Pharmacy Induction for Junior Doctors

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Pharmacy Induction for Junior Doctors

• RHSC
• Edinburgh

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Overview

• Background to safe prescribing in paediatrics and
  Golden Rules
• Common pitfalls
• Hospital and trust policies
• Lothian joint formulary
• Pharmacy services
• Scenarios
• Safe prescribing quiz
• Tomorrow
• Pain management
• Quiz feedback

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Background

• Safe prescribing is an essential generic skill
• Particular issues for paediatrics
• Most medications prescribed by weight
• Most children dont like tablets so liquid
  formulations used
• Differing pharmacokinetics in different age
  groups
• Dose errors more likely to be significant

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Pharmacokinetic differences

• Absorption
• Gastrointestinal tract pH higher?decreases
  absorption of phenobarbitone, phenytoin
• Gastric emptying slower Skin, thin striatum,
  well hydrated
• Muscle, less muscle mass, altered blood flow PR,
  slower and incomplete

• Distribution of body fluid
• Premature neonate 92 body water Newborn 75
  Child 50, Gentamicin
• Low fat, 3 in premature, 12 newborn, 1 year old
  30 Adults 18
• Protein Binding Low affinity and
  capacity,Phenytoin

• Metabolism
• Enzyme systems are immature Huge differences
  from premature to 2 weeks old.
• Phenytoin 72 hours to 8 hours. Phenobarbitone
  from 200 hours to 20.
• From age 1 9 clearance can exceed adult values
  /m2

• Elimination
• Glomerular Filtration Rate increases with age
  until around 1 year.
• Tubular secretion immature, solute loads
  including Sodium, Potassium.

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Golden Rules for Safe Prescribing

• NHS Lothian version on intranet
• Adapted for use in RHSC (induction pack)
• Standardised NHS Lothian drug kardex from
  September 2009

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Golden Rules

• Write clearly in block capitals in black
  ballpoint pen
• Complete all required patient details on the
  front of the kardex, and name/DOB on each page in
  use
• Use approved (generic) names for medications
• Exceptions oral morphine, combination
  products, specific products

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Golden Rules

• Write the drug dose clearly
• Accepted abbreviations g, mg, ml
• Round to sensible doses eg 82mg ?80mg
• Avoid decimel points if possible
• eg 100 MICROGRAMS not 0.1mg
• Use accepted routes of administration
• IV, IM, SC, SL, PR, PV, NG, ID, TOP, INHAL
• Write other routes in full eg ORAL, INTRATHECAL

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Golden Rules

• 6. Enter start date
• If medication not required on some days, use an
  X in the box when the medication is not needed
• For once only treatment, use front of chart
• Sign and PRINT your name on the prescription
• Enter details of any other charts in use

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Golden Rules

• Times of administration use the 24 hour clock
• BD 06 18
• TDS 08 16 24
• QDS 06 12 18 24
• 11. Never alter prescriptions cancel and
  rewrite
• Discontinue medications correctly
• 13. Rewriting a kardex score through each page,
  use original start dates

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Hospital PoliciesIncident Reporting

• DATIX forms (intranet), feeds back to PNDT
• Anonymous
• Identifies extent and nature of errors
• Improved awareness of high risk situations
• Changes implemented to minimise future risks

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• INTRANET
• HEALTHCARE
• A-Z
• RISK MANAGEMENT

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Trust Policies

• INTRATHECALS
• Trained staff on register only
• Registrar level and above
• Prepared in pharmacy
• IV and Intrathecal medications not charted at the
  same time on different charts
• Errors can lead to fatalities

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Lothian Joint FormularyInternet
www.ljf.scot.nhs.uk

• Aims
• Promote safe, effective and economic prescribing
  in primary and secondary care
• Produce greater familiarity with a limited range
  of medicines
• Develop agreement across the interface between
  primary and secondary care
• Promote a seamless approach to prescribing

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Lothian Drug Budget 100,000,000

• 40 of drugs used in primary care are influenced
  by secondary care.
• Audit Comission A prescription for improvement.
  
• London HMSO 1994

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Committees

• Scottish Medicines Consortium
• Evaluates new medicines
• Formulary Committee
• Lothian wide, monthly meetings
• Considers SMC advice and NICE, SIGN guidelines
• Reviews new applications -FAF1 Drugs approved
  by SMC
• -FAF2 Drugs predating the SMC
• -FAF3 Unlicensed/off label drugs
• Implementation working group
• Increase awareness and use of the LJF in
  Lothian, using promotional material

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Drug Licensing

• Ensures all medicines reach standards for safety,
  quality and efficacy
• License allows drug to be marketed for
• -specific conditions
• -in agreed dose range
• -by particular route
• -using tested formulation
• Based on clinical trials data

• Drug Company
• Licensing authority
• Licence
• Drug Company
• Market Drug

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Problems with Licensing in Paediatrics

• Lack of clinical trials
• eg 1994-98 80 of new drugs had no info in
  children
• Ethics
• Long term effects
• Micro-analytical techniques
• Low return for investment
• lt40 of medicines prescribed by hospital
  paediatricians are outside the licence or have no
  licence

