td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10961 [post_author] => 235 [post_date] => 2020-08-05 16:10:31 [post_date_gmt] => 2020-08-05 06:10:31 [post_content] => The COVID-19 pandemic has made pharmacists even more vital for medicine safety in aged care, a royal commission has been told. PSA’s recent submission to the Royal Commission into Aged Care Quality and Safety stated that services such as residential medication management reviews (RMMRs) have been made even more valuable in the current climate. PSA provided nine recommendations to improve medicine safety in aged care, including:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10952 [post_author] => 1703 [post_date] => 2020-08-05 15:52:58 [post_date_gmt] => 2020-08-05 05:52:58 [post_content] => There is a link between the perceived quality of care provided by community pharmacists and patients’ adherence to prescribed medicine, new Australian research has shown. The study, conducted by researchers from the University of Sydney Pharmacy School and published in Patient Education and Counselling recently, found both perceived service quality and medicine adherence were rated lower among patients recruited from pharmacies with a focus on price, when compared to those with a focus on service.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10951 [post_author] => 23 [post_date] => 2020-08-05 15:43:24 [post_date_gmt] => 2020-08-05 05:43:24 [post_content] => Insufficient or unhelpful communication from authorities has been the most frustrating aspect of the COVID-19 crisis since restrictions started, according to Victorian pharmacists. Changes in systems, mixed messages around digital image prescriptions, minimal personal protection equipment (PPE) supplied to pharmacies and public panic have added to the challenges. Staff are weary, they told Australian Pharmacist this week.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10931 [post_author] => 235 [post_date] => 2020-07-29 17:01:20 [post_date_gmt] => 2020-07-29 07:01:20 [post_content] => Nearly 800 residents in Victorian residential aged care facilities (RACFs) have tested positive for COVID-19, taking the state’s total number of cases to 9,049. Aged care residents represent about 7% of all new coronavirus cases reported in Victoria since 1 July, and 5% since 1 April, Federal Health Minister Greg Hunt said today. A further nine people have died of the virus, which has taken Victoria's death toll to 92. Premier Daniel Andrews said today that seven of those nine new fatalities – two aged in their 90s, five in their 80s and one each in their 70s and 60s – were linked to private sector aged care. A total of 295 cases were identified in the previous 24 hours, down from a record of more than 500. The national death toll is now 176 with more than 5,000 active cases, mainly in Victoria and New South Wales. Two 19-year-old Queensland women who travelled to Queensland via Melbourne and Sydney have also tested positive for coronavirus prompting extensive contact tracing. Mr Andrews also revealed more than 150 residents in aged care had been, or were being, transferred to hospitals. That included 34 people from the Epping Gardens Aged Care facility in Epping in Melbourne's north – one of more than 50 RACFs whose residents have been exposed to the coronavirus. Despite the increase in RACF cases, Mr Hunt said the aged care sector was ‘immensely prepared’. ‘Prior to the Victorian outbreaks, less than half a percent of aged care facilities were affected,’ he said. ‘Importantly, there has been real progress in cooperation and protection in relation to our older Australians, and Victoria has reported progress in the numbers today.’ Mr Hunt said the aged care infections were a result of community transmission, ‘which we know affects workplaces’. ‘Offices, meatworks, school environments, hospital environments – any sector can be vulnerable,’ he said. His comments echoed those of Prime Minister Scott Morrison, who spoke yesterday about the ‘very complex’ situation. ‘You have a combination of the community transmission, which is widespread in Melbourne, finding its way into many facilities and in particular it has found its way into the aged care workforce,’ Mr Morrison said. The Federal and Victorian governments have now launched the Victorian Aged Care Response Centre to manage the pandemic across RACFs. The Australian Defence Force (ADF) has also been called in, with ADF nurses taking on shifts in facilities where staff have been forced into self-isolation. Consultant pharmacist Neil Petrie MPS told Australian Pharmacist last week he had seen a decline in the Residential Medication Management Reviews he conducts in aged care homes since the second wave of the virus.
