Transcript Pharmacy – ED – Registrar Training February 2016

Emergency Department
Western Health
Registrar Training
Pharmacy Education
Adrian Weeks
0435 962 527
[email protected]
Pharmacy Service
MONDAY to FRIDAY
0800 – 1630
Monday & Tuesday: Sunshine ED
Wednesday & Thursday: Footscray ED
Friday – Admin Day (call my mobile)
Call 0435962527 if you have any immediate questions
Email [email protected] if you want something followed up
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Medication Histories in ED
Don’t rely on medication lists from GPs
• Most often out of date
• Often contain every single medication ever prescribed
for the patient
For up to date information
• OPTION A: check the medication brought into ED with
the patient (patients can take the medications
differently from the labels)
• OPTION B: call the local pharmacy and ask for a fax of
the dispensed medications (most pts will be able to tell
you the name/location of the local chemist)
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Medication Histories in ED cont.
Difficult patients to be aware of
1. RDNS administer the meds: RDNS leave the
histories in the patients home. Medications are
often kept in locked boxes and cannot give you
information over the phone
2. Psych patients in SRS/supported accom: the
non medically trained carers give the psych
medication, the patients often self manage
their “other meds” (i.e methadone/chronic
disease)
3. Methadone
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Bossnet pharmacy drug summary
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A bit closer up...
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Analgesia ... Give it
Options for guidance
• NHMRC Emergency Care Acute Pain
Management Manual
 http://www.nhmrc.gov.au/guidelines/publications/cp135
• TGs
 Via http://www.health.vic.gov.au/clinicians
• OzEmedicine
 http://www.ozemedicine.com/wiki
Don’t leave patients in ED with a single dose of analgesia to just wait and
see. Write adequate orders so the nurses have the scope to treat up until
the patient is pain free.
EOU or a cubicle. Treat pain properly
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http://www.ozemedicine.com/wiki
Search analgesics – listed as WH ED: discharge pain medications
patient information sheet for adults.pdf
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WH ‘Transdermal Medicated Patch’ Procedure
*Now available on the WH Intranet*
 Prescribing Requirements:
ASK!!!!
Do you wear a patch?
You know, the sticker with the medicine???
 All medication orders (prescriptions) for patches
must include:
 Generic drug name (To further distinguish
brand name can be included in brackets).
 Dose
o Opioid patch (Fentanyl and
Buprenorphine): Prescribe dose as hourly
rate eg 12microg/hr
o Lignocaine (Versatis®) patch: Prescribe as
5%.
o All other patches: Prescribe the dose as
total dose in prescription (dose per 24
hour)
 Frequency of application.
o Patches in situ for more than 24 hours :
• Cross out the days on the administration section of
the medication chart (AD 271)
• Write the nursing ‘Check Application’ section for
patches on > 24 hrs. Prescribers’ responsibility to
complete this section.
o Patches requiring drug-free period
• If the patch has specific ON and OFF times (e.g.
glyceryl trinitrate patches), clearly specify this on
the “Administration times” section of the medication
chart.

Prescribing
Considerations:
 Timing of application: for opioid
patches, midday changeover time is
preferred - allows decisions to be
made on the morning round prior to
re-application.
 Be aware that more than one
strength of patch is often available
for the same medication.
 Information about rate and total drug
content is often on the pack & can
be confusing. e.g. Fentanyl Sandoz®
patches contain 2.1 mg fentanyl, but
rate for prescribing is
12 microgram/hour.
 Consult ward pharmacist or check
product information for possible drug
interactions and adverse reactions.
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NPEP
Non-occupational Post Exposure Prophylaxis
Change in the available medications
for both Sunshine and Footscray ED.
PREPACKED STOCK
• Truvada tab x 7
• (tenofovir-emtriciabine 300mg200mg).
• Combivir tab x 14
• (lamivudine-zidovudine 150mg300mg).
• Kaletra tab x 28
Process
1. Identify the patient risk
2. Take a thorough history
3. Phone the on call ID consultant
4. Dispense the recommended
medicines from the after hours
cupboard
5. Refer to ID clinic for follow-up
within the week
• (lopinavir-ritonavir 200mg-50mg).
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SAS FORM
Fill these in
1. For unregistered
medicines
2. Cat A: Lifesaving drug
Cat B: not time critical
3. Without the form the
hospital cannot order
more stock
DRUGS TO BE AWARE OF
- Labetalol
- Esmolol
- Cyanokit
Fax to pharmacy once complete.
Don’t file in the medical record.
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The intranet...HOW TO FIND THINGS
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The new intranet...HOW TO FIND THINGS
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Febrile Neutropenia
•
The guideline is very prescriptive
•
You can’t remember all of the time
• Just know where to look (on the intranet)
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Treatment of Febrile Neutropenia
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Think outside the IT box...
