td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10745 [post_author] => 2325 [post_date] => 2020-07-14 19:36:38 [post_date_gmt] => 2020-07-14 09:36:38 [post_content] =>
Telehealth for pharmacists has been around for some time, but will its expansion during the COVID-19 pandemic era make it normal practice?
Telehealth may be the ‘abiding legacy’ of COVID-19 for health professionals, Health Minister Greg Hunt declared two months ago as Australia went into virtual lockdown.1
And the recent introduction of telehealth medicine reviews means community pharmacists are now also able to discover the benefits of telehealth for patient care. Following PSA’s drive to improve access to medicine reviews, the federal government announced in April that pharmacists could, for the first time, provide funded medicine review services via telehealth for patients who met the eligibility criteria.
PSA National President Associate Professor Chris Freeman said then that face-to-face consultations remained best practice but he welcomed the announcement as it allowed medicine reviews to be conducted more frequently to deliver the best outcomes for patients.
Nicolette Ellis MPS was one of the first pharmacists to conduct medicine reviews using telehealth in her role as the senior clinical pharmacist for Beyond Pain. Last year’s PSA Queensland Early Career Pharmacist of the Year, now a consultant and educator specialising in persistent pain treatment and management, Ms Ellis works alongside an allied health team that orders medicine reviews once an in-depth consultation with the patient is completed.
‘The benefits for the patient are really good. It reduces anxiety, it’s easier for them and more economical. In rural and remote areas most people wouldn’t see a pain specialist or have access to a multidisciplinary program team,’ she told Australian Pharmacist.
‘I think it’s something that can be used more because there are barriers to accessing healthcare for lots of different demographics.’
A range of options is available for conducting telehealth pharmacy consultations, from a phone call to video calling apps and software such as Zoom, Skype, FaceTime, Duo and GoToMeeting.
The PSA has echoed government advice that to ensure patient privacy, it is important to use platforms that have adequate encryption. Some additional encrypted platforms used by pharmacists in Australia include:
doxy.me: A telemedicine platform that enables patients to video call without downloading an app. It offers live chat, a patient queue and patient check-in.
HealthEngine: An app that enables phone consults, secure video, a waiting room, new patient forms and integration with practice management systems.
Telehealth has been used increasingly in Australia over the past decade, especially in remote areas, for services from rural hospitals to healthcare services across a wide area.
While there has been limited research into Australian pharmacists’ use of telehealth, it has been shown to be a cost-effective way of improving service quality, promoting the safer use of medicines and reducing hospitalisation due to medicine misadventure in remote communities.2 However, start-up time and costs have proved a barrier to the wider rollout of telepharmacy in non-remote areas.3
That barrier was lifted as COVID-19 emerged in Australia, and pharmacists’ use of telehealth was fast tracked by the pandemic, says Krysti-Lee Rigby MPS, the Vice President of PSA NSW and Professional Services Account Manager at instigo.
Late last year, she helped instigate the pharmacy-facilitated teledentistry ViDe service at Moodies Pharmacy in Bathurst, NSW, before an intended rollout in pharmacies in the NSW central west area and the Australian Capital Territory.
‘The biggest barrier before [the pandemic] was usually the pharmacist themselves,’ Ms Rigby said. ‘COVID-19 …has made people jump on board, get up to date with the technology and change their practice. Once you get over the fear of the unknown you realise you can have a very successful consultation.’[caption id="attachment_10748" align="alignright" width="226"] Callan Beesley MPS can see benefits in HMRs via telehealth, especially for those who were isolated during the pandemic travel restriction phase.[/caption]
Callan Beesley MPS, a pharmacist in Coffs Harbour, NSW, was initially cautious about conducting home medicines reviews (HMRs) via telehealth and has deferred most of these until he can do them face to face.
However, after he started conducting phone or videoconferencing consultations for patients whose reviews could not wait, he saw the benefits – particularly for patients isolated during the pandemic.
‘For a lot of these patients telehealth is also about a bit of a welfare check,' he said.
‘When they’ve been isolated and not talking to people, they are often keen for a chat, and, taking longer than usual to do a bit of small talk helps initially – to build that relationship.
‘In my experience, patients are also less defensive [about their HMR] by phone.’
Pharmacists may temporarily use telehealth to deliver essential medical management consultations such as a MedsCheck, Diabetes MedsCheck, HMRs or Residential Medication Management Reviews (RMMR) to eligible patients via telehealth.
Eligible patients include:
Following the federal government’s response to the Interim Report of the Royal Commission into Aged Care Quality and Safety, HMRs and RMMRs now include the option for pharmacists to conduct follow-up services within 9 months of the initial patient consultation.
PSA has issued guidelines for telehealth medicine review services that stress the importance of initial contact with the patient, the use of appropriate technology, and the need to document consent from the patient. The guidelines note that telehealth consultation may not be appropriate for all patients.
The PSA’s updated Guidelines for comprehensive medication management reviews and Guidelines for Quality use of medicines (QUM) services (see resources box below) can be found on its dedicated COVID-19 information page.
As doctors have previously faced Medicare audits, and questions about the safety of telehealth, Ms Ellis says it’s important for pharmacists to ensure they follow the correct process.
The key to using telehealth safely, she says, is to properly structure the consultation, ensure you write down that the patient consented, document ‘everything’ and refer if necessary.
Ms Ellis always takes the time for an in-depth conversation with patients before discussing medicines and follow-ups, with clear instructions via email. ‘It’s better to be on top of that at the beginning as we are proving we can do this.’
The Australian Health Practitioner Regulation Agency (APHRA), put out a telehealth guidance for practitioners in April this year. (See resources box).
Ms Rigby says it’s also important for pharmacists to adjust workflow to ensure the consult goes smoothly.
‘For example, before an HMR you can have a pre-telehealth conversation and go through the steps of what they need to do in preparation, like putting all their medicines on the dining room table on the morning of, or taking a photo and emailing it.
‘Go through the steps to prepare them and discuss what platforms they feel comfortable with, from video conferencing on their phone to a phone call.’ (See resources box opposite.)
‘If there is an abiding legacy on the health front of what will come out of the pandemic, my hope and my belief and my commitment is to make that telehealth,’ Greg Hunt said of its wider introduction in May to health practitioners of many types for those ‘at home, alone, or isolated’.
Pharmacists who have used telehealth say it should probably be considered a good default option rather than the norm. It provides a realistic way of connecting with patients who would not otherwise have had access to care.[caption id="attachment_10749" align="alignnone" width="1000"] John Pisasale MPS has moved to telehealth Medschecks to comply with physical distancing regulations for the usual 20–30-minute consultation. He and his pharmacy staff also assist with medicines and body mass index information for patients in his isolated community who take up the option of a telehealth consultation with a general practitioner, using an encrypted service, from this private room in his pharmacy at Robinvale, on the Victorian-NSW border.[/caption]
Remote Victorian pharmacist John Pisasale MPS has been offering patients the option of a telehealth consultation with a doctor from a private room in his Amcal pharmacy, using an encrypted telehealth service on a tablet.
With weeks-long waiting lists to see a local GP, he says telehealth is a good option for an isolated community like Robinvale, on the banks of the Murray River in north-western Victoria where many of his patients don’t have a regular doctor or can’t get a GP appointment when it’s necessary.
Telehealth has enabled him to triage patients, connect them to medical care when needed, and even deliver medicines without patients needing to leave their homes.
He estimates that about 70% of his patients’ needs can be met via telehealth.
‘Rather than sending people on their way, it just means taking that little bit of extra time to set them up [with a telehealth consultation].
For people who can’t get their regular medicine or find it hard to access a doctor, it’s really filled a gap and we have found quite high demand,’ he says.
Mr Beesley says that telehealth will provide an important option on the NSW mid-North Coast for the foreseeable future, though there will need to be more investment in infrastructure and training for pharmacists to use it effectively.
Ms Rigby agrees telehealth will be an important option for pharmacists post-pandemic.
‘Face-to-face will always give the best outcome compared to telehealth services, but if you don’t have telehealth services available, there are a lot of people who are going to miss out on really important care.
I think telehealth will bridge that.’
TELEHEALTH – RESOURCES FOR MEDICINE REVIEWS
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10715 [post_author] => 235 [post_date] => 2020-07-08 16:29:11 [post_date_gmt] => 2020-07-08 06:29:11 [post_content] => Pharmacists have welcomed the renewed focus on rural and regional communities as Associate Professor Ruth Stewart takes up her role as Australia’s new National Rural Health Commissioner (NRHC). A former GP and researcher with extensive experience in rural areas, A/Prof Stewart follows Professor Paul Worley, who recently finished his term as the inaugural NRHC. [caption id="attachment_10718" align="alignright" width="185"] A/Prof Ruth Stewart is Australia’s new National Rural Health Commissioner. (Image: Twitter)[/caption] She will be supported by two Deputy Commissioners who will have a specific focus on allied health, nursing and Indigenous health. PSA National President Associate Professor Chris Freeman said he looked forward to working with A/Prof Stewart on behalf of pharmacists to improve health outcomes. ‘Highlighted in PSA’s Pharmacists in 2023, it is important to align incentives for pharmacists to support rural and remote communities as well as equip pharmacists with skills and knowledge to deliver closing-the-gap initiatives for Indigenous Australians,’ he said. A/Prof Stewart, who currently lives and works on Thursday Island in the Torres Strait, said assessing the impact of the COVID-19 pandemic on the rural health workforce and working towards closing the gap would her initial priorities. ‘This is an exciting challenge for my office to develop and promote innovative and integrated approaches to health care delivery in rural and remote areas,' she said.
A greater roleAs the most accessible – and occasionally the only – health professionals in remote communities, pharmacists are often the first port of call for everything from first aid to mental health challenges. [caption id="attachment_10719" align="alignright" width="223"] Samuel Keitaanpaa MPS.[/caption] This is something Samuel Keitaanpaa MPS, pharmacist in charge at Berry Springs Pharmacy, about 50 kilometres from Darwin, knows all too well. ‘In my rural pharmacy practice I have so many examples where I have steered people away from mental health crises, provided counselling that has reduced adverse effects of medicines and educated people how to manage their health significantly better,’ he told Australian Pharmacist. ‘Over 5 years I have seen the real outcomes of this and now feel like a valued member of the community. It changes your world when you get a phone call asking for advice and the person finishes with, “I’m glad it’s you on, you gave me such good advice previously”.’ Peter Fell MPS, Operations Manager – Pharmacy for UFS Dispensaries in Ballarat, Victoria, echoed Mr Keitaanpaa’s comments about the vital role of pharmacists in regional communities. ‘Increasingly, pharmacists are becoming a “navigator” for patients who do not understand or are having difficulty accessing the health system in non-metropolitan areas,’ he told AP. ‘They perform critical roles in supplying medicines and assessing and monitoring the response and effectiveness, and supporting patients throughout their lives.’
