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Nurse Advisor and Health Information Advisor Clinical Update For the release of CAS Clinical Version 15 Handling Medicines Enquiries Document control Author/s Version Date for review Purpose of circulation Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Janet Haslam/Carys Murray/Anne Joshua/Davina Wraight/Caron Taylor 1 August 2006 To support clinical version v15 release Page 1 of 44 Contents Page Content 3 Introduction 4 Answering Medicines Enquiries using CAS Clinical v15 7 Documenting Patient Medical History 12 Using the Other Problems Algorithm 32 Where to find information about medicines 43 Learning summary: Portfolio reflection Document reviews Date Reviewed by Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Comment Page 2 of 44 Introduction and Background to the Development Other Problems Algorithm-Medicines Enquiries In CAS clinical release V13 an algorithm was introduced to assist the documentation process for Nurse Advisors in recording information on enquiries related to medicines. This was a process used for non-symptomatic calls only. Let’s revisit some of the principles behind its development. Nurse advisors traditionally entered call details for non-symptomatic patients within the add/view comments function leaving the call unstructured with little supporting evidence. For medicines enquiry calls it is important that relevant questions are asked and that any potential problems can be avoided. The addition of the Other Problems Algorithm enabled general enquiries that did not require assessment or health information and those calls relating to social circumstances to be documented in a consistent manner, whilst also enabling an audit trail. A cautionary question was written into the initial assessment question to inform Nurse Advisors that this algorithm should not be used if any active symptoms were present, however it may be appropriate to launch as a secondary algorithm should it become evident that there is a medicine element to the consultation. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 3 of 44 Section 1: Answering Medicines Calls using CAS Clinical Version 15 The following section introduces Nurse Advisors and Health Information Advisors to a development within the Other Problems Algorithm to further assist non-symptomatic medicines calls. In CAS clinical version 15 using the Other Problems Algorithm, Medicines Enquiry algorithm alias it is now possible to address medicines enquiries with a format that offers structure and enables advisors to collate all the relevant information to understand what the patient is calling about. Some calls about medicines do not involve symptoms or changes in conditions and where there are Health Information staff trained to handle medicines calls they should continue to do so as indicated within the NHS Direct National Policy for Handling Medicines Calls (NHS Direct 2005).; ‘Health Information staff must access training to support practice and have access to a specialist Medicines Information Service. Where this is not the case, calls should be dealt with by Nurse Advisors’ (NHS Direct 2005). A number of Health Information staff have undergone specialist training to handle medicines enquiries using specifically developed protocols that are currently available on the Medicines and Pharmacy intranet site. The Medicines Enquiry algorithm in CAS clinical version 15 will now host the information from the protocols and will be accessible by both Health Information Advisors and Nurse Advisors. The NHS Direct policy for managing medicines enquiries gives clear definitions on what constitutes a medicine, pharmacy or poisons call and which staff discipline should manage the call process for each call type: The National Policy for Handling Medicines Calls (NHS Direct 2005) Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 4 of 44 For the purpose of this document the list below outlines those calls which may be managed by Nurse Advisors but not by Health Information Advisors. The subject of the call is taking 3 or more medicines. For some enquiries about a high-risk medicine, for example, warfarin, aminophylline, carbamazepine, ciclosporin, digoxin, lithium, methotrexate, phenytoin or theophylline The individual is pregnant (excluding calls where there is a Medicines Q&A that answers the question e.g. is it safe to take paracetamol in pregnancy). The individual is currently breastfeeding The enquiry relates to a child under the age of 16 years The medication enquiry is ethically sensitive – ‘Can you tell me what methadone is, I have just found a bottle of it in my son’s bag?’ The enquiry conflicts or undermines a GP or Consultant recommendations The prescribed dose is outside of the usual range The enquiry relates to an unlicensed medicine (NHS Direct 2005) It is important to understand when handling medicine calls the conditions where medicines may present a particular challenge as the response to the medication may be compromised and those medicines that have a narrow window between therapeutic effect and toxicity Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 5 of 44 Medicines Information Service Referral to a Medicines Information service is a valuable resource and the usual reasons for referral are: Caller has complicated medicine and/or past medical history Information is missing, contradictory, unclear or confusing Enquiry is outside of professional competence Difficulty in understanding the question or problem The service is currently only available 9-5 Monday to Friday excluding Bank Holidays so this has to be considered when handling the call. Take this opportunity to check your local UK Medicines Information service number and record below. Please refer to the following guidance on the Medicines and Pharmacy intranet site; (http://nww.intranet.nhsdirect.nhs.uk/medpharm/) NHS Direct Working with UKMi Guidance for sites (NHS Direct 2005) NHS Direct Guidance for Referral of Complex Medicines Calls to UKMi (NHS Direct 2005) NHS Direct Working with UKMi Guidance for sites (NHS Direct 2005) NHS Direct Guidance for Referral of Complex Medicines Calls to UKMi (NHS Direct 2005) Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 6 of 44 Section 2 Documenting Patient Medical