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[post_content] => For 93-year-old Patrick Timbs MPS, pharmacy provided a lifelong vocation and the chance to be a passionate community advocate in his hometown of Glen Innes, in rural New South Wales.
Mr Timbs passed away shortly after this article was published in the April 2021 edition of Australian Pharmacist. The PSA would like to extend its sympathies to his family.
How did you get your start in pharmacy?
When I first started out, you had to do a 4-year apprenticeship in order to qualify. I began my apprenticeship at a pharmacy in Newcastle, New South Wales, in 1946, before moving to Sydney in 1947 to attend the University of Sydney and finish up my apprenticeship at a pharmacy in Guildford. After graduating, I moved back to Newcastle until my uncle, who was based in Kyogle, northern NSW, told me that the local pharmacist wanted me to come and work up there.
After 3 years in Kyogle, where I met my wife, who was a nurse at the hospital, we were making our way back down to Newcastle when we passed through Glen Innes to visit my grandfather. He lived next door to a pharmacist, who asked me if I wanted a job.
I worked with him until 1955, when I asked for a raise, which he said he’d think about. When I asked him again a few months later, he said he was still thinking about it, so I went to work for another pharmacy up the road.
The pharmacist in change, Mr Grover, was a remarkable man and mentor who paid me above the award and let me buy the pharmacy at half the goodwill price in 1962. I owned Timbs Pharmacy until I retired about 12 years ago at the age of 80.
You also worked in the hospital?
When I first moved to Glen Innes, the local hospital needed a pharmacist. For 50 years, I would do the morning shift 3 days a week from 7:30– 9:00 am before heading back to the community pharmacy for the day.
I particularly enjoyed the last few years I worked as a hospital pharmacist. I collaborated with the doctors to reduce the number of medicines that patients were taking. I would do a drug profile on a patient and then discuss with the doctors which medicines should be discontinued.
Some of the older patients were on up to 25 medicines before we intervened. As a pharmacist, I think pharmacovigilance is really important, and we don’t always see enough of it.
'The biggest change I’ve seen in my lifetime is the number of new medicines that have been developed to treat specific diseases.'
What are your retirement activities?
Aside from playing golf three times a week, I continued to visit Glen Innes Prison up until recently to provide guidance to some of the young men there. I was a volunteer at the prison for almost 33 years.
What has changed in pharmacy practice since you started your career?
The biggest change I’ve seen in my lifetime is the number of new medicines that have been developed to treat specific diseases.
In the first 20–25 years of my career, we used to have to compound our own medicines – suppositories, pills, ointments and creams were all made up for each patient.
What’s the best thing about working in rural and remote pharmacy?
The service. As accessible healthcare practitioners, the pharmacists in rural and remote areas are required to give patients a lot of medical advice. The practices are all locally owned and operated, and the pharmacists know their patients individually and are concerned about the medicines they take.
What advice would you give to young pharmacists just starting out?
I recommend doing drug profiles on all your patients and establishing a great working relationship with the local GPs. That way, you can easily communicate with them should a patient need to change or add a medicine to their treatment plan.
[post_title] => A long life of service to a community
[post_excerpt] => For the late Patrick Timbs MPS, pharmacy provided a lifelong vocation and the chance to be a passionate community advocate.
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[post_content] => With the launch of a new PSA report, pharmacists in regional and remote areas highlight disadvantages that access to more funding, collaboration and medication management reviews could improve.
Out in the back blocks of far west New South Wales, a man dying of cancer on an isolated rural property forgot that it was mail day. Living in a house in the middle of a 100,000- hectare station, he usually drove 40 kilometres to the nearest village to collect his mail.
On this day he needed some prescriptions dispensed and the Australia Post contractor had already left.
PSA’s 2019 Pharmacist of the Year Peter Crothers FPS, the only pharmacist in Bourke, 250 kms southwest, swung into action.
‘The patient was absolutely desperate about the prospect of going without his medication for 4 or 5 days, and we were concerned, too,’ Mr Crothers says.
Rural and remote Australia statistics7 million rural and remote Australian residents 72,500 annually admitted to hospital for medicine-related problems $400 million annual cost to healthcare system 50% of this harm is preventable 1.3 million do not take medicines at all, or as intended $2.03 billion estimated annual contribution to health costs of medicine non-adherence By 2027, as few as 52 pharmacists per 100,000 people estimated to work in regional and remote areas, comparable to 113 in major cities1 |
Using his deep community connections, Mr Crothers ‘made a few phone calls and we ended up having the medicine delivered to his doorstep by a guy who was going out on a gyrocopter aircraft to do some mustering’.
The pilot was asked to drop the delivery at the local pub, but when he named the place, Mr Crothers said the pilot knew the property had an airstrip and delivered it ‘straight to’ the patient.
‘There are those sorts of things where you clap and jump up and down a bit and think you’ve had a win,’ he says.
But there are many no-win situations for the 7 million Australians in rural and remote – sometimes extremely isolated – areas where healthcare is haphazard or non-existant, or too far away. In these areas there are not enough pharmacists. There are not enough measurements of healthcare delivery and if patients are too much ‘out of sight, out of mind’, even pharmacists, when there is no GP or hospital nearby, cannot help adequately.
For an already under-served, vulnerable population, there is currently an inadequate supply of the health workforce in moderately accessible, remote or very remote areas to provide necessary services.
In the latest of its medicine safety reports, Medicine safety: rural and remote care,1 PSA outlines the imbalance between city and rural and remote pharmacist workforces.
