Role Preparation for Dental Nurse Advisors Handling Medicines Calls

1
Role Preparation for Dental Nurse
AdvisorsHandling Medicines Calls

• NAME
• Medicines Information Pharmacist
• NAME Medicines Information Service

2
Morning Timetable

• Introduction learning outcomes
• Navigating key information sources
  Quiz
• Tea break
• Handling calls about medicines
• Medicine Calls Workshop
  2
• Lunch

3
Afternoon Timetable

• Adverse drug reactions Workshop 3
• Tea Break
• Drug interactions Workshop 4
• Where are the risks?
• Close

4
Morning Timetable

• Introduction learning outcomes
• Navigating key information sources
  Quiz
• Tea break
• Handling calls about medicines
• Medicine Calls Workshop 2
• Lunch

5
Aim

• To enable Dental Nurse Advisors to be able to
  handle medicines related calls safely and
  effectively within their area of competence and
  to know when and how to refer calls.

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Learning Outcomes
Handle medicines calls safely and effectively

• Gather the necessary background information to
  clarify the question and minimise the risks when
  advising the caller.
• Navigate the key medicines information sources.
• Interpret information about medicines and turn it
  into appropriate advice.
• Be able to advise safely on the use of analgesics
• Know when and how to refer to the MI Service.

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Structure of MI Services

• UKMI - supports MI needs of NHS health
  professionals
• gt½ million enquiries 2004
• 16 regional 260 local centres
• Specialist services - pregnancy, breastfeeding,
  dentistry
• Training, websites, QA, drug reviews

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Name Medicines Information Service
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NAME Medicines Information Service

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

• 9am - 5.00pm
• TEL NUMBER

10
Morning Timetable

• Introduction learning outcomes
• Navigating key information sources
  Quiz
• Tea break
• Handling calls about medicines
• Medicine Calls Workshop 2
• Lunch

11
Navigating the eBNF, eMC netdoctor and NHSD FAQs
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British National Formulary (BNF)

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

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Dental Practitioners Formulary

• Provides list of items prescribable by dentists
  on the NHS
• Private prescriptions may be written for items
  not on the formulary
• Also available in the Drug tariff

• http//www.ppa.org.uk/ppa/edt_intro.htm

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eMC (Electronic medicines Compendium)

• Summary of Product Characteristics (SPC) and
  Patient Information Leaflets (PILs)
• Updated daily
• Information provided by manufacturers
• SPC - very detailed, written for healthcare
  professionals
• PIL - written for members of the public

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NetDoctor

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

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Medicines Chest Online

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

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Medicines Complete
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Medicines FAQs
Located on the Medicines Pharmacy
Microsite http//nww.intranet.nhsdirect.nhs.uk/me
dpharm/

• Can a person on warfarin take paracetamol?
• Does paracetamol interact with antibiotics?
• Can paracetamol be taken during pregnancy?
• Can breastfeeding mothers take ibuprofen?
• Can ibuprofen be taken during pregnancy?
• What to do if you have missed a dose of
  antibiotics
• When can patients start drinking alcohol after
  finishing metronidazole?
• Which over-the-counter analgesics interact with
  alcohol?
• Which oral antibiotics interact with alcohol?
• Can breastfeeding mothers take over-the-counter
  analgesics?
• Is it necessary to stop clopidogrel, dipyridamole
  or low dose aspirin prior to minor surgery?

Single Source
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Quiz Navigating Medicine Sources
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Morning Timetable

• Introduction learning outcomes
• Navigating key information sources
  Quiz
• Tea break
• Handling calls about medicines
• Medicine Calls Workshop 2
• Lunch

21

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Morning Timetable

• Introduction learning outcomes
• What is a medicine
• Navigating key information sources
  Quiz
• Tea break
• Handling calls about medicines
• Medicine Calls Workshop 2
• Lunch

23
Handling a Medicines Call
Clarify the question
Refer to MI
Record all stages
Plan search strategy research problem
Evaluate the information
Tailor the answer/advice
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The Iceberg Theory
This is what the caller may ask
This is the rest of the story!!
?
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Essential questions to ask

• THE PERSON
• Age?
• Allergies/disease states?
• Pregnant no. of weeks, going well, medicine
  taken already?
• Breastfeeding baby age, term/pre-term,
  well/unwell, medicine taken already?