Pharmacies to distribute masks to vulnerable VictoriansWith new restrictions requiring residents in Melbourne and the Mitchell Shire to wear a face mask when leaving home, the Victorian Government will distribute 2.1 million reusable face masks to vulnerable people within the state. Victorians who meet the eligibility criteria – such as those with chronic conditions, people living with disability and people living in public housing or who are homeless – can collect masks from a number of local government and community health services, including community pharmacies. PSA Victoria Branch President John Jackson welcomed the announcement, which he said made sense as community pharmacists were the most accessible healthcare professionals. ‘Pharmacists can make a judgement themselves on the resourcing they have available to participate,’ he said. ‘It is important that people with symptoms of COVID-19 do not present to the pharmacy to collect a mask and that they send someone else to do so.’ Following feedback from members, PSA has called on the Victorian government to ask the public not to enter a community pharmacy while displaying any symptoms of the virus or while waiting on results from a COVID-19 test. This comes after Premier Daniel Andrews reported 90 per cent of people did not self-isolate between showing symptoms and getting tested, and 53 percent did not self-isolate while awaiting test results. Mr Jackson said it was critical those who are in isolation do not present at a pharmacy. Pharmacists are encouraged to discuss contactless services – such as home delivery – for those who require essential medicines. ‘Our members have told us that people who are self-isolated are confused as to whether they are to go to a pharmacy to access health care,’ he said. ‘To stop community transmission and to protect the health of pharmacists and pharmacy staff, if members of the community have been tested or are in self-isolation – do not go out into the public.' [post_title] => COVID-19: Huge numbers of residents infected in Victorian aged care facilities [post_excerpt] => Nearly 800 residents in Victorian residential aged care facilities (RACFs) have tested positive for COVID-19, taking the state’s total number of cases to 9,049. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => huge-numbers-residents-infected-victorian-aged-care-facilities [to_ping] => [pinged] => https://www.australianpharmacist.com.au/pharmacies-demand-for-masks/ [post_modified] => 2020-08-02 19:17:20 [post_modified_gmt] => 2020-08-02 09:17:20 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10931 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => COVID-19: Huge numbers of residents infected in Victorian aged care facilities [title] => COVID-19: Huge numbers of residents infected in Victorian aged care facilities [href] => https://www.australianpharmacist.com.au/huge-numbers-residents-infected-victorian-aged-care-facilities/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 10932 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10920 [post_author] => 1703 [post_date] => 2020-07-29 11:12:11 [post_date_gmt] => 2020-07-29 01:12:11 [post_content] => There is room for improvement in the relationship between people with chronic pain and their pharmacist, new research has shown. Chronic pain is arguably Australia’s fastest growing medical condition, with more than 3.37 million people of all ages living with this invisible illness in 2020. In a survey from Chronic Pain Australia that asked people to rate how they felt their pharmacist was managing their pain, the average score was four out of 10. This is a drop from eight out of 10 in 2019. Many of the 1,200 people surveyed said they felt unheard, not believed and generally stigmatised when they visited a pharmacist or general practitioner. In fact, stigma remains one of the biggest issues facing people living with chronic pain, according to the organisation. The survey results were released to mark the start of National Pain Week, held from 27 July to 2 August. Pharmacist Jarrod McMaugh MPS, President of Chronic Pain Australia, said the results presented an opportunity for health professionals to improve their relationships with people living with pain.
Asking the right questionsCommunity pharmacist Kate Gill MPS can relate to the survey findings, having lived with neuropathic pain on her right side for the past 10 years. Through her own research, solid support and corrective surgery, Ms Gill has decreased her pain from a nine out of 10 to a three or four out of 10. She said her clinical practice had changed enormously as a result of her experience. ‘I take my perspective and experience as a person living with pain into my daily work,’ she said. ‘I know what it’s like to be questioned about my pain levels and I know what it’s like to be treated with suspicion, but I now know the benefit pharmacists can provide to assist people to manage their pain and help improve their quality of life.’ For pharmacists assisting people with chronic pain, Mr McMaugh said the main point was to treat everyone as an individual. ‘Asking how [you are] going to help this person today, and always listening, gets rid of inadvertently unhelpful questions,’ he said. These could include the well-intentioned but potentially offensive, ‘maybe you just haven’t found the right thing for your pain?’. It is also important to remember that, as a pharmacist, you are part of a wider healthcare team. ‘Pharmacists should find out what advice the patient has been given so far, because everyone’s care plan is individualised,’ Mr McMaugh said. In the case of out-of-stock medicine, or other difficulty filling a prescription, pharmacists could offer assistance to find another pharmacy that has the medicine or, for a PBS-listed medicine, offer to speak to the patient’s GP about a new script. For any pharmacist–patient discussion, Mr McMaugh cautioned against assuming a person would want to move to a private consultation room unless it was their choice, as they could feel singled out.