It points out the medicine-related harms, including preventable hospital admissions, disease burden, risks to Indigenous Australians, unintentional drug-induced deaths and fluctuating medicine adherence – all cocooned in a lack of empirical data which creates opacity that has resulted in inaction by state and federal governments for years.
‘Rural and remote Australians experience poorer health outcomes, higher rates of hospitalisation and poorer access to primary care,’ the report states.2
Launched last month by NSW Health Minister Brad Hazzard at the Annual Therapeutic Update (ATU) at Manly, the report makes five recommendations (see Box 1) aimed at reducing the extent of medicine-related harm experienced by those living in rural and remote areas.
As PSA National President Associate Professor Chris Freeman says: ‘It should not matter where you live – all Australians are worthy of the best healthcare the country can provide.’
Carli Berrill MPS, co-owner of the Australian mainland’s northern-most pharmacy at Bamaga, on Cape York, Queensland, and at Thursday Island in Torres Strait, and a speaker at the Queensland ATU the week following the NSW ATU, says a ‘huge’ medicine safety issue is patients not taking their medicines ‘because they didn’t know what it was for or no one had ever explained it to them’.
She cites the case of a 60-year-old man from one of the outer islands who missed doses of perindopril, metformin, aspirin and amlodipine for 2 weeks when visiting another island which did not have a local health centre.
‘When I completed my pharmacist support visit I witnessed the effect of not taking his medicines for 2 weeks. He developed osteomyelitis due to uncontrolled diabetes and on his return was lucky to avoid medical evacuation to a hospital,’ Mrs Berrill points out.
‘This patient needed daily antibiotic injections and daily home nurse visits until he was able to get his infection and BGLs under control. His renal function also declined due to this episode.’
BOX 1 – Recommendations for rural and remote care: at a glance1
|
Taren Gill MPS was educated at the University of Sydney and worked for 10 years in the NSW regional town of Orange, population 40,000, where she was given the PSA Early Career Pharmacist of the Year award in 2014. Today she co-owns a pharmacy in rural Maryborough, Victoria, with just 7,000 people. Other professionals commute in from Ballarat, and doctors don’t see patients on weekends.
Maryborough is within the shire that has the highest cancer incidence in Victoria, the highest cardiovascular disease rate and wasn’t far behind Ararat as the ‘most overweight shire’. Throw in domestic violence and mental health issues and ‘there’s enough sick people’ for pharmacists and general practitioners alike, she says, of the good relationship she has with local GPs.
She cites the case of a patient taking sertraline 50 milligrams, with its out-of-stock issues, as well as different brands sold at different pharmacies. The patient didn’t realise that the brand from one pharmacy in one town was the same as the different brand from another pharmacy elsewhere. He then added it to his ‘daily regime – doubling and tripling the dose, and having medicine misadventure as a result’.
‘Another issue,’ Ms Gill says, ‘is the idea that city hospitals think they can discharge people at any time and assume that the access and resources when they hit their towns is going to be like a city, where you can go into the pharmacy at 8 pm, or that the pharmacies are resourced and open to create a WebsterPak on discharge or have weird and wonderful items in stock.’
The rate of hospitalisations for Indigenous Australians for chronic conditions, for instance diabetes, is on average, more than three times that for non-Indigenous people. They have a burden of disease 2.3 times higher than non-Indigenous Australians and reduced life expectancy.
Compliance is a huge issue and can’t be fixed alone by telehealth medication reviews, says Carli Berrill.
‘It needs a pharmacist on the ground as much as possible at the clinic to ensure that all possible clients are seen and culturally appropriate medication education and reviews have been completed with follow-up and reiteration of information as needed.’
And caps on MedsChecks and Home Medicines Reviews (HMRs) for remote pharmacies should be ‘uncapped’, she says.
Pharmacy service integration with Aboriginal Community Controlled Health Organisations (ACCHOs) is ‘uncommon’, according to the report.
[caption id="attachment_13024" align="alignright" width="302"]
Ellen Jones MPS, ACCHO pharmacist, Mt Isa, Queensland. (Photo credit: Joanna Giemza-Meehan)[/caption]
Ellen Jones MPS, who works for the Gidgee Healing ACCHO in Mt Isa, Queensland, says a ‘key challenge’ in sourcing more pharmacists in such roles is ‘recognition and remuneration’.
‘We are significantly under-represented in the Medicare Benefits Schedule, and other funding arrangements make funding for positions scarce. The strict rules around the HMR program sometimes make it logistically challenging to execute, as well as not always being the most culturally appropriate way to deliver pharmacist care.’
She says engagement with ACCHOs is integral to establishing community and organisational needs around identifying patients at risk of medicine misadventure.
In Bourke, Indigenous Australians make up about 38% of the population. Peter Crothers says assisting Aboriginal people accounts for two-thirds of his workload.
‘Aboriginal people have some particular issues around medication safety,’ he says. ‘One factor is low personal security. You meet a lot of people who don’t have a wallet or a handbag, for example, because they don’t feel confident in keeping those things safe. That can create issues around the possibility of other people getting access to people’s medications, medications getting lost – those sorts of things.’
The co-chairman of Rural Pharmacy Network Australia Fred Hellqvist MPS has had nearly a decade of first-hand experience of the invisible work done by remote pharmacists that is also unpaid.
His Dover Pharmacy is the most southern on the Tasmanian mainland, and the only one in his postcode.
As the only active pharmacist in his outer regional location, there is a ‘huge workload’ connecting with state healthcare providers, the local fire services during bushfires and ‘the police to make sure you can get your medications in’. And then, there have been COVID-19 issues on top.
