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Sharing your medical history with clinicians

It is often assumed that the person carrying out a consultation has acces to your medical records and your full medical history. Sometimes telephone consultations are carried out with a clinician who doesn’t know (or have access to) your medical history.

This is quite common. As we get older and are likely to have more than one medical problem (‘multimorbidity’ in jargon), and services are frequently delivered by different specialists from a variety of different professions (‘sub-specialisation‘ in jargon).

If we have a medical condition that has been ongoing for many years and is well controlled, we may forget to tell the clinician. You may forget to mention something like asthma for example, because it hasn’t been problematic for a while. It’s really important not to miss these areas, as the safety and effectiveness of your treatment plan depends on it.

It may help, before the consulation, to write a list of:

  • Previous illnesses, including mental health problems*, sleep problems and mood variations (‘no health without mental health’)
  • Previous hospital admissions & operations
  • All your long term conditions (the chart below shows an acronym ‘MJTHREADS’ used by clinicains). Alternatively it may be helpful to think of a ‘systems review’ in terms of a ‘body scan’, starting with the head.
  • All health related people (including complementary therapists, & support groups ) that you see.

In addition some (or all) of the follwing details will be relevant. Think about:

  • Your prefereneces and beliefs about treatments, including rescussitation & end of life care (often called advanced decisions or advance care plans)
  • Who cares for you or who you care for. People don’t always realise (or tell clinicians) that they are caring for others
  • Your job or lack of a job , or how you occupy your time
  • Financial worries
  • Your social circumstances – who do you live with? -do you have close family & friends? -do you feel isolated? -live in a remote loctaion? – do you feel vulnerable? – your hobbies?
  • How you feel about your own safety – have you ever felt like harming yourself?
  • Past (or recent / ongoing) trauma and abuse
  • Your spiritual beliefs
  • Recent travel abroad
  • Your ethnicity
  • Your diet and any recent changes
  • Recent weight loss or weight gain
  • How much exercise you take
  • Your sleep pattern and any recent changes
  • Your family history
  • Other areas (listed here in no specific order) such as childhood history, preganancy history, risk taking history or sexual history

*In response to feedback on this blog from patients, it’s important to note that there may be some details related to mental health that patients do not want to share with all clinicians.

The above list may look daunting, and is obviously not all needed in all consultations, however it’s worth reviewing. I have come across people who were waiting to be asked some of the above questions, and wanted to tell someone something important, who told me they only opened up because they were asked.

This blog links to the blog for patients on making the most of telephone consultations. It’s a ‘rolling blog’. I will be updating it based on feedback, and incorporating all coimments and suggestions.

Steve Turner is a nurse prescriber and clinical educator & Associate Lecturer at Plymouth University. Steve shares health information from the Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS #TeamCOVID19  and on the web site www.patientled.education

Click here for the Care Right Now CIC web site

If you have any questions about coordinating care for a loved one, you can contact Steve by email: steve@carerightnow.co.uk

Published: 01.05.2020

Author: Steve Turner

Version: Draft 1b 11.05.2020

Revision history: Asterisked note on patients’ preferneces for data sharing inclided.

Making the most of telephone consultations – a guide for patients (*rolling blog)

It is now very common for clinicians to carry out consultations with patients over the ‘phone.

If you have time to prepare for the consulation here are some suggestions. This is part of our patient led clinical education work. The aim being to help all patients / users of health and care services lead on their own care.

In some cases, you may be talking to someone who has never met you, so preparation is key.

Here is some general advice:

Preparation

  1. Write it all down before you ring as it’s difficult to remember otherwise.
  2. Take some observations if you are able. Temperature blood pressure heart rate other measurements, including your feelings, mood and areas such as sleep & appetite. If the problem is something visible (like a rash for example) send pictures & monitor changes over time.
  3. Tell them how you are different from your norm.
  4. Tell your story of why you are calling, in your own words.
  5. Be honest and remember mental health and physical health are equally important. Inseparable in fact.
  6. Ask if you don’t understand anything.
  7. Don’t be afraid to check that the clinician has followed what you are saying.

It’s important that you are allowed time at the outset to tell your story in your own words, to be able to share your ideas, your concerns and what you are expecting for the consultation. If you are speaking to someone who doesn’t have access to your medical history, they will also go through this with you in detail.

This checklist will help you prepare for the consultation and lead to an agreed plan for what to do next. Think particularly about what you would like to have happen. This is a question you may well be asked.

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Your clinician will also need to refer to your medical history. If they have this to hand they may check that it’s up to date with you. Often they may not have this information and will have to go through your history with you. This is vital in order to ensure you come up with an appropriate and safe plan for your care. Click here for a second short blog on giving a history.