More services neededWhile pharmacists play an integral role supporting residents in regional communities to achieve better health outcomes, they need more support themselves, said Mr Keitaanpaa. Distance from distribution points makes it harder to balance cash flow with stock levels, he said, especially as pharmacies need to juggle their regular patients and cater to any visitors. ‘The other challenge is the lack of access to referral services, which means that patients’ conditions often deteriorate because they can’t access a physiotherapist, dentist or pain specialist,’ he said. ‘This means I have to balance best practice against the reality of my patient’s situation.’ [caption id="attachment_10720" align="alignright" width="191"] Peter Fell MPS[/caption] Mr Fell recounted similar experiences, and said rural pharmacists face many challenges their city-based counterparts don’t. ‘We find that GP access and hospital emergency department access can be challenging, so pharmacists are often in a situation of patients presenting with health issues and requesting advice when they really should have been seen by a doctor,’ he said. ‘Access to professional development is also more difficult as most face-to-face offers are in metropolitan areas. Mental health support can be challenging and peer support or peer networking is significantly reduced.’ A/Prof Freeman said it was important to prioritise support for rural pharmacists, so they could continue to deliver high levels of service. ‘As part of the Seventh Community Pharmacy Agreement, $24.6 million has been allocated to rural support programs, which is a good step forward,’ he said. ‘PSA looks forward to working with government on these programs, as well as progressing regional and rural health reforms with the NRHC and other healthcare bodies.’
Regional recruitmentStaffing is a constant challenge for pharmacies in regional and rural areas, Mr Fell said. This is despite there often being more opportunities for advancement, with early career pharmacists given the chance to take on management roles or work their way towards pharmacy ownership sooner than in a metro location. 'Ballarat is only around 100 kilometres from Melbourne but to attract capable pharmacists out of the city is nearly impossible,’ he said. ‘We are lucky in that as a reasonably large organisation with multiple pharmacies we have a better capacity to cover illness and leave periods, but recruitment is essentially always on our agenda.’ Mr Keitaanpaa said more work was needed to provide resources for rural pharmacies – both in terms of staff and digital health. ‘There needs to be real leadership to prioritise solutions to issues like workforce recruitment, growing interdisciplinary relationships and enhancing IT capability so that we can support more remote patients directly,’ he said. [post_title] => Pharmacists welcome renewed focus on rural and regional health [post_excerpt] => Pharmacists have welcomed the renewed focus on rural and regional communities as Associate Professor Ruth Stewart takes up her role as Australia’s new National Rural Health Commissioner. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => new-national-rural-health-commissioner-to-improve-health-outcomes-in-regional-areas [to_ping] => [pinged] => [post_modified] => 2020-07-10 18:05:57 [post_modified_gmt] => 2020-07-10 08:05:57 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10715 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Pharmacists welcome renewed focus on rural and regional health [title] => Pharmacists welcome renewed focus on rural and regional health [href] => https://www.australianpharmacist.com.au/new-national-rural-health-commissioner-to-improve-health-outcomes-in-regional-areas/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 10716 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10706 [post_author] => 23 [post_date] => 2020-07-08 13:54:08 [post_date_gmt] => 2020-07-08 03:54:08 [post_content] => Temporary Continued Dispensing Emergency Measures will be extended to at least 30 September, allowing Australians to continue to access essential medicines at Pharmaceutical Benefits Scheme (PBS) prices if their prescription has run out. The emergency measures were originally put in place during the bushfire season and extended when the COVID-19 pandemic unfolded. It was due to expire on 30 June. Under the initiative, eligible pharmacists can supply a patient with certain PBS and Repatriation Pharmaceutical Benefits Scheme medicines without a prescription. A patient can only get one supply per eligible medicine every 12 months. Controlled drugs are not included in the arrangement. Medicines supplied under continued dispensing are subject to PBS patient contributions and refund requirements and section 51 of the National Health (Pharmaceutical Benefits) Regulations 2017 – immediate supply 20 day and 4 day rule. The medicine also counts toward the patient's PBS Safety Net threshold.
Support in a crisisFor Cameron Walls MPS, Pharmacist Manager at United Chemists Wodonga on the Victorian side of the Victoria–New South Wales (NSW) border, the recent border closure and escalation of restrictions in Victoria show how important ongoing continued dispensing is. ‘Many of our patients are finding it difficult to see their doctor and access prescriptions for the medicine they need. Being in a regional area, getting in to see your GP is difficult at the best of times,’ he told Australian Pharmacist. ‘Even though many GPs are embracing telehealth, we’ve had to use the continued dispensing provisions fairly regularly over the last few months because our patients just can’t see their doctors soon enough.’ Dickson Yan MPS, Pharmacist Owner at Capital Chemist in Bowral, NSW, said the continued dispensing arrangements had been a good thing for his regional town, beginning in March when people were reluctant to leave their homes for fear of contracting the virus. The pharmacy continues to deliver dispensed medicines without the need for customers to go outside. His pharmacy also encounters visitors who have left their prescription at home and need an emergency supply, Mr Yan told AP. He wants to see the arrangements continue for the convenience and safety of his community. But not all pharmacists have experienced a large number of requests for emergency supply through the continued dispensing arrangements. Kingsley Coulthard FPS, a rural locum in South Australia’s Yorke Peninsula, said he currently sees many more telehealth faxed and emailed prescriptions, with the added workload these bring. However, he supports the concept of continued dispensing, so people don’t miss out on getting their regular medicines. ‘Anything that ensures continuity of medication supply has to be positive,’ he told AP.
Essential medicines accessPSA National President Associate Professor Chris Freeman welcomed last week’s ‘commonsense decision’ and urged the government to make continued dispensing arrangements permanent. ‘While the extension of the continued dispensing emergency arrangements is pleasing, PSA will continue to call for emergency supply provisions of this nature to be made standard practice,’ he said. ‘It is important that patients requiring chronic therapy are supported in emergency situations and can continue to receive their medication. ‘All Australians need to be confident they can access vital medicines when faced with an emergency or disaster.’ PSA had been working with the government to support both patients and pharmacists by ensuring all Australians could access essential medicines during the pandemic, A/Prof Freeman said. ‘As frontline health professionals, it is important that pharmacists have the necessary tools to ensure they can meet the health care needs of their patients and the community in a timely manner,’ he added. An addendum to PSA’s Continued Dispensing Guidelines was published last week to provide further guidance to pharmacists supplying PBS medicines to people affected by the COVID-19 pandemic. [post_title] => Crisis support: continued dispensing arrangements extended [post_excerpt] => Temporary Continued Dispensing Emergency Measures will be extended to at least 30 September, allowing Australians to continue to access essential medicines at Pharmaceutical Benefits Scheme (PBS) prices if their prescription has run out. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => pharmacists-provide-support-in-a-crisis-with-the-extension-of-continued-dispensing [to_ping] => [pinged] => https://www.australianpharmacist.com.au/bushfire-update-and-emergency-dispensing-rulings [post_modified] => 2020-07-10 18:04:37 [post_modified_gmt] => 2020-07-10 08:04:37 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10706 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Crisis support: continued dispensing arrangements extended [title] => Crisis support: continued dispensing arrangements extended [href] => https://www.australianpharmacist.com.au/pharmacists-provide-support-in-a-crisis-with-the-extension-of-continued-dispensing/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 9847 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10694 [post_author] => 23 [post_date] => 2020-07-08 11:13:06 [post_date_gmt] => 2020-07-08 01:13:06 [post_content] => Victorian pharmacists are providing methadone and medicines to people in lockdown and dealing with challenges due to the Victoria–New South Wales border closure, as residents in greater Melbourne and the Mitchell Shire prepare for the reintroduction of Stage 3 restrictions for six weeks from midnight tonight (8 July). It follows the government imposing Stay at Home orders on residents in 36 suburbs across 10 postcodes last week, and putting nine public housing sites in Flemington and North Melbourne in lockdown. Pharmacists are responding to the crisis in a number of ways: reassuring panicked and confused patients, conducting pharmacy services with minimal patient contact, arranging medicine deliveries, liaising with the Department of Health and Human Services Victoria (DHHS) and keeping up with rapidly changing regulations.
|COVID-19 in Victoria key points:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10656 [post_author] => 235 [post_date] => 2020-07-01 14:58:45 [post_date_gmt] => 2020-07-01 04:58:45 [post_content] => Nearly all Australian pharmacies are now registered for the My Health Record, following an increase in the use of technology brought about by the COVID-19 pandemic.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10538 [post_author] => 1092 [post_date] => 2020-06-22 08:30:16 [post_date_gmt] => 2020-06-21 22:30:16 [post_content] => [vc_row][vc_column width="2/3"][vc_column_text]When Paul Karason died of a heart attack in 2013, age 62, few noticed. But he had achieved global infamy in 2008 when he appeared on the US morning TV show Today.
