Role Preparation for Nurse Advisors Handling Medicines Calls Day 1

1
Role Preparation for Nurse AdvisorsHandling
Medicines CallsDay 1

• NAME
• Medicines Information Pharmacist
• NAME Medicines Information Service

2
Medicines Training for Nurses
Training 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
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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
4
Timetable - Day 1 Afternoon
Overview 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
5
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
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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
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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
8
NHS Directs 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
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NHS Directs Pharmacy and Medicines Services

• 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
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NHS Directs Pharmacy and Medicines Services

• 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
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NHS Directs Pharmacy and Medicines Services
Principles for Handling Medicine Calls

• 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

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NHS Directs Pharmacy and Medicines Services
Guidance for specific types of 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

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NHS Directs Pharmacy and Medicines Services
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 ingestions Interim 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
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Identification and prioritisation of medicines
calls
Annotating calls

• 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

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Identification and prioritisation of medicines
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?
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Identification and prioritisation of medicines
calls
Annotating H calls
H1 Assessment within 20 minutes If extremely anxious or distressed Eg I have just been diagnosed with breast cancer. I dont 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?
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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
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What is UK Medicines Information?

• UKMI- supports MI needs of NHS health
  professionals
• gt½ million enquiries 2006
• 16 regional 260 local centres
• Specialist services - pregnancy, breastfeeding,
  liver disease, dental
• Training, websites, QA, drug reviews

www.ukmi.nhs.uk
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What is UK Medicines Information?
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
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What is UK Medicines Information?

• Staff
• Pharmacists
• Pre-registration pharmacists
• Secretarial support
• Services to NHS Direct
• Complex medicines calls
• MI skills training
• Quality Assurance
• National work

• Mon- Fri 9am - 8.00pm
• Weekends 9am 3pm
• Except Bank Holidays
• Speed Dial 004

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What is UK Medicines Information?
Referral to UKMI

• 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

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Examples of Complex Medicines Calls
What is UK Medicines Information?

• 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 QA
• Breastfeeding
• No UKMI QA
• Baby pre-term / unwell
• Uses / choice
• Contra-indicated
• Doses outside norm

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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
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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

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Ethical Dilemmas

• I found a tablet.
• My G.P. says this. but Ive read something
  different
• Does heroin interact with..?
• Could my partners tablets cause?
• What are my friends tablets for.?

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Ethical Dilemmas

• 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.

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Workshop 1 Ethical Dilemmas

• A woman says she has found some medicines in her
  sons 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?
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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
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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 ..
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What is a medicine?
Naming medicines
Generic Brand
Amoxicillin Amoxil
Salbutamol Ventolin
Fluoxetine Prozac
Omeprazole Losec
Mefloquine Lariam
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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 Only P May be sold in a pharmacy but not a general shop e.g. Piriton
Prescription Only POM May only be supplied on prescription e.g. Amoxicillin
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What is a medicine?
Controlled Drugs (CDs)
Misuse of Drugs Act 1971 CDs are POMs with
stricter controls on production, supply or
possession
Class A eg heroin, LSD, ecstasy, morphine,
Class B eg amphetamines, barbiturates, codeine,
Class C eg anabolic steroids, cannabis,
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What is a medicine?
Unlicensed Medicines

• Off Label
• UK product licence but being used for an
  indication/at a dose/by a route not in the licence

• No Licence
• No UK product licence

• Methotrexate for asthma and lupus
• Sodium valproate for prevention of migraine

• Thalidomide
• Melatonin
• Most herbal products

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What is a medicine?
Black Triangle medicines

• Newly licensed
• Monitored intensively by Commission for Human
  Medicines (CHM) which reports to MHRA
• Black triangle status usually reviewed after 2
  years

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What is a medicine?
Medicines that may not be prescribed in the NHS

• Known as the Black List
• Pricing Prescription Authority (PPA) will not
  reimburse dispensing cost.