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DKA – summarised in the resus protocols
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Insulin
• Must be prescribed in ‘a clear and unambiguous manner’
• Dosage is to be written in full as UNITS (not U or I.U can be
mistaken for 0 or 10)
• Chart insulin by BRAND i.e Apidra®, Lantus®, Novomix 30®
• Be clear re: the route of administration IV or subcut. SC can
be mistaken for SL (subling)
• Remember we feed patients at very strange times
0800, 1200-1230, 1730. Chart short acting insulin doses
accordingly.
• Be clear when confirming doses ie. “17 – so one seven or
seven zero??”
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Insulin is tricky...don’t be tricked!
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Ask about pumps
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Iron Infusions, an Emergency?
Iron Polymaltose:
1g in 100ml N/S rate APP (over 1 hour), IV fluid chart
Made in pharmacy (or by nurses)
Iron Carboxymaltose:
Only for patients who have had an ADR to iron polymaltose
OR for use in “Outpatients”
If want to use in ED, patient cannot be in EOU or under a unit.
Need IV chart + PBS script, patient will pay co-payment ($6.20 or $38.30)
Up to 1g over 15mins in 250mL N/S
Iron Carboxymaltose
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500mg
1g IV over 15mins
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Inpatient Antibiotics
A guidance MS approval is NOT
the same as a PBS approval
INPATIENT
DISCHARGE
Restrictions on
supply are put in
place by the
hospital
formulary/ID
Restrictions on supply
are put in place by the
government (PBS)
Policed by the
pharmacy
department
Policed by the PBS
IMPORTANTLY
Patients on concession
cards will not pay the
non-PBS price for a
medication
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• Mostly we have the Antibiotics
you will need in ED in the
imprest (the drug cupboard)
• Occasionally the antibiotics
will need to be supplied from
the pharmacy dept and will be
on the WH restricted antibiotic
list
• Pharmacy will NOT supply
these meds without the
Guidance MS approval number
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Restricted Antimicrobials
Highly Restricted Antimicrobials*.
Highly Restricted Antimicrobials*.
Aciclovir (IV and oral)
Azithromycin
Cefepime
Cefotaxime
Ceftazidime
Albendazole
Amikacin
Amphotericin B desoxycholate
Amphotericin Liposomal
Artemether+lumefantrine
(Riamet®)
Artesunate (SAS)
Atovaquone
Aztreonam
Caspofungin
Cefoxitin
Chlorampenicol (IV)
Chloroquine
Ertapenem
Ethambutol
Flucytosine (SAS)
Foscarnet
Isoniazid
Itraconazole
Ivermectin
Lincomycin
Linezolid
Ceftriaxone
Ciprofloxacin
Clindamycin (IV)
Famciclovir
Fluconazole
Gentamicin
Meropenem
Moxifloxacin
Norfloxacin
Oseltamivir
Piperacillin/Tazobactam
Ticarcillin/clavulanic acid
Fusidic acid
Tobramycin (IV and inhalational) Ganciclovir
Valaciclovir
Pentamidine
Primaquine
Pyrazinamide
Quinine (IV – SAS)
Quinupristin+dalfopristin
Rifabutin
Rifampicin (IV and oral)
Teicoplanin
Tetracycline (SAS)
Tigecycline
Trimethoprim/Sulfamethoxazole
(IV)
Voriconazole
Vancomycin
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Inpatient Antibiotics
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Use the same login and password you use to open your email
Ensure you choose the correct hospital
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This is where you
get the approval
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This tells you what you
can get an approval for
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Once you have got the approval write it on the
drug chart prior to faxing the chart to pharmacy
14/8/12 Ciprofloxacin
IV
0800
500mg BD
XXX-1408-5
D.Octor
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2000
Dr D Octor
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If your patient doesn’t meet
this criteria you need to call ID
for the approval and they will
give you the approval number
Contact the ID consultant via
the switch board
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PBS APPROVALS
(not just Antibiotics)
www.pbs.gov.au
2 approval types for ED
– Streamlined (write the approval on the script with no
phone call)
– Phone approval required (for restricted drugs or
increased quantities, or extra repeats)
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12345
ED
Miss Patience Waiting
Caravan 1, Half Moon Caravan Park
Millers Road, West Footscray
01/01/1950
Levetiracetam
(New medication)
500mg PO, 1 BD
60
N Y 4928
Write the streamlined
authority next to the
item so it is clear what
the approval is for
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If the PBS website
states “Authority
required” you
need to call the
phone number
on the bottom of
the script and
state which
authority
indication the
patient meets
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12345
ED
Miss Patience Waiting
Caravan 1, Half Moon Caravan Park
Millers Road, West Footscray
01/01/1950
Ciprofloxacin
500mg PO, 1 BD
28
N Y
ML2589C
Write the phone
authority next to the
item so it is clear what
the approval is for
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Epipens
Script needs authority – ask for 2
Demo pens in draw of nurse in
charge’s desk (please return after use)
www.epiclub.com.au – support program for patients
Ensure family know how to use as well as patient
Use:
- Blue cap off
- Orange end into anterolateral aspect of the thigh at 90ᵒ
- Device will “click”
- Hold for 10 seconds
- Release
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METHADONE / BUPRENORPHINE
Cannot dose until you have:
1. Confirmed the dose with the dosing point (pharmacy)
2. Have confirmed that the dose hasn’t been given today
3. Faxed off the DHS paperwork or complete online
Cannot dose the patient AT ALL, if the patient has missed 3 days of
methadone OR 5 days of buprenorphine.
