors handling medicines calls day 1

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