‘We are significantly under-represented in the Medicare Benefits Scheme, and other funding arrangements make funding for positions [in ACCHOs] scarce.’ Ellen Jones MPS
‘Because of our socioeconomics, which also drive the high chronic disease rates in our area, we have to solve problems then and there. A lot of people are poorer, so they may have a car but they can’t afford to drive their car back and forth. Or they may not have a car and rely on others for transport,’ he says.
‘When they do come to the pharmacy, we have to, as much as possible, solve [the problem]. That could mean speaking with GPs, specialists or other healthcare professionals on the patient’s behalf.
And, ‘it’s about solving it adequately’, so the patient can continue treatments, or a healthcare plan until the next GP or specialist appointment.
‘You can imagine the time that this sometimes takes, which is currently unremunerated. It’s not captured. It’s not monitored.’
For governments, ‘the priority should be to improve remuneration for services, as well as workforce incentives for the already existing network’, Mr Hellqvist says.
Pharmacies in towns where general practitioners are already scarce in relation to patient numbers ‘can exacerbate health disparities’, the PSA report states.
‘In 2017, the full-time service equivalent (FTE) per 100,000 population was 65, 75 and 85 FTE per 100,000 in very remote, remote and outer regional areas, respectively, compared to 110 FTE for major cities and inner regional areas.’
One report cited a prediction that in 2027–28 ‘there would be 80 and 52 pharmacists per 100,000 people in regional and remote areas, respectively, compared to 113 pharmacists per 100,000 people in major cities.3
Reduced doctor and telehealth services in the bush has meant an 80-year-old patient of Karen Carter FPS, who lives outside Gunnedah, NSW, missed her annual HMR this year, as well as last year. As the patient’s condition worsened, Karen’s pharmacy supplied a dose administration aid (DAA), but when the patient lost it, the pharmacy needed to make a special delivery with another DAA.
Another patient, aged 78, could not get another prescription for tramadol for his pain, so stopped it, Ms Carter recalls.
‘His mood plummeted. He saw a doctor who prescribed an antidepressant.’
It was later sorted out when the patient spoke to Mrs Carter’s pharmacist, who then ‘spoke to the doctor who restarted tramadol and not antidepressants’.
Outside major cities, there is a higher prevalence of health risk factors, including obesity, smoking, non-nutritional diets, sedentary lifestyles and alcohol abuse.
According to the PSA report, the burden of disease increases with remoteness ‘for coronary heart disease, chronic kidney disease, COPD, lung cancer, stroke, suicide, self-harm and type 2 diabetes’.
In addition, outside capital cities, Australians pay more for goods and services but receive 18% less in weekly household income. The burden for remote-living Australians has been estimated at 1.4 times that of those living in cities, and 2.3 times for Indigenous Australians.4
But due to a lack of empirical data, the contribution of medicine-related harm to the burden of disease is not possible to strictly determine. It is likely, however, that such a burden implies increased need for medicines and thus increased risk of harm.
Potentially avoidable deaths occur in very remote regions at a rate 2.5 times that of major cities,5 while proportionally higher potentially preventable hospitalisations (PPH) and presentations to Emergency Departments in rural and remote areas compared to cities, likely due to medicine-related harm,’ the report states.
Shortages of healthcare professionals, which includes pharmacists, in rural and remote areas is well known and a major contributor to poorer health outcomes.
Challenges include higher workloads than metropolitan counterparts, which can be exacerbated by short staffing, difficulty accessing locum relief, more duties and working as a sole practitioner.
On top, as the report states, the cost of accommodation and travel for pharmacists already under financial hardship and difficulties taking leave without replacement staff then interfere with ongoing training and professional development conference attendances.
Taren Gill can’t recruit pharmacists to her town. ‘If I don’t grow my own,’ she says, referring to her three interns, ‘I can’t get any‘. And even they will leave, eventually.
[caption id="attachment_13028" align="alignnone" width="1000"]
Photo credit: Joanna Giemza-Meehan[/caption]
Some of the factors which contribute to medicine-related harm include polypharmacy – ≥5 medicines (including ‘hyper-polypharmacy’ – ≥10 or more medicines and ‘extreme hyper-polypharmacy – ≥15 or more medicines), medicine adherence, mental ill-health, transitions of care and overuse of opioids.
About half of people with chronic disease don’t take their medicines correctly, or at all, sometimes.6
As Mr Hellqvist points out, pharmacists ‘fill a lot of gaps. We have to advise on diabetes care, because we don’t have diabetes educators on a regular basis.There’s a lot of mental health, where we have to follow people over time, because we’ve gained their trust over the years. People trust us [pharmacists] with more things regarding their health.’
FIGURE 2 – Extent of medicine use in rural and remote Australia|
Australian data |
Rural and remote residents |
|
|
People taking a prescribed medicine every day |
> 9 million |
2.61 million |
|
People taking two or more prescribed medicines in a week |
8 million |
2.32 million |
|
People taking over-the-counter medicines daily |
> 2 million |
0.58 million |
|
People taking a complementary medicine daily |
> 7 million |
2.03 million |
Reference: NPS MedicineWise8
With complex and multifactorial causes of medicine safety problems, a specific focus on the rural health workforce is needed, the report states.
‘Without a specific focus on the rural health workforce in Australia we will see little improvement in complex and chronic disease management, and we risk failure in delivering on the objectives of Australia’s 2019 Long Term National Health Plan and unique National Medicines Policy.’
It is imperative that integrated healthcare emphasises greater collaboration between services with a ‘new way of providing primary care’.
‘Rural and remote pharmacists in Australia have an opportunity to significantly address the breadth of disadvantage afflicting many people living in rural and remote Australia. Innovative models of care, available to rural and remote practitioners, should be adopted and implemented as a matter of urgency,’ the report states.
