To explore problems encountered when children are discharged from hospital on an unlicensed medicine Dr Sharon Conroy, Lecturer in Paediatric Clinical Pharmacy and Mandeep Bhoday, Research Associate, University of Nottingham, Derbyshire Children’s Hospital

to the NPPG for funding the project HUGE THANK YOUs to the NPPG for funding the project and to everyone who has helped so far

Introduction Unlicensed medicines are used when no suitable licensed product is available Made extemporaneously, bought in as a Special or imported

Background & Incidence Neonatal intensive care: 10% prescriptions unlicensed Conroy S, McIntyre J, Choonara I. Arch Dis Child Fetal Neonatal Ed 1999;80:F142-5 General paediatric wards across Europe 7% prescriptions unlicensed Conroy S, Choonara I, Impicciatore P et al. BMJ 2000;320:79-82

Aims of the study To explore the experiences of families and healthcare professionals in obtaining or providing further supplies of unlicensed medicines in the community. To identify potential means to improve current systems.

Methods Hospital pharmacies & ward pharmacists in Derby, Nottingham, Leicester & Sheffield identify prospective participants for the study Telephone interviews with parents, GPs, community pharmacists and outreach nurses to discuss experiences & suggestions for improvement or examples of good practice.

Parent Results (n=35) GP related issues GP won’t prescribe as medicine is not on their computer Hospital paperwork not reached GP in time Community Pharmacist (CP) related issues CP doesn’t know where to order medicines from so parents have to travel back to hospital each month CP uses a different supplier each time so consistency of medicine is different every time CP will not order medicine until they see prescription

GP Results (n=4) Lack of communication/delays in receiving information from hospitals (n=3) Reluctance to prescribe UL medicines - due to high costs in community and limited clinical evidence (n=1) Not all GPs are able to add new products to computer list making it difficult to prescribe UL medicines (n=1) Happy to prescribe – if sufficient written information from hospital regarding drug and dose (n=1)

GP suggestions Improved communication (n=4) phone call from hospital doctor, nurse or pharmacist would be appreciated to pre-warn surgery and provide opportunity to ask relevant questions and advice written information including clinical indication from hospital consultant with clear instructions including information on monitoring Preference for hospital to continue supply (n=2) as already familiar with prescribing, obtaining and monitoring UL medicines

CP Results (n=11) Lack of awareness Lack of communication parental expectation very high - expect medicines to be available as quickly as in hospital (n=8) Lack of communication from GPs, hospitals, and parents (n=7) Lack of adequate supply upon discharge hospital supply runs out while waiting for prescription from GP or further supply from CP (n=4)

CP suggestions for improvement Improved communication from hospitals encourage parents to take discharge notes to CP fax details to GP and CP at discharge ask parents which CP they use & telephone at patient discharge provide parents with contact details for paediatric pharmacists Hospitals to educate parents prior to discharge many parents unaware that UL medicines are not available “off the shelf” Hospitals to provide adequate supplies

Outreach Nurses Results (n=2) Problems experienced by families are due to Parents leaving it to last minute before ordering further supply - leads to children missing doses GPs unwilling to prescribe liquids due to cost – nurses have to provide prescriptions from hospital Outreach nurse team is helped by Having a pro-active hospital pharmacist who educates parents before discharge & contacts GPs and CPs if/when problems have occurred.

Top 10 problem medicines Name of medicine No. of times reported Spironolactone 9 Omeprazole 7 Phenobarbital 6 Furosemide Chlorothiazide 4 Clobazam Glycopyrronium 3 Tizanidine Captopril Sodium Chloride 2

What can we do? Communication is key! highlighted by parents, GPs, CPs and outreach nurses need to be contacting GPs and CPs with details of formulations, strengths, suppliers, dose & warn when supply will run out in order to ensure seamless care need to take a pro-active role in educating parents about UL medicines before they go home

Opportunities? Specials Tariff New medicines service Medicines Use Reviews

Any Questions?