More haste, less speed.

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Dont you just hate it when customers cannot wait for their medicines to be dispensed? They are told “it will be 5-10 minutes or so” and ive had people say…”what that long?” Obviously i don’t mean a  one item prescription will take 10 minutes but you know the type im talking about. The 5 scripts, 6 item per prescription with dressings one.

I don’t think im a “slow pharmacist” but when it’s just you in the dispensary, answering the telephone, labelling, dispensing and checking, things are obviously delayed.

I think it’s the culture and norm these days to expect everything at a “fast food” level. Things are needed yesterday. But where is the patience with our customers?

I for one will not rush a prescription for anybody. More haste, less speed….if i make a mistake, it will take longer to rectify and worse still cause harm to the individual.

So is there and average time to dispense an item? ( see poll below). I’m guessing approx 2 minutes per item. what are your thoughts?

 

 

 

 

Bye bye hospital Pharmacy

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Well its been a while since i’ve blogged. The big news is that come June i will no longer be a Hospital Pharmacist. Im going to the “other side”….community pharmacy.

Why???? i hear you scream. Well the simple fact is that i get to spend more time with my children. Its less hours, no on calls and best of all i will have no childcare costs and my children have me all to themselves.

Its going to a big change. I will miss working as a hospital pharmacist. But who says community pharmacists cant be clinical too? I for one intend to provide my customers with a brilliant clinical service.

Im not selling my soul to the big mutilples. I will be working for an independent pharmacy.

So join me in my new journey……community pharmacy, here i come.

Is warfarin on its way out?

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3 mg (blue), 5 mg (pink) and 1 mg (brown) warf...

Image via Wikipedia

A few weeks back, a drug rep came to see us to provide more information on a new drug just added to the hospital formulary. This drug was dabigatran (Pradaxa ® Black triangle),  a direct thrombin inhibitor licensed for the prophylaxis of  venous thromboembolism in adults after total hip replacement or total knee replacement surgery. This talk made me think… ” will warfarin still be used in 10 years time?”

Warfarin has been around since the 1950′s . It is licensed for the prophylaxis of embolisation in rheumatic heart disease and atrial fibrillation; prophylaxis after insertion of prosthetic heart valve; prophylaxis and treatment of venous thrombosis and pulmonary embolism and transient ischaemic attacks (BNF 60).

Although the two newer oral anticoagulants dabigatran and rivaroxaban (Xarelto®  Black triangle) available in the UK are not licensed for use in AF or treatment of venous thrombosis, pulmonary embolism  and in valve patients,  its only a matter of time before they are licensed for these indications once trial data is available.

Dabigatran  as mentioned above is a direct thrombin inhibitor and rivaroxaban is a direct inhibitor of activated factor X. They are given orally but unlike warfarin do not require dose adjustments, and therapeutic drug monitoring (INR testing).  They also do not have a narrow therapeutic range or have the same long list of drug and food interactions.

from http://www.australianprescriber.com/magazine/33/2/38/41/#t1
Comparison of oral anticoagulants
Property Warfarin Rivaroxaban Dabigatran etexilate
Anticoagulant action Reduced synthesis of functional clotting factors II, VII, IX and X Direct competitive reversible inhibition of activated factor X Direct competitive reversible inhibition of thrombin
Prodrug No No Yes
Bioavailability Almost 100% 80% 6.5%
Onset of anticoagulant action 36–72 hours Within 30 minutes
Tmax 2.5–4 hours		 Within 30 minutes
Tmax 0.5–2 hours
Duration of anticoagulant action 48–96 hours 24 hours 24–36 hours
Elimination half-life (anticoagulant activity) 20–60 hours 5–9 hours in young adults
11–13 hours in older adults		 7–9 hours in young adults
12–14 hours in older adults
Predictable pharmacokinetics No Yes Yes
Interactions with diet or alcohol Yes, clinically significant Low potential Low potential
Drug interactions Numerous clinically significant interactions Potent cytochrome P450 3A4 and P-glycoprotein inhibitors augment anticoagulant effect (e.g. ketoconazole, clarithromycin, ritonavir) Proton pump inhibitors reduce absorption Possible interactions with P-glycoprotein inhibitors and inducers
Dosing and dose adjustments Dose individualised for each patient, requires frequent INR monitoring and adjustment Fixed according to clinical indication Fixed according to clinical indication
Monitoring INR every 1–2 weeks No routine monitoring required No routine monitoring required
Use in liver failure Contraindicated or caution advised Contraindicated as hepatic metabolism Possibly safe as no hepatic metabolism but caution advised
Use in severe renal impairment No dose adjustment required Increased drug exposure and elimination half-life in renal impairment
Safety and dosing not yet established
Contraindicated in severe renal impairment		 Increased drug exposure and elimination half-life in renal impairment
Safety and dosing not yet established
Contraindicated in severe renal impairment
Use in pregnancy Category D
Teratogenic in first trimester		 Contraindicated as safety not established (excluded from clinical trials) Contraindicated as safety not established (excluded from clinical trials)
Reversibility after cessation Several days, requires synthesis of clotting factors 24 hours, dependent on plasma concentration and elimination half-life 24–36 hours, dependent on plasma concentration and elimination half-life
Antidote Immediate reversal with plasma or factor concentrate
Reversal within hours with vitamin K		 None available None available
INR international normalised ratio 