Medicines and treatments (of any kind)

Consultations often involve medicines and treatments. Because of this it’s important that you share details of all medicines and related substances you take, not just those that are prescribed. This includes herbal medicines, over the counter medicines, supplements and anything borrowed or bought over the internet. It’s vital to be honest, as interactions can be very serious, sometimes fatal. Your clinician will not think badly of you if, for example, you don’t take a prescribed medicine or are trying something else. Statistics show that at least 50% of people don’t take their medicines as prescribed. That’s 50% of the whole population with mental or physical illnesses, not just a specific group of people.

Remember a medicine isn’t always the answer, share with the clinician details of non-medicine related treatments and approaches you take, and how well this works.

This chart shows the information you need to share. Very importantly this includes details of any allergies or sensitivities and how these affected you.

What happens next – The plan

Finally, many consultations do not result in a medicine, or specific treatment, being prescribed. Some may result in a medicine or treatment being stopped, changed or reduced. Sometimes it’s a case of ‘watch and wait’. The most important thing is that both the patient and clinicians have agreed on plan, know how to monitor progress and what to do if things change.

What’s important is that:

  1. You have agreed a plan
  2. You know what tests are needed (if any) and they are arranged
  3. You know what referrals have been made and when to expect to have these consultations
  4. You know the signs of improvement or the signs of deteriorations to look for
  5. You have information on the problem and access to more in a format you prefer
  6. You know when & who to contact if things deteriorate
  7. You know the signs to look out for and when to call 999
  8. Everyone involved in your care shares this information

Summarised in the chart below:

*This is a rolling blog. I welcome all suggestions for amendments, deletions and additions from everyone. Please email steve@carerightnow.co.uk

I am grateful to my friends and colleagues who helped me put together this information.

Steve Turner is a nurse prescriber and clinical educator & Associate Lecturer at Plymouth University. Steve shares health information from the Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS #TeamCOVID19  and on the web site www.patientled.education

Click here for the Care Right Now CIC web site

If have any questions about coordinating care for a loved one, you can contact Steve by email: steve@carerightnow.co.uk

Published: 20.04.2020

Author: Steve Turner

Version: 1

Revision History: 27.04.2020 – added a note about taking and sending pictures (‘Preparation’ point 2.)

Life in Lockdown: Coronavirus (StAustell Voice 15.04.2020)

I was working up to retirement when Coronavirus hit us. I work on clinical education and service development. I have lived in the St Austell area for 18 years. Some of my work, such as supporting Pharmacies in the North West, was already carried out from home.  Most of my teaching work has now stopped so I have applied to return to #NHS. While I’m waiting to hear back, I’m sharing health information from my Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS #TeamCOVID19 .

I am also helping coordinate mum’s care. Mum is 90. She lives 300 miles away & is very frail & poorly. Normally my brother & I would go straight to her when she needs us. So this is a really worrying time. Mum has fantastic carers; community support and a great GP. Because mum has multiple long-term conditions and is seen by several different health and care teams, I am finding that the coordination I do for her is vital to ensure that she receives the best care, nothing is duplicated, she receives her medicines and has the right equipment in the home. If any local families have any questions about coordinating care for a loved one please let me know. I’m happy to share some tips. steve@carerightnow.co.uk

I’ve also started a serives of blogs based on our patient led clinical education work. The first one is on telephone consultations: click here to see it.

More than ever now, we love to spend time in our garden. We’re planting vegetables and the garden’s looking better than ever.

Take care #StAustell

Steve Turner is a registered general and mental health nurse prescriber and Managing Director of Care Right Now CIC. http://www.carerightnow.co.uk

First published in the StAustell Voice

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Steve is Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University  and a former NICE Medicines and Prescribing Programme Associate.

@MedicineGovSte

LinkedIn profile.

info@carerightnow.co.uk

Author: Steve Turner

First published: 16.04.2020 Revised: 27.04.3030

Version:1c


‘Are my medicines really necessary?’

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‘Are my medicines really necessary’ is one of the most frequent questions from our patient led clinical education sessions.

In this blog Steve Turner, Head of Medicines & Prescribing @MedicineGov,  reflects on the need to combine research and guidleines with the patient’s actual experience, when deciding on medicines.

 

My experiences and learning

I was speaking about the use of medicines at a conference when I mentioned that medicines are ‘over prescribed’. Although nobody questioned and challenged me on this I was troubled by my use of this expression. By saying medicines are prescribed too frequently it seems to me this can be interpreted as a bad reflection on the prescribers.