• THE MEDICINE
• Name, dose, frequency?
• Who is it for?
• What prescribed for?
• Why asking?
• Other medicines? Name, dose, frequency?

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Key Information Sources

• BNF / eBNF
• Electronic Medicines Compendium (eMC)
• Netdoctor
• NHSD Frequently Asked Questions (FAQ)
• Medicines Chest online
• Medicines Complete

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Standard Search Strategies
Encourage best practice and sharing of expertise

• Pointers to the best sources available to answer
  particular types of medicines call.
• Not a definitive list of sources and should check
  other sources as appropriate.
• No need to check every source in the search
  strategy for every call.

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Reasons for Documentation

• Patient record in case of ongoing enquiry.
• Risk management.
• In case of query in the future.
• Record/evidence of how you arrived at the answer.
• Training.

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What should be documented?

• Website e.g. eBNF, eMC, netdoctor
• All places looked including those where no
  information was found.
• Brief detail of information found.
• Brief detail of what was said to caller.

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Example documentation

• Is ibuprofen safe in 3rd trimester of pregnancy?

eBNF Malformations. eMC No monograph. netdoctor
Do not use. Toxbase Malformations. Advised to
speak to GP / Dentist by end of day.
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Referral to the MI Service

• Complex medicines call.
• Difficult to interpret what is being asked.
• No information or it is unclear or conflicting.
• Not within your competency or a second opinion
  needed.

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Examples of Complex Medicines Calls

• Complex drug history
• Lots of medicines
• Unclear what is taken
• Unlicensed medicines
• Not on formulary
• Side effects
• Symptoms due to medicines
• Drug interactions
• Narrow therapeutic range medicines e.g. digoxin,
  warfarin

• Pregnant
• Medicines taken but info sources say avoid is to
  avoid
• Breastfeeding
• Medicines taken but info sources say to avoid
• Baby pre-term / unwell
• Uses / choice
• Contra-indicated
• Doses outside norm

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Morning Timetable

• Introduction learning outcomes
• What is a medicine
• Navigating key information sources
  Quiz
• Tea break
• Handling calls about medicines
• Medicine Calls Workshop 2
• Lunch

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Analgesia

• A state of insensitivity to pain stimuli

derives from Greek an-, "without", and -algia,
"pain"
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Analgesics - Paracetamol

• Adult dosage
• 0.51 g every 46 hours to a max. of 4 g
  daily
• Childs dosage
• Dependent on age of child
• Strength of paracetamol product
• Form of paracetamol
• Multi-constituent preparations

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Analgesics - NSAIDs
Non-Steroidal Anti-Inflammatory Drugs

• Ibuprofen
• Adult dosage
• 400mg three times daily
• Higher doses on prescription
• Children from 3 months
• Dependent on age

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Contraindications Cautions to NSAIDs

• Allergy to any NSAID or Aspirin
• Asthma
• Stomach ulcer or bleed
• Kidney, liver or heart conditions
• Blood clotting defects
• Hypertension
• Pregnancy or Breast feeding

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Adverse effects of NSAIDs

• Gastrointestinal effects
• Nausea, diarrhoea, discomfort, bleeding
• Allergy
• rashes, breathing difficulties
• Fluid Retention
• TAKE WITH OR AFTER FOOD

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Analgesics - Aspirin

• Adult Dosage
• 300 - 900mg every 4-6 hours
• Maximum 4g daily
• Analgesic and antiplatelet dosages
• OTC products will recommend lower doses
• Child Dosage
• Not to be given to children under 16 years old
• Reyes Syndrome
• Adverse effects and cautions similar to NSAIDs