History What is a Medicine? A medicine can be any substance used therapeutically that is administered by systemic, topical, inhalation, rectal, vaginal, intramuscular, subcutaneous or intravenous route. Recording Patient Medical History (PMH) When collecting the relevant patient medical history Advisors should ensure that the history collected contains any medicines being taken including the name, dose, frequency and any existing conditions or allergies and record within the PMH function. This is a mandatory field in this type of call in order to complete all medicine enquiries. For this reason all medicines enquiries should be recorded in the name of the patient who is taking the medicine. The Patient Medical History screen is accessed using the following process: Select Patient Medical History. Clicking on patient information on current tasks will leave PMH accessible for the call duration Copyright © 2004 CAS Services Ltd. All Rights Reserved Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 7 of 44 To launch PMH when required within the episodes of care click on the PMH within ’MY CURRENT TASKS’. Key information that needs to be collected in all medicines enquiries includes: What is the drug? What has it been prescribed for? What is the dose and frequency? Any other medicines? Any other disease states? Who is it for?- it should be for the person who is ringing otherwise classed as third party The age of the patient? This will have been collated already and will be seen on screen ‘In symptomatic calls the PMH collected should be relevant at the time of the call. Recording of medicines in these circumstances may not require dose and regime’. To add to the PMH click on to ADD PMH on the menu bar. This will make the Medicines, Conditions and Allergies active. Copyright © 2004 CAS Services Ltd. All Rights Reserved Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 8 of 44 Copyright © 2004 CAS Services Ltd. All Rights Reserved Any active PMH will be displayed in the applet and will appear on the call report. Copyright © 2004 CAS Services Ltd. All Rights Reserved Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 9 of 44 Editing PMH Clicking on show all will show any errors or inactive PMH entered into the patient record Copyright © 2004 CAS Services Ltd. All Rights Reserved Copyright © 2004 CAS Services Ltd. All Rights Reserved Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 10 of 44 If you need to edit any of the information select edit PMH from the menu bar and using the drop down menu choose the item you wish to edit. Once you have made changes to the PMH information in the applet will indicate when the item was modified and by whom. Other information that is displayed in the applet includes; The date any PMH was entered, The time it was entered and The name of the user who entered it. Key Board shortcuts As each item of PMH has to be entered and saved before adding any more the following key board shortcuts may assist in reducing the number of mouse actions required to enter the information; CTRL + S allows you to save any data added CTRL + Z will cancel any data you do not wish to save while the applet is active CTRL + Q will close the applet Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 11 of 44 Section 3 Using the Other Problems algorithm to support medicines enquiries Medicine topics addressed within the Other Problems Algorithm, Medicines Enquiry algorithm alias incorporates the following single select options; Adverse effects Interactions Therapeutic dose Travel medicine Administration and dosage Identification Access In launching the algorithm Advisors should first fully explore what it is the patient is asking, for example if they want to know if Ciprofloxacin can cause headaches it is important to ascertain whether the patient is experiencing them or wondering about the potential for this to happen. If headaches are occurring then an assessment of the current symptoms should be undertaken using the appropriate algorithm by a nurse advisor. If the patient has taken an overdose of a medicine that has not been ascertained at the call streaming and prioritisation stage of the care process, the algorithm will transfer out to the ‘ingestion’ algorithm in order that an appropriate assessment is made or transferred to a nurse advisor for assessment. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 12 of 44 Using the Medicines Algorithm Alias to answer medicine enquiries Let’s look at the single select topics addressed within the Medicines Enquiry algorithm alias relating to medicines individually and highlight any key issues and the appropriate search strategy. Adverse Effects Think about the terminology a patient is using, the Medicines Enquiry algorithm alias should only be used if the patients concern relates to potential not actual side effects. In ascertaining the patient history you would need to find out the following: 1. Is the medicine they are enquiring about currently being taken or when do they plan to start? 2. What is it being taken for? 3. What is the specific question or concern regarding the medicine? Document the patient responses using the ‘add note’ applet within the algorithm. Search Strategy eBNF nww.intranet.nhsdirect.nhs/bnf/ The interactions appendices is very comprehensive and will usually state if there is an interaction present or not, but in a lot of cases does not give details on how to manage the interaction. eBNF or eBNFc (BNF for children). Accessible via Medicines Complete (Use Medicine Chest Online to confirm the active ingredient in an OTC Medicine before looking it up with eBNF or eBNFc). eMC http://emc.medicines.org.uk The company SPC again will state most of the interactions re[ported for that product, in some cases gives more detailed and practical details of what to do. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 13 of 44 detailed and practical details of what to do. Drug Interactions – Stockley now via Medicines Complete Comprehensive source that covers interactions in more detail, giving you an idea of how serious the interaction is, timescale and practical advice on what the patient should do. NHS Direct FAQ's Can be used as a sole source to document an enquiry. This resource can be found on the NHS Direct Online site and at www.ukmi.nhs.uk Can be used as a sole source to document an enquiry. This resource can be found via the NHS Direct Intranet add link Additionally in support of the system information the following can be used for complimentary medicines: Herbal medicines, Pharmaceutical Press Dietary supplements, Pharmaceutical Press Herbal Safety News, www.mhra.gov.uk Top Tips/Referral If an adverse reaction occurs and a patient has been on a medicine for years do not assume the medicine is not the cause, some times adverse reactions can occur after a period of many months. Interactions 1. What medicines is the caller enquiring about? 2. Why does the caller wish to know this? 3. Which of the medicines is the caller already taking and how long have they been taking them for? 4. Have the medicines been taken together? (If so how long has the combination been taken for and have any symptoms been seen) 5. Is the caller taking any other medicines? 6. What are they being taken for? Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 14 of 44 7. Who prescribed the medicine or was the medicine bought from a pharmacy? Has a potential side effect already been seen, or are they asking just be on the safe side. Is the caller worried about any side effect in particular, has the caller read about an interaction somewhere and if so where. If it is because new symptoms have been noticed the call should be passed to a nurse advisor. The algorithm supports the following questions when assessing an enquiry relating to actual or potential interactions; You will need to collect details not only of the medicine the patient has concerns about but also any other medicines being taken. The caller takes medicine X and wants to take medicine Y. The caller takes medicines X & Y. The caller takes medicine X and wants to drink alcohol or eat for Y. A caller should never be advised to take medicine that has been prescribed for someone other than themselves. Check the following reference sources: --- eBNF or eBNFc (BNF for children). Accessible via Medicines Complete (Use Medicine Chest Online to confirm the active ingredient in an OTC Medicine before looking it up with eBNF or eBNFc). --- eMC --- NetDoctor --- Patient.co.uk (Drug Information Leaflets section) --- Medicines Q&As --- Shockley's Drug Interactions (accessible via Medicines Complete) In addition, for Complementary Medicines: Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 15 of 44 --- Herbal Medicines (Accessible via Medicines Complete) --- Dietary Supplements (Accessible via Medicines Complete) --- Herbal Safety News --- UKMI Factsheets on Complementary Medicines Top Tips/Referral If you are unable to find an interaction listed in the eBNF do not assume that it means there is no interaction, check other sources first. If you are unable to find any information or don’t understand the information you have found – contact the Medicines Information Service. Therapeutic Use An example of a therapeutic use enquiry could be that of a patient who is about to take a long haul flight and wishes to take aspirin prophylactic ally and wants to know if this is OK as they have mild asthma Again it needs to be confirmed whether the patient is taking any other medicines or has any other existing medical condition and if they are pregnant or breast feeding. Document the nature of the enquiry confirm the name, dose and frequency of all medicines? CLINICAL INSIGHT: CAN I TAKE? Is Is Is Is it OK to take medicine X? The caller has condition Y. it OK to take medicine X? The caller has allergy Y. it OK to take medicine X? The caller is having test Y. it OK to take prescribed medicine X for unlicensed indication Y? Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 16 of 44 A caller should never be advised to take medicine that has been prescribed for someone other than themselves. Consider: Medicines X may interact with other medicines taken by caller. Medicine X may be contra-indicated in one of the caller's medical conditions of diseases. Search Strategy Depending on the type of enquiry the search strategy and best use of resources will vary REFERENCE GUIDELINES: Check the following reference sources: --- eBNF or eBNFc (BNF for children). Accessible via Medicines Complete (Use Medicine Chest Online to confirm the active ingredient in an OTC Medicine before looking it up with eBNF or eBNFc). --- eMC --- NetDoctor --- Patient.co.uk (Drug Information Leaflets section) --- Medicines Q&As --- Best Treatments --- Prodigy In addition, for Complementary Medicines: --- Herbal Medicines (Accessible via Medicines Complete) --- Dietary Supplements (Accessible via Medicines Complete) --- Herbal Safety News Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 17 of 44 --- UKMI Factsheets on Complementary Medicines HALFLIFE Time medicine/Drug stays in the body, blood or urine (half life) How long does medicine X stay in the body? How long does drug X stay in the blood or urine? The caller is having a drug screen test. Consider: Medicine X may take longer to be removed from the body because of an interaction with one of the other medicines taken by the caller. Medicine X may take longer to be removed from the body because of one of the caller's other medical conditions or diseases. REFERENCE GUIDELINES: Check the following reference sources: --- eBNF or eBNFc (BNF for children). Accessible via Medicines Complete (Use Medicine Chest Online to confirm the active ingredient in an OTC Medicine before looking it up with eBNF or eBNFc). --- eMC --- Martindale - The Complete Drug Reference (Accessible via Medicines Complete) --- Medicines Q&As Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 18 of 44 Examples of typical therapeutic use enquiries and the appropriate search strategies are described within the table below; Is it okay to take this medicine if I have this existing condition or known allergy? Is it okay to take this medicine as caller is having a test or investigation? Is it okay to take this medicine for unlicensed useage? Is it okay to drive or operate machinery whilst taking this medicine? Is it okay to take this medicine whilst pregnant? Is it okay to take this medicine whilst breastfeeding? How long does this medicine stay in the body? How long does this medicine stay in he blood or urine? The caller is