The uglyWhy? Mr Karason was blue, literally blue. Persuaded of the healing powers of colloidal silver – minute silver particles suspended in a liquid – Mr Karason concocted and consumed his own brew of water and silver nanoparticles. After several years, he developed an irreversible condition called argyria, a blue-grey discolouration of the skin.1,2 Because of his daily dosing, the silver particles accumulated, ionised in his stomach and were transported to the skin. There they reacted with sunlight, causing the blue discolouration.2 Mr Karason was not alone in his misbelief. Celebrities such as Gwyneth Paltrow espoused alleged health benefits from ingesting colloidal silver. The supposed benefits range from boosting the immune system to treating cancer, HIV/AIDS, shingles, herpes, eye ailments and prostatitis.1,3 However, no rigorous studies supporting these claims exist.3
The badWorse, as Mayo Clinic physician and researcher Dr Brent Bauer notes: ‘Excessive doses of colloidal silver can cause possibly irreversible serious health problems, including kidney damage and neurological problems such as seizures’. Heavy ingestion can also cause bone marrow suppression, hepatotoxicity and acute tubular necrosis. Colloidal silver products also interact with some medicines.2,3 Little wonder, then, that in 1999 the US Food and Drug Administration ruled that products containing colloidal silver ingredients or silver salts were neither safe nor effective.4 Similarly, in 2002 the Therapeutic Goods Administration (TGA) concluded: ‘There are no colloidal silver products approved for supply as medicines in Australia.’5 Both the TGA and the US Health Department’s National Center for Complementary and Integrative Health note that while unsupported by evidence, products marketed as ‘dietary supplements’ are available online.4-6
The goodSilver was once widely used. In AD 78, Pliny the Elder reported that slag from smelting silver ‘has healing properties as an ingredient in plasters’. According to Herodotus, Cyrus the Great – king of Persia from 550 BC to 529 BC – stayed healthy by drinking only boiled water stored in silver flagons. During the Middle Ages, monks popularised the use of silver nitrate, a salt formed by reacting silver with nitric acid, to treat ulcers and burns.1,7 As early advocates observed, silver does have antiseptic properties. Until the advent of antibiotics, it was used topically with variable success.8 The exact mechanism by which silver attacks bacterial cells is unclear. Scientists suggest the key is the biocidal effect of heavy metals such as silver. They kill microbes by binding to proteins, thus inhibiting enzymatic activity.9 Today, the biocidal effect is being harnessed anew. Although thorough testing and standardisation of products has not yet been undertaken, silver-containing coatings on medical devices and fabrics can have clinical uses.9 Among these uses are: wound care, bone prostheses, reconstructive orthopaedic surgery, cardiac devices, catheters, surgical appliances and, of relevance to COVID-19, ventilators.10 References
[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row] [post_title] => The good, the bad and the ugly: Colloidal silver and its chequered history [post_excerpt] => Celebrities such as Gwyneth Paltrow espoused alleged health benefits from ingesting colloidal silver. However, no rigorous studies supporting these claims exist. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => colloidal-silver-chequered-history [to_ping] => [pinged] => [post_modified] => 2020-06-29 21:51:35 [post_modified_gmt] => 2020-06-29 11:51:35 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10538 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => The good, the bad and the ugly: Colloidal silver and its chequered history [title] => The good, the bad and the ugly: Colloidal silver and its chequered history [href] => https://www.australianpharmacist.com.au/colloidal-silver-chequered-history/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 10539 )
- Pickett, M. Colloidal silver turns you blue—but can it save your life? Wired 2017 Feb 10. At: www.wired.com/story/does-colloidal-silver-work/
- Bracy NA, Zipursky JK, Juurlink DN. Argyria caused by chronic ingestion of silver. CMAJ 2018;190(5):E139. At: www.cmaj.ca/content/190/5/E139.long
- Bauer BA. My dad takes colloidal silver for his health, but is it safe? Mayo Clinic. 2017. At: www.mayoclinic.org/healthy-lifestyle/consumer-health/expert-answers/colloidal-silver/faq-20058061
- US Food and Drug Administration. Over-the-counter drug products containing colloidal silver ingredients or silver salts. Fed Regist 1999;64(158):44653–8. At: www.ncbi.nlm.nih.gov/pubmed/10558603
- Therapeutic Goods Administration. Change to excluded goods order: Colloidal silver products. 19 December 2002. At: www.tga.gov.au/sites/default/files/foi-156-1213-25.pdf
- National Institutes of Health. National Center for Complementary and Integrative Health. Colloidal silver. At: www.nccih.nih.gov/health/colloidal-silver
- Alexander JW. History of the medical use of silver. Surg Infect 2009;10(3):289–92. At: www.liebertpub.com/doi/10.1089/sur.2008.9941
- Chopra I. The increasing use of silver-based products as antimicrobial agents: a useful development or a cause for concern? J Antimicrob Chemother 2007;59(4):587–90. At: pubmed.ncbi.nlm.nih.gov/17307768/
- Lumen Learning. Using Chemicals to Control Microorganisms. At: courses.lumenlearning.com/microbiology/chapter/using-chemicals-to-control-microorganisms/
- Lansdown A. Silver in health care: antimicrobial effect and safety in use. In: Biofunctional textiles and the skin. Hipler UC, Elsner P (eds). Curr Probl Dermatol Basel, Karger 2006;33:17–34. At: www.karger.com/Article/Abstract/93928
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10519 [post_author] => 36 [post_date] => 2020-06-22 06:57:48 [post_date_gmt] => 2020-06-21 20:57:48 [post_content] => [vc_row][vc_column width="2/3"][vc_column_text]There are 344 registered interventional clinical trials under way for the treatment and prevention of COVID-19. The WHO is looking at four of them. At the time of press on 22 May, there are more than 5.2 million confirmed cases of novel coronavirus disease 2019 (COVID-19) around the world.1 COVID-19 is caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2).2 Approximately 80% of infections with clinical presentations will cause mild respiratory illness and people will recover without hospital care.3 Another 15% will present with moderate to severe pneumonia requiring hospital care, and 5% will need intensive care due to critical illness.3 At this stage, it is not known how many people are asymptomatic and infected. Additionally, it is unclear if succumbing to COVID-19 is a result of the virus itself or the innate immune response.4 Given the global emergency and the speed at which the virus has spread, drug repurposing has obvious advantages, particularly given the amount of time usually required to take a molecule from drug discovery to regulatory approval. Some of these agents have received more media interest than others, e.g. hydroxychloroquine (Plaquenil), following social media tweets by people such as US President Donald Trump. This led to excessive attempts to acquire the medicine, resulting in the introduction of restrictions to ensure supply only to those with a therapeutic need (e.g. rheumatoid arthritis, lupus). While numerous therapies are being tested all around the world, there are no pharmacological agents approved for either the treatment or prevention of COVID-19. In Australia, the consensus guidelines state: ‘For patients with COVID-19, only administer antiviral medications or other disease-modifying treatments in the context of clinical trials with appropriate ethical approval.’2 A recent review looked at the registered interventional clinical trials for the treatment and prevention of COVID-19.5 As of 20 March 2020, 344 studies were registered, of which 100 involved the use of traditional Chinese medicine, e.g. herbal medicines and acupuncture. The remainder include5:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10477 [post_author] => 23 [post_date] => 2020-06-17 11:13:30 [post_date_gmt] => 2020-06-17 01:13:30 [post_content] => The offspring of mothers exposed to extreme stress, undernutrition or infectious diseases during pregnancy are at heightened risk of psychosis, studies suggest.1
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10393 [post_author] => 23 [post_date] => 2020-06-03 15:47:17 [post_date_gmt] => 2020-06-03 05:47:17 [post_content] => Changes to regulations on opioid supply in Australia came into effect this week, with new Pharmaceutical Benefits Scheme listings resulting in smaller quantities and restrictions around opioid prescribing for pain treatment.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10344 [post_author] => 23 [post_date] => 2020-05-27 12:18:46 [post_date_gmt] => 2020-05-27 02:18:46 [post_content] => For people with food allergies, medicines meant to benefit health can in fact present a risk due to food products used as inactive (excipient) ingredients.
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Penny, a pharmacist, is appointed and responsible for cold chain management in the pharmacy where she works. On a Saturday evening, Penny receives an alert to her mobile phone indicating there has been a cold chain breach. Penny was about to go out to dinner with her friends; however, she knows that timely management of a cold chain breach is vital for optimising vaccine and temperature-sensitive medicine viability and reducing the cost of replacing stock.
Penny informs her friends that she will be late for dinner and immediately visits the pharmacy. On arrival, the purpose-built dispensary refrigerator alarm is sounding loudly. Penny can see that the refrigerator door has been inadvertently left open. Penny closes the door. Penny then follows the pharmacy’s cold chain breach protocol. Information about the duration of the breach period was downloaded from the data logger, the minimum and maximum temperatures during the breach were also recorded. All stock was isolated and clearly marked ‘Do not use’, and kept refrigerated between +2 °C and +8 °C.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards addressed (2016): 11.1, 1.3, 2.3, 2.4, 3.2
Pharmacists play a vital role in the distribution, dispensing and administration of life saving vaccines. A vaccine is a fragile, biological product that may contain live attenuated, modified, toxoid or killed microorganisms, which when administered into the body (vaccination), provides immunity to a disease. For a vaccine to be effective, it needs to be stored between +2 and +8 degrees Celsius (°C) from the time of manufacture to the point of administration.1 The system of transporting and storing vaccines within this temperature range is known as the ‘vaccine cold chain’.2
Ensuring vaccines and temperature-sensitive medicines are not exposed to temperatures outside this range is known as ‘cold chain management’. When a vaccine is exposed to a temperature outside 2–8 °C it is known as a ‘temperature excursion’ or a ‘cold chain breach’.2 All individuals who handle vaccines are responsible for cold chain management. It is recognised as a key responsibility for the pharmacist or nominated person.
While between 2–8 °C is the temperature range appropriate for vaccine storage, the recommendation for pharmacists and immunisation providers is to ‘Strive for 5’.2 This refers to storing vaccines at 5 °C, the optimal temperature for vaccines and the midpoint between 2–8 °C. National guidelines state that it is acceptable for vaccines to be exposed to temperatures of up to +12 °C for no longer than 15 minutes at a time due to a known cause (e.g. while restocking the refrigerator); any temperature deviations outside of this need to be reported.2
The stability of different vaccines varies considerably, however all vaccines slowly lose their potency and become inactive over time. For this reason, it is imperative that the expiry date for every vaccine is checked prior to dispensing and/or administration.1 When a vaccine is exposed to temperatures outside the cold chain, this loss of potency is accelerated. In general, most vaccines lose a degree of potency every time they are exposed to temperatures outside the cold chain. That is, there is an accumulation of potency loss.3 Some vaccines are also light sensitive. Once lost, potency cannot be restored.4
Research shows that health professionals have a good understanding that exposing vaccines to heat (>+8 °C) reduces immunogenicity, however further education on the risks of vaccine exposure to freezing temperatures (0 °C or below) is required.5 In Australia freezing of vaccines is the most frequent reason for loss of vaccine potency.2 One review found that in developed countries 33% of vaccines were exposed to freezing temperatures during the cold chain.5
It is necessary to monitor and record the temperature of vaccines throughout the cold chain. Continual temperature monitoring identifies temperature excursions and thereby loss of vaccine potency. In short, it helps ensure that immunogenic vaccines are administered by the end user. Temperature monitoring also identifies problems with equipment and procedures, which in turn can be fixed to optimise cold chain management.⁶
Vaccines arriving at the pharmacy must be immediately checked, documented and stored in the purpose-built refrigerator.
Before accepting a vaccine delivery, a pharmacist or nominated person should immediately check the cold chain monitor (CCM), a device used to monitor vaccine temperatures during transport.2 Cold chain monitors have indicators that warn if the temperature has deviated from the allowable temperature range (+2 °C to +8 °C). Examining the CCM will enable the pharmacist to determine whether the cold chain has been maintained during transit. In general, CCMs are for single use only. The vaccine delivery should be checked for signs of physical damage (wet, soggy packaging). However, research shows that identifying vaccines exposed to freezing is not easily determinable by sight.
Always check expiry dates while reconciling vaccine stock. Inform the wholesaler of expired or short-dated stock. Once checked, store the vaccines immediately in the purpose-built refrigerator. Record the CCM check on the minimum/maximum temperature chart.
Pharmacies are required to have appropriate vaccine storage and monitoring equipment to promote optimal cold chain management. Equipment needs to be set up correctly and maintained appropriately. This prevents individuals being dispensed and/or administered a compromised vaccine. It also reduces both the direct (e.g. financial) and indirect (e.g. loss of consumer confidence) costs associated with revaccination.
Setting up correctly and maintaining the purpose-built vaccine refrigerator
It is a requirement for pharmacies to use a purpose-built vaccine refrigerator (PBVR) to store vaccines (also known as purpose-built dispensary refrigerator).7 Purpose-built refrigerators are designed and constructed specifically for the storage of vaccines and temperature sensitive therapeutic medicines (e.g. insulins). They provide a stable, uniform and controlled environment that maintains the temperature between +2 °C to +8 °C.
Purpose-built vaccine refrigerator positioning
To promote optimal refrigeration, the vaccine refrigerator should be appropriately positioned. The following should be adhered to:
Storing and selecting vaccines and other temperature-sensitive medicines
Vaccines should be appropriately stored within the purpose-built refrigerator. Vaccines should be stored in their original packaging, in open-weave plastic baskets. Storing vaccines in their original packaging allows for easy identification and protects the vaccine from temperature fluctuations and UV and fluorescent light.8 Refrigerator shelves and plastic baskets should not be overfilled. There should be space between baskets to allow for air circulation.
