Download Medicines Optimisation PPT

Medicines Optimisation
Training
Objectives
•
•
•
•
•
•
•
What is Medicines Optimisation?
Nice Guidance
MHRA – yellow card reporting
Summary Care Records
Consultation Skills and Shared Decision Making
Hot Topics
Patient Group Directions
Medicines Code (and related
SOPS)
• See Medicines Code for further
information around Medicines Optimisation
and medicine related issues
Intranet  Staff  Policies
• Trust formulary:
www.sssftformulary.nhs.uk
Definition
A person-centred approach to
safe and effective medicines use
to ensure people obtain the best
possible outcomes from their
medicines
Ensuring medicines are:
• Clinically appropriate
• Safe and effective
Goals for the patient:
• Improved outcomes
• Adherence
• Improved medicines safety
The RIGHT patients get the RIGHT
medication at the RIGHT time at the
RIGHT dose and in the RIGHT form
Group Work
What might you need to consider when
choosing a medication for the following:
• ‘Average’ patient
• Patient of low weight
• Woman of child bearing
age/Breastfeeding/pregnant woman
• Elderly
• Child/teenager
• Patient with a physical health problem
(diabetes, overweight, high blood pressure)
NICE GUIDANCE
Medicines Optimisation: the safe and
effective use of medicines to enable the
best possible outcomes
Guideline Development Group:
•
•
•
•
•
Nurses
Doctors
Pharmacists
Public involvement
Industry
Multi Disciplinary Approach
• 8 recommendations of which 3 have been
identified as priority for implementation
1) Systems for identifying, reporting and
learning from medicines-related
patient safety incidents
How do we do this within our Trust?
• Safeguard reporting system
• Report on Rio with
incident number (serious
incidences  scan PDF
onto RiO)
• Helps to improve learning
from medicines related
patient safety incidents
• (Ward pharmacist receives notification
 can help support any training/learning
needs)
Adverse Drug Reactions (ADRs)
Patient takes a penicillin tablet  starts to
develop a rash and having trouble breathing
 dial 999
Patient has an adverse drug
reaction
Patient is admitted to acute DGH
for treatment and returns to ward
when better
?
Medicines and Healthcare products
Regulatory Agency (MHRA)
• Regulates medicines, medical devices and
blood components for transfusion in the
UK
• Yellow card scheme – system for
recording adverse incidents with
medicines and medical devices in the UK
• The yellow card scheme is vital in helping
the MHRA monitor the safety of all
healthcare products in the UK
• This ensures that all products are
acceptably safe for patients and users
When to Report?
• For established medicines and vaccines report all serious suspected ADRs (even if
the effect is well recognised)
• For new medicines and vaccines (▼) –
ALL suspected ADRs should be reported
How to Report
• Through the Yellow Card website
(https://yellowcard.mhra.gov.uk)
• Send a Yellow Card report by post
(download from MHRA website)
• By writing to FREEPOST YELLOW CARD
• By emailing [email protected]
• Phone – 08081003352 (10.00 – 14.00
Mon – Fri only)
What to Report
• Suspect Drug (route, dose, dates of
administration)
• Suspect Reaction (what actually
happened)
• Patient Details (sex, age, patient’s weight,
patient initials, local identification number)
• Reporter Details
• If known – other drugs taken, allergy
status and any other relevant information
Would you contact the MHRA for the
following?
a) Oculogyric crisis with haloperidol?
b) Pruritus with vortioxetine (▼)?
c) Suspected tardive dyskinesia with
mirtazapine?
2) Medicines – Related communication
systems when patients move from one
setting to another
3) Medicines Reconciliation
What percentage of patients have an error
or unintentional change to their medicines
when moving from one care setting to
another?
Up to 70%
How can we, as a Trust, help to
reduce this?