Tmax time to maximum concentration

So will they replace warfarin?  Although the dosing regimens are simpler  it can be argued that since intensive monitoring is not required, compliance may become an issue if they replace warfarin . I think until the costs of these new anticoagulants decrease and their safety and efficacy is proven in AF and the treatment of PEs and DVTs  and heart valve patients, warfarin (and the other vitamin K antagonists, acenocoumarol and phenindione) will be around for a good few years yet.

see also

On call payment Review and Confusion

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So what’s exactly happening with the on call situation? Anyone confused.com? Hmmm….yup i think we need to look at the current situation.

The current on call arrangements are due to end on  31/3/2011. The NHS staff council invited responses to its draft principles to harmonised on call arrangements and closed on 10th September 2010.

The NHS Staff Council have now signed off the final principles and these will be published soon along with guidelines for local implementation of the principles. This means the end of the emergency duty commitment payment that is currently paid for providing on call services, along with any local arrangements that have previously been protected. In its place will be whatever is agreed locally as from 1st April 2011. The principles can be found at http://www.sor.org/news/files/images/principles_final_2.pdf

Once they have been published, local partnerships (Staff and management side) should come together to develop harmonised terms and conditions for on call. But what is meant by local? This could mean individual Trusts, a group of Trusts, or SHA’s. The process that follows should involve trade union representatives and management side representatives (HR, Directors etc) getting together to negotiate new terms and conditions for on call that follow the principles agreed by the NHS Staff Council.

The important thing to note is the principles provide a framework for local partnerships and it is the partnership that decides the level of remuneration in line with the principles.

The Guild of Healthcare Pharmacists (GHP) have voiced concern that in some SHAs, the management side appear to be taking the view that from the 1st April the interim arrangements currently within Section 2, part 2 of the Agenda for Change handbook will come into place and there will be no pay protection arrangements. This could result in a large loss of earnings for pharmacists delivering on call. Based on a 1 in 12 rota, a band 6 pharmacist would be paid as little as £17 per night (£510 per year) to be on call and provide advice over the telephone.

Whilst this can be imposed upon staff with the appropriate period of notification, it is not in line with the principles that will be published by the NHS Staff Council. Any members that are issued with such notification should contact their union representatives as soon as possible (this would include local Unite rep, Trust staff side lead and regional officer) to allow this position, which is not in the spirit of the Agenda for Change principles, to be challenged.

Be under no illusion, this will happen. Some of us will have a reduced income because of this. Just make sure anything that is proposed is challenged so as to make it fair for all pharmacists.

So my advice:

1. Read and be familiar with the principles from the NHS council

2. Read and be familiar with the Agenda for change handbook

3. Join a Union – GHP/Amicus

4. DO NOT accept the current arrangements in section 2 of the Agenda for change handbook

5.  and most importantly.. be involved with the process. Don’t just sit back then complain about it. DO something and help make a change that is fair to all

 

Links

1. GHP http://www.ghp.org.uk/home

2.  Agenda for change handbook  http://www.nhsemployers.org/SiteCollectionDocuments/AfC_tc_of_service_handbook_fb.pdf

 

 

Don’t pharmacists communicate with their patients anymore?

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After waiting 90 minutes for me and my 2 year old son to be seen by the GP for an emergency appointment (and register as a temporary resident whilst away from home) we visited the pharmacy next door to have my sons prescription dispensed.My son had an acute exacerbation of asthma, most likely viral.