Dispensary refrigerators should never be used to store food or other products. Most purpose-built refrigerators have a glass door, enabling easy detection of stock prior to opening. This reduces the time that the fridge door needs to be open to select vaccine stock. When a purpose-built refrigerator does not have a glass door, a guide to where specific vaccines and other medicines are stored in the refrigerator should be located outside.
Monitoring and recording vaccine refrigerator temperatures
All purpose-built refrigerators must be monitored by both a:
Data loggers are small portable electronic devices that continually measure the refrigerator temperature and keep a record of the results. Some purpose-built refrigerators have an in-built data logger, others can be retrofitted with a data logger; most will require the use of a portable digital data logger. Portable data loggers are always battery operated. This enables continuous temperature monitoring irrespective of whether the refrigerator is operating (e.g. power cord removed, power switched off, power outage). Batteries for the data logger should be replaced according to the manufacturer’s recommendation (usually between every 6–12 months). Portable data loggers should be positioned close to vaccine stock (e.g. on the middle shelf of the refrigerator in an empty vaccine box and not against the refrigerator walls).2 This enables a more accurate reading of the temperature-sensitive medicines and vaccines.
Both in-built and portable data loggers should be set to measure and record temperatures at least every 5 minutes. The data logger should be downloaded, and results reviewed each week by the pharmacist or nominated person responsible for cold chain management. This helps to identify if there has been a cold chain breach and, if so, the duration of the breach. National guidelines state that it is acceptable for vaccines to be exposed to temperatures of up to +12 °C for no longer than 15 minutes at a time for a known reason. For example, while stocktaking or restocking the refrigerator. Pharmacists should still record such fluctuations.2 In the event of a cold chain breach, the pharmacist should follow the Cold Chain Breach Protocol (see Table 1). The downloaded information from the data logger must be backed up and stored securely for a minimum of 10 years.
Some purpose-built refrigerators have an in-built thermometer with a digital display of the current internal temperature and records of the minimum and maximum readings. If a refrigerator does not have an in-built thermometer, a portable minimum/maximum thermometer must be used.9 Irrespective of continuous data logging the pharmacist must manually record the refrigerator’s current, minimum and maximum temperatures twice daily (generally first thing in the morning and late in the afternoon). The minimum/maximum thermometer should be reset after each manual reading. Pharmacists may use the Strive for 5 minimum/maximum vaccine refrigerator temperature chart9 to record and plot data (www.health.gov.au/sites/default/files/strive-for-5-vaccine-fridge-temperature-chart-poster.pdf)
In the event of a cold chain breach, the pharmacist should follow the Cold Chain Breach Protocol (see Table 1).
Most refrigerators will also have a localised alarm system, which will sound when there is a temperature excursion (e.g. door is left open). Depending on the quality and design, some have the capacity to notify the pharmacist (responsible for cold chain management) remotely when there has been a cold chain breach (e.g. via a notification to a mobile phone). This function enables the pharmacist to respond to the breach in a timely manner.
TABLE 1 – Cold chain breach protocol
Vaccine storage self-audits
According to current national guidelines, all immunisation service providers, including pharmacists, are required to carry out an annual vaccine storage self-audit. A checklist to perform this annual self-audit can be found at www.health.gov.au/sites/default/files/national-vaccine-storage-guidelines-strive-for-5_0.pdf
As part of the self-audit, the battery-operated portable min/max thermometer should be calibrated at least yearly or according to the manufacturer’s recommendations (if more often). To check the accuracy of the min/max thermometer, external calibration by the supplier or a slush test can be performed.2[table id=12 /]
Cold chain breach
There are both avoidable and unforeseen unavoidable reasons for a cold chain breach. Avoidable reasons for a cold chain breach include:
Unavoidable reasons include:
Management of cold chain breaches
When a cold chain breach cannot be resolved immediately (e.g. plugging refrigerator back in, closing refrigerator door) vaccines should be transferred to a predesignated storage site (e.g. a portable insulated container). See Table 1.
BOX 1 – KEY RESOURCES
Temporary vaccine storage
When storing or transporting vaccines in a portable insulated container (e.g. cooler, vaccine cold box or carrier), it is always important to maintain and monitor the cold chain. To do this the temperature of the insulated container should be between +2 °C to +8 °C prior to packing vaccines into it. Setting up and maintaining temporary vaccine storage will be covered in the next issue of the Australian Pharmacist journal.
Advice to consumers about vaccine storage
When dispensed vaccines are not administered in the pharmacy, it is essential that consumers are advised on storage. Ideally the pharmacy would be near the GP surgery and the vaccine is picked up immediately prior to planned administration; a foil-lined fridge bag should be sufficient for vaccine transportation in this instance. If this is not possible, consumers should be advised to bring a standard cooler (e.g. Esky) with a wrapped ice or gel pack (i.e. tea towel, bubble wrap) to prevent inadvertent freezing of the vaccine. The vaccine should be transported in its original packaging in the cooler that is placed in a cool place, out of the sun.10 Minimal transit time should be emphasised and if storage at home is absolutely necessary, the following advice should be given10:
Is the vaccine still viable?
To determine if a vaccine is still viable both the time and magnitude of temperature excursions is needed. For vaccines funded via the National Immunisation Program (NIP) or state and territory government program, the pharmacist must consult the state or territory health department for further information. Most vaccines in the pharmacy setting are purchased from a wholesaler (and not funded under the NIP). To determine viability, the manufacturer for each vaccine should be contacted. In general, exposing most vaccines to >8 °C does not render a vaccine ineffective. Rather it leads to an acceleration of the natural decline in potency. The manufacturer may advise an amended expiry date for the vaccine. There is no uniformity in the natural decline across the different types and brands of vaccines, which is why individual manufacturers must be contacted for advice. Some vaccines will no longer be viable (potent) and should be discarded. Where appropriate the pharmacies’ insurance company should be consulted.
Individuals who have been dispensed a compromised vaccine should be contacted (where possible) and provided with an immunogenic vaccine replacement. Individuals who have been vaccinated with potentially compromised vaccine(s) should be revaccinated.2
Case scenario continued
As the stock exposed to the cold chain breach had been purchased from the wholesaler, and was not National Immunisation Program stock, the manufacturer for each vaccine was contacted and informed about the duration of the cold chain breach and asked about potency loss. For some vaccines the manufacturer advised that there was a new (shortened) vaccine expiry date. Where viability could not be guaranteed, the stock was discarded, and an insurance claim was made. At a staff meeting, all pharmacy staff were provided with a refresher on the importance of cold chain management.
Sharing responsibility with manufacturers, distributors and other health professionals, pharmacists have a long history in vaccine cold chain management. Pharmacists have a legal and professional obligation to ensure they dispense and, when required, administer immunogenic vaccines.
For key resources please see Box 1.
The system of transporting and storing vaccines within +2 and +8 degrees Celsius (°C) is known as the ‘vaccine cold chain’. Ensuring vaccines and temperature sensitive medicines are not exposed to temperatures outside this range is known as ‘cold chain management’.
Most vaccines lose potency when frozen, some lose potency when exposed to heat and others are sensitive to light. Once lost, vaccine potency cannot be restored.
‘Strive for 5’ refers to storing vaccines at 5 °C, the optimal temperature for vaccines and the midpoint between 2–8 °C.
Pharmacists have a legal and professional obligation to ensure they dispense and, when required, administer immunogenic vaccines. To do this they must ensure vaccine cold chain management.
All vaccine refrigerators must be purpose-built, monitored by both a digital minimum/maximum thermometer with a display (usually the in-built refrigerator display), and a continuous data logger.
Minimum and maximum refrigerator temperatures must be checked and recorded twice daily (roughly the same times each day), and the digital thermometer reset after each check.
The data logger must be downloaded and reviewed weekly by the pharmacist or nominated person responsible for cold chain management. It should also be reviewed when there is a cold chain breach.
Dr Mary Bushell BPharm (Hons), PhD, GCTLHE, AFACP, AACPA, MPS is a practising pharmacist and the Clinical Assistant Professor in Pharmacy at the University of Canberra. She has research interests in vaccinations, clinical pharmacy and evidence-based medicine. [/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row][post_title] => Cold chain management and vaccines [post_excerpt] => Ensuring vaccines and temperature-sensitive medicines are not exposed to temperatures outside this range is known as ‘cold chain management’. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => cold-chain-management-vaccines-cpd [to_ping] => [pinged] => [post_modified] => 2020-07-14 21:08:08 [post_modified_gmt] => 2020-07-14 11:08:08 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10755 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Cold chain management and vaccines [title] => Cold chain management and vaccines [href] => https://www.australianpharmacist.com.au/cold-chain-management-vaccines-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 10756 )
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Ms Tadros is a 41-year-old mother of three school-aged children. She comes to the pharmacy to pick up a prescription for her daughter. You notice dark circles under her eyes and she appears stressed. She has recently lost her job and her children are all studying from home. Her husband has taken up two extra night shifts at the local hospital. Ms Tadros is worried that she is unable to sleep properly. She tells you that she goes to bed at 11.00 pm and usually wakes between 4.00 am and 6.00 am. Furthermore, she wakes up 3–4 times per night and tosses and turns for about 20–30 minutes. On further discussion you discover that Ms Tadros looks for jobs online prior to going to sleep. What can you do to help her?
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards addressed (2016): 1.1, 1.2, 1.4, 1.5, 2.2, 2.3, 3.1, 3.3
The world is in the grip of a pandemic as a result of COVID-19.1 In the absence of a vaccine and evidence-based treatments, public health strategies (e.g. travel bans, social distancing, closure of non-essential services) have been put in place to manage transmission in an attempt to halt the disease. This has resulted in the requirement for e-services and the need to set up home offices and home learning that has been further compounded by the requirement to learn new technologies. These situations can disrupt established daily routines and affect sleep patterns resulting in acute sleep disorders such as insomnia. As pharmacies remain open, pharmacists may likely see an increase in requests for strategies to manage stress and insomnia.