Summary Care Records
• Free (online) access to information about
patient’s medication, their allergies and
any adverse reactions to medication (24
hours a day, 365 days a year)
• Reduces the time, effort and resources
needed to obtain patients’ information
directly from their GPs
• All medical staff, all nurses (including
community MH nurses, community LD
nurses, children’s nurses, nursery nurses),
inpatient admin, community admin,
medical secretaries and pharmacy staff
now have access to the SCR
This is a real step forward for Medicines
Reconciliation as it has been shown that
using the SCR reduced the time, effort
and resources needed to obtain patients’
information directly from their GP with a
45% reduction in phone calls to GP
surgeries from the hospital
How to Access the SCR
1) The link to the SCR can be found within
RiO
2) Click the link
3) Enter Patient’s Details
(NHS number easiest)
4) In the Top Right Hand Corner – will
confirm if patient has an SCR or not. Click
on view SCR
Be wary of:
• When SCR was last updated
• Patients who have not been taking all their
medicines when they were at home
• ‘Medicines’ that patients don’t consider to
be medicines eg OTC/herbal/homeopathic
• Any medication that patients may have left
at home
• Etc!
Discharge
• Currently discharge summary written by
junior doctor and posted to GP
• In the future - pharmacy will be ensuring
that a copy of the discharge prescription is
put in with the discharge medication with a
view to the patient taking this to the GP
• In the future – a copy of the discharge
prescription will be faxed to the GP from
the ward
• CPN will attend the discharge meeting and
will be notified of any changes to
medication
• When patient obtains their next supply of
medication from their GP the CPN will
reconcile this supply against the discharge
summary
4) Medication Review
5) Self-management plans
6) Patient decision aids used in
consultations involving medicines
Choice and
Medication Website
7) Clinical decision support
8) Medicines – related models of
organisational and cross-sector
working
Making the Patient the Centre of the
Consultation and Shared Decision
Making
Why is it
important that we
get this right?
• Estimated that between 30 -50%
medicines prescribed for long term
illnesses are not taken as directed
• 30-66% non adherence in patients with
severe depression
• 30 – 65% non adherence in patients with
bipolar disorder
• 40 – 50% non adherence in patients with
schizophrenia
• NHS invests and spends a lot of money on
medicines
• Overall NHS expenditure on medicines in
2013-2014 was £14.4bn
• Research has improved our knowledge –
but adherence rates do not seemed to
have changed over the last 4 decades
At any one time what is the cost of
medication lying unused around people’s
houses:
a) £300 million
b) £90 million
c) £50 million
Shared decision-making is an
essential part of evidence-based
medicine, seeking to use the
best available evidence to guide
decisions about the care of the
individual patient, taking into
account their needs, preferences
and values
Why do you think patients
are non adherent with their
medicines?
What can we do to help
support adherence?
• Lack of insight
• Attitudes towards and previous
experiences of medication
• Co-morbidity and symptom severity
• Level of social and family support
• Social isolation
• Strength of therapeutic alliance between
patient and their doctor (healthcare
professional)
• Patient feels better
•
•
•
•
Side effects
Insufficient efficacy
Drug/alcohol abuse
Irregular daily routines (shift work,
unemployment)
• Dietary/religious (etc) beliefs
• Cost of prescription*
• Intentional vs non intentional adherence
* https://www.gov.uk/get-a-ppc
Importance of
taking the
medicine
Concerns
• Important that we talk to our patients to
understand their beliefs and concerns
about their treatment and find out what
they wish their medicines to achieve for
them
Health Coaching Model
• Not telling patients how to behave – but
helping patients to identify what outcomes
they want and what methods for achieving
these
• Encouraging the patient to be an active
participant in their own care
1) Find Out What the Patient knows
 What do you know?
 Have you been told about your condition?
2) Find Out about the Patient’s beliefs and
concerns
 What benefit do you think this medicine will
give you?
 What, if anything, are your worries about this
medicine?
(Use of Drug Attitude Inventory)
3) Ask what the Patient wants the Medicine
to Achieve for Them
 What would you like your medicine to allow
you to do?
4) Help the Patient decide whether they
want to take their medicine
 This helps the patient to ‘own’ their decision
to take their medicine (rather than us
assuming they will)
5) Encourage the Patient to Consider the
Practicalities of taking their Medicine
 Help the patient to plan how to take their
medicine every day and how they’ll monitor
their own adherence and medicine
effectiveness
‘What Matters to You?’
Rather than
‘What is the Matter?’
