1. Role Preparation for Nurse Advisors Handling Medicines Calls Day 2 Your name Medicines Information Pharmacist Your Medicines Information Service

2. Role Preparation for Nurse Advisors - Day 2 Medicines Training for Nurses TrainingDurationTrainer Week 4Using Toxbase® to support poisons calls½ dayNHSD Week 5/6Handling Calls about medicines and the Medicines Algorithm Trainer evaluation Further medicines case scenarios 1 ½ days ½ day UKMI UKMI + NHSD Self directed Week 10Handling calls about Hormonal Contraception and Emergency Contraception EC algorithm – further scenarios ½ dayUKMI Self directed 3-6 monthsMedicines calculations for NAs e-Toxbase® One-to-one medicines training on request Self directed UKMI 6 monthsHandling calls about medicines during pregnancy and breastfeeding ½ dayUKMI

3. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Morning Welcome & re-cap Handling calls about Adverse Effects & Drug Interactions Workshop 4: Case scenarios on Adverse Effects and Drug Interactions Break Handling calls about analgesia Workshop 5: Case scenarios on analgesia Lunch

4. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Afternoon Medicines Algorithm Workshop 6: Case scenarios using the medicines algorithm Break Where are the risks when handling medicines calls? Examples of common mistakes Review and close

5. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Morning Welcome & re-cap Handling calls about Adverse Effects & Drug Interactions Workshop 4: Case scenarios on Adverse Effects and Drug Interactions Break Handling calls about analgesia Workshop 5: Case scenarios on analgesia Lunch

6. Role Preparation for Nurse Advisors - Day 2 Adverse Drug Reactions Account for 2-6% of hospital admissions Type A predicted by mode of action Type B idiosyncratic or unpredictable Estimated that 10-20% of patients suffer an ADR during hospital stay Length of stay may be increased in up to 50% of in-patients Unwanted effect that drug has on a person

7. Role Preparation for Nurse Advisors - Day 2 Incidence of Adverse Effects Very common>10% Common>1% Risk of dying from cancer if smoke 20 a day for 30 years Uncommon>0.1% Risk of being injured on the stairs in next 12 months Rare>0.01% Risk of dying in an accident at home in next 12 months Very rareup to 0.01% Risk of being killed by lightening

8. Role Preparation for Nurse Advisors - Day 2 Yellow Card Reporting Scheme NEWER DRUGS & VACCINES (  ) All ADRs even if Not certain that drug has caused it Reaction well known Other drugs at same time ESTABLISHED DRUGS & VACCINES All serious ADRs Fatal, life threatening or disabling Prolonged hospital stay Even if well known

9. Role Preparation for Nurse Advisors - Day 2 Patient reporting to Yellow Card Scheme Patients can report suspected adverse effects www.yellowcard.gov.uk Patient report forms from 4000 GPs in pilot or MHRA Help MHRA understand the patient experience and perspective of suspected adverse effects Patients can view anonymous data on website

10. Role Preparation for Nurse Advisors - Day 2 MHRA Website www.mhra.gov.uk Medicines & Healthcare Products Regulatory Authority

11. Role Preparation for Nurse Advisors - Day 2 Recent Drug Alerts / Scares Rofecoxib Withdrawn,  risk MI/stroke HRT Avoid long-term,  risk breast cancer Kava-KavaWithdrawn, hepatoxicity CerivastatinWithdrawn, rhabdomyolysis Co- proxamol Risk of death in overdose Paroxetine Not if <18 yrs,  risk suicide

12. Role Preparation for Nurse Advisors - Day 2 Drug Interactions One drug modifies the effect(s) of a second drug. More likely if taking several medicines.  Toxicity Warfarin + amiodarone = greater risk of bleeding  Efficacy Thyroxine + Rifampicin = more thyroxine needed

13. Role Preparation for Nurse Advisors - Day 2 One way medicines work The more neurotransmitter the more the receptor is stimulated Noradrenaline released from nerve endings stimulates bronchioles in the lung to dilate Nerve ending Neurotransmitter Receptor on cell