The chemist was an independently owned one. We walked in to find one dispenser playing cards and the other playing with her mobile phone! Ok, I know they were not busy, but playing cards! There must have been something else they could have been doing. Theres always something to do at a pharmacy, clean up, date check, tidy shelves, put stock away, I could go on.

I handed the pharmacist the prescription, he barely acknowledged me. Within 5 minutes it was ready. Now where i work at a hospital pharmacy our standard operating procedure (SOP) states that we should counsel the patients on their medication when handing it out.

This pharmacist just handed it to me and that was that. Judging by his registration number on his Responsible Pharmacist certificate he had been qualified for the same length of time as me, so not a newbie although that’s no excuse. Why didn’t he ask me if i knew how to use the inhaler and spacer for my son? Why didn’t he tell me about the possible side effects of the steroid tablets? I know why, he had a game of cards to get back to!

To top it all off, he didn’t even put a patient information leaflet in with the steroid tablets! Very bad indeed.

It is a requirement of the Medicines for Human Use Regulations 1994, as amended (in accordance with the related European Directive) that a Patient information leaflet (PIL) is provided on each occasion medicinal product is supplied. Pharmacists must therefore ensure that a PIL is supplied with every dispensed medicinal product.

If pharmacists can’t even be bothered to tell their customers/patients about their medication, then who will? A GP doesn’t always have time, they assume the pharmacist will do it.

Maybe im naively thinking this was a one off, not all community pharmacies are like this, surely?

In case some of us have forgotten, here are the principles of our Code of Ethics:

1. Make the care of patients your first concern

2. Exercise your professional judgement in the interests of patients and the public

3. Show respect for others

4. Encourage patients to participate in decisions about their care

5. Develop your professional knowledge and competence

6. Be honest and trustworthy

7. Take responsibility for your working practices

I think some pharmacists need to re-evaluate how they work.

Calpol is not a cure all

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Calpol or paracetamol suspension is NOT a cure all! It’s lovely pink liquid and possible strawberry taste is loved by millions of children worldwide.

But It’s for pain relief and reducing a fever. It is not a magic cure all. I’ve heard people say, ” oh he has got a cough, give him Calpol” or she looks ill let’s give her Calpol. It won’t cure a cough and it won’t make your child look well!

How many parents are giving their children Calpol for random reasons? People, it’s a drug. Just because it looks and tastes nice does not mean it’s without it’s consequences especially on overdose.

So the next time you sell a bottle pharmacists, take that extra time to re-educate your customers/patients.

That is all.

Banana Benefits

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3 bananas on a yellow background

After talking about bananas on twitter i thought i would look up the medical properties of bananas. (it was being discussed if peeling a banana from the top is the correct way to peel it, or should you peel from the bottom)

Please note: im not sure how true the statements below are, it’s a collection of claims from the web

Anaemia: High in iron, bananas can stimulate the production of haemoglobin in the blood and so helps in cases of anaemia.

Blood Pressure: This unique tropical fruit is extremely high in potassium yet low in salt, making it the perfect food for helping to beat blood pressure. So much so, the US Food and Drug Administration has just allowed the banana industry to make official claims for the fruit’s ability to reduce the risk of blood pressure and stroke.

Brain Power: 200 students at an English school were helped through their exams this year by eating bananas at breakfast, break and lunch in a bid to boost their brain power. Research has shown that the potassium-packed fruit can assist learning by making pupils more alert.

Constipation: High in fibre, including bananas in the diet can help restore normal bowel action, helping to overcome the problem without resorting to laxatives.

Depression: According to a recent survey undertaken by MIND amongst people suffering from depression, many felt much better after eating a banana. This is because bananas contain tryptophan, a type of protein that the body converts into serotonin – known to make you relax, improve your mood and generally make you feel happier.

Hangovers: One of the quickest ways of curing a hangover is to make a banana milkshake, sweetened with honey. The banana calms the stomach and, with the help of the honey, builds up depleted blood sugar levels, while the milk soothes and re-hydrates your system.

Heartburn: Bananas have a natural antacid effect in the body so if you suffer from heart-burn, try eating a banana for soothing relief.

Morning Sickness: Snacking on bananas between meals helps to keep blood sugar levels up and avoid morning sickness.

Mosquito bites: Before reaching for the insect bite cream, try rubbing the affected area with the inside of a banana skin. Many people find it amazingly successful at reducing swelling and irritation.

Nerves: Bananas are high in B vitamins that help calm the nervous system.