As Fred Hellqvist says, with more funding via workforce incentives, more pharmacists can be attracted to rural areas – and the invisible work may at last be paid.
References
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[post_content] => Queensland recorded three new cases of COVID-19 today (31 March), as residents of Greater Brisbane wait to hear if they will spend the Easter break in lockdown.
One new case was acquired overseas, but the remaining two were locally acquired and connected to a cluster at Princess Alexandra (PA) Hospital. One of these is a nurse at the hospital who received her first dose of the COVID-19 vaccination a fortnight ago.
The PA was placed in lockdown yesterday, for the second time this month. It was previously locked down on 12 March when a doctor tested positive for COVID-19 after working with infectious patients.
Mater Mothers’ Hospital also sent home some staff after it was discovered a recent visitor is one of the confirmed COVID-19 cases.
Meanwhile in New South Wales (NSW), masks will be mandatory in the north-east of the state and a raft of social-distancing restrictions will be tightened after a new COVID-19 case was found in Byron Bay last night.
A man in his 20s who attended the Byron Bay Hotel with friends tested positive and will be included in Thursday’s official NSW COVID statistics, Premier Gladys Berejiklian confirmed today. A nurse from Princess Alexandra Hospital in Brisbane attended a hen’s night at the same hotel on 20 March and later tested positive for the virus, along with 6 others in attendance. The man’s friend’s have since tested negative.
From 5 pm today until the end of Easter (11.59 pm on Monday) social-distancing restrictions in the Tweed, Byron, Ballina and Lismore local government areas (LGAs) will be tightened, with masks mandatory for hospitality workers and everyone else while shopping and using public transport, taxis and ride-sharing services.
Visitors in homes will be capped at 30 and the four-square-metre rule will apply in hospitality venues, where patrons must also be seated.
‘Fingers crossed’ for Easter
Queensland Premier Annastacia Palaszczuk said there had been more than 33,000 tests conducted in the last 24 hours.
‘If we see the same number of test results tomorrow this is very good news,’ she said.
‘The fact we do not have any unlinked community transmission in the south east or in our state is absolutely encouraging.’
Greater Brisbane – including Logan, Ipswich, Redlands and Moreton Bay council areas – went into a 3-day lockdown at 5 pm on Monday, after health authorities discovered four new locally-acquired cases.
Under the lockdown, residents can only leave their homes for essential reasons, including grocery shopping, work if they cannot work from home, medical care and exercise.
Schools have been shut and face masks are mandatory outside of the home.
‘This is going to be part of the Australian way of life until everyone is vaccinated,’ Ms Palaszczuk said when announcing the lockdown.
She will provide an update at 9 am tomorrow (1 April) about whether the lockdown will be extended.
‘Fingers crossed all will be looking good for Easter,’ she said.
‘If we see very good testing rates across Queensland and we don’t see any unlinked community transmission, the signs for Easter are looking positive.’
There are now 10 new cases in the state, all linked to two clusters: a doctor at Princess Alexandra Hospital and the nurse who travelled to Byron Bay while infectious.
From 8 pm today, only people who have received their first COVID-19 vaccination will be permitted to care for people in Queensland hospitals with the coronavirus.
Advice for pharmacists
As always, community pharmacies are keeping their doors open during the lockdown, in order to provide essential services and medicines to the community.
Pharmacists should:
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[post_content] => Bridget Totterman MPS is a master behind the scenes, helping pharmacists deliver a seamless service to patients and improving access to medicines in challenging times.
As the Chief Operating Officer of the White Retail – White Medical Group, Ms Totterman rapidly translated and adopted new protocols when COVID-19 first hit to help the pharmacists in her network best serve their communities.
She was recognised for this outstanding leadership and change management at the 2021 PSA Queensland Pharmacist Awards on 20 March.
Ms Totterman’s reach also spans policy, education and general practice as a Clinical Fellow of the Queensland University of Technology; a member of PSA’s Queensland Branch Committee; leader and manager of seven pharmacies and eight medical practices; and business owner of an additional four pharmacies.
‘Bridget has demonstrated exceptional leadership, business acumen and change management within her career,’ PSA Queensland Branch President Shane MacDonald said.
‘PSA commends Bridget for building frontline healthcare teams in primary care, across both pharmacy and general practice, and for her contribution to the profession across immunisation, palliative care initiatives, the urinary tract infection pilot and now supporting COVID-19 vaccination.’
Despite her numerous achievements, Ms Totterman told Australian Pharmacist she was humbled to receive the award.
‘There are so many worthy pharmacists in our industry across all different fields, so I feel very honoured,’ she said.
‘But it's a real thrill and the highlight of my career, to be honest.’
Supporting pharmacists during COVID-19
At the start of the COVID-19 pandemic, Ms Totterman acted quickly by rallying teams to follow systems and updating pharmacists on the constant legislative and practice changes.
‘There was so much information coming from [everywhere],’ she said.
‘I saw myself as a conduit for all that information. I put it together and sent emails to our team – weekly, daily and even hourly – with regards to legislative or dispensing changes.’
Delivering timely information to pharmacists on the frontline freed them up to focus on patient care with confidence.
Pharmacists’ mental health and wellbeing was also prioritised through regular check-ins and ensuring team members’ hours were rotated.
Ms Totterman coordinated the safety upgrades for the pharmacies in her group, including social distancing stickers on the floors, sneeze screens and hand sanitiser stations.
To prepare for the rollout of the COVID-19 vaccine, Ms Totterman organised the Expression of Interest (EOI) submissions for the GP clinics she oversees.