As I mentally mulled this over (I’m not a quick thinker) I came to the conclusion that a beter expression may be ‘medicines are overused’. After all it’s us (the patients) who go to our Doctors, Pharmacists and Nurses and us who accept their prescriptions. Therefore if we agree that people can rely too heavily on medicines, and there’s wealth of evidence for this, then we need to sort this out together.

My social enterprise company’s Patent Led Clinical Education work came about because a large section of the population are prescribed multiple medicines, with potential for interactions and increased side-effects.

It’s widely accepted that 50% of the population don’t take their medicines as prescribed. Add to this the sometimes overlooked fact that people also use alternatives including over the counter medicines, herbal medicines , suplements, illicit drugs, self-medicate with alcohol, buy medicines over the internet, or borrow medicines from other people.


‘The human and financial costs of over use of medicines are immense. ‘


In our patient led clinical education sessions we have learned that many people don’t know what their individual medicines are for, and we see how many medicines are prescribed purely to counteract the side-effect of another medicine can pile up.


‘So far, nobody who has attended one of our sessions has expressed a wish to take more medicines, and those who did express a view all said that they didn’t want to take medicines if they didn’t have to.’


So what can we do together?

This blog aims to help us make sense of the vast amount of guidance available and describing why ‘trusted information’ is important in making decisions about medicines, and why this is only helpful it it’s linked to the patient’s actual experience.

So much information, so many policies & guidance?

There’s an overwhelming amount of information and guidance on medicines, coming out on a daily basis. Even clinicians struggle to keep up and need help.

Two things are important in trying to make sense of this information overload.

  1. Making sure that the information you are looking at is from a ‘trusted’ source, (by this I mean ones that your prescriber is expected to use). see http://www.medsinfo.guru
  2. Linking this to patient experiences and support from others who have the same conditions.

 

  1. ‘Trusted’ information

The National Centre for Heath and Care Education [NICE] in England produces guidance, standards, indicators and evidence services covering health and social care. It’s not just about medicines. There’s a massive amount of trusted information on their web site, which covers:

  • Conditions and diseases
  • Health protection
  • Lifestyle and wellbeing
  • Population groups
  • Service delivery, organisation and staffing

To get a feel for this one place to start is the NICE Pathways, where you can browse the topics, pick one and have the information presented in a diagram, where you can click on the headings for more information.

In some areas has been a move away from producing guidelines on a single illness or condition to a more holistic person based approach. This better reflects the complexities of real life, where it would often be a luxury to have just one illness with no complicating factors. NICE guidance on medicines optimisation, multi-morbidity clinical assessment and management, and patient experience in adult NHS services are good examples.

In addition NICE produces a document on Key Therapeutic Topics as part of the NICE Medicines and Prescribing Programme. This document is reviewed and refreshed annually. Click here for the topic list.

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2. Patient experiences

Medicines (for adults) are tested and approved before that can be prescribed, and their safety is monitored, especially in the early stages, or if there are concerns (black traingle drugs). However drug trials are most often carried out on relatively small groups of poeple, usually from a limited range of ethnic groups, who who do not necessarily represent the population as a whole. For example, these ‘controlled trials’ usually exclude people with multiple illnesses, heavy drinkers or smokers, older people, and people with other illensses such as addiction or mental ill health.

Controlled drugs trials are not carried out on children.

In addition the effect of medicines, including side-effects fall into two categories. Firstly, those that can be predicted (pharmaco dynamic effects – that the effect of the drug on the body). Secondly, those that vary according to the bodily make up of the patient (called pharmacokinetic effects – the effect of the body on the drug).

It’s only when you combine the guidance with the specific circumstances of the patient, including the ethnicity and physical make up and lifestyle of the patient that a decision on a medicine can be made effectively. For this to work, the patient must be part of this decision, and be allowed to lead on their own care. Our work shows this:

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Testimonials on our patient led clinical education work.


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Managing long term pain. A NICE Key Therapeutic Topic.

Medicines optimisation in long-term pain.

 

‘#jargonbuster ‘Medicines Optimisation’ means getting the medicines right for the individual. This may involve an alternative medicine, an alternative treatment or approach, and / or not taking medicines. The person’s experience, beliefs and what matters to them most should drive this decision, with clinicians providing guidance, advice and education on trusted sources of information, the evidence base and on safety’. (Steve Turner)

 

This is a brief summary relating to a topic in  the 2018 update of Medicines optimisation: key therapeutic topics

To access the pain management topic [KTT21] click here.

The section on medicines optimisation in long term pain contains a huge amount of information, including links to numerous other documents, on an areas critical to patient safety & wellbeing.