Overweight and at work? Studies at the Institute of Psychology in Austria found pressure at work leads to gorging on comfort food like chocolate and crisps. Looking at 5,000 hospital patients, researchers found the most obese were more likely to be in high-pressure jobs. The report concluded that, to avoid panic-induced food cravings, we need to control our blood sugar levels by snacking on high carbohydrate foods (such as bananas) every two hours to keep levels steady.

PMS: Forget the pills – eat a banana. The vitamin B6 it contains regulates blood glucose levels, which can affect your mood.

Seasonal Affective Disorder (SAD): Bananas can help SAD sufferers because they contain the natural mood enhancer, trypotophan.

Smoking: Bananas can also help people trying to give up smoking, as the high levels of Vitamin C, A1, B6, B12 they contain, as well as the potassium and magnesium found in them, help the body recover from the effects of nicotine withdrawal.

Stress: Potassium is a vital mineral, which helps normalise the heartbeat, sends oxygen to the brain and regulates your body’s water-balance. When we are stressed, our metabolic rate rises, thereby reducing our potassium levels. These can be re-balanced with the help of a high-potassium banana snack.

Strokes: According to research in “The New England Journal of Medicine”eating bananas as part of a regular diet can cut the risk of death by strokes by as much as 40%!

Temperature control: Many other cultures see bananas as a “cooling” fruit that can lower both the physical and emotional temperature of expectant mothers. In Thailand, for example, pregnant women eat bananas to ensure their baby is born with a cool temperature.

Ulcers: The banana is used as the dietary food against intestinal disorders because of its soft texture and smoothness. It is the only raw fruit that can be eaten without distress in over-chronic ulcer cases. It also neutralises over-acidity and reduces irritation by coating the lining of the stomach.

Warts: Those keen on natural alternatives swear that, if you want to kill off a wart, take a piece of banana skin and place it on the wart, with the yellow side out. Carefully hold the skin in place with a plaster or surgical tape!

Some of these might just be wild claims, but there is no denying it, bananas are a super fruit! Enjoy…yum yum

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Dosette boxes: Its not always the answer

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I despise dosette boxes (pill organisers, calendar blister packs, Nomad plenty of other names for them). I’m not denying the fact that in a small proportion of patients it really does benefit them. But they are not the answer to all compliance problems. It’s the community pharmacists and dispensers i feel sorry for having to count out trillions of tablets/capsules and then checking them. I’m sure they must suffer from RSI and eye strain.

Where i work at a hospital we do not prepare dosette boxes. It’s always such a nightmare to sort a dosette out with the GP and community pharmacist at the last minute prior to discharge.

Simple measures can be taken to improve compliance:

  • Educating patients about disease and treatment

  • Simplifying drug regimens: minimising the number of drugs and frequency of doses

  • Using modified or controlled release preparations to decrease dosage frequency

  • Involving carers in management of medication

  • Telling patients about common side effects

  • Using drug diaries, calendars, or medication charts

  • Using ordinary bottle tops instead of child resistant containers

  • Using large print for labels on containers

  • or a pill that texts your mobile phone when you have forgotten to take your medication! ( see previous blog post)

For example I had a patient on my ward who was about to be discharged. the medical team wanted a dosette box organised because the patient wouldn’t take her medication. So how was putting it into a dosette box going to help? I explained to her  medical team what she needs is encouragement to take her medication from carer/family member. Putting it into a compliance aid wont help her take her medication  if she didn’t want to!

What are other people’s thoughts and experiences on dosette boxes? Love them? Hate them?

Top 10 reasons to become a pharmacist

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These are some funny and obscure  reasons i found whilst surfing the web:

  1. Being a pharmacist can be interesting work- unless you are stuck behind the counter doing the same thing over and over again
  2. It is a respectable profession do patients/customers actually know what we do?
  3. A pharmacist can alleviate pain- if you are a type of person that wants your prescription filled in 2 minutes the pharmacist will cause you pain !
  4. A pharmacist does not need to be sitting all day- yes but you are standing all day and you end up with varicose veins
  5. It is a profession which is stable- not in this current economic climate
  6. A pharmacist gets to wear a lab coat- not anymore due to infection control
  7. Pharmacists are respected among doctors -that’s debatable!
  8. Pharmacies are very tranquil- ummm not if you work for certain retail pharmacy chains which shall not be names
  9. A pharmacist can work alone for much of the day- and that’s a good thing?
  10. It is a profession that many years of schooling is not needed- so 4 years at university and 1 year pre-registration training is not alot?

Has anybody got any other reasons?

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