‘I’ve been working with the practice managers in each GP clinic to ensure a smooth and frictionless process for patients when they come in [for the COVID-19 vaccine],’ Ms Totterman said.
‘But they're the real heroes who do all the hard work. I'm just trying to take whatever pressure I can off them, so they can keep doing what they do.’
All the pharmacies Ms Totterman oversees put forward an EOI to administer the COVID-19 vaccine, and she has met with pharmacy managers to plan for the delivery of a safe service should they be approved.
Making medicines more accessible
What Ms Totterman loves about pharmacy practice is providing advice and ready access to safe medicines to treat problems before they become worse.
And her involvement in Queensland’s Urinary Tract Infection Pharmacy Pilot, a provision for pharmacists to provide antibiotics to patients with uncomplicated UTIs, aims to do just that.
‘There’s such a need for patients to have access to these medicines,’ Ms Totterman said.
‘Pharmacies are open long hours and offer a walk-in service. We can help patients get timely access to the right medicine and prevent patients experiencing a worsening infection and further ramifications, such as missing work, through the delays that may be encountered if they cannot get a timely appointment at their GP clinic.’
Improving access to medicines for palliative care patients is another area Ms Totterman is passionate about.
‘I went to a palliPHARM focus group early on, where I learned that many pharmacies don’t stock medicines that are needed for end-of-life treatment,’ she said.
‘If you have a loved one at the end of life who needs a script filled to make them more comfortable and the pharmacy needs to order the medicine in – that’s just not good enough.’
Touched by what she learned from the focus group, Ms Totterman made it her mission to ensure all the pharmacies in her network keep palliative care medicines in stock based on palliPHARM’s most used medicines list.
‘Even if the medicine expires, we'll order in another one to keep the pledge of continuing to stock these medicines on our shelves, should anyone in our community need them,’ Ms Totterman said.
More pharmacists honoured
Ms Totterman wasn’t the only Queensland pharmacist honoured for outstanding work recently.
Hospital pharmacist Hannah Knowles MPS received the Early Career Pharmacist (ECP) of the Year award for her contribution towards transitions of care and action for change.
Ms Knowles’ work and advocacy saw PSA secure an election promise from the Palaszczuk government to look at best practice transitions of care across all 16 Hospital and Health Services in the state.
Since coming on board as a PSA branch committee member, she has provided insights from her hospital residency, community pharmacy and through her contribution to International Pharmaceutical Federation committees.
‘Her willingness to contribute and lead and support fellow early career pharmacists is exceptional,’ Mr MacDonald said.
Joshua Clements was recognised for his academic excellence and contribution to the pharmacy community through his receipt of the James Dare PSA Graduate of the Year award.
Mr Clements was awarded a Bachelor of Pharmacy with Distinction from Griffith University in December 2020 and earned the Griffith University Awards for Academic Excellence for every year of his enrolment, from 2017–2020.
As an active member of PSA for more than 45 years, former State Councillor Gilbert Yeates was awarded the Lifetime Achievement Award.
He was recognised for his significant and ongoing contribution to the profession over many years and across all walks of practice – from community pharmacy to hospital, academia, professional development, policy, advocacy and professional indemnity.
‘Gilbert is well respected by his patients and peers for his confidential and expert advice on professional responsibilities,’ Mr MacDonald said.
‘He engages with those at all levels of the profession, and generously provides counsel to many pharmacists in official and informal capacities.
‘There has not been an issue relating to the practice of pharmacy in recent history that Gilbert has not been involved with and significantly contributed to, from pharmacist immunisation though to medicine management, prescribing and practitioner development.’
The PSA also recognised the contribution of pharmacists who have been elevated to the honour of PSA Fellowship. This year both Joyce McSwan FPS and Prof Beverly Glass FPS were conferred as PSA Fellows.
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[title_attribute] => Queensland pharmacist of the year shows leadership in crisis
[title] => Queensland pharmacist of the year shows leadership in crisis
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[post_content] => The Australian Asthma Handbook has been updated to help healthcare professionals provide advice to patients around the COVID-19 vaccine.
A key recommendation is to reassure patients with asthma (including severe asthma) and allergic rhinitis that their condition does not prevent them from having the COVID-19 vaccine or increase the risk of adverse reactions.
Professor Nick Zwar, Chair of the Australian Asthma Handbook Guidelines Committee, said the National Asthma Council Australia was encouraging people with asthma to get the COVID-19 vaccine as soon as it is available.
‘Studies [of COVID-19 vaccines] have included people with asthma and there has been no evidence of increased rates of reactions to the vaccines,’ Professor Zwar told Australian Pharmacist.
‘And of course, now that rollouts are occurring en masse in some countries, such as the UK and US, surveillance in those larger populations shows there haven't been any signals of concern.’
Consultant pharmacist and asthma educator Debbie Rigby FPS said it is important for community pharmacists to reassure patients about the safety of COVID-19 vaccines.
‘Authorities like the National Asthma Council, as well as the Chief Medical Officer, say that it's safe and appropriate for people with asthma and chronic obstructive pulmonary disease to get the COVID-19 vaccine, so we just have to emphasise to patients that the evidence says it’s safe,’ she said.
‘It's also a matter of explaining that even though the development [of the COVID-19 vaccines] has been rapid, the right steps have still occurred, and there has been the rigour in making sure things are safe,’ Professor Zwar added.
Asthma medicines advice
Healthcare professionals should encourage patients to continue using their asthma medicines both before and after they receive the COVID-19 vaccine, Professor Zwar said.
Patients should also be advised that monoclonal antibody therapies for asthma (omalizumab, mepolizumab, benralizumab and dupilumab) do not suppress the immune system or interfere with COVID-19 vaccines.