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Analgesics Combination products
BEWARE
Not only painkillers contain analgesics
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Workshop 2 - Medicines Calls
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Morning Timetable

• Introduction learning outcomes
• What is a medicine
• Navigating key information sources
  Quiz
• Tea break
• Handling calls about medicines
• Medicine Calls Workshop 2
• Lunch

43

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Afternoon Timetable

• Adverse drug reactions Workshop 3
• Tea Break
• Drug interactions Workshop 4
• Where are the risks?
• Close

45
Adverse Drug Reactions
Unwanted effect that drug has on a person

• Type A predicted by mode of action,
  dose-related, common but not severe e.g.
• Diarrhoea with antibiotics

• Type B unpredictable, not dose-related, can be
  severe/fatal e.g.
• Anaphylaxis with penicillins

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Incidence of Adverse Effects
Very common gt10
Common gt1 Risk of dying from cancer if smoke 20 a day for 30 years
Uncommon gt0.1 Risk of being injured on the stairs in next 12 months
Rare gt0.01 Risk of dying in an accident at home in next 12 months
Very rare up to 0.01 Risk of being killed by lightening
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Afternoon Timetable

• Adverse drug reactions Workshop 3
• Tea Break
• Drug interactions Workshop 4
• Where are the risks?
• Close

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Workshop 3 - Adverse Effects
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Afternoon Timetable

• Adverse drug reactions Workshop 3
• Tea Break
• Drug interactions Workshop 4
• Where are the risks?
• Close

50

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Afternoon Timetable

• Adverse drug reactions Workshop 3
• Tea Break
• Drug interactions Workshop 4
• Where are the risks?
• Close

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Drug Interactions

• One drug modifies the effect(s) of a second drug.
• More likely if taking several medicines.

• ? Toxicity
• warfarin erythromycin greater risk of
  bleeding
• miconazole quinidine greater risk of
  arrhythmias

• ? Efficacy
• penicillin microgynon reduced contraception
• levothyroxine rifampicin more levothyroxine
  needed

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One way medicines interactAbsorption of the drug

• Antacids can absorb other drugs e.g.
  Ciprofloxacin
• Cholestyramine (Questran?) binds to many drugs so
  give 1 hour before or 4-6 hours after
  cholestyramine

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More ways medicines interactMetabolism of the
drug

• DRUG LEVEL

• Metabolic Enhancers
• Smoking
• Alcohol
• Carbamazepine
• Phenytoin
• Rifampicin

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More ways medicines interactMetabolism of the
drug

• Metabolic
• Inhibitors
• Cimetidine
• Ciprofloxacin
• Erythromycin
• Metronidazole

• DRUG LEVEL

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Narrow Therapeutic Range Drugs

• CARBAMAZEPINE
• CICLOSPORIN
• DIGOXIN
• LITHIUM
• PHENYTOIN
• THEOPHYLLINE
• WARFARIN

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Afternoon Timetable

• Adverse drug reactions Workshop 3
• Tea Break
• Drug interactions Workshop 4
• Where are the risks?
• Close

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Workshop 4 - Drug Interactions
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Afternoon Timetable

• Adverse drug reactions Workshop 3
• Tea Break
• Drug interactions Workshop 4
• Where are the risks?
• Close

60
Where are the risks when handling a Medicines
Call?
Clarify the question
Refer to MI
Record all stages
Plan search strategy research problem
Evaluate the information
Tailor the answer/advice
61
Learning Outcomes
Handle medicines calls safely and effectively

• Gather the necessary background information to
  clarify the question and minimise the risks when
  advising the caller.
• Navigate the key medicines information sources.
• Interpret information about medicines and turn it
  into appropriate advice.
• Know when and how to refer to the MI Service.