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Directive 89/341/EEC

• All doctors can prescribe
• there is no statutory requirement to disclose to
  a patient when a medicine is unlicensed
• prescriber should be aware of unlicensed
  prescribing
• decision to prescribe unlicensed medicines should
  be in best interests of patient
• All pharmacists can dispense

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Off Licence Examples

• IV injection given orally- Midazolam
• IV injection given intranasal- Diamorphine
• Not recommended in children- Pentasa tablets
• Outwith the age range- Paracetamol neonates
• Different indication- Domperidone for GOR

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Pharmacy Services

• Location Opposite ward 4
• Hours Monday-Friday 0830 1700
• Weekend 1100-1200
• Ward pharmacists
• Dispensing and one-stop
• Aseptic Chemo, TPN, IV antibiotics,
  intrathecals
• Distribution/ward top up
• Medicines information enquiries, drug
  interactions, named patient drugs
• Clinical pharmacy drug levels, general
  medicines advice
• Out of hours emergency cupboard/on call
  pharmacist

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Scenarios

• A 6 year old boy is admitted with pneumonia and
  is to be managed with IV augmentin and
  maintenance IV fluids. He is requiring 2l of
  oxygen to maintain his saturations. He has a
  history of cerebral palsy, epilepsy and asthma.
  Current medications are phenytoin 16ml BD, clenil
  modulite 2 puffs BD and salbutamol PRN. He is
  not currently wheezy.
• What further information is needed to complete
  his drug kardex and IV fluid chart, and where
  would you find it?
• What else might you want to prescribe for him?

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• What further information is needed to complete
  his drug kardex and IV fluid chart?
• -Name, DOB, CHI, consultant
• -any allergies
• -Weight-actual or estimate
• weight (age 4) x 2 (64) x 2 20kg
• -Dose of IV augmentin-monograph
• -Strength of phenytoin suspension - BNFC
• -Strength of clenil modulite inhaler patients
  own, recent letter, GP
• -UE results
• What else might you want to prescribe for him?
• -Oral paracetamol /- ibuprofen as antipyretics
• -Rescue medication for seizures if appropriate

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• Name Joe Bloggs, DOB 01/02/04, CHI 0102049900
• Consultant Dr Jeckyll
• Actual weight 24kg
• No known allergies

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• IV augmentin IV monograph
• 30mg/kg TDS 30 x 24 720mg TDS
• Clenil Modulite BNFC 50, 100, 200 strength
• Salbutamol BNFC 100 or 200 strength
• Phenytoin BNFC 30mg/5ml
• 16ml 30/5 x 16 96mg

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• Na 136, K 3.2
• Weight 24kg
• Fluid Prescription IV fluid guidelines
• 1st 10kg 100 x 10 1000ml
• 2nd 10kg 50 x 10 500ml
• Next 4kg 20 x 4 80ml
• TOTAL 100050080 1580ml
• Hourly rate 1580/24 65ml/hr
• Use 0.45 NaCl/5 Glucose with 10mmol KCl per
  500ml

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• 2. A 10 month old infant called John Smith
• (weight 8.1kg, DOB 01/10/09, CHI 0110090000) has
  returned to the surgical ward following washout
  of a septic joint. No analgesia has been
  prescribed. He has vomited twice since theatre
  and seems to be in pain.
• Can you prescribe appropriate analgesia?

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• Paracetamol Vomiting, so use PR or IV route
• PR BNFC or acute and postoperative pain
  guidelines
• Loading dose
• 30mg/kg load 40 x 8.1 324mg
• Suppositries 60, 125, 250, 500mg strength
• Use 1 x 250mg 1 x 60mg 310mg
• Maintenance dose
• 20mg/kg 6 hourly 20 x 8.1 162mg
• Use 1 x 125mg 125mg (max 90mg/kg/day)

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• Paracetamol IV Use RHSC IV monograph
• 10mg/ml
• Loading dose
• 20mg/kg 20 x 8.1162mg (round to 160mg)
• Maintenance dose
• 10mg/kg 4 hourly 10 x 8.1 81mg (round to
  80mg)

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• Ibuprofen use BNFC or acute and postoperative
  pain guidelines
• Check no contraindications
• Dose
• 10mg/kg 6 hourly
• 5 x 8.1 40.5mg, round to 40mg
• Volume
• 100mg/5ml suspension
• Dose 5/100 x 40 2ml

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• John has stopped vomiting and has had rectal
  paracetamol and oral ibuprofen, but remains
  tachycardic and unsettled. What do you do?
• Assess to ensure no complications of surgery
  causing tachycardia/pain eg bleed, hypovolaemia,
  infection. Use analgesic ladder and acute and
  postoperative pain guidelines, prescribe codeine.
• Codeine orally 1mg/kg 4 hourly
• 1 x 8.18.1mg, round to 8mg
• 25mg/5ml suspension dose 5/25 x 8 1.6ml

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Summary

• Safe prescribing an essential generic skill
• Pitfalls common
• Use available resources
• Ask for help seniors / pharmacists
• Safe prescribing quiz

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