However, it is not recommended to receive this treatment and the COVID-19 vaccine on the same day, as this could make it difficult to identify the source of any adverse effects.
‘If a patient had a reaction like a fever, headache or sore arm, separating the dose of these therapies from the COVID-19 vaccine will remove any confusion about the cause,’ Professor Zwar said.
As patients typically receive monoclonal antibody treatments every 4 weeks or bi-monthly, Ms Rigby said pharmacists should advise patients to continue this therapy when it’s due, and book in their COVID-19 vaccine accordingly.
The updated Handbook also states that patients should not use nebulisers to administer inhaled medicines due to their propensity for spreading COVID-19, so pharmacists should advise them of alternative methods.
‘There is very strong evidence that using a metered dose inhaler plus a spacer is just as effective as a nebuliser, so it’s important to emphasise this to patients or parents of children with asthma,’ Ms Rigby told AP.
Some patients with asthma will not be in the earlier priority groups for receiving the COVID-19 vaccine, so Professor Zwar recommended they discuss the optimum time to receive their influenza vaccine with a healthcare professional.
‘Healthcare professionals should reassure their patients with asthma that they don’t need to wait until they have the COVID-19 vaccine to get the flu vaccine,’ he said.
‘Given that supply of COVID-19 vaccines is limited, it is likely that flu vaccine will become available first.’
‘Again, it’s a matter of timing,’ Ms Rigby added.
‘Pharmacists should be helping people understand the timing of all of these vaccinations, as well as their medicines.’
Prevention and other recommendations
As we approach another winter during the COVID-19 pandemic, and with flu season kicking off, the Handbook also recommends patients continue taking their preventer medicines.
Adherence to corticosteroid-containing medicines (regular preventers, as-needed combination relievers, or maintenance-and-reliever therapy) will reduce the risk of asthma exacerbation or flare ups.
‘We know that for many people, having a virus such as influenza is a trigger for their asthma,’ Ms Rigby said.
‘So coming into winter, and potential flu season, they should be taking their medicines, preventers in particular, as prescribed.’
'It’s also important to remind patients not to rely on their relievers, Ms Rigby said.
‘Many adults and adolescents with asthma do over-rely on relievers, particularly over-the-counter salbutamol,’ she said.
‘Pharmacists have a real responsibility to help people understand the risk associated with that over-reliance, as it actually increases the likelihood of having an exacerbation or flare up.’
Other recommendations include:
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[post_content] => By encouraging open communication and breaking down barriers, pharmacists can help empower women when it comes to their sexual and reproductive health.
It’s been nearly two decades since pharmacists in 2004 began providing immediate access to the emergency contraceptive pill (ECP) without a prescription as a Pharmacist Only Medicine.
However, unlike in New Zealand and some parts of the United States and United Kingdom, women cannot access the oral contraceptive pill from specially trained pharmacists. Instead they must see a general practitioner (GP) for a prescription.
Those seeking MS-2 Step for medical abortion also face a barrier in the number of GPs certified to prescribe it – 1,345 out of 35,000 practising GPs – as well as finding a pharmacist who is certified to supply and dispense the medicine.
Any pharmacist can register to be a certified MS-2 Step dispenser through MS Health. The certification is pharmacist-specific rather than pharmacy-specific, so every pharmacist who dispenses MS-2 Step in a particular pharmacy must be certified.
‘Women in Australia currently experience structural (for example, financial and geographical), personal (lack of knowledge) and provider-related (biases or conscientious objection) barriers to accessing comprehensive contraception services,’ says Pip Buckingham, PhD candidate and researcher for the Centre of Research Excellence in Sexual and Reproductive Health for Women in PrimaryCare (SPHERE).
This situation has worsened during the pandemic, says Ms Buckingham, whose research focuses on broadening women’s contraceptive choice in general practice and pharmacy.
Indeed, a 2020 report by Marie Stopes Australia into sexual and reproductive health rights in Australia found access to contraception and emergency contraception, and pregnancy and sexually transmitted infection (STI) testing, was reduced due to COVID-19. This inequity has been greater for people who already experience barriers to healthcare, including Aboriginal and Torres Strait Islander people, migrant and refugee communities, young people and those living in regional, rural and remote areas.
Rates of unintended pregnancy are also disproportionately higher among women who are socio-demographically disadvantaged and those living outside metropolitan regions.
Pharmacists can address many of these barriers and present a number of opportunities for accessible contraceptive counselling, products, screening for STIs and medical abortion.
TAREN GILL MPSPriceline Pharmacy, Maryborough, Vic We’re in a country town where everyone knows everyone. There are only two pharmacies in Maryborough and only ours is open on a Sunday. We’ve had teenagers come in to get emergency contraception and they don’t want everyone to know – that is one of the barriers we have to overcome. One of the ways we try to be more discreet is to have a card (above) in the feminine hygiene section of the pharmacy that says ‘Secret Women’s Business’. It explains that if you want to talk to the pharmacist, you just need to deposit the card at the counter. We have contraceptive conversations with teenagers who don’t want their parents to know, and I give a talk to Year 10 girls at the local high school about sexual and reproductive health. I like to think that grassroots education helps to increase awareness around these issues and helps empower girls to take control of their reproductive health. That said, we make sure women who come into the pharmacy looking for contraceptive advice are aware that contraception comes in many forms, including IUDs and implants, and that this is something they can discuss with their doctor. For example, as the contraceptive pill requires a lot of compliance, a 3-month injection may be a better option. When women come in to access emergency contraception, we try to find out more about their cycle, or what’s going on for them. One of the most common groups looking for this type of help is happily married women with multiple kids who don’t want any more. There is no need for stigma and judgement about the reasons a woman wants to access emergency contraception. We don’t have a prescriber in town for MS-2 Step. The nearest pharmacy is Ballarat or Bendigo [about 70 kilometres away]. I would feel comfortable about having some forms of contraceptive pill available over the counter if I was able to assess that the person didn’t have risk factors for side effects such as a clot, or wasn’t a smoker or overweight, as they may require closer monitoring. There would be a few things you would need to tick off, and our responsibility as pharmacists is to make sure that the medicines we dispense are safe and efficacious. |
It is important that pharmacists feel ready and confident to have discussions about women’s sexual and reproductive health and recognise the actual or perceived barriers women may face, says Stefanie Johnston MPS, PSA’s General Manager – Knowledge Development.