Key points:

Opioids

  • There is little evidence that opioids are helpful for long-term pain.
  • Patient safety incidents relating to the unsafe doses of opiates remain a major concern. People develop a ‘tolerance’ to opiate medicines, meaning that higher and higher doses may be needed to deliver the same effect. However this tolerance rapidly goes away when the opiates are stopped, so restarting at the old dose may be fatal.

 

This image is taken from: ‘Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain.

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Click on the image to enlarge it.

Link: http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware

 

‘A review of medicines-related safety incidents involving controlled drugs reported to the NRLS over 7 years found the risk of death with controlled drug incidents was significantly greater than with medication incidents generally (odds ratio 1.48, 95% CI 1.02 to 2.17). Incidents involving overdose of controlled drugs accounted for 89 (70%) of the 128 incidents reporting death or severe harm. Five controlled drugs (morphine, diamorphine, fentanyl, midazolam and oxycodone) were responsible for 113 (88%) of these 128 incidents.’

 

Non-opioid medicines in long-term pain

  • Patients can be prescribed gabapentin or pregabalin for certain types of pain. Both of these medicines can lead to dependence and may be misused or diverted.

#jargonbuster ‘diverted’ = passed on or sold one to someone else.

 

Finally, emotional influences are real:

  • When assessing pain with someone it’s vital that clinicians take all aspects of the person’s life into account, including lifestyle, nutrition, hydration, social and housing factors, safeguarding, sleep and rest, other illnesses, emotional influences and their mental health.

And take a full history of medicines being taken, or recently stopped, including over the counter medicines, internet bought medicines, borrowed medicines and illicit substances.


Overall key points to remember on pain management:

  • Adopt a  holistic patient-centered approach

  • Aim to prevent acute pain becoming chronic pain

  • There is little evidence that opioids are helpful for long-term pain


Related Guidance:

NICE Guidance NG5 Medicines Optimisation

NICE Guidance CG76 Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence

NICE Guidnace CG173 Neuropathic pain in adults: pharmacological management in non-specialist settings

NICE Guidance NG59 Low back pain and sciatica in over 16s: assessment and management

Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain

NICE Guideline NG46 Controlled drugs safe use and management

NICE Guidance CG140 Palliative care for adults: strong opioids for pain relief


 

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University  and NICE Medicines and Prescribing Programme Associate.

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Author: Steve Turner

First published 1/8/2017. Revised and updated 13/12/2018


 

Managing medicines in care homes – four top tips –

Managing medicines in care homes – implementing Quality Standards.

This blog is designed to provide information for care homes and for those choosing a  care home.

In a previous blog I looked at the implications of implementing the NICE Guideline on Managing Medicines in Care Homes.

As with all my posts this is  a ‘rolling blog’. I welcome feedback and comments. I will take into account all feedback and use the blog to share new learning. If I’ve missed anything or I am wrong on something I will admit it, and share the learning. Please comment via twitter @MedicineGovSte or by email to: steve@carerightnow.co.uk .

Some tips:

1. Care Homes must have a medicines policy that is regularly reviewed.

It’s worth considering how your policy links to staff training and how user friendly it is. Are procedures outlined clearly in the policy, do they link to competency assesments and do you use checklists?

For example, we recently helped a care home produce a checklist on the key information needed when contacting a doctor. It is based on the SBAR (situation-background- assessment-recommendation) principle to help focus on the key information. This is proving popular as it saves time on the ‘phone, and the structured approach is popular with GPs. Staff commeted that its has saved them hours of chasing, has improved responsiveness & their realtionship with local services.

Here’s our method of working. It’s not rocket science and it works. I recommend this approach. (Click here to find out more).

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2. People must have an accurate listing of their medicines on the day they transfer to the care home.

This is an area where care home staff are dependent on others. Hours can be spent trying to sort out problems. My advice here is for managers to ensure that discrepancies are always reported back to the source (in writing), and ask for feedback on how they are followed up. Additionally it’s helpful to record your satisfaction with good quality and complete discharge information.

Our experience is that can electronic systems greatly improve quality of this information.

An NHS Patient Safety Alert highlights the importance of communication of discharge information.

3. People who live in care homes should have at least 1 multidisciplinary medication review per year.

There is considerable variation in practice around medicines reviews, with increasing help available from Clinical Commissioning Group Medicines Management Teams and Specialist Clinicians in most areas.

Although this is an area largely outside the control of care homes there are 3 things which can help.