No Decision About Me Without Me
Consultation Skills needed:
•
•
•
•
•
•
Welcoming
Listening
Be aware of body language
Reflecting back
Appropriate use of questions
Empathy
• Support a patient in taking responsibility
for taking their medicine
• Enable a patient to integrate taking a
medicine into his/her lifestyle
Better Adherence
Remember!
The Best Outcomes in many conditions are
from a combination of :
• Self-help
 Risk reduction, self-management
• Help from others
 Support, psychotherapy, education
• Medication
 To control symptoms
Self-help
Help from others
Medication
3 supports –
fairly stable
with care
2 supports – can
be done but one
wobble and you
could be
struggling
1 support – can be
done with a lot of
hard work but one
wobble and you
could be really
struggling
Hot Topics
• eBNF, Drug Attitude Inventory, High Dose
Antipsychotics and Formulary
• Drug Driving Rules
• Sleep (Hypnotic Prescribing Guidelines)
• Physical Health
• Smoking and Medication
• Sodium Valproate
• CQC
How to access eBNF
on RiO
How to Access the DAI on RiO
Clinical Portal
– Client’s View
How to Access HDAT Monitoring Sheet on
RiO
How to Access the
Formulary on RiO
New Drug Driving Rules
• From 2/3/15 new law introduced around
driving after taking certain drugs in
England and Wales
• It is (already) an offence to drive whilst
impaired due to illegal or legal drugs
(section 4 of RTA 1988)
• This new law refers to driving, attempting
to drive or being in charge of a vehicle with
a specified controlled drug in the body in
excess of a specified limit
These ‘specified controlled drugs’ can be
(broadly) split into 2 groups
First Group
• ‘Zero tolerance’ group
• Consists of commonly abused drugs
• Low limits have been set
•
•
•
•
•
•
•
Cannabis (THC)
MDMA (ecstasy)
Ketamine
Methylamphetamine
Cocaine
LSD
Heroin/diamorphine
Second Group
• Mainly licensed medicines that have a
high potential to be abused.
• Specified limits have been set at a higher
level than the first group
• This means that people taking the
medication within the therapeutic range
are unlikely to test positive
• Morphine, other opiate/opioid based
medication (eg codeine, tramadol or
fentanyl)
• Diazepam, clonazepam, flunitrazepam,
lorazepam, oxazepam, temazepam
(medication used to treat anxiety or sleep
disorder)
• Methadone
• Amphetamine
• Roadside drug screening devices to be
developed that will use saliva to identify if
the person driving has taken a listed drug
(or one that may be metabolised into one
of these drugs)
• Following a positive screening result the
person can be requested to provide a
blood sample (for evidential purposes) to
enable prosecution
‘Statutory Medical Defence’
(For people who test positive)
Entitled to raise ‘statutory medical defence’
if:
• The drug was lawfully prescribed,
supplied, or purchased over-the-counter,
for medical or dental purposes; and
• The drug was taken in accordance with
advice given by the person who prescribed
or supplied the drug, and in accordance
with any accompanying written instructions
(so far as the latter are consistent with any
advice of the prescriber)
Notes
• May be helpful to advise patients to keep
some evidence on themselves when
driving to be able to prove that they are
legally taking the medication
• If police are satisfied that the driver is
taking the medicine on appropriate advice
then will not prosecute
NB
• It remains the responsibility of the driver to
consider whether they think their driving is,
or might be, impaired (eg by feeling
sleepy)
• It will still remain an offence to drive if
driving is impaired by drugs
Responsibilities
Patient:
• To decide whether they consider their
driving is impaired
Prescriber:
• To provide patients with advice/information
around medications that may cause
drowsiness and thus might impair driving
https://www.gov.uk/drug-driving-law
Sleep
What can help to ensure a restful night’s
sleep?