‘PSA has a number of practice support tools, including a Pharmacist Only Medicine guidance document and online education modules to enable pharmacists to upskill in this area,’ she says. ‘Pharmacists are in a great position to provide information to women who have questions about their contraception and what may be the best option for them.’
One barrier is feeling a sense of shame or vulnerability when talking to a pharmacist about emergency contraception, or contraception more generally. A simple solution is to offer patients more privacy, says Ms Johnston. For example, if a woman appears on edge or is constantly looking towards the pharmacy entrance, suggest moving into a consultation room where others can’t see or overhear the conversation.
A lack of knowledge can also make women feel unsure when it comes to their sexual health, so it is important to explain why you need to ask certain questions when providing certain medicines, Ms Johnson says.
‘It’s rare that emergency contraception isn’t appropriate.’ But there are instances, she adds, where it cannot be taken. This could be due to other health conditions, other medicines or the length of time since unprotected sexual intercourse.
As there may be reduced efficacy of ECPs with increasing body weight, pharmacists should also be prepared to ask potentially confronting questions.
‘If it’s a situation where you feel uncomfortable, rehearsing the conversation and considering how you phrase things could be a good idea,’ Ms Johnston says. ‘For example, “I need to ask you a couple of questions to make sure I give you the right medicine and ensure it is as effective as it can be”. ‘
Counselling patients on emergency contraception also provides an opportunity to increase someone’s knowledge about contraception and sexual health more broadly – but only if the patient is open to it.
‘You need to meet people where they are. Some people find it a very personal conversation and are embarrassed, while some are happy to talk about it.’
[table id=18 /]
EVA QUEK MPSSanctuary Lakes, Victoria We’ve never refused to issue emergency contraception because there isn’t much of a contraindication. Sometimes though, we have had to explain that, because the patient has left seeking advice more than 5 days [after sexual intercourse], it is too late, and they will need to go and see their doctor for a discussion about their options. If this is needed, we might offer to schedule an appointment for them. If is someone whose first language is not English, we have staff members who speak Vietnamese, Greek, Serbian, Hindi and Mandarin. There is also the Translating and Interpreting Service. We also find out about any medicines they are on, and we always counsel them on the adverse effects. We might let them know that a more long-term form of contraceptive, like the oral contraceptive, or an implant, may be a useful consideration and suggest they discuss this with their doctor. As pharmacists, we can provide more information to women who have questions about their contraception. For example, I have spoken to women in the past who have raised concerns about the risks of deep vein thrombosis with certain oral contraceptive pills and they have decided to consider alternative contraception methods, such as a contraceptive implant instead. We have two pharmacists in our pharmacy who are registered to provide MS-2 Step. |
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[post_content] => New boxed warnings for pregabalin and gabapentin give pharmacists the opportunity to discuss pain management with patients.
The Therapeutic Goods Administration (TGA) announced on 1 February that medicines containing pregabalin and gabapentin will now come with boxed warnings in the Product and Consumer Medicine Information (CMI), following an investigation of ongoing misuse of pregabalin, and abuse of and dependence on both pregabalin and gabapentin.
In its investigation, the TGA cited data from the National Coronial Information System, which found that pregabalin-related deaths have increased exponentially, rising from 16 in 2013 to 121 in 2016. Most of these deaths were unintentional.
The warnings will serve as a guide for health professionals to screen for abuse or misuse, as well as inform patients about the risks associated with use.
Impact on patients
According to Jarrod McMaugh MPS, PSA Senior Pharmacist, Consulting and past President of Chronic Pain Australia, the boxed warnings may have a particular impact on patients who inadvertently overuse pregabalin and gabapentin.
[caption id="attachment_10922" align="alignleft" width="216"]
Jarrod McMaugh MPS[/caption]
‘Patients who are not achieving adequate pain relief may be less likely to take an extra dose when they are made aware of the black box warning,’ he said.
Despite this benefit, Mr McMaugh said some prescribers may be over cautious and see the warnings as a reason to reduce the supply of these medicines.
‘There is a risk that patients might suddenly lose access to these medicines, or they might decide to cease or reduce their use of pregabalin or gabapentin of their own accord,’ Mr McMaugh told Australian Pharmacist.
‘But as long as healthcare professionals review their patients adequately and provide a treatment plan around ceasing use, then it shouldn't be a problem.
‘It would also be useful if gabapentin and pregabalin were included in Real Time Prescription Monitoring (RTPM) programs to ensure that people at increased risk of overuse can be identified and assisted early on,’ he said.
Both gabapentin and pregabalin will be incorporated in some jurisdictions’ RTPM systems, including Queensland’s QScript, which should roll out later this year.
Counselling advice
Mr McMaugh said the CMI provides pharmacists with an opportunity to discuss patients’ treatment with pregabalin and gabapentin, particularly those who have just commenced use.