having a drug screen test or urinalysis Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 eBNF (consult for all calls) eMC netdoctor (www.netdoctor.co.uk) Martindale NHS Direct FAQ (sole source) In addition for complementary medicines Herbal Medicines, Pharmaceutical Press, plus Dietary supplements, Pharnaceutical Press Herbal safety News (www.mhra.gov.uk) which are not identified within the CAS system eBNF (consult for all calls) eMC In addition for complimentary medicines Herbal Medicines, Pharmaceutical Press Dietary Supplements, Pharmaceutical Press Further questions to add to the usual list before researching medicines in pregnancy calls or referring to medicines information: Already taken or considering taking? Who has advised the medicine is taken? Weeks pregnant/date of last menstrual period? Any problems in previous pregnancies? eBNF (consult for all calls) eMC In addition for breastfeeding advice UKMI Central (www.ukmicentral.nhs.uk) In addition for complimentary medicines Herbal Medicines, Pharmaceutical Press Dietary Supplements, Pharmaceutical Press Further questions to add to the usual list before researching medicines in breastfeeding calls or referring to medicines information: Already taken or considering taking? Who has advised the medicine is taken? Age of baby, for neonates number of weeks at term? Baby well? Breastfeeding going well? How often baby feeding? eMC Martindale NHS Direct FAQ's (sole source) Page 19 of 44 Administration and Dosage Enquiries that relate to administration and or dosage can relate to missed doses, not taking enough of the medicine, or what to do if a medicine that has been taken is out of date. Wherever possible for administration and dosage the patient leaflet should be referred to. Where the medicine taken has expired the patient should be referred to a pharmacist or the nurse advisor should seek guidance from the Medicines Information Centre. Where the medicine taken has expired the patient should be referred to a pharmacist or the nurse advisor should seek guidance from UKMI . Search Strategy Reference sources to check: eBNF via MC The interactions appendices is very comprehensive and will usually state if there is an interaction present or not, but in a lot of cases does not give details on how to manage the interaction. BNF for Children via MC Emc http://emc.medicines.org.uk The company SPC again will state most of the interactions reported for that product, in some cases gives more detailed and practical details of what to do. Within the algorithm specify the type of administration and dosage enquiry (Select One): 1. The caller has been prescribed a different dose of the same medicine 2. The caller is enquiring about how to store a medicine 3. The caller is enquiring about out-of-date medicines / safe disposal 4. The caller has difficulty in reading the label /opening the bottle 5. The caller is enquiring about how / when to take a medicine 6. None of the above Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 20 of 44 CLINICAL INSIGHT: DIFFERENT DOSAGES Enquiries regarding different doses of the same medicine should be dealt with by a Pharmacist. STORAGE Enquiries about storage of medicines use the following reference sources: --- eBNF or eBNFc (eBNF for children) (Accessible via Medicines Complete (Use either eBNF or eBNFc for all calls)) --- eMC (Sole Source) OUT OF DATE/SAFE DISPOSAL Enquiries regarding safe disposal or out of date medicines should be dealt with by a pharmacist. DIFFICULTY READING LABEL/OPENING BOTTLE Simple information regarding child resistant bottles can be given over the phone if know. All other enquiries regarding difficulty reading the label or opening a bottle should be dealt with by a pharmacist. HOW/WHEN TO TAKE A MEDICINE Enquiries about how and when to take a medicine use the following reference sources: Check the following reference sources: --- eBNF or eBNFc (BNF for children). Accessible via Medicines Complete (Use Medicine Chest Online to confirm the active ingredient in an OTC Medicine before looking it up with eBNF or eBNFc). --- eMC Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 21 of 44 --- Medicines for Children In addition, for Complementary Medicines: --- Herbal Medicines (Accessible via Medicines Complete) --- Dietary Supplements (Accessible via Medicines Complete) --- Herbal Safety News --- UKMI Factsheets on Complementary Medicines Travel In all travel medicines enquiries it is best practice to find out, who the medicine is for, why do they need it/or why have they had it, where they are travelling to and for how long and what sort of holiday they are going on. When they last had any travel medicine/vaccinations is also important. You will also need to find out whether the patient is on any medication and/or has an existing medical condition. 1. Identify who is travelling and whether this includes any children 2. Identify the exact destination(s) to be visited and nature of the travel (e.g., backpacking) 3. Find out about the type of accommodation to be used (e.g., camping, hotels) 4. Check the length of stay and proposed travel dates 5. Check if any of the travellers have any pre-existing medical problems 6. Check whether any female travellers are pregnant, breastfeeding or thinking of trying to conceive CLINICAL INSIGHT: Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 22 of 44 Destinations: Recommendations vary according to the part of the world and also within a given country. For example, high mountainous areas are unlikely to have malaria carrying mosquitoes, but the low lying areas nearby may have. At Risk: If a caller is thinking of trying to conceive, they should be referred to their own GP for discussion. Information on travel vaccinations can be found on the Travax web site For all other queries check DORIS for specialist clinics or advise the caller to contact their own GP. Where there are a number of people travelling at the same time a record should be created for each as their age, existing medical history or medicines being taken could influence the advice given Search Strategy For travel enquiries a two-stage approach is required: eBNF netdoctor (www.netdoctor.co.uk) Health Information for Overseas Travellers (yellow book) Use TRAVAX to identify what should be taken Top tips For complicated travel itineries refer to the Medicines Information Service Use the search strategies for therapeutic use to answer the enquiry 'can I take', for example for a child or for pregnancy and travel related enquiries. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 23 of 44 Identification When answering this type of enquiry it is important to collect the following information: Specify the type of medicine identification enquiry (Select One): 1. The caller says their medicine has a different name to that usually prescribed, OR the medicine is the same but has a different name 2. The caller has been prescribed a medicine abroad and wants to know the UK equivalent 3. The caller is asking what a particular medicine is for CLINICAL INSIGHT: DIFFERENT NAME Check the following reference sources: --- eBNF or eBNFc (BNF for children). Accessible via Medicines Complete (Use Medicine Chest Online to confirm the active ingredient in an OTC Medicine before looking it up with eBNF or eBNFc). --- eMC --- NetDoctor Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 24 of 44 --- Patient.co.uk (Drug Information Leaflets section) --- Martindale - The Complete Drug Reference (accessible via Medicines Complete) Note: It may be due to brand and generic names. The caller should be referred to a pharmacist if a different drug. MEDICINES FROM ABROAD The caller may have been prescribed a medicine from abroad and wishes to know the UK equivalent. SPECIFIC MEDICINE IDENTIFICATION The caller may have found a medicine or substance and wishes to identify it. Who is asking for a medicine to be identified? Is it the caller’s medicine? If not do they have the owners consent? Why do they want it identified? Is it a foreign medicine, if so where from? The Nurse Advisor is presented with an ethical dilemma when a caller is requesting the identification of a medicine belonging to a third party. Think about the issues third party medicine identification presents and make notes on what they might be and how you would respond to the request. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 25 of 44 An exception to third party identification request is where the caller is acting as an intermediary or where the caller is the primary carer for the person for whom the medicine is prescribed. Search Strategy Calls requesting an identification of an unknown medicine that is not the callers property should be referred to a community pharmacist once it is established there is no immediate or urgent clinical risk. It is not reliable to identify a medicine from a physical description only without seeing it first hand. Depending on the type of enquiry the following reference sources should be used: Section A "What it is or is for" netdoctor (www.netdoctor.co.uk) Martindale Section B "Different name" eBNF (consult for all calls) netdoctor (www.netdoctor.co.uk) eBNF (consult for all calls) eMC Martindale In addition information may be sourced from netdoctor (www.netdoctor.co.uk) Section B "Different name" eBNF (consult for all calls) netdoctor (www.netdoctor.co.uk) In addition information may be sourced from Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 26 of 44 eMC Martindale Section C "Foreign Medicines" Martindale (sole source) Top Tips/Referral UKMI have access to further reference information to assist with Medicine Information Services have access to further reference information to assist with identification and could advise on equivalent preparations. Access There are a number of access issues relating to medicines including administration, where to obtain supplies. Consideration should be taken if the call is received in the Out of Hours period as to the urgency and whether it can be managed in the in hours period the following day. The enquiry concerns access to oxygen therapy, pharmacy opening times, or repeat prescriptions? CLINICAL INSIGHT: ACCESS TO OXYGEN THERAPY Home oxygen is now provided directly by four specialist oxygen companies and NOT pharmacies, although people will still receive their oxygen cylinders or concentrators as before. The supplier (dependent on where people live), details are held in DORIS and updated as national records. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 27 of 44 Note: Due to initial difficulties experienced by some patients in accessing their supplies via the new system, some local pharmacies have agreed to continue providing oxygen. Where possible, local contacts are listed in DORIS. The supply situation changes rapidly and patients will need to confirm with individual pharmacies whether they are able to provide oxygen. ACCESS TO PHARMACY OPENING TIMES Check the following reference sources: LOC - Pharmacy in DORIS (For Bank Holiday and OOH provision), or nhs.uk ACCESS TO REPEAT PRESCRIPTIONS IN HOURS A repeat prescription would usually be issued by the initial prescriber (e.g., GP). For callers who are not registered with a local GP, details can be found on nhs.uk ACCESS TO REPEAT PRESCRIPTIONS OUT OF HOURS If out of hours, callers should be advised to contact their own GP unless there is an immediate need for the medicines. Details of out of hours providers can be found in DORIS. REPEAT PRESCRIPTIONS DISPENSED BY PHARMICIST For UK residents the caller should be advised that some medicines on repeat prescriptions can be dispensed by pharmacists as an emergency supply. The pharmacist must interview the person requesting the medicine(s) and ensure that the following legal requirements are met: 1. There is an immediate need for the medicine(s) and it is impracticable to obtain a prescription. 2. A doctor has previously prescribed the medicine(s) for the person. 3. The dose is appropriate for the person to take. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 28 of 44 Supply is limited to 5 days treatment, except if the medicine is: Insulin, an ointment, a cream, eye drops or an inhaler device (whereby the smallest pack available can be given). An oral contraceptive (whereby a full cycle can be given). An antibiotic (whereby a full course of treatment can be given). The medicine must not be a controlled drug (e.g., Heroin, Morphine, Amphetamines). An emergency supply of Phenobarbitone is permitted, provided that it is for the treatment of Epilepsy. Supply of any medicine(s) is a t the discretion of the pharmacist concerned and he/she is allowed to charge a private prescription fee (usually 1.5 times the base cost of the medicine(s)) or a minimum charge of the NHS prescription fee, even if the patient is exempt. If a prescription is later issued, it may be possible to re-claim the cost. Check LOC - Pharmacy in DORIS, or nhs.uk and give details of Pharmacists open at the time required the caller must be advised that they need to telephone the pharmacy first to check opening times. Examples of access issues can include parental nutrition, needle exchanges, administration of intra-muscular injections (e.g. a carer giving medication to a relative and the carer has injured their hand – they may require a District Nurse to administer the IM in the interim), dialysis. The list is not exhaustive and you have probably a number of other examples. Search Strategies Nhs.uk Indirect Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 29 of 44 DORIS Drug Tariff Top Tips If the call requires another provider e.g. District Nurse using DORIS LOC to find the relevant service will enable you to tag the referral source to the call events. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 30 of 44 Section 4 Documenting Medicine Enquiries Advice Within the clinical algorithm the rationale will advise which resources you would need to access for the nature of the enquiry. Within the home care advice topics you will be able to select those resources you have consulted and this will then automatically enter them into the patient’s record. You should also copy the hyperlink of the web page actually used to provide the information into the advice recommended applet. Section 5 Resources to Manage Medicines Enquiries Electronic resources for the management of medicines enquiries should be accessed via the National NHS Direct intranet. The NHS Direct Medicines FAQ’s are hosted on the Pharmacy and Medicines micro-site on the intranet. The eBNF should always be consulted as a routine dose check as part of the call even if the answer to the enquiry is not likely to be found there. For all medicine calls information needs to be clear and at least two sources must be consulted to find the information unless a sole source is stated within this learning resource. On launching the home page clicking on the Medicines Complete hyperlink which can be located on the left hand pane will take you to the log on page. Log on using the Medicines Complete password This will then give you access to the electronic resources required to manage medicines enquiries. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 31 of 44 Where to find information about medicines? Getting Started This section looks at the basic electronic information resources that are available at your NHSD site. It is not meant to be exhaustive but is designed to give you an introduction to handle medicines related calls. It looks at what each source covers, and some of the strengths and limitations and gives search tips to find information eBNF NHS Direct intranet or www.bnf.org The eBNF should be your first port of call for every medicines call. There are 15 main chapters that cover the main areas of therapeutics. This is where the main monographs for each medicine can be found, and will include uses, side effects, doses, cautions & contraindication. The 9 appendices cover more specialist areas such as medicines in pregnancy, breast-feeding, liver/renal disease. Strengths Comprehensive & reliable source of information on medicines. Updated every 6 months. Specialist appendices e.g. drug interactions, medicines in pregnancy Some information on unlicensed uses of medicines. Difficult to navigate – need to practice a lot. Scan down the whole page as content may sometimes be hidden from view. Fair amount of jargon e.g. quinolones, sympathomimetics, MAOIs, No information on complementary medicines, apart from St. John’s Wort. Pitfalls Tips for searching. Searching for general information Click on the words that say “No Frames” at the top left hand corner. Type the name of the medicine in the white box at the top right hand of the screen, then click Search Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 32 of 44 The main information about a medicine can be found by clicking on the name of that medicine when it is written in CAPITAL letters eg. FUROSEMIDE / FRUSEMIDE Searching for Interactions between medicines Use interactions search to find interactions between pairs of drugs. Enter the drugs you wish to search for in the white search box at the top left of the page. o To search for the interactions of a single drug, enter a single word (e.g. aspirin) a phrase enclosed in double quotes (e.g. "ace inhibitors") OR o To search for interactions between pairs of drugs, enter the drugs separated by a space (e.g. Furosemide Lithium) Click on the interactions button. If an interaction is listed, you will be able to click on the name of these medicines highlighted in blue & underlined. Note down the classes of drugs that this interaction refers to, so you can find these on the next page. You MUST look for the name of the other medicine in this list AND the class of drugs it belongs to. Information about an interaction is given next to the drug/class of drugs it refers to. The importance of an interaction relates to the background colour behind the text; Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 33 of 44 Yellow Background Red Background – Tips Do not usually have serious consequences Potentially hazardous Try to use generic names, not brand names. Other useful information about that medicine can be found by clicking of the words underlined in blue and will take you to information about that medicine. The information in black will tell you what kind of information you will find by clicking on it. If you go to back to page you were looking at before, just click on the button that says back in the top left hand corner of the page. If no interaction is listed, do not assume that none exists. Check other resources such as the eMC (see later) or Stockleys – Drug Interactions (Text Book). eMC www.emc.medicines.org.uk The eMC holds the Summaries of Product Characteristics (SPCs) and Patient Information Leaflets (PILs) produced by drug companies. Every drug company must produce an SPC & PIL for every medicine, but not every one can be found on the eMC. Can view the Patient Information Leaflet (PIL) that is given to the patient. Strengths Comprehensive source of information on medicines. Very easy to search. Updated when changes made to the Summary of Product Characteristics (SPC). Pitfalls Information on branded medicines only. Information on licensed uses only. Written by the manufacturer of the medicine so the information can be circumspect because of medico-legal concerns. Tips for searching Search the eMC using the search bar on the top right hand side of the screen, using the generic or brand name of the medicine. Make sure the name is spelt correctly. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 34 of 44 The results page is the same layout in each case; a list of the preparations will be seen, specifying in each case whether it is the SPC (SPC) or the PIL (PIL). The SPC is a document describing the properties, effects and warnings about the medicine such as indications, dosage information, adverse effects, interactions, use in pregnancy/lactation, ingredients etc and is written to guide healthcare professionals use of the medicine. The PIL is the leaflet intended to be read by the patient and is included in the medicines packaging. Click on the name of the medicine highlighted in blue next to the SPC or PIL box depending on what you want to look at. Each is set out in exactly the same way, making navigation straightforward once you are familiar with the format. www.netdoctor.co.uk netdoctor This website is specifically aimed at patients. It aims to provide basic information written in a patient friendly style. It is edited and updated by a team of health professionals including doctors and pharmacists. It is found at the following link: http://www.netdoctor.co.uk . It can be a very useful source of information but does not have the depth found in the eBNF or eMC. Medicines content has much input from pharmacists – it has good focus on the key Strengths facts to be aware of. Good source of general information on medicines, especially as a starting point Pitfalls before looking at a more complicated Not very helpful for information about text. medicines during pregnancy or whilst Very easy to search. breastfeeding. Written for the lay public with limited Very little information about amount of jargon. Worded such that it complementary medicines. can be read to the caller with little Does not have the depth of information adaptation. found in other sources such as the BNF or eMC. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 35 of 44 Tips for searching Click on the Medicines button in centre of the homepage to go to the section about medicines. NHS Direct FAQs NHS Direct intranet or www.ukmi.nhs.uk There is a set of standard answers to some of the more common medicine related questions. These have been produced by pharmacists who are specialists in medicines information. The are fully referenced and may be used as a sole reference source when handling a medicines call. They are housed on the UKMI website, available via the following link: http://www.ukmi.nhs.uk/ Click on "FAQs" on the Medicines Information section of the home page. Strengths Answers to frequently asked questions about medicines. Topics identified by NHSD Nurse Advisors and Health Information Advisors. Content developed by UKMI pharmacists and is well researched, peer reviewed and referenced. Use of the FAQs was fully tested at 2 NHSD sites. Updated every 15 months but immediately if warranted. Can be used as sole information source. Pitfalls Limited number of FAQs but more planned. Tips for Searching The FAQs section of the UKMi site holds FAQs written for NHSD, which are shown in green, and FAQs written for the wider NHS, shown in blue. Those shown in blue have not been written with NHSD in mind and are often quite technical, so should not be copied to patients or used for counseling. A username and password is required to access the FAQs. It is available in your NHSD site. The password and login gives you access to a range of other materials on the UKMi site that you must not copy to patients unless the text explicitly gives you permission. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 36 of 44 Many of the NHSD FAQs are available on the NHS Direct online website in a patientfriendly format. They can be found at http://www.nhsdirect.nhs.uk/innerpage.asp?Area=60 UKMI Website - Complementary medicines factsheets www.ukmi.nhs.uk There is a set of factsheets that gives key information on the use of some of the more common herbal medicines. These have been produced by pharmacists who specialise in medicines information and are fully referenced. They are housed on the UKMI website, available via the following link: http://www.ukmi.nhs.uk/ Click on "Complementary therapies" in the Medicines Information section of the home page. Strengths Well researched, peer reviewed and referenced. Pitfalls Helpful summary of key facts about common herbal medicines and dietary supplements. Limited number of factsheets so far but more planned. At present they cover echinacea, garlic, glucosamine, St Johns Wort, Saw Palmetto & Valerian. Toxbase – Poisoning in pregnancy monographs http://www.spib.axl.co.uk Toxbase contains the specialist database from the National Teratology Information Service (NTIS). It holds information about the risks associated with exposure to certain medicines during pregnancy and in some cases lactation. There is also a section that looks at how to manage certain conditions in pregnancy. Strengths Very useful monographs on the use of individual medicines e.g. amoxicillin but also groups of medicines e.g. antibiotics during pregnancy. Well researched, peer reviewed and referenced. Some information on illicit drugs. Pitfalls Not all medicines covered. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 37 of 44 Tips for searching Click on the text that says “Poisoning in Pregnancy” Remember to look for both the drug name and the class of drug. UKMI Central – Medicines in Breastfeeding www.ukmicentral.nhs.uk This guide is written by the UK Drugs in Lactation Advisory Service - a joint service provided by the West Midlands and Trent Medicines Information Services. Whilst this guide is a simplified summary of possible adverse effects of commonly prescribed drugs in breast milk, it is your responsibility to familiarise yourself with these effects. It is intended to be used only to assess risk where the infant is normal, healthy, and born fullterm. Calls about infants born prematurely, or with serious illnesses or more complex problems should be referred. Strengths Useful traffic light coding for safety medicines use whilst breastfeeding. Difficult to find this information elsewhere. Well researched, peer reviewed and referenced. Pitfalls Written by specialists in breastfeeding, and can sometimes contradict manufacturers advice. If in doubt obtain further advice. Medicines Enquiry Algorithm Alias CAS Clinical v15 31 05 06 Page 38 of 44 Tips for searching Click on the “quick reference guide” under the heading Drugs in Lactation on the home page. Scroll down the list to find drugs grouped together in their therapeutic class eg. antihistamines, antidepressants. Immunisation Against Infectious Disease (‘Greenbook’) www.dh.gov.uk The Green Book is a document, which charts the history of immunisation and immunisation advice over the years. It was published in 1996 as a book, which has now been superceded with the on-line version housed on the Department of Health website: www.dh.gov.uk . To find it search using the exact term “Green Book”, including the inverted commas. This is an essential guide for any enquiry regarding vaccination or immunisation. It should always be used in conjunction with the eBNF/eMC. NHS Direct CAS Clinical v15 Other Problems/Medicines Enquiry Page 39 of 44 The first 12 chapters provide general information regarding immunisation including general indications/contraindications, adverse effects, storage conditions and immunisation schedules. The following chapters are each dedicated to an individual infection, covering background to each infection, how vaccines are used to treat it, dosage instructions, adverse effects and more specific contraindications for that vaccine. Each chapter is a separate PDF file that can be downloaded. This means that by using the binoculars function, you can search the document for a particular word/phrase. It will scan the document and highlight the relevant part of text, a useful way of quickly finding information in the document. Produced by Richard WK Lee & Davina Wraight Principal Pharmacists and NHS Direct Leads. London & London and South East Medicines Information Services. Contact: [email protected] & [email protected] October 2004. NHS Direct CAS Clinical v15 Other Problems/Medicines Enquiry Page 40 of 44 Approved Information Sources For Medicines Calls First line information sources for most medicines calls eBNF (intranet link) eMC http://emc.medicines.org.uk/ Netdoctor “Medicines” http://www.netdoctor.co.uk/medicines/ Medicines FAQs (see next page for specific links, also HIA protocols) Medicine-Chest (for information about OTC medicines) http://www.medicinechestonline.com/ Administration & dose Medicines for Children (intranet link) Therapeutic use / contraindications Prodigy http://www.prodigy.nhs.uk/ClinicalGuidance/ReleasedGuidance/GuidanceList.asp Best Treatments http://www.besttreatments.co.uk/btuk/home.html Side effects MHRA http://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&nodeId=5 Drug interactions Stockley’s Drug Interactions (in Medicines Complete) Pregnancy Toxbase “Go to exposures in pregnancy” http://www.spib.axl.co.uk/ Breastfeeding UKMICentral “Drugs in lactation” http://www.ukmicentral.nhs.uk/drugpreg/guide.htm Complementary medicines UKMI Herbal Factsheets http://www.ukmi.nhs.uk/Med_info/compthera.asp Herbal Safety News http://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&nodeId=96 Herbal Medicines, J. Barnes, Pharm. Press Dietary Supplements, P. Mason Pharm. Press Unlicensed medicines / off label use Prodigy http://www.prodigy.nhs.uk/ClinicalGuidance/ReleasedGuidance/GuidanceList.asp Best Treatments http://www.besttreatments.co.uk/btuk/home.html Martindale (in Medicines Complete) NHS Direct CAS Clinical v15 Other Problems/Medicines Enquiry Page 41 of 44 Immunisation & travel medicines Travax http://www.travax.scot.nhs.uk/ Immunisation.nhs.uk www.immunisation.nhs.uk Department of Health www.dh.gov.uk/PolicyAndGuidance/HealthAdviceforTravellers Fitfortravel www.fitfortravel.scot.nhs.uk Access to medicines NICE http://www.nice.org.uk/ BMA http://www.bma.org.uk/ap.nsf/content/splashpage Family Planning Association (oral contraception) www.fpa.org.uk DORIS (on intranet) Hormonal contraception Family Planning Association www.fpa.org.uk Prodigy http://www.prodigy.nhs.uk/ClinicalGuidance/ReleasedGuidance/GuidanceList.asp Time in the body Martindale (in Medicines Complete) Foreign medicines Martindale (in Medicines Complete) Patient friendly language Patient.co.uk “Drug information leaflets” http://www.patient.co.uk/dils.asp NHS Direct CAS Clinical v15 Other Problems/Medicines Enquiry Page 42 of 44 National Learning & Development Practice Profile Having read through this learning resource and completed the learning activities take time to write a reflective piece to include in your practice profile: Consider the following: How does the information relate to my practice? Were the intended learning outcomes met? If so, has my knowledge increased as a result? Are there any areas that I can apply immediately in my practice at NHS Direct? Have any other learning needs been identified as a result of this learning? If so, what is my plan of action and do I need to contact anyone else to assist me in this? NHS Direct CAS Clinical v15 Other Problems/Medicines Enquiry Page 43 of 44 If you have any feedback on the pack please direct it to your ETD lead who will correlate the feedback from your site for the authors. Please complete the following details and forward to the Learning and Development Lead for inclusion in your training L&D record. Complete the following details Name: _________________________________ Post:_____________________ Date Information Pack Completed: ____/____/06 I confirm that I have completed the Information Pack on Medicines Enquiries ______________________________ Signature NHS Direct CAS Clinical v15 Other Problems/Medicines Enquiry Page 44 of 44