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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
37
(No Transcript)
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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
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Key Information Sourceson Medicines
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Key Information Sourceson Medicines
Electronic British National Formulary (eBNF)

• Published every six months
• Information on drugs generally prescribed in UK
• Designed for rapid reference
• Less detail on specialist areas
• Appendices at the back

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Key Information Sourceson Medicines
Electronic Medicines Compendium (eMC)

• 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

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Key Information Sourceson Medicines
NetDoctor

• Easy to Search
• Laymans language
• Good for use, side-effects, drug interactions
• Medicines section written by pharmacists
• Updated daily

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Key Information Sourceson Medicines
MedicinesChestOnline

• Online version updated daily book published
  annually
• Guide to over the counter medicines
• Particularly useful for checking active
  ingredients
• Very little clinical information

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Key Information Sourceson Medicines
NHS Direct Medicines QAs

• 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 QAs added regularly

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Key Information Sourceson Medicines
MedicinesComplete

• 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

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Key Information Sourceson Medicines
When to use each Source
eBNF For all calls unless QA 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
QAs Single reference source. Question asked must exactly match QA
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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
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Workshop 2 Navigating Key Resources
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Key Information Sourceson Medicines
Merits Disadvantages
eBNF Gold standard Some opinion Care when searching Jargon
eMC Easy to search Comprehensive info Technical Unlicensed / off label Not all medicines
NetDoctor Easy to search Laymans terms Use, side effects, drug interactions Pregnancy Breastfeeding
Medicines Chest Good for details on active ingredients of OTC products Very little clinical information
QAs Saves time Difficult to find info Limited number Need prompt updating
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Timetable - Day 1 Morning
Welcome 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 QAs and Medicines Complete
Lunch
51
(No Transcript)
52
Timetable - Day 1 Afternoon
Overview 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
53
Timetable - Day 1 Afternoon
Overview 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
54
Baseline knowledge for handling medicines calls
Clarify the question
Refer to MI Using Speed Dial 004
Record all stages
Plan search strategy research problem
Evaluate the information
Tailor the answer/advice
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Baseline knowledge for handling medicines calls
The Iceberg Theory
This is what the caller may ask
This is the rest of the story!!
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Baseline knowledge for handling medicines calls
Confirm no new or worsening symptoms

• 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?

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Standard Search Strategies
Baseline knowledge for handling medicines calls

• 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.

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Reasons for Documentation
Baseline knowledge for handling medicines calls

• 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.

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What should be documented?
Baseline knowledge for handling medicines calls

• 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.

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Example documentation
Baseline knowledge for handling medicines calls

• Is warfarin safe in the 1st trimester of
  pregnancy?

eBNF Malformations. eMC No monograph. NetDoctor
Do not use in pregnancy Toxbase
Malformations. Advised to speak to GP by end of
day.
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Timetable - Day 1 Afternoon
Overview 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
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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?

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Handling medicines calls
Examples

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

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Handling medicines calls

• Medicines in Pregnancy
• 35 of women will take medicines at least once
  during pregnancy
• All medicines should be avoided in pregnancy
  unless they are essential
• Medicines whilst Breastfeeding
• Unnecessary drug use should be avoided
• Assess benefit/risk ratio for both mother and
  infant

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Timetable - Day 1 Afternoon
Overview 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
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Workshop 3 Case Scenarios
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Timetable - Day 1 Afternoon
Overview 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
68
(No Transcript)
69
Timetable - Day 1 Afternoon
Overview 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
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Overview of Community Pharmacy Services

• 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

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Overview of Community Pharmacy Services

• 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
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Overview of Community Pharmacy Services
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
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Overview of Community Pharmacy Services
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

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Overview of Community Pharmacy Services
Exemptions from prescription charge

• 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.

.
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Overview of Community Pharmacy Services
Emergency Supply by a pharmacist

• 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

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Overview of Community Pharmacy Services
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

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Overview of Community Pharmacy Services
Emergency Supply by a pharmacist

• 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

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Overview of Community Pharmacy Services
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

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Timetable - Day 1 Afternoon
Overview 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
What is a Medicine? revision Overview of Community Pharmacy Services
Review and close