‘Pharmacists should inform patients that gabapentinoids are quite potent and they do have some risks associated with them,’ he said.
‘But it’s important to ensure that message is delivered appropriately without alarming the patient, which could lead to cessation.’
If patients do exhibit increased anxiety, pharmacists should reassure them that medicines prescribed for the correct indication are safe, but carry risks.
‘It's very much about allaying a patient's unnecessary fears and putting any concerns they have into perspective,’ Mr McMaugh said.
‘Pharmacists should balance the realistic harms that a patient could be exposed to against the benefits of treatment and the harms of stopping suddenly.
‘It's a matter of taking each person's case individually, and understanding what their risks are and what they are hoping to gain from treatment without lecturing them.’
If a patient is still hesitant, pharmacists should refer them to their prescriber to discuss a treatment plan for tapering to reduce any side effects associated with sudden cessation.
Efficacy of treatment
Nicolette Ellis MPS, Senior Clinical Pharmacist for Beyond Pain, said pharmacists should be acutely aware that increased use of pregabalin or gabapentin does not necessarily mean the patient has a substance use disorder.
[caption id="attachment_10175" align="alignright" width="220"]
Nicolette Ellis MPS (right) with Beyond Pain founder Anjelo Ratnachandra[/caption]
Many patients who live with chronic pain may increase their dose with the expectation that the medicine will improve their pain experience, so it’s important to start the conversation with open-ended questions, such as inquiring about how the pain might be impacting their day-to-day life or what they find beneficial about the medicine for their pain.
‘Gabapentinoids have many side effects including weight gain, peripheral edema, low mood, cognitive decline and sedation which can pose a significant barrier to improving an individual’s function, psychosocial abilities and quality of life,’ Ms Ellis told AP.
‘Up to 50% of patients taking gabapentinoids will experience adverse effects and identification of these medicine-related harms tends to be under-recognised. It’s essential that when we are having these conversations we are also screening for these symptoms.’
Ms Ellis also emphasised the importance of talking to patients about the purpose of taking a medicine for chronic pain, which is to improve their function and quality of life.
‘There should be a measurable goal in mind when patients start or continue a medicine for persistent pain, such as being able to walk for 20 minutes daily in the next 1–2 months,’ she said.
Ms Ellis suggested pharmacists offer the use of validated tools to measure the benefits of their treatment, which should be selected based on the purpose of use, such as to improve their function, sleep or mood. These tools include:
Gabapentinoids have been increasingly prescribed as the “non-opioid alternative” for all types of chronic pain, including non-neuropathic conditions such as non-specific lower back pain, fibromyalgia and osteoarthritis, despite there being little or no evidence for their use to treat these conditions.
But even in the treatment of neuropathic pain, Ms Ellis said, gabapentinoids should be prescribed and dispensed judiciously, as much of the trial evidence is limited to those who live with post-herpetic neuralgia or diabetic peripheral neuropathy.
Guidelines also recommend that patients on long-term therapy should attempt to challenge the efficacy and dose of therapy on an annual basis.
‘The benefits and risks of gabapentinoids can be a lot to unpack, and I would encourage pharmacists to use services such as a MedsCheck or Home Medicines Review,’ Ms Ellis, said.
‘Pharmacists should feel confident to discuss medicine risks and how to manage them, particularly when there is concomitant prescribing with other high-risk medicines.’
Evidence indicates that there may be up to a 49% increase in the risk of opioid overdose when combined with gabapentinoids.
‘If a pharmacist believes a patient is at risk of overdose, they should confidently discuss their concerns with the prescriber and ascertain how this risk is being managed,’ Ms Ellis said.
‘If there is no plan, pharmacists need to take a supportive approach and recommend harm minimisation strategies, such as staged supply, dose administration aids, gradual tapering plans and naloxone therapy, if combined with opioids.’
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[post_content] => The first government-funded training modules for the COVID-19 vaccination have been released, as federal Minister for Health Greg Hunt confirms the rollout will begin later this month.
In a statement launching the training on Monday (8 February), Minister Hunt said the first modules are aimed at health professionals in hospitals who will administer the Pfizer vaccine, with modules for the AstraZeneca vaccine to come shortly.
Training will include ‘all of the elements which will be critical to ensuring that vaccination occurs in a safe and effective way’, Minister Hunt said, including handling, storage, safety and surveillance.
‘[The training is] not difficult, but it’s an important step, and that includes content which is relevant to the vaccines that Australia will be using, in particular the use of what are called multi-dose vials,’ he said.
‘Instead of a single shot from one vial, what we’ll see is that there are multiple doses, six in the case of Pfizer, 10 in the case of AstraZeneca on provisional advice, subject to TGA [Therapeutic Goods Administration] approval.’
Minister Hunt said the Pfizer vaccine remains on track for a late February start, with an early March commencement for the AstraZeneca vaccine.
Last week, the Federal Government called on community pharmacists to help vaccinate millions of Australians against COVID-19 from the start of Phase 2a. Expressions of interest for community pharmacists to participate close on 19 February.
At a senate hearing on Friday (5 February), Secretary of the Department of Health Professor Brendan Murphy said the government expected a strong response from pharmacists, and that there would be ‘stringent conditions’ for vaccine centres.
‘We've got to be able to deliver no wastage, have the right facility and have all the right support structures,’ he said.
Hope Peisley, Assistant Secretary, COVID-19 Vaccine Taskforce, Department of Health, said the aim of the expression of interest process was to ensure ‘equity and coverage across the country’.
‘The worst thing that could happen is that we have an oversupply in one area and not in another, so we need to ensure that we've equity coverage so that people can be accessing the vaccