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. firstname.lastname@example.org
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.
‘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 if 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.
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
Linking this to patient experiences and support from others who have the same conditions.
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
Lifestyle and wellbeing
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.
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 people, 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 illnesses 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 pharmaco-kinetic 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:
Testimonials on our patient led clinical education work.
Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University and a former NICE Medicines and Prescribing Programme Associate.
‘#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)
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.
‘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
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: email@example.com .
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.
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.
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 Pharmacies & local NHS teams 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 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.
These fall in to three categories.
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).
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.