  • Firstly, by consistently referring back any prescriptions which don’t have complete and unambiguous directions.
  • Secondly, by ensuring that there is an easily accessible record of what each medicine is being prescribed for, (regular medicines, one-off prescriptions and as required medicines). I am still amazed that this isn’t always the case.
  • And thirdly, whilst staff residents / relatives are not expected to be experts on medicines, access to basic information the each medicine, including on side-effects and interactions should be readily available (see www,medsinfo.guru ).

4. Ensure you have safe systems for administering and recording medicines.

It is vital that you have a relaible and auditable system of MAR [medicine administration record] charts in place and that the process of administration of medicines to residents  is safe.

Two main points spring to mind:

4.1. MDS vs OPD. Seeing beyond misleading information about methods  administering medicines in residentail settings.

There has been a recent move by some of Pharmacies to change residential homes from Monitored Dose Systems [MDS] (also called blister packs) back to Original Pack Dispensing [OPD] (sometimes referred to as ‘patient pack dispensing’). The reason for this is often given as to improve safety. It is sometimes implied that guidelines are driving this move back to original pack dispensing, even that OPD can help prevent polypharmacy & reduce medicines waste. All of these statements are misleading.

Interestingly, the cost to the Pharmacy of  putting the medicines in MDS blister packs  is not mentioned in their promotions original pack dispensing [OPD].

I have not been able to find any evidence that original pack dispensing is safer than monitored dose systems. Additionally the related NICE guidelines, quality standards and the CQC report ‘Medicines in Health and Social Care’ do not state this.

What’s important is that the home uses the safest system of delivering the medicines to the residents, taking into account the patients’ wishes, the home’s skill mix, staff competencies, workload and capacity. This is particularly important as staff tell me original pack dispensing takes ‘twice as long’.

I am also aware of problems with OPD, for example: ‘Care home receives a box of meds. The medication is checked in and the resident has 2 MAR entries for same drug. Diligent staff member (calls the system provider and) prevents patient harm.In this example the boxed medicine had wrong start date, which led to duplication duplication on the MAR chart. In a blister the dispenser would have noticed the start date error on one item and made the data entry correction prior to the box medicine reaching the patient bedside.

My advice on the subject of MDS vs OPD is that if you are being lobbied to change to original pack dispensing, here are some key questions to consider:

A. Bearing in mind that OPD could take twice as long, what are the advantages of moving to this? Can you be sure , for example that unsafe practices such as ‘potting up’ will not creep into use? Will it improve patient safety & compliance with NICE Guidelines and quality standards?

B. Ask for evidence on the benefits of OPD as opposed to MDS.

C. Ask for evidence to back up the claim that OPD will help reduce polypharmacy? (In my view this is a bizarre claim).

D. Ask for evidence to back up the claim  that OPD will reduce medicines waste.

E. Ask the residents or their families, or (if there’s an Lasting Power of Attorney [LPA] or Court of Protection order in place), ask the Attorneys or Deputys.

F. Ask the staff.

G. Ask the prescribers.

I’m interested in feedback on this. I am a nurse by trade and used to be a proponent of OPD in all circumstances. Since working in social care and with residential homes I’ve re-visited this view.

I now believe that care home residents need well designed systems and that, unless the patient can manage their medicines themselves (always the first consideration), a good MDS system is often a safer way to administer medicines.

4.2 . The benefits of using electronic MAR charts.

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These fall in to three categories.

  1. Improved legibility.
  2. Improved access (e.g. if the charts are accessed and updated on a computer or portable device there is less risk of losing, damaging  or mislaying them).
  3. eMAR chart systems that obtain the data taken directly from the Community Pharmacy system eliminate the need for transcribing, which is a high risk area.

In addition to the three benefits mentioned, carefully planned and  implemented eMAR systems contribute to a decrease in medicines errors, reduced administrative costs and improved quality of care.

Click here to read more about eMAR systems. Link: https://medicinegovorgmedlearn-innovation-event-nhs.blog/2018/07/16/using-technology-in-care-homes-emar/

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Author: Steve Turner, Managing Director Care Right Now CIC and Information Governance / Clinical Lead for CareMeds Ltd.

For information on our clinical review, professional development and teaching services contact: e: steve@carerightnow.co.uk  m: 07931 919 330

Last updated: 05.09. 2019

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http://www.carerightnow.co.uk

 

Steve Turner is Data Protection Officer and Information Governance Lead for CareMeds Ltd.

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and Head of Medicines & Prescribing @MedicineGov

#EDUCATION

Useful links:

NICE Guideline Managing Medicines in Care Homes

NICE Quality Standard Managing Medicines in Care Homes

CQC Managing Medicines in Health and Adult Social Care


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