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Pharmacy Induction for Junior Doctors

Pharmacy Induction for Junior Doctors. RHSC Edinburgh. Overview. Background to safe prescribing in paediatrics and ‘Golden Rules’ Common pitfalls Hospital and trust policies Lothian joint formulary Pharmacy services Scenarios Safe prescribing quiz Tomorrow Pain management

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Pharmacy Induction for Junior Doctors

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  1. Pharmacy Induction for Junior Doctors RHSC Edinburgh

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

  3. Background • Safe prescribing is an essential generic skill • Particular issues for paediatrics • Most medications prescribed by weight • Most children don’t like tablets so liquid formulations used • Differing pharmacokinetics in different age groups • Dose errors more likely to be significant

  4. Pharmacokinetic differences • Absorption: • Gastrointestinal tract pH higher→decreases absorption of phenobarbitone, phenytoin • Gastric emptying slower: Skin, thin striatum, well hydrated • Muscle, less muscle mass, altered blood flow: PR, slower and incomplete • Distribution of body fluid • Premature neonate 92% body water :Newborn 75% Child 50%, Gentamicin • Low fat, 3% in premature, 12% newborn, 1 year old 30% Adults 18% • Protein Binding Low affinity and capacity,Phenytoin • Metabolism : • Enzyme systems are immature :Huge differences from premature to 2 weeks old. • Phenytoin 72 hours to 8 hours. :Phenobarbitone from 200 hours to 20. • From age 1 – 9 clearance can exceed adult values /m2 • Elimination • Glomerular Filtration Rate – increases with age until around 1 year. • Tubular secretion immature, solute loads including Sodium, Potassium.

  5. Golden Rules for Safe Prescribing • NHS Lothian version on intranet • Adapted for use in RHSC (induction pack) • Standardised NHS Lothian drug kardex from September 2009

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

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

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

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

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

  11. INTRANET HEALTHCARE A-Z RISK MANAGEMENT

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

  13. Lothian Joint FormularyInternet www.ljf.scot.nhs.uk Aims • Promote safe, effective and economic prescribing in primary and secondary care • Produce greater familiarity with a limited range of medicines • Develop agreement across the interface between primary and secondary care • Promote a seamless approach to prescribing

  14. Hospitals 15% 85% General Practices Lothian Drug Budget £100,000,000 40% of drugs used in primary care are influenced by secondary care. Audit Comission: A prescription for improvement. London HMSO 1994

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

  16. Ensures all medicines reach standards for safety, quality and efficacy License allows drug to be marketed for -specific conditions -in agreed dose range -by particular route -using tested formulation Based on clinical trials data Drug Company Licensing authority Licence Drug Company Market Drug Drug Licensing

  17. Problems with Licensing in Paediatrics Lack of clinical trials eg 1994-98: 80% of new drugs had no info in children Ethics Long term effects Micro-analytical techniques Low return for investment <40% of medicines prescribed by hospital paediatricians are outside the licence or have no licence

  18. Directive 89/341/EEC All doctors can prescribe • there is no statutory requirement to disclose to a patient when a medicine is unlicensed • prescriber should be aware of unlicensed prescribing • decision to prescribe unlicensed medicines should be in best interests of patient All pharmacists can dispense

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

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

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

  22. What further information is needed to complete his drug kardex and IV fluid chart? -Name, DOB, CHI, consultant -any allergies -Weight-actual or estimate: weight = (age +4) x 2 = (6+4) x 2 = 20kg -Dose of IV augmentin-monograph -Strength of phenytoin suspension - BNFC -Strength of clenil modulite inhaler – patient’s own, recent letter, GP -U&E results What else might you want to prescribe for him? -Oral paracetamol +/- ibuprofen as antipyretics -Rescue medication for seizures if appropriate

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

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

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

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

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

  28. Paracetamol IV – Use RHSC IV monograph 10mg/ml Loading dose 20mg/kg = 20 x 8.1=162mg (round to 160mg) Maintenance dose 10mg/kg 4 hourly = 10 x 8.1 = 81mg (round to 80mg)

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

  30. John has stopped vomiting and has had rectal paracetamol and oral ibuprofen, but remains tachycardic and unsettled. What do you do? Assess to ensure no complications of surgery causing tachycardia/pain eg bleed, hypovolaemia, infection. Use analgesic ladder and acute and postoperative pain guidelines, prescribe codeine. Codeine orally 1mg/kg 4 hourly = 1 x 8.1=8.1mg, round to 8mg 25mg/5ml suspension dose 5/25 x 8 = 1.6ml

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

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