14. Role Preparation for Nurse Advisors - Day 2 One way medicines interact: At the receptor Nerve ending Atenolol closes the bronchioles Salbutamol opens the bronchioles Receptor stimulated Receptor blocked Nerve ending

15. Role Preparation for Nurse Advisors - Day 2 How medicines are handled by the body ABSORPTIONDISTRIBUTION METABOLISM ELIMINATION Kidney Liver Blood Gut wall

16. Role Preparation for Nurse Advisors - Day 2 One way medicines interact: Absorption of the drug Antacids can absorb other drugs e.g. Ciprofloxacin Cholestyramine (Questran  ) binds to many drugs so give 1 hour before or 4-6 hours after cholestyramine

17. Role Preparation for Nurse Advisors - Day 2 More ways medicines interact: Metabolism of the drug DRUG LEVEL Metabolic Enhancers Smoking Alcohol Carbamazepine Phenytoin Rifampicin

18. Role Preparation for Nurse Advisors - Day 2 More ways medicines interact: Metabolism of the drug Metabolic Inhibitors Cimetidine Ciprofloxacin Erythromycin Metronidazole DRUG LEVEL

19. Role Preparation for Nurse Advisors - Day 2 Narrow Therapeutic Range Drugs CARBAMAZEPINE CICLOSPORIN DIGOXIN LITHIUM PHENYTOIN THEOPHYLLINE WARFARIN

20. Role Preparation for Nurse Advisors - Day 2 Where to look for Information on Drug Interactions and ADRS eBNF eMC Stockley (via MedicinesComplete) Recommended to confirm in more than one source If nothing found do not assume no interaction or ADR Often no info on OTC or herbal medicines

21. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Morning Welcome & re-cap Handling calls about Adverse Effects & Drug Interactions Workshop 4: Case scenarios on Adverse Effects and Drug Interactions Break Handling calls about analgesia Workshop 5: Case scenarios on analgesia Lunch

22. Role Preparation for Nurse Advisors - Day 2 Workshop 4 – Case Scenarios

23. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Morning Welcome & re-cap Handling calls about Adverse Effects & Drug Interactions Workshop 4: Case scenarios on Adverse Effects and Drug Interactions Break Handling calls about analgesia Workshop 5: Case scenarios on analgesia Lunch

24. Role Preparation for Nurse Advisors - Day 2

25. Timetable - Day 2 Morning Welcome & re-cap Handling calls about Adverse Effects & Drug Interactions Workshop 4: Case scenarios on Adverse Effects and Drug Interactions Break Handling calls about analgesia Workshop 5: Case scenarios on analgesia Lunch

26. Role Preparation for Nurse Advisors - Day 2 What is a medicine? Simple analgesics (pain killers) Paracetamol Ibuprofen Aspirin Co-codamol

27. Role Preparation for Nurse Advisors - Day 2 What is a medicine? Ibuprofen Reduces pain, fever and inflammation Used for mild to moderate pain eg toothache, headache, muscle pain Side effects include: Heartburn/indigestion, stomach ulcers, stomach bleeds, allergy – rash, wheezing, breathlessness, worsening of asthma Should not be taken if: Allergic to aspirin, have asthma, stomach ulcer or previous stomach bleed, high blood pressure or on medication to thin the blood (e.g. warfarin)

28. Role Preparation for Nurse Advisors - Day 2 What is a medicine? Paracetamol Reduces pain and fever Used for mild to moderate pain eg toothache, headache Side effects not usually a problem Must not exceed recommended dose – dangerous in overdose Must not take with other products containing paracetamol

29. Role Preparation for Nurse Advisors - Day 2 What is a medicine? Aspirin When used as a pain killer has similar effects and precautions as ibuprofen. Must not be given to children under 16 years. Also used at low doses to prevent heart attacks and strokes.