A challenging timeMr McMaugh said a series of recent events, including the COVID-19 pandemic and changes to regulations on opioid supply, had impacted the experiences of people with chronic pain. ‘It is no surprise to us that the challenges of the COVID-19 pandemic have put pressure on the relationships people in pain have with their pharmacist and GP,’ he said. [caption id="attachment_10922" align="alignright" width="223"] Pharmacist and President of Chronic Pain Australia Jarrod McMaugh MPS[/caption] Mr McMaugh said the opioid supply changes, which came into effect last month, had caused patients to feel they were being questioned more about pain medicines, or not getting the same access to prescribed medicines. PSA has developed a new cautionary advisory label (CAL) to help pharmacists start conversations about medicine safety with their patients, without any stigmatising language. The COVID-19 crisis had been very challenging for people with chronic pain, agreed Carol Bennett, CEO of Painaustralia. ‘There was a general sense of real anxiety during this difficult time,’ she said. Having an understanding pharmacist, who was prepared to listen and not simply offer a one-size-fits-all solution, could be life-changing to a person in chronic pain, she added. Mr McMaugh noted that during COVID-19 lockdowns, people with chronic pain were unable to access the facilities needed to manage their pain levels, such as hydrotherapy, gyms, exercise bikes and other physical therapies. On a positive note, he said telehealth consultations had proved especially useful for people with chronic pain who needed to see a doctor every month for a prescription. It could save time and, often, prevent pain triggered by travel or stress. [post_title] => Here’s how pharmacists can help patients manage chronic pain [post_excerpt] => There is room for improvement in the relationship between people with chronic pain and their pharmacist, new research has shown. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => pharmacists-can-help-patients-manage-chronic-pain [to_ping] => [pinged] => https://www.australianpharmacist.com.au/pharmacies-demand-for-masks/ [post_modified] => 2020-08-02 19:17:50 [post_modified_gmt] => 2020-08-02 09:17:50 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=10920 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Here’s how pharmacists can help patients manage chronic pain [title] => Here’s how pharmacists can help patients manage chronic pain [href] => https://www.australianpharmacist.com.au/pharmacists-can-help-patients-manage-chronic-pain/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 10921 )
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10842 [post_author] => 23 [post_date] => 2020-07-22 12:04:46 [post_date_gmt] => 2020-07-22 02:04:46 [post_content] => Australian pharmacists now have access to international consensus principles for medication management in frail older people, a group rarely included in clinical practice guidelines or research.1 Frailty is a geriatric condition associated with functional impairment and multiple organ system decline. Frail older people have greater exposure to polypharmacy and complex regimens, with increased vulnerability to medicine-related harm. Dementia, poor eyesight and limited dexterity increase the risk of harm from medicine errors.1-3 The new principles relate to clinical practice, research and education. The clinical practice principles are1:
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] => 10816 [post_author] => 131 [post_date] => 2020-07-21 09:52:49 [post_date_gmt] => 2020-07-20 23:52:49 [post_content] =>