Insomnia is defined as ‘difficulty getting to sleep, staying asleep or having non-restorative sleep…together with associated impairment of daytime functioning…’ Up to 33% of Australian adults find it difficult to either fall asleep or stay asleep; stress and anxiety can be a contributing factor.2,3
Whilst the exact function of sleep is not known, it is believed that sleep serves a restorative purpose by providing a physiological period of rejuvenation, facilitating memory consolidation and setting a time for the body to cell-repair.4 There is no definitive theory explaining sleep regulation. The theoretical ‘two process’ (Process S and Process C) model is widely accepted, where an interaction between the circadian rhythm (or biological clock) and sleep-wake homeostasis leads to the sleep-wake cycle.4–6
For every moment spent awake, the body’s intrinsic need to sleep is incrementally accumulated, this is known as the homeostatic drive. Therefore, the homeostatic drive is influenced by elapsed time since the last episode of adequate sleep. Some sleep scientists have postulated that the level of adenosine in the brain reflects the ‘sleep pressure’ that controls the homeostatic drive.4–6 Adenosine accumulates throughout the day (or time spent awake), at higher levels it induces sleep. Adenosine suppresses arousal and maintains sleep throughout the night.4–6 Caffeine is an adenosine receptor antagonist, hence its stimulating effect.4
The circadian clock, situated in the suprachiasmatic nucleus (SCN) in the hypothalamus, regulates the sleep wake cycle which in turn is influenced by night and day (i.e. exposure to lightness and darkness).4 Melatonin secretion from the pineal gland is regulated by night-day length as a result of information sent from light sensitive cells in the retina to the SCN.4–6 Pineal melatonin feeds back to the SCN, modulating the body’s circadian rhythm. This modulation also directs an intricate mechanism of ‘clock genes,’ transcription factors and transcription factor regulators distributed in cells of all major organs in the body which work through biochemical feedback loops to regulate cellular clock related genes.7 The SCN is known as the master clock as it is the pacemaker for circadian rhythm modulated cellular functioning.6 Besides exposure to ‘light’, well established social routines from childhood, meal times and exercise also play a role in ‘setting’ the circadian clock.8 The circadian clock regulates cycling of body temperature, blood pressure, cortisol levels, sleep patterns and other time bound patterns in almost all physiological processes in the body. These cycles offer a period of rest and rejuvenation to various organ systems in the body.4
The circadian and homeostatic processes (referred to as Process C and Process S) need to occur in alignment for good quality sleep; misalignment of these two processes leads to sleep loss.5
Sleep and the circadian rhythm may also mediate innate and adaptive immune responses, in addition to its restorative function (e.g. physiological processes and memory consolidation).
Experimental studies have demonstrated the effect of the circadian clock on the immune spectrum, from leukocyte movement and chemotaxis to T cell differentiation, cytokine release and antibody development.7
Short habitual sleep (<6 hours per night) in humans is correlated with a higher vulnerability to viral infections and reduced antibody titres after vaccination.9–11 Sleep deprivation can also result in the increased production of pro-inflammatory cytokines,12–14 and in experimental studies, sleep loss can disrupt immune effector cell function (e.g. natural killer cell activity).15,16 There is a correlation between disruption in sleep or circadian function and increased susceptibility to infections.7 Although social distancing, contact tracing, testing and quarantine are mechanisms to combat COVID-19, maintaining healthy sleep routines and minimising stress may offer additional protection.
Many changes to well-established routines (e.g. working and schooling from home, extended or altered shifts at the pharmacy, social interaction, exercise and financial changes) have occurred as a result of COVID-19, disrupting Process C and Process S and therefore sleep.8
Additionally, those living in confined spaces may also have limited exposure to light (especially morning light) which may de-synchronise the master clock and linked circadian rhythms.8 There may be age and gender related vulnerabilities. For example, in Wuhan after the COVID-19 outbreak, females reported higher levels of post-traumatic stress disorder (PTSD), and those younger than 35 who were exposed to more than 3 hours of media coverage on COVID-19 similarly reported higher levels of anxiety.17 Clearly maintaining a healthy routine, regularised sleep-wake cycles and building sleep pressure (sleep debt) during the day (e.g. exercise routines, limiting naps) would be important considerations for sleep quality.
Research during the Wuhan COVID-19 outbreak highlighted the importance of sleep: better sleep quality was associated with a lower incidence of PTSD.17 Another study comparing residents from Hubei province versus non-endemic areas in China found that in 2 weeks in February as COVID-19 raged, anxiety levels progressively improved but sleep quality did not.18
To safely function, a certain amount of sleep is required. Studies of large populations have shown a U-shaped relationship between mortality/morbidity and sleep duration (i.e. short sleep [too little] or long sleep [too much] is associated with increased mortality).19 The recommended sleep duration associated with the lowest adverse outcome is 7–8 hours.19
Even in the pre-COVID-19 era, sleep problems in Australia have been quite prevalent with about 7.4 million Australians reportedly not obtaining the recommended amount of sleep.20 In 2016–17, it was estimated that inadequate sleep cost the Australian economy $26.2 billion.20 Accumulated sleep loss (regularly getting insufficient sleep) has a significant impact on both physical and mental health. For example, sleep loss has been linked to an increased risk of developing conditions such as obesity, diabetes, cardiovascular disease, cancer, depression, substance abuse and dementia.21
Insomnia is generally considered chronic/persistent if the symptoms occur >3 nights a week for >3 months a year.22 In older terminology, the classification of primary versus secondary insomnia was used where the latter implied insomnia resulting secondarily from comorbid conditions. These terms are now obsolete. Insomnia is now considered a disorder in its own right.22
Insomnia is often trivialised, many consumers seek self-help, home remedies and over-the-counter medicines from pharmacies.23-25 The Sleep Health Foundation offers advice on how to manage sleep and stress in the COVID-19 era (see Table 1).16
First line management is cognitive behavioural therapy for insomnia (CBTI) – see Table 1). However, treatment success can be time dependent, therefore pharmacological management may be required in the interim (see Box 1).26
Benzodiazepines and z-drugs are sedative hypnotics that modulate the inhibitory effect of GABA at GABA-A receptors; they should not be used for more than 5–10 days.26 Benzodiazepines are useful in both sleep onset and sleep maintenance, however they are associated with serious adverse effects (e.g. falls, dependence, physical and cognitive impairment) with some evidence of poor pneumonia outcomes and mortality.27 Zolpidem immediate release can be specifically useful where sleep onset is an issue. However, due to adverse effects (e.g. increased likelihood of dangerous behaviour), due diligence is required.28
Suvorexant is a dual orexin antagonist (OX1 and OX2 receptors) with a better safety profile than benzodiazepines and z-drugs. Suvorexant is relatively new to the Australian market and may be helpful for sleep maintenance rather than sleep onset issues.26
Melatonin is an endogenous hormone that helps regulate the circadian rhythm. In Australia, a sustained release formulation is indicated for the short-term treatment of insomnia in those 55 years and over.29
BOX 1 – Medicines used for insomnia
References: ltena E et al 8, Liu N et al17
Over-the-counter sedating antihistamines cause sedation by antagonism of centrally active H1 receptors; due to risk of tolerance, they are indicated for short-term use in insomnia.24,28
Complementary and alternative therapies in insomnia are not evidence based, however they can be used if unacceptable adverse outcomes can be excluded (i.e. drug-drug and drug-disease state interactions) as benefits may result from the placebo effect.26 Regular review is required to ensure optimal patient outcomes.
Sleep maintenance appears to be more prominent than sleep onset in cases of insomnia.30 Pharmacists can actively screen for and help manage insomnia, ensuring evidence-based and quality use of medicines.31 Furthermore, research suggests that pharmacists can provide behavioural treatments for insomnia.32
Case scenario continued
Ms Tadros has several issues:
You reassure Ms Tadros and tell her that with some proactive sleep health behaviours, her sleep pattern may normalise. You explain that cognitive behavioural therapy may help and suggest that she may also benefit from short term pharmacotherapy. You encourage her to keep a sleep diary and to come back to the pharmacy next week.
Insomnia, stress and anxiety have resulted from COVID-19; mental health issues and sleep disorders may ensue. Community pharmacists, who are at the forefront of patient interaction, can identify insomnia and provide adequate advice, management strategies and pharmacotherapy when required.
BANDANA SAINI BPharm, MPharm, MBA, PhD, GradCert Ed Studies, GradCert Imple Sci, MPS is Professor and Academic Lead (Education) at Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row] [post_title] => Insomnia and stress in the era of COVID-19 [post_excerpt] => As pharmacies remain open through the COVID-19 pandemic, pharmacists may likely see an increase in requests for strategies to manage stress and insomnia. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => insomnia-stress-covid-19-cpd [to_ping] => [pinged] => [post_modified] => 2020-07-08 20:32:16 [post_modified_gmt] => 2020-07-08 10:32:16 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10684 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Insomnia and stress in the era of COVID-19 [title] => Insomnia and stress in the era of COVID-19 [href] => https://www.australianpharmacist.com.au/insomnia-stress-covid-19-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 10689 )
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Case scenarioLachlan, a 28-year old man with type 1 diabetes, presents to the pharmacy to speak with a pharmacist. He has a headache, sore throat, dry cough, fever (39.5 °C) and muscle pain. The symptoms started 20 hours ago. Lachlan was anticipating getting the flu vaccine. However, he said he had not got around to it yet. As a young father, Lachlan is particularly concerned about spreading the viral infection to his family. He asks if it is too late to have the influenza vaccine.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Influenza or ‘the flu’ is generally a self-limiting acute viral illness. However, it can also be severe and fatal. In 2019, there were 308,847 laboratory confirmed cases of influenza in Australia.1 Many more cases went unconfirmed. A total of 3,915 individuals were hospitalised and 812 died from influenza.1 The World Health Organization (WHO) estimates globally, that annual epidemics of influenza cause approximately 1 billion infections, 3–5 million severe infections and between 290,000 and 650,000 deaths.2 Prevention and control of suspected and diagnosed influenza are key to reducing its disease burden.
Influenza is an acute, highly contagious, viral infection of the upper (and sometimes lower) respiratory tract that affects individuals of all ages and backgrounds. It is primarily spread by large respiratory droplets (>5 microns) and aerosols, produced when an infected individual coughs, sneezes or talks, that are subsequently inhaled by others. It can also be spread by self-contamination through hand-to-nose, hand-to-eye, hand-to-mouth transmission after touching virus-laden fomites (door handles, toys) or the skin or hands of another person.
It has an average incubation period of between 0.5 and 2 days. Signs and symptoms present abruptly and may include fever (≥37.8 °C)/chills, sore throat, non-productive cough, malaise, headache, myalgia, arthralgia and loss of appetite.3 Some individuals will experience nasal rhinitis and sneezing. Most individuals have symptom resolution within 3–7 days of onset, although a dry cough and/or general malaise may continue for up to 2 weeks.
There are many overlapping symptoms between the common cold, influenza and COVID-19. Table 1 (previous page) outlines the similarities and differences between the three.
Complications of influenza include primary viral and secondary bacterial pneumonia, bacterial coinfection, myocarditis, myelitis, pericarditis, croup, bronchitis, myositis, sinus infection, otitis media, encephalopathy, encephalitis, Reye’s syndrome and death.4 Influenza can also exacerbate existing chronic disease (e.g. asthma, COPD, diabetes, congestive heart failure). Complications of influenza are more frequently seen in individuals who are immunosuppressed, have a chronic disease, residents of aged care facilities, Indigenous, elderly, very young, pregnant, or morbidly obese.5 See Table 2.
Influenza viruses are single stranded RNA-containing viruses that belong to the family Orthomyxoviridae. There are three types of influenza virus that infect humans – types A, B, C. Influenza A and B are by far the most common and responsible for seasonal epidemics. From January through to October 2019, the World Health Organization Collaborating Centre for Reference and Research on Influenza (WHOCC) isolated and characterised 3,949 influenza viruses globally.1 Of this, 88% were influenza A: 60% influenza A, (H3N2) and 28% influenza A (H1N1)pdm09 and 12% were influenza B (11% influenza B Victoria lineage, 1% influenza B Yamagata lineage). During the same time period in Australia, 76.9% of laboratory confirmed influenza cases were influenza A and 22.8% were influenza B.1 While influenza B is responsible for a considerable number of hospital admissions and can be life-threatening, it is not known to cause pandemics. In terms of genetic and antigenic properties, influenza B viruses generally change more slowly (see antigenic drift and shift below).