If this has occurred you need to speak to Drug and Alcohol
Be wary that the patient may not be on a current opioid
replacement program
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FAX TO: 1300 360 830
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METHADONE / BUPRENORPHINE
Cannot dose until you have:
1.
2.
3.
4.
Confirmed the dose with the dosing point (pharmacy)
Have confirmed that the dose hasn’t been given today
Faxed off the DHS paperwork
Charted the methadone in milligrams
(patients will often tell you they are on mLs of methadone...meaning
the milligram dose...but methadone syrup is 5mg/mL so if you chart the
mL dose as mg the patient will have a 5 times overdose)
14/2/12 Methadone syrup 5mg/mL PO 120mg 14/2 0900
Methadone paperwork faxed to DHS 14/02 0830
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D.Octor Dr D Octor
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Afterhours Prepacked Medications
Labels are being updated due to jargon on directions
eg. Take ….. capsule(s) …bd… times a day until finished
Patient didn’t know what to do
Was Left Blank
Circle correct option eg Take ONE/TWO capsule(s) twice a day
Ensure that the patient knows exactly what to do with the medication
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14A026
14A027
Adrian Weeks
20/02/2016
Adrian Weeks
20/02/2016
A script needs to be written and filed for legal purposes
NO ONE can send DDs (eg OxyNorm) home with patients out of the safe
– This is illegal
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Nursing Home patients
If changes to meds...
- Complete eForm IRCMAC (interim residential care medication administration chart)
- Complete script with any new/changed meds
- Place in red sleeve and give to nurse to return to facility
- If for IV Abx: Add N/S flush as PRN and also add oral Abx for completion of
course
How to find IRCMAC:
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1.
2.
3.
4.
Select a patient in BOSSNET
Hover over “EMR”
Click “Other EFORMS”
Select ED & After Hours
IRCMAC (AD61)
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Note the “Change Status”
field on the right-hand side
If more than ONE chart is required Print AND Submit the
first chart, then start again for the second.
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Discharge Scripts from ED
SUGGESTED GUIDELINES
• Only write up the new medicines
• Unless, you have changed the old
medications. Then indicate changes
• Document CLEARLY if you have ceased
any medications
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12345
ED
Miss Patience Waiting
Caravan 1, Half Moon Caravan Park
Millers Road, West Footscray
01/01/1950
NEW
Metoprolol
Frusemide
Warfarin
50mg PO, 1 BD
100
40mg PO, 2 BD (0800/1200) 100
1mg/1.5mg alternating nocte, PO
until INR (19/02/16) 50
N Y
N Y
increased dose
N Y
decreased dose
Aspirin 100mg daily CEASED THIS ADMISSION
Other medications remain unchanged
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Discharge Analgesia
– spot the difference –
This is why it’s important ...
The dose
you
intended is
clear
The max
frequency
is clear
IDENTITY is clear
“PBS” is not a legal
script!
Generic
prescribing
preferred
{
Words and figures for
DD’s is a legal
requirement
I know what you have changed!
Some consideration of SE
I know you’re authorised to prescribe this
Risk
management.
A trigger for us both
It is clear you want a
smaller qty than the
whole pack
If anything needs to be clarified I can call you
Not so crash hot...
Dose ???
Identity???
Frequency ???
“PBS” is not a legal
script!
{
Not generic
prescribed

No words and figures.
CANNOT BE
DISPENSED!
No indication of change
No document of consideration of SE
Are you a dentist? A nurse practitioner? A Doctor?
Have you even
checked the
allergies???
Getting 50 diazepam now
None of the above can be clarified
Discharge Letters
You must clearly state in your discharge letters, any:
• Changes to medications: Up, Down and Ceased
• The ACTUAL drugs you have commenced
– Phone calls to the consultant asking about opioids and all
the letter says is analgesia. Legalities
– Represents to ED 12 hours post D/C requiring more pain
relief. Bossnet not up to date. Simply says “analgesia”. Not
helpful to anyone.
• Plans for monitoring: INR, TDM, Electrolytes. WITH
TIME FRAMES
• Clearly indicated time until review by GP
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