Case scenarioDorothy is a 54-year-old lady who smoked a packet of cigarettes daily for more than 30 years. She stopped smoking about 5 years ago. She has a chronic cough and complains of breathlessness when walking up hills and doing housework. There is no history of asthma. About 18 months ago, Dorothy started on tiotropium inhaler daily. Initially she only used it intermittently, but now takes it regularly as she perceives some benefit. However, she is now troubled by dyspnoea and white sputum on waking. She uses a salbutamol metered-dose inhaler without a spacer several times daily to help with increasing breathlessness with daily activities. Dorothy is requesting another salbutamol inhaler today.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
|Few symptoms||Breathless walking on ground level||Breathless on minimal exertion|
|Breathlessness on moderate exertion||Increasing limitation of daily activities||Daily activities severely curtailed|
|Little or no effect on daily activities||Recurrent chest infections||Exacerbations of increasing frequency and severity|
|Cough and sputum production||Exacerbations requiring oral corticosteroids and/or antibiotics|
|Short-acting beta2 agonist (SABA)||Salbutamol||Ventolin, Asmol||pMDI|
|Short-acting muscarinic antagonist (SAMA)||Ipratropium||Atrovent||pMDI|
|Long-acting muscarinic antagonist (LAMA)||Aclidinium||Bretaris||Genuair|
|Long-acting beta2 agonist (LABA)||Salmeterol||Serevent||Accuhaler*|
|Vilanterol#||Trelegy, Breo, Anoro||Ellipta|
|Inhaled corticosteroid (ICS)||Beclomethasone||Qvar||pMDI, Autohaler|
|Fluticasone propionate||Flixotide||pMDI, Accuhaler|
|ICS/LABA||Fluticasone propionate/ salmeterol||Seretide||pMDI, Accuhaler|
|Fluticasone + salmeterol Cipla, Salplus F, Pavtide||pMDI|
|Fluticasone propionate/ formoterol||Flutiform||pMDI|
|ICS/LAMA/LABA||Fluticasone furoate/ umeclidinium/vilanterol||Trelegy||Ellipta|
|START||Short-acting relievers (used as needed): SABA or SAMA|
|ADD||Long-acting bronchodilators: LAMA or LABA|
|Consider need for combination LAMA/LABA depending on symptomatic response|
|CONSIDER||Add ICS (Single inhaler triple therapy may be suitable)|
|STRONG SUPPORT||CONSIDER USE||AGAINST USE|
|History of hospitalisations for exacerbations of COPD 2 or more moderate exacerbations per year Blood eosinophils >300 cells/μL History of, or concomitant, asthma||1 moderate exacerbation of COPD per year Blood eosinophils 100–300 cells/μL||Repeated pneumonia events Blood eosinophils <100 cells/μL History of mycobacterial infection|
Case scenario continuedDispensing history and My Health Record show regular dispensing of tiotropium inhaler over the last 6 months, but four recordings for OTC salbutamol inhalers. You have dispensed one script for antibiotics in the last year, which Dorothy says was for a chest infection. On questioning, Dorothy says she has had her pneumococcal vaccine and gets an annual influenza vaccine at the GP. She doesn’t have a COPD Action Plan. A MedsCheck is suggested to discuss her COPD management and assess her technique for her inhalers. Dorothy’s tiotropium device technique is acceptable; however, her MDI co-ordination of actuation and inhalation is poor and she doesn’t use a spacer. On your advice, Dorothy purchases a spacer and feels more confident using her reliever. However, you further discuss that she may benefit from a check-up with her GP to better control her breathlessness, improve her exercise tolerance and generally improve her quality of life. Another goal is to reduce the risk of future exacerbations and suggest she may benefit from a combination bronchodilator. You provide a referral to her regular GP, detailing your interventions and suggesting a step-up to LAMA/LABA combination therapy. A note is made in the dispensing software to check her inhaler technique next time she is in the pharmacy.
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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.