When viewing influenza A and B viruses via an electron microscope, they are nearly indistinguishable. In both A and B the virus particle (virion) has a spherical or filamentous shape and the virus genome is made up of eight negative single-stranded RNA segments. Once enclosed in a host cell-derived lipid membrane, influenza A and B are studded with haemagglutinin (HA) and neuraminidase (NA) surface proteins.6
Haemagglutinin enables the virus to bind to the sialic acid (SA) receptor on host cells. Once bound, the virus can penetrate inside the host cell by membrane fusion and subsequently become infected. To be virulent, the virus must leave the infected host cell and go on to infect another cell. To do this, the neuraminidase enzyme acts to cleave (or cut) sialic acid from the haemagglutinin molecule attached to the surface of the influenza virus, thereby assisting release of the virus from the host cell. The neuraminidase enzyme is the target for neuraminidase inhibitors (antiviral drugs), including oseltamivir and zanamivir.7
Influenza A, but not influenza B, has matrix (M2) ion channels that traverse the membrane. Inside the lipid membrane, encoded by the virion, are three viral RNA polymerase subunits (PA and PB1, PB2) and the nucleoprotein (NP).
Influenza A viruses can infect a range of mammalian (including human) and avian species. Influenza B virus is categorised based on lineage and spreads almost exclusively in humans (and seals).8
Influenza viruses have a standard nomenclature, i.e. there is an internationally accepted convention for naming influenza viruses.9
Naming involves the:
People at high risk for developing serious influenza-related complications
Other people at high risk from influenza:
Additional details are provided in online edition of The Australian Immunisation Handbook. immunisationhandbook.health.gov.au (refer to Additional resources for primary medical care/vaccination providers).30
Influenza viruses change in two notable ways, antigenic drift and antigenic shift. Antigenic drift is a gradual process which occurs in all influenza viruses and is due to frequent point mutations when the RNA virus replicates. Eventually the mutations accumulate in multiple antigenic sites (e.g. HA or NA) and the virus is no longer recognisable to antibodies that were generated to the parental virus. Without the protection from the antibodies the host once again becomes susceptible to infection by the ‘drifted’ influenza strain. Influenza B viruses change via the more gradual process of antigenic drift; they are not known to cause pandemics.6
In contrast, antigenic shift occurs in influenza A viruses only when there is a major change in the H or N surface protein. It may be a result of genetic reassortment (when influenza viruses swap gene segments). This genetic reassortment can occur when one host (e.g. a pig) is infected with two different influenza viruses. The mixing of the viruses may encode completely novel antigenic proteins (HA and/or NA), to which the human population has no immunity. A pandemic occurs when there is a novel influenza virus (no existing immunity), which can be transmitted in immunologically naive humans. There have been seven antigenic shifts (reassortments) in influenza A virus since 1899 causing five pandemics.9 Pandemics can cause widespread morbidity and mortality across international borders. Influenza pandemics have resulted in millions of influenza-related deaths. The influenza pandemic of 1918, also known as the ‘Spanish flu’, was responsible for approximately 50 million deaths globally.9 The biology and history of influenza A viruses informs us that future pandemics are unavoidable.
Vaccination remains the best protection against influenza. Nationally, pharmacists play a critical role in increasing vaccination uptake and administering vaccinations, particularly in healthy young and middle-aged adults.10 Influenza viruses are rapidly and continuously evolving. This is the rationale behind changing the influenza vaccine composition each year. Vaccination is indicated annually for all individuals aged >6 months.
To provide the greatest protection, seasonal vaccinations should contain viruses that ‘match’ or are antigenically like those currently circulating. Vaccine efficacy is yet to be determined for last year’s influenza season. It will be calculated through observational studies (cohort and case control studies). However, preliminary 2019 data comparing 1,502 circulating influenza viruses to the corresponding vaccine component revealed ‘good’ vaccine effectiveness. Noting that influenza vaccine effectiveness is usually between 30–60%.11
Influenza is easily spread, mainly through respiratory droplets and aerosols, produced when infected individuals sneeze, cough or talk. The virus can also be spread by fomites (any surface that the virus has landed on) that is then touched and passed from the hands to the nose, mouth or eyes. One small study (N =26) showed that on average individuals touch their face 23 times per hour.12 One way of reducing risk of influenza infection and transmission is by thorough hand hygiene.13 Studies show that routine hand hygiene with either soap and running water or alcohol-based hand rubs (ABHR) are effective at removing influenza virus from hands.14,15 Pharmacists should counsel individuals on the importance of regular hand washing with soap and water for at least 20 seconds. When soap and water are not readily available, and hands are not visibly soiled, individuals should be advised to use a hand sanitiser (containing between 60% and 80% v/v ethanol or equivalent) to prevent influenza transmission. Alcohol-based hand rubs should cover the hands thoroughly and cleaning should take 20–30 seconds. More information can be found online at Hand Hygiene Australia at www.hha.org.au
Pharmacists should advise unwell individuals to cover coughs and sneezes, and cough into their elbow. They should also be informed to dispose of used tissues appropriately.
Social distancing measures reduce influenza transmission.16 At a public health level, social distancing strategies that may be employed in an influenza pandemic include school and work closure, working from home, voluntary isolation of cases, quarantine of contacts and cancellation of mass gatherings.
A single use face mask (or surgical mask, face shield) is a loose fitting, disposable face mask that provides a protective barrier around the wearer’s nose and mouth. They are primarily designed to trap respiratory droplets from the wearer and in theory should reduce transmission of infectious microorganisms to others. Several case-control studies identified that wearing masks reduce the incidence of respiratory viruses (OR 0.32, 0.25 to 0.40; NNT = 6, 4.54 to 8.03).17 While a systematic review states that there is little robust evidence to support the effectiveness of face masks to prevent transmission of influenza virus in the natural setting.18
Disposable respirators (e.g. P2, N95) are designed to protect the wearer from infectious aerosols. Respirators can filter out approximately 94% of particles <5 microns in size. Case-control studies have identified they reduce the risk of incidence of respiratory viruses (OR 0.09, 0.03 to 0.30; NNT = 3, 2.37 to 4.06).17
Pharmacists should advise patients to change the mask when it becomes moist, to wash their hands if they touch or dispose of a used mask and to maintain proper hand hygiene.
To date, in Australia, there are three classes of antivirals available for the treatment and prevention of influenza; the M2 ion channel inhibitors, the neuraminidase inhibitors (NAI) and a new antiviral, polymerase inhibitor, which was trialled in several Australian hospitals in 2019.
M2 ion channel inhibitors (e.g. amantadine) prevent the release of viral RNA into the host cell, by targeting viral uncoating. While M2 inhibitors have recognised antiviral activity against influenza A, greater than 95% of the isolated H1N1 and H3N2 influenza viruses are now resistant. Appropriately, this class of medicines is not currently indicated for the treatment or prevention of influenza due to high resistance which has rendered them ineffective.19
Neuraminidase inhibitors (NAI), oseltamivir (Tamiflu) and zanamivir (Relenza), are used clinically worldwide including in Australia. Both work by inhibiting the influenza virus surface protein enzyme neuraminidase (NA). Neuraminidase is a virulent factor and facilitates the release of the influenza virus from the host cell, enabling the influenza virus to go on and infect other healthy host cells. Inhibiting NA reduces the release of the recently formed virus particles from infected cells. Observational studies that included people at high risk of influenza or mortality from influenza, showed that treatment with a NAI is associated with a reduction in influenza complications, hospital admissions and deaths. However, studies of healthy, low-risk adults did not identify a risk reduction in hospitalisation or death (HR 1.03 95% CI 0.64 to 1.65).20 Studies report treatment with a NAI reduces the duration of influenza symptoms by approximately 1 day; oseltamivir 16.8 hours (95% CI 8.4 to 25.1 hrs); zanamivir 0.6 days (95% CI 0.39 to 0.81 days).20 The earlier treatment starts after symptom onset, the shorter and less severe the influenza. Common adverse effects of NAIs include nausea, vomiting and headaches.21
Oseltamivir is administered orally, and is commercially available in both capsules (30 mg, 45 mg, 75mg) and an oral liquid (6 mg/ml). For the treatment of influenza in adults and children 13 years and older, oseltamivir should be given at a dose of 75 mg twice daily for 5 days.21 Treatment is most effective when commenced within 48 hours of symptom onset. Dose reduction is required in individuals with renal impairment. Dosing in children under 13 years is according to total body weight.
For prevention of influenza (e.g. when a household contact has influenza and the individual wants to reduce their risk of getting ill), oseltamivir should be dosed within 2 days of exposure. Adults and those 13 years and over should take 75 mg once daily for 10 days. Children between 1 to 13 years are dosed according to total body weight. In the event of a community outbreak oseltamivir may be taken once daily for 6 weeks.20,22
Case scenario continued
Lachlan has suspected influenza. COVID-19 has been excluded. Individuals with diabetes (type 1, type 2, or gestational), are at high risk of influenza complications, which can result in hospitalisation and even death.
You refer Lachlan to his general practitioner as he will likely benefit from an antiviral. You counsel Lachlan to get rest (stay at home away from work and public places), drink lots of water, to take paracetamol to reduce his fever and relieve his headache and muscle pain.
To reduce spread, you point out the importance of hand hygiene, respiratory/cough etiquette and encourage the use of a face mask. Commencement of antiviral therapy is most effective when commenced early.
As there are many strains of influenza and individuals can catch the flu more than once in a season, you advise Lachlan to get the flu vaccine when he has recovered.
Zanamavir is administered via oral inhalation only. It is available commercially as a dry powder inhaler (DPI), which contains 5 mg of zanamivir inhalation powder in each pre-dispensed blister. For the treatment of influenza, within 48 hours of symptom onset, adults and children 5 years and over should inhale 2 blisters (10 mg), twice daily (approximately 12 hours apart) each day for 5 days.21 When prevention is required treatment should commence within 36 hours of exposure, and two blisters should be inhaled once daily for 10 days. Prevention can be extended up to 28 days when required (e.g. during a community outbreak).
Poor inhaler technique, results in inadequate drug delivery and therapeutic failure. Pharmacists should provide appropriate counselling (including device demonstration) on how to administer and use the DPI for all individuals prescribed zanamivir. Individuals who take a bronchodilator at the same time as zanamivir, should use the bronchodilator first, followed by the antiviral. During pregnancy zanamivir is the preferred NAI due to its low systemic bioavailability.21
Recent surveillance data has identified that oseltamivir-resistant viruses are circulating.23 Of concern, is that drug-resistant virus strains can spread to contacts. Resistance to neuraminidase inhibitors, is of concern at the public health level, as they are stockpiled and used in the prevention and treatment of pandemics.24
Baloxavir marboxil (trade name Xofluza) is a new influenza antiviral with a novel mechanism of action, that is effective at reducing the severity of both influenza A and B.25
Each influenza virus contains three polymerase subunits (PA, P1 and P2). The subunits are responsible for the replication and transcription of viral mRNA genome.26 Baloxavir targets, binds and inhibits the endonuclease function of the viral PA polymerase subunit. Binding prevents the transcription of viral mRNA and subsequent replication of the virus in the host cell. Baloxavir marboxil offers a novel mechanism of action when compared to older antivirals. None of the currently available antivirals for the treatment of influenza are listed on the Pharmaceutical Benefits Scheme.27
As the most accessible health professional, many individuals seek care and advice from pharmacists when symptomatic with influenza. Pharmacists are well placed to both recommend symptomatic treatment and refer individuals when required. Symptomatic treatment includes recommendations such as rest, drinking plenty of water and using analgesics such as paracetamol for pain. Pharmacists should encourage individuals at high risk of developing influenza-related complications (see Table 2) to see their general practitioner for an assessment and possible early antiviral treatment.