Sleep Hygiene
• Establish a regular routine eg getting up at
the same time each day
• Say ‘no’ to naps
• Daily exercise (but nb! Not within 4 hours
before going to bed)
• Don’t drink tea/coffee within 4 hours of
going to bed
• Avoid alcohol and smoking – both are
stimulants (? Avoid smoking within 6 hours
of going to bed)
• Comfort (bedroom not too hot or cold)
• Avoid using televisions or computer
monitors prior to sleep
• Don’t eat a big meal or spicy foods just
before bedtime
• Aromatherapy
• Use anxiety management/relaxation
techniques
• Go to bed to sleep
• Etc
If all else fails …get up and go and do
something else in another room
Insomnia – facts and figures
• Sleep is a vital biological process
• People with insomnia have been shown to
have higher rates of mental health
problems, drug and alcohol abuse, cardiac
morbidity, healthcare utilisation and to be
at increased risk of accidents and overall
mortality
• Remember there is a variation in people’s
sleep patterns
• Quality of sleep important – not actual time
spent sleeping
Non – Pharmacology Strategies
• Should be discussed first
• Psychological therapies more effective in
the long term compared to hypnotic
medication alone
• Cause of insomnia should be determined
(and treated)
Medications that can cause Sleep
Disturbance
• Antidepressants (SSRIs, venlafaxine,
bupropion, duloxetine and MAOIs)
• Antiepileptics (lamotrigine and phenytoin)
• Antihypertensives (beta blockers, calcium
channel blockers)
• Antipsychotics (aripiprazole, flupentixol)
• Hormones (corticosteroids, thyroid
hormones)
• NSAIDs
• Stimulants: (methylphenidate, modafinil)
• Sympathomimetics: (salbutamol,
salmeterol, theophylline,
pseudoephedrine)
• Others: (baclofen, trihexyphenidyl,
dantrolene, antimuscarinics, tizanidine)
When Should the Use of Hypnotics
be considered and what
precautions are necessary when
using them?
Hypnotics
• Management of severe insomnia
interfering with normal daily life
• Short periods of time (4 weeks usually
including any tapering off)
• Long term prescribing = off license
• Reason must be documented in patient’s
progress notes (if prescribing more than 4
weeks)
• First choice (within SSSFT) is zopiclone
• Second choice is temazepam
• It is recommended that switching from one
hypnotic should only occur if a patient
experiences adverse effects
• Use of sedating antihistamines,
antidepressants and antipsychotics not
recommended
Considerations for Certain Populations
Zopiclone
Temazepam
Elderly
Reduce dose
Reduce dose
Respiratory disease
Caution
Caution
Respiratory depression
Contra-indicated
Contra-indicated
Hepatic impairment
Reduce dose (avoid if severe)
Reduce dose (avoid if severe)
Renal impairment (severe)
Reduce dose
Reduce dose
Addiction Prone
Avoid
Avoid
Clozapine
Caution
Caution
Administration
• Should not be routinely offered (if on PRN)
• Only offer if attempts have been made to
relax and sleep
• Should only be administered after 11pm
• Avoid giving in early hours of the morning –
‘hangover effect’ patient may not get up and
engage in therapeutic activities
Do we (as a Trust) do this?
We should NEVER develop a
newly dependent patient by virtue
of a hospital admission
Physical Health
• Why the concern?
• People with a serious mental health illness
die an average of 15-20 years earlier than
the rest of the population
• People with a serious mental illness at
increased risk of a range of physical
illnesses/conditions – respiratory disease,
coronary heart disease, diabetes, high
blood pressure, stroke (etc)
• Mental Health Taskforce
– ‘The Five Year
Forward View for Mental
Health’ February 2016
• The Kings Fund –
‘Bringing together
Physical and Mental
Health’ March 2016
• New models of care
• Integrated approach
• Reduced life expectancy among people
with severe mental health illness largely
attributable to poor physical health
• Many contributing factors – one of them
being medication
• Champion for physical health in mental
health services and vice versa
Smoking and Medication
• Cigarette smoking can interact with some
medications
• Polycyclic aromatic hydrocarbons in
cigarette smoke that stimulate production
of enzymes which results in some
medications being metabolised faster
• As majority of interactions are not due to
the nicotine (in cigarettes) this problem
does not occur when using NRT
• Beware if a patient stops/starts smoking
Physical Health Medication
•
•
•
•
Warfarin
Theophylline
Insulin
? Beta blockers
Psychotropic Medication
•
•
•
•
•
•
•
•
Chlorpromazine
Clozapine
Olanzapine
Haloperidol
Fluphenazine
Duloxetine
Fluvoxamine
Methadone
Valproate
• Sodium valproate and valproic acid
(epilepsy)
• Semi sodium valproate (mood stabiliser)
Known to cause teratogenic side effects:
Increased risk of congenital malformation
• Woman not on valproate
• Woman on valproate
Developmental Disorders
• Exposure to valproate in utero can have
an adverse effect on mental and physical
development
• Up to 30-40% experience delays in their
early development such as talking and
walking later, lower intellectual abilities,
poor language skills (speaking and
understanding) and memory problems
Toolkit
• February 2016 – launch of a new ‘toolkit’
to ensure female patients are better
informed about the risks of taking
valproate medicines during pregnancy.