30. Role Preparation for Nurse Advisors - Day 2 What is a medicine? Co-analgesics Many painkillers contain several drugs Often paracetamol + other(s) Examples: Co-codamol contains paracetamol and codeine Co-dydramol contains paracetamol and dihydrocodeine Co-proxamol contains paracetamol and dextropropoxyphene Co-codaprin contains aspirin and codeine

31. Role Preparation for Nurse Advisors - Day 2 What is a medicine? Cough and cold products Many cough and cold products contain analgesics Beechams Powders® Aspirin 600mg + caffeine 50mg Lemsip Max® Paracetamol 500mg + caffeine 25mg Nurofen Cold and Flu® Ibuprofen 200mg + Pseudoephedrine 30mg

32. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Morning 9.30Welcome & re-cap 9.45Handling calls about Adverse Effects & Drug Interactions Workshop 4: Case scenarios on Adverse Effects and Drug Interactions 11.15Break 11.30Handling calls about analgesia Workshop 5: Case scenarios on analgesia 1.00Lunch

33. Role Preparation for Nurse Advisors - Day 2 Workshop 5 – Case Scenarios

34. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Morning 9.30Welcome & re-cap 9.45Handling calls about Adverse Effects & Drug Interactions Workshop 4: Case scenarios on Adverse Effects and Drug Interactions 11.15Break 11.30Handling calls about analgesia Workshop 5: Case scenarios on analgesia 1.00Lunch

35. Role Preparation for Nurse Advisors - Day 2

36. Timetable - Day 2 Afternoon 1.30Medicines Algorithm Workshop 6: Case scenarios using the medicines algorithm 3.15Break 3.45Where are the risks when handling medicines calls? Examples of common mistakes 4.15Review and close

37. Role Preparation for Nurse Advisors - Day 2 Demonstration of Meds Algo led by CAS trainer Medicines Algorithm

38. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Afternoon 1.30Medicines Algorithm Workshop 6: Case scenarios using the medicines algorithm 3.15Break 3.45Where are the risks when handling medicines calls? Examples of common mistakes 4.15Review and close

39. Role Preparation for Nurse Advisors - Day 2 Workshop 6 – Case Scenarios

40. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Afternoon 1.30Medicines Algorithm Workshop 6: Case scenarios using the medicines algorithm 3.15Break 3.45Where are the risks when handling medicines calls? Examples of common mistakes 4.15Review and close

41. Role Preparation for Nurse Advisors - Day 2

42. Timetable - Day 2 Afternoon 1.30Medicines Algorithm Workshop 6: Case scenarios using the medicines algorithm 3.15Break 3.45Where are the risks when handling medicines calls? Examples of common mistakes 4.15Review and close

43. Role Preparation for Nurse Advisors - Day 2 Where are the risks when handling a Medicines Call? Clarify the question Plan search strategy & research problem Evaluate the information Tailor the answer/advice Refer to MI Record all stages

44. Role Preparation for Nurse Advisors - Day 2 Where are the risks when handling Misunderstanding what the caller said Missed symptoms Incomplete background information Omitting relevant information sources Working outside level of competency Caller doesn’t understand the answer Incomplete or inaccurate documentation

45. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Afternoon 1.30Medicines Algorithm Workshop 6: Case scenarios using the medicines algorithm 3.15Break 3.45Where are the risks when handling medicines calls? Examples of common mistakes 4.15Review of learning outcomes and close

46. Role Preparation for Nurse Advisors - Day 2 Examples of common mistakes Thinking ‘interaction’ not total daily dose Hearing what you want to hear Asking important questions as fillers Using jargon Incorrect interpretation from information sources Not understanding what you read Using Self Knowledge

47. Role Preparation for Nurse Advisors - Day 2 Timetable - Day 2 Afternoon 1.30Medicines Algorithm Workshop 6: Case scenarios using the medicines algorithm 3.15Break 3.45Where are the risks when handling medicines calls? Examples of common mistakes 4.15Review and close