DR MARY BUSHELL BPharm (Hons), PhD, GCTLHE, AFACP, AACPA, MPS is the Clinical Assistant Professor in Pharmacy at the University of Canberra.[post_title] => Managing suspected influenza [post_excerpt] => Influenza or ‘the flu’ is generally a self-limiting acute viral illness. However, it can also be severe and fatal. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => managing-suspected-influenza-cpd [to_ping] => [pinged] => [post_modified] => 2020-06-29 21:33:38 [post_modified_gmt] => 2020-06-29 11:33:38 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10595 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Managing suspected influenza [title] => Managing suspected influenza [href] => https://www.australianpharmacist.com.au/managing-suspected-influenza-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 10596 )
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Case scenarioSteve is a 69-year-old man with T2DM who was diagnosed two years ago by his GP. He is classified as obese with a body mass index of 31; he has a past history of cardiovascular disease, peripheral neuropathy, anxiety and a 40 pack/year smoking history which he quit after being diagnosed with T2DM. His current medicines include: clopidogrel, atorvastatin, ramipril, duloxetine, metformin and insulin glargine 100 units/mL. He has no other comorbidities nor allergies. As his regular pharmacist, you know that Steve was reluctant to start on insulin glargine 100 units/mL 4 months ago even though his ‘sugars were a mess’; he has been having difficulty managing the dose to control his blood sugar levels. Since he commenced the insulin, you’ve noticed he’s become more anxious, often calling you – uncertain about his dose and what to do if he gives himself the wrong dose. You know that Lantus Solostar will no longer be available from 1 July 2020 and Steve will need to transition to an alternative option. Whilst Steve has his other medicines dispensed as generics, you’re uncertain how he’ll react to a change in brand of his insulin glargine 100 units/mL. You’re concerned he’ll potentially be given the wrong information by someone else, risking harming the relationship you have with Steve as well as further compromising his diabetes control.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Case scenario continuedYou contact Steve’s prescriber, Phil, to discuss your concerns and suggest he review Steve before the upcoming discontinuation of Lantus Solostar. You ask Phil if you can provide any assistance to help with the transition or if he has any questions about the options that are available. Phil agrees with the significance of reviewing Steve prior to July to assess his T2DM management and provide information. Phil is happy for you to discuss brand options with Steve. When Steve is next in the pharmacy, you discuss his options, informing him there is a biosimilar and second brand available. You offer Steve information about the options, including CMIs and patient information leaflets. Steve thanks you for the information and informs you he doesn’t need his insulin glargine 100 units/mL today and will make a decision later when he fills the script.
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IntroductionCommonwealth Pharmaceutical Benefits Scheme legislation enabling electronic prescribing was introduced in October 2019. It has paved the way for electronic prescriptions to become a valid and legal method for a person to receive medicines from their pharmacist while paper prescriptions will still be available. Implementation cannot occur overnight. Progress has been made in instructing the clinical software vendors of both dispensing and prescribing software of the features required to ensure conformance. Conformance requirements are set out in the Australian Digital Health Agency’s (the Agency) technical framework that includes the conformance profile.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
BOX 1 – CRITERIA FOR GENERATING AN ELECTRONIC PRESCRIPTION
BOX 2 – CRITERIA FOR COMMUNICATING AN ELECTRONIC PRESCRIPTION
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Andrew Matthews MPS is the Australian Digital Health Agency’s Director of Medicines Safety. In that role, he hopes to ensure pharmacists are fundamental to healthcare’s digital future.
With a career including hospital and community pharmacy, academia, industry executive positions and now government, what has been most personally rewarding?
Pharmacy continues to provide a broad range of opportunities as a career, beyond what would typically be recognised as ‘pharmacy’. This is reflected not only in the variety of roles I have undertaken, but in the diversity of jobs that many pharmacists now are appointed to.
Despite training for a specific vocation, pharmacy provides a solid foundation in core sciences and problem solving that is adaptable to many different roles. No matter what the role, it’s the opportunity to make a difference that is personally rewarding. This may be directly to one patient or indirectly, for example, through the impact of a national program.
How challenging was it to move into government and the digital space?
Very challenging! It’s a whole new world of terminology and acronyms and job titles. I’ve been grateful for the initial confidence in me from my employer. They reassured me that I wasn’t appointed for my technical skills in digital technology. That’s why we have a team of technical experts such as solution architects and business analysts. What I first brought to the agency was an extensive network of connections and a solid awareness of medicines safety principles and an understanding of the health system and pharmacy industry.
What are the major ways that digital healthcare can benefit medicines safety?
Digital healthcare in medicines safety is about health professionals having better medicines information for their patients and about their patients, at the point of care. We know that transitions between episodes of care are prone to error and are times of risk. The absence of complete and up-to-date medicines data can contribute to instances of care becoming high risk, resulting in medicine misadventures and unnecessary hospital re-admissions.
From a software perspective, this digital information needs to be seamlessly integrated into workflows and to provide efficiencies, not extra steps and processes.
How will My Health Record and other digital transformations change healthcare in the coming years?
As of March 2020, there were nearly 122 million medicine documents uploaded into My Health Record. The agency received good-use cases of its functionality during the bushfire disasters this year. Pharmacists were able to source medicines information of patients who had lost their scripts (and may not have been a regular customer of that pharmacy) and supported emergency medicine supply and continuity of care in a safe and legal fashion.
The first legal electronic prescription in primary care was prescribed and dispensed on 6 May 2020. For our electronic prescribing work and the introduction of electronic prescriptions, it is more about what this digital future will enable: enhanced patient convenience, reducing administrative burdens for healthcare providers and organisations, new models for prescribing and script access (e.g. through telehealth and remote script provision) and innovative apps and software functionality.
Real-time prescription monitoring is already having an impact. Tasmania has had a clinician view of clinical information and dispensing data about Schedule 8 drugs since 2011. Data shows a shift in Tasmania’s per capita death rate from prescription opioids from about 30% above the national average (from 2002–2006) to about 27% below the national average (from 2012–2016). Similar benefits have followed the implementation of SafeScript in Victoria.
And the future of digital healthcare?
I want us to overcome fragmentation of data across organisational silos. I see My Health Record becoming more intrinsic to daily pharmacist and medical practice as a source of clinical information. More broadly, I see greater interoperability across systems with consistency in standards and terminology.[post_title] => Digital first [post_excerpt] => Andrew Matthews MPS is the Australian Digital Health Agency’s Director of Medicines Safety. In that role, he hopes to ensure pharmacists are fundamental to healthcare’s digital future. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => digital-first [to_ping] => [pinged] => [post_modified] => 2020-07-08 20:32:26 [post_modified_gmt] => 2020-07-08 10:32:26 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10679 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Digital first [title] => Digital first [href] => https://www.australianpharmacist.com.au/digital-first/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 10680 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10514 [post_author] => 1925 [post_date] => 2020-06-22 05:49:58 [post_date_gmt] => 2020-06-21 19:49:58 [post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Jocelyn Watson, a PSA life member, was awarded an Order of Australia medal in January for services to Launceston and contributions to her church, horticultural society and her industry.
Where and when did you start your career in pharmacy?In 1956, I started as an apprentice in the Ballarat pharmacy. I would work during the day and study a correspondence course in the evenings. I was interested in the medicine side of the profession and wanted a career where I could help people. Although attracted to nursing, I felt pharmacy was a better fit. In those days, as now, pharmacy was a good career choice for a woman because of the flexible hours.
What attracted you to community pharmacy?When I graduated, I worked at the Royal Melbourne Hospital, which was good training for a young person. It exposed me to the full range of services a pharmacist provides. Then I went to a large pharmacy in Mildura. I preferred it because there was more contact with the community and I could see how we were helping people. When I got married, my husband and I moved to Launceston, which is where he was from. Again, pharmacy proved to be a good career choice. When we started a family, I was able to pick and choose my hours. I worked one day a week in different pharmacies whenever someone needed a locum.
What advice would you give early career pharmacists?I would advise them to take every opportunity and keep learning. It is a rewarding business. I would advise them to leave some of their learning until after they have done some practical work. That way they can apply the things they read in books to the things they see in the workplace. A hospital pharmacy is a great place to learn. Another thing I would recommend is to become a specialist in a particular area you are interested in. I was interested in wound management and dermatology and got to learn a lot about these fields. And finally, keep your eyes open. Pharmacists can learn a lot from their clients. No two are the same. I think closely monitoring patients, especially people being discharged from hospitals, is a vital role for pharmacists. You need to see how people are doing with their medicines. They usually get only a week’s supply on discharge and often there are questions or mistakes when they go to their doctors for new prescriptions. Hospital admission for medicine misuse is a significant issue.
What changes were the best in the profession between when you started and your retirement?Computerisation was unquestionably the best thing that happened to pharmacy. It made such a huge change to the way we did business day to day. The other big changes that affected me were the changes in the legal requirements. When I started, we used our judgement a lot more, especially around the dispensing of things like codeine and pseudoephedrine. There are definitely more opportunities for pharmacists these days, including new contributions in healthcare and hospitals.
What is your next project?I plan to enjoy my retirement. We want to do a bit more travel after going to the west coast of Tasmania a few months ago. We are restricted because of COVID-19, but we have plans ready to visit our grandchildren in Brisbane, Adelaide, Melbourne and in the United States. I like gardening and to keep fit at the PCYC. I’m a School for Seniors member, I do singing for pleasure and Scottish country dancing, but they have been cancelled because of the virus. I’m on the pastoral committee of the Pilgrim Uniting Church in Launceston. The other thing I like to do, which is what I always did as a pharmacist, is to stay in touch and care for people wherever I can.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row] [post_title] => Still blooming… [post_excerpt] => Jocelyn Watson, a PSA life member, was awarded an Order of Australia medal in January for services to Launceston and contributions to her church, horticultural society and her industry. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => still-blooming-psa-life-member [to_ping] => [pinged] => [post_modified] => 2020-06-29 21:41:15 [post_modified_gmt] => 2020-06-29 11:41:15 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10514 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Still blooming… [title] => Still blooming… [href] => https://www.australianpharmacist.com.au/still-blooming-psa-life-member/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 10515 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10451 [post_author] => 1532 [post_date] => 2020-06-15 21:27:50 [post_date_gmt] => 2020-06-15 11:27:50 [post_content] => Hannah Knowles MPS loves being involved in every stage of a patients’ journey, an interest well suited to her new role at a leading Brisbane hospital pharmacy.
Why did you choose pharmacy?Coming from a rural background, I saw the impact of a pharmacist on a community. Pharmacy combines my interest in science and people and the opportunity to work in a wide range of practice areas. Throughout my degree, I worked in different community pharmacies and then transitioned into hospital pharmacy in my intern year. I am currently completing my residency training at Royal Brisbane and Women’s Hospital.
Was community pharmacy a stepping stone for your current interests?Yes, working in community pharmacy has been invaluable for my development as a pharmacist. I have worked with and been mentored by some exceptional pharmacists who fostered my passion for the profession, my appreciation for the importance of developing effective relationships, and the key skill of explaining medicines in a way patients can understand.
How has COVID-19 impacted your role?This is a response that could change quite quickly! Currently, I am upskilling for partnered charting and as being the second check for medicine administration in addition to my regular work. In partnered charting, credentialled pharmacists work closely with the medical team to undertake a medication review and chart medicines for nursing staff to administer. There are COVID-19 specific research projects and trials within the department ongoing, and social distancing has meant that all meetings have moved onto a virtual platform.
What are the benefits to early career pharmacists in attending FIP and PSA conferences?Conferences are a fun and effective way to connect with other people in the profession, to discuss current issues in pharmacy and to share ideas. Through attending International Pharmaceutical Federation (FIP) conferences, I have gained a global network of pharmacy colleagues, broadened my understanding of international pharmacy practice and the importance of policy to implement programs and how it relates to my daily practice.
What are your thoughts on pharmacists’ remuneration?The role of a pharmacist is evolving quickly to meet the needs of patients and the healthcare system. The increasing complexity and accountability of pharmacy roles should be supported with training pathways and advanced practice credentials. This change in role needs to be reflected in remuneration. This is discussed in detail in the PSA Roles and Remuneration report published last year.
What’s next?I’m excited to see new roles for pharmacists emerging. For now, I will be completing my foundation residency training, attending professional conferences and working on my research skills.
A DAY IN THE LIFE of Hannah Knowles MPS, Resident Pharmacist at the Royal Brisbane and Women’s Hospital8.00 am: Organisation and planning Administration and prioritisation of workload. Set goals and expectations for intern. Attend ward MDT meeting for overview of patients, planned procedures and expected discharges. 8.30 am: Discharges Clinical review of medication, reconciliation, patient counselling, HF titration schedules, liaising with pharmacies to ensure medicine supply. One patient admitted with angioedema from ramipril was started on irbesartan and prescribed a C1 esterase inhibitor in case of reoccurrence. I organised supply of stock and liaised with her closest hospital to keep medicine for any required administration. The patient was also counselled about identifying future episodes of angioedema, what actions to take and the importance of having medicine on hand when travelling. 12.00 pm: Reviews Admission histories, clinical and medicines supply – all part of being involved in every stage of the patient journey. Work closely with the ward team, identifying missing therapy, drug interactions, giving dosing and administration advice, TDM, reviewing appropriateness of therapy, identifying and reporting adverse drug reactions. 3.00 pm: Continuing education and research An array of education opportunities available within the department and hospital. Recent topics: COVID-19, renal medicine, research skills, case based discussions and journal club. 4.00 pm: Outpatient reviews With blood tests, I identified iron deficiency in a female, aged in her 60s, with fatigue and shortness of breath and a background of heart failure (HFrEF). The patient received my recommended iron infusion. This avoided an extra visit to the heart failure clinic for medicine uptitration where the patient was then referred. IV iron replacement is shown to improve symptom burden and quality of life in patients with HFrEF.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10429 [post_author] => 235 [post_date] => 2020-06-10 12:51:25 [post_date_gmt] => 2020-06-10 02:51:25 [post_content] => You couldn’t pay 99-year-old William ‘Bill’ Lumley MPS to be a pharmacist in the ‘new normal’ world today. Set to celebrate his 100th birthday on 16 June, Mr Lumley responded with a resounding ‘no way’ when asked if he wished he could, like others called out of retirement, work during the pandemic. ‘My pharmacy training was far different from what is practiced today,’ said the Life Member, who clocks up 70 years with PSA next month. Mr Lumley joins Queenslander JSD ‘Stan’ Mellick (Member Insight AP April 2020) in the PSA centenarian stakes this year. As with Mr Mellick, much has changed since 29-year-old Bill graduated from the Victorian College of Pharmacy in 1949 and began working as a locum in Korumburra, 120 km south-east of Melbourne. Two years later he became a pharmacy owner, running his own practice in Chelsea, a Melbourne suburb, for 13 years. Following this, he served as an inspection pharmacist at the then Commonwealth Department of Health, and remained in the Melbourne office until his retirement in 1983. Like many young men of his time, Mr Lumley had lived an entire life before he began his pharmacy career. At just 17, he joined the Militia, now known as the Army Reserves. At this time he also was studying applied science at Melbourne Technical College, now RMIT. In September 1939, two days after Britain declared war on Germany following Hitler’s invasion of Poland, the Australian Government announced it would begin calling up members of the Militia to aid the war effort. Mr Lumley ultimately received his call in 1941, when he joined the Second Australian Imperial Force (AIF) and became a second lieutenant in the 2/2nd Field Regiment. The regiment was due to leave for Libya shortly afterwards, but plans changed with the bombing of Pearl Harbour in November. As a result, Mr Lumley’s regiment remained in Australia, where he spent time helping protect Western Australia. After his discharge from the AIF in 1944, Mr Lumley joined the Royal Australian Air Force (RAAF). In December of that year he was granted leave to marry Barbara Eltis, with whom he raised three children – Michael, Catherine and Ian.
Community mindedAs well as his military service, Mr Lumley devoted much of his life to the community and helping people. After leaving the RAAF he worked in his brother’s pharmacy and went on to study pharmacy at the Pharmacy College in Melbourne. Mr Lumley was the first President of the Victorian Pharmacy Students' Association and, when the Victorian association joined with its New South Wales counterpart to form the National Pharmacy Students' Association, Mr Lumley became the first president of that organisation, too. He was also active in local politics, serving as a councillor for the City of Chelsea and as the city’s Mayor in 1955–56. In the 1960s, he was the First Aid Officer and Treasurer of the Chelsea Life Saving Club and trained in first aid with the St John Ambulance Brigade. As his son Mike remembers fondly, at this time Mr Lumley had a rare 16 mm film projector, which he would use to screen first aid training films and entertain members of the Life Saving Club, family and friends. He was also President of the Peninsula Ambulance Service for 5 years until it was absorbed into the Melbourne Metropolitan Ambulance Service in 1987. ‘My father was then Vice President of the Metropolitan Ambulance Service for 2 years before he retired in 1989,’ Mike Lumley told Australian Pharmacist. ‘This was all voluntary service … He has spent much of his life serving and supporting the health of the Victorian community.’ Bill was recognised for this work in 1991, when appointed a Member of the Order of Australia (AM). Mr Lumley, who said he has been waiting for the milestone birthday to happen for a long time, attributes his longevity to ‘pure living’. ‘I have had a fairly good life,’ he said. ‘I’ve lived reasonably well. I was married to Barbara for 62 years. I will be relieved when the birthday is over and I can look forward to the next 100 years.’ With no group birthday parties possible, colleagues are invited to send letters or cards to Mr Lumley at: Village Glen Aged Care Residences, 34a Balaka St, Capel Sound. VIC. 3940. Or call him on 0403 813 575. [post_title] => Another 100 years ... says birthday boy [post_excerpt] => You couldn’t pay 99-year-old William ‘Bill’ Lumley MPS to be a pharmacist in the ‘new normal’ world today. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => another-100-years-says-birthday-boy [to_ping] => [pinged] => [post_modified] => 2020-06-10 12:58:02 [post_modified_gmt] => 2020-06-10 02:58:02 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10429 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Another 100 years … says birthday boy [title] => Another 100 years … says birthday boy [href] => https://www.australianpharmacist.com.au/another-100-years-says-birthday-boy/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 10430 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10306 [post_author] => 1925 [post_date] => 2020-05-25 09:20:16 [post_date_gmt] => 2020-05-24 23:20:16 [post_content] => Australian Pharmacist of the Year 2017 Irvine Newton OAM FPS was inaugural chairman of PSA’s Harm Minimisation Committee in Victoria, presenting patient perspectives and treating substance abuse as a health, not criminal, issue.
What started you on the road to community pharmacy?Becoming a pharmacist was one of my two preferred career options in high school (the other was to be a carpenter)! I was always attracted to what I saw as a professional role that would allow me to help people with their healthcare. I have been very fortunate to enter a profession that I came to love and would certainly take the same path if I had my time over. Later, I became a PSA Victoria board member and PSA Victorian President because I believe we have a great story to tell. One, in particular, became especially important to me – drug dependence and a pharmacy’s role in providing treatment and support for people with drug dependencies. I ran a methadone program at my pharmacies and saw firsthand how important pharmacy could be in helping these people. I became a passionate advocate for better pharmacist training in harm minimisation and drug treatment.
What insights can you bring to pharmacists after your many years in the profession?Pharmacists have a valuable role in healthcare, but our skills and knowledge are under-utilised. Some governments are starting to acknowledge and provide for expanding pharmacy services, such as providing emergency contraception, medicine management, influenza and other vaccines and some prescription medicines. But we can do so much more. Patients need us.
How has the role of the pharmacist changed until your recent retirement?Pharmacy has changed enormously since I started in the early 1970s. We have developed great professional services, discovered and developed our critical role in drug-dependence treatment and support and we now provide prescribing support in hospitals and other facilities.
What have the changing qualifications and language meant to the profession?I have never answered to being a “chemist”. My response is that I am a “pharmacist” and very proud to be one. After all, we complete a pharmacy degree, not a science degree. From a degree status point of view, we have never rated higher and I believe our graduates are the best educated they have ever been.
What do you think are your greatest achievements in harm minimisation?There was a time when my attendance at drug treatment meetings and conferences was questioned. I can gladly say that has changed. There is a genuine respect for pharmacists now, particularly in their role in the methadone/buprenorphine program. Our clients value what we do and many trust and respect pharmacists above all others. The Australian pharmacy/general practice model is world’s best practice.
What are your plans in retirement?I still have a small role in harm minimisation education, and I maintain my interest in pharmacy. Otherwise, I am enjoying my love of carpentry, building maintenance and gardening. I am not getting to the golf course at all under virus restrictions but I still plan to travel when it is all over. And, of course, I can’t wait to get back to the footy to watch my beloved Essendon Bombers. [post_title] => Minimising harm, building trust [post_excerpt] => Australian Pharmacist of the Year 2017 Irvine Newton OAM FPS was inaugural chairman of PSA’s Harm Minimisation Committee in Victoria. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => minimising-harm-building-trust [to_ping] => [pinged] => [post_modified] => 2020-05-25 15:58:36 [post_modified_gmt] => 2020-05-25 05:58:36 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10306 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Minimising harm, building trust [title] => Minimising harm, building trust [href] => https://www.australianpharmacist.com.au/minimising-harm-building-trust/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 10307 )
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.