https://www.gov.uk/government/publications/
toolkit-on-the-risks-of-valproate-medicinesin-female-patients
Checklist and
important
discussion points
for prescribers and
patients
Credit card sized
information leaflet
Patient booklet
Healthcare professional booklet
Need to consider:
• Risk vs benefit
• Pregnant – planned?
- unplanned?
• Child bearing age/not of child bearing
age?
• (Use of reliable contraception if the woman
is of childbearing age)
CQC
• Omitted/Delayed Doses
• RT
• Lithium red top alert (9/8/16) – poor blood test
monitoring in relation to lithium management
E-Learning Module
In order to obtain the Medicines Optimisation
Competency an e-learning module on
Medicines Management also needs to be
undertaken
This can be accessed via:
[email protected]
(Any problems contact Sharon Dennison)
Patient Group Directions
PGDs
Patient Group Directions (PGDs)
• A PGD is a written instruction for the
supply and/or administration of a named
licensed medication for a defined medical
condition to a group of patients that fit the
criteria laid out in the PGD.
• It allows specified healthcare professionals
to supply and/or administer medicine
directly to a patient without the patient
needing to see a prescriber.
• Important to remember that it is a
‘direction’ – by writing a PGD you are not
prescribing
What Do I need to Do to be able to use a
PGD to Administer Medication?
• Complete the PGD part of the Medicines
Optimisation Training initially on starting
with the Trust and then on a 3 yearly basis
• Work through and complete the PGD
Resource pack
• Once completed contact your line
manager (who will assess you to confirm
competency)
• Line manager should then assess nursing
staff yearly (? At annual appraisal) to
ensure continual competence
Complete the front page
of each PGD that you are
able to use
The original will be kept in
the PGD folder on the
ward
A photocopy will be kept in
your personnel file
N.B. PGDs vary between clinical settings.
• Check trust website
•
•
•
•
•
•
Nurses (Inpatients)
Nurses (Inpatients, specific areas (EDU)
Nurses (Crisis Team)
Nurses (Sub Misuse)
Nurses (GUM)
Nurses (Outpatient specific areas eg Drug
and Alcohol)
Etc!
When to Use a PGD
For short term conditions e.g
• Short term pain relief
• Short term relief of constipation
• Short term relief of indigestion
• Short term relief of anxiety or agitation
When should a PGD NOT be Used
• PGDs are NOT suitable for chronic
disease management (Long term pain
management, long term insomnia, long
term anxiety etc)
• PGDs cannot be used to alter a prescribed
dose
• PGDs cannot cover repeat prescribing
• If any of the exclusion criteria in the PGD
are fulfilled then that PGD cannot be used
and a prescriber must be consulted (and if
necessary come out and prescribe the
medication)
• Staff employed directly by SSSFT can use
PGDS. (If you are doing a bank shift on
another ward as long as you are signed off
for a PGD on your base ward then you can
also write that same PGD on a different
ward)
• Staff who are NOT directly employed by
SSSFT must not write PGDs
How To Use a PGD to
Administer Medication
Inpatient
• Peptac
• Nurse who writes the PGD should also
administer the first dose
• Any subsequent doses that are administer
can only be done by PGD trained nursing
staff
• Need to document on RiO that the patient
has had a medication using a PGD for a
certain condition and document the PGD
number
Community
• Different paper work
• Crisis  one book for supplying and one
book for administering (controlled drug
book)
• Amounts are tallied each time a PGD is
administered
This presentation only gives an overview
Healthcare Professionals need to familiarise
themselves with the Competency Based
Assessment (which is adapted from the
National Prescribing Centre) and the
framework within this.
There should be a PGD Learning Resource
Pack on each ward.
Thanks for listening
Any Questions?