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10925 [post_author] => 1925 [post_date] => 2020-07-29 11:26:06 [post_date_gmt] => 2020-07-29 01:26:06 [post_content] => Kurtis Gray, a final year Master of Pharmacy student at the University of Western Australia (UWA), is the 2020 PSA Mylan Pharmacy Student of the Year. Mr Gray believes his decision to study pharmacy was the best he has made. He beat a strong field from around the country to take the prestigious award this month, following in the footsteps of UWA colleague Alice Hashiguchi, who won last year. Each of the state finalists were presented with a patient via webcam who acted out a variety of symptoms. After a consultation and the opportunity to ask follow-up questions for more information, the finalists recommended a course of treatment and advice before a panel of judges. ‘It was a tough competition but a great opportunity for us to put into practice what we have learnt,’ Mr Gray said afterwards. ‘I really enjoy providing advice about medication to people who are unwell, and this competition enabled me to demonstrate this.’ The win came at a good time for Mr Gray, who is looking for an internship. But what to choose? ‘I love the clinical aspect of pharmacy, so I could see myself becoming a clinical pharmacist specialising in psychiatric medications,’ he told Australian Pharmacist. ‘Alternatively, I would love to somehow work in a community pharmacy which specialises in treating the homeless and people with mental health issues. ‘However, I could just as easily see myself being a general practice or a rural pharmacist, working with the Aboriginal Medical Services.’ Mr Gray believes he is joining the profession at the perfect time. ‘I think Australian pharmacists have been brilliant during the pandemic and have really stepped up. All the front line, essential health care workers have worked incredibly hard to facilitate effective healthcare during difficult times,’ he said. ‘I believe the work done will not be forgotten, and will make it easier for us future pharmacists to continue to expand awareness of our capabilities.’ Mr Gray hopes the recognition of pharmacists’ work will increase to the point where the term “pharmacist” is synonymous with “clinician”. ‘The hard work will make it easier for the new generation of pharmacists to continue to pioneer and expand the profession,’ he said. ‘The self-care fact cards that we can give out to patients are brilliant. When you have 10 patients all needing your time and attention, these cards are a good way to ensure that everything you say to a patient will, at the very least, make it home with them. I make a point to try and give these to as many patients as possible.’ Thomas Duong, from Monash University (VIC) took home the People’s Choice award. [caption id="attachment_10928" align="alignright" width="308"] Thomas Duong won the People’s Choice award[/caption] It was a huge opportunity and responsibility to represent Monash in such a major competition, Mr Duong said, and he is also now looking for an internship. ‘I’m interested in hospital pharmacy with its clinical dynamics,’ he said. ‘I am also interested in doing research so I may consider that pathway to higher study.’ PSA National President Associate Professor Chris Freeman congratulated both students. ‘We saw a very strong field line up this year and it is great to see such talented and passionate pharmacy students showcasing their skills and knowledge,’ he said. ‘This competition provides students with the opportunity to grow and learn with active listening, gaining patient insights and patient understanding important skills that support medicine safety and maximise patient outcomes. ‘It is heartening to see the future of our profession in good hands,’ A/Prof Freeman said, ‘and we were impressed with the overall level of knowledge from students during both the state and national finals.’ As his prize, Mr Gray will receive funding for pharmacy-specific education from Mylan. Mylan Australia Product Manager David Lai said the standard of students competing at this year’s PSOTY was impressive again. ‘It gives me great confidence to know the future of our pharmacy industry lies within the hands of these students,’ Mr Lai said. ‘They have excelled beyond my expectations.’ This year’s finalists:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10910 [post_author] => 2431 [post_date] => 2020-07-28 08:17:12 [post_date_gmt] => 2020-07-27 22:17:12 [post_content] => An enterprising intern ditched her planned diabetes consultations to master pandemic communication skills. The novel coronavirus (COVID-19) presented new challenges for Australians – among them community pharmacists. During the initial hysteria, our shelves were stripped bare due to stockpiling of essential items. Rapidly changing regulations on multiple repeats of prescription medicines and over-the-counter (OTC) salbutamol inhalers left patients frustrated and confused. Some of us experienced unheard of levels of consumer aggression. With the shift to prescriptions via email or fax, our workload increased; sorting and searching, back and forth communication with medical centres when one method inevitably failed, and consolidating paper prescription copies. As the first point of contact in managing minor ailments, pharmacists have a strong public health ambassador role. During unprecedented uncertainty and stress, we supported our patients and provided evidence-based health advice from peer-reviewed studies and reports by government and international bodies such as the World Health Organization. As an intern during the coronavirus peak period in March and April this year I had the added challenge of executing my public health program. But my planned 10-minute consultations on diabetes management would have contradicted physical distancing rules. And while the chronic conditions of many of our patients don’t disappear at such a time, the overriding health concern was COVID-19. Before the promotion, we received many questions from concerned consumers, such as:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 10905 [post_author] => 1925 [post_date] => 2020-07-28 04:50:37 [post_date_gmt] => 2020-07-27 18:50:37 [post_content] => Todd Marion MPS, in Kiama, New South Wales, has been on the front line during the COVID-19 pandemic. He is also a specialist in sleep services.
Was pharmacy your goal?Growing up, I thought I would do sport science. My career adviser and a pharmacist neighbour convinced me otherwise. I didn’t understand a pharmacist’s role until I went to university. But once I did, it was a perfect fit.
Then it was community pharmacy?I spent time as a student with some ideal role models and it started my ambition for pharmacy ownership and partnership. Finding a niche in sleep services, compounding and home medication reviews evolved from that ownership. My family history of sleep apnoea was also a big factor. After university, I interned in a busy community pharmacy in the Illawarra (NSW) and undertook a leadership role in a small Sutherland Shire pharmacy in Sydney. Excellent pharmacy owners fanned my ambitions and a relocation led to a partnership opportunity in Kiama. Community pharmacy has freedom in practice areas, human interaction, team environment, lifestyle and community engagement.
What are the biggest daily challenges?The unexpected. In my time we have had drastic industry reform in remuneration and increased scope of practice. A massive development next door has led to road closures and traffic congestion. And, of course, the pandemic. The ability to identify risks and opportunities, and adapt accordingly, is important but also fatiguing.
Why do you specialise in sleep devices?The initial drivers were becoming involved in the pharmacy partnership and my parents’ family history. At the same time, industry reform presented the challenge and the opportunity for diversification. The final driver was personal expertise development, which is similar for medication review and compounding.
How does it help patients?The main benefit for them is access. Sleep services were reasonably new when I started in pharmacy, but not new in health. Rural patients often had limited contact with sleep services and the established model was overwhelmed. Pharmacy presented the ideal platform for sleep. It’s totally congruent with standard dispensing. Pharmacy has always been an excellent screening platform. Once a person is diagnosed with sleep apnoea a pharmacist can supply treatment, advice, support, troubleshooting and follow-up.
The challenges from COVID-19?Offering expanded services has been difficult. While swamped with patient panic behaviour, we also had unprecedented demand for influenza vaccinations. With social distancing mandates and concerns for staff safety, we have temporarily delayed sleep services for anything but urgent/severe cases and limit face-to-face interaction for them. Medication reviews were put on hold and compounding was mostly done out of hours. To cope, but also to set up a long-term course of action, we set up a patient checkpoint to screen for symptoms with a one way route through the store, increased our home delivery capacity, utilised technology such as MedAdvisor and online flu bookings and gave patients numerous communication channels such as email, social media, voice messaging and an after hours prescription dropbox.
Your tips for early career pharmacists?Observe as many different people in different scenarios as you can. Identify their admirable traits, behaviours and habits and use them. Get safely out of your comfort zone to gain different experiences. You will soon start to learn what you like and what you are good at. Then start finding a niche.
What’s next?Sleep, compounding and medication review are all works in progress and, I feel, will always be. I have an ever-changing opinion of how they will need to look in the future and keeping up with that is a pathway in itself. I think more formal further education and credentials within these disciplines is required. The post COVID-19 period will also mean dramatic change and upheaval.
A DAY IN THE LIFE of Todd Marion, partner pharmacist at Kiama Pharmacy, Kiama, NSW.7.30 am – The day begins Begin usually by compounding medicines, such as melatonin suspension for infant sleep disorders; omeprazole suspension for infant reflux (or for adults too); diltiazem cream for anal fissures. Have also compounded doxycycline, in oral paste form, for horses. 9.00 am – Getting ready Scan the workplace/stock levels, check for carryover jobs, wear and tear, cleanliness, deliveries, dose administration aid changes, pending prescriptions. Greet staff, formulate what’s needed. Delegate jobs. 10.00 am – Paperwork Conduct services and write medical correspondence. It could be for sleep, home medication review, meds checks, vaccination or blood pressure monitoring. 2.00pm – Back to work after lunch Conduct services. Keep up with medical correspondence or more compounding. 4.30 pm – Getting set for sleep Set up a sleep study – about 30 minutes. Recently, a man in his late 30s presented after years of poor sleep with erratic breathing and snoring. General sleepiness had affected his career. After a type 2 sleep study, a sleep physician discovered he had erratic breathing 85 times an hour, with severe oxygen desaturation and hypertension. After taking the sleep device overnight the patient reported an immediate turnaround – breathing score dropped into normal range and fatigue and work performance improved dramatically. He said his sleep problems would never have been addressed without a service available in his own town. 5.30 pm – Thinking ahead Check ordering priorities, scan workplace. Then home to the family. 7.00 pm – Homework Catch up on emails, planning. Complete medication review reporting, monitor potential stock issues. I try to have two full days off each week, limit late nights and ensure I get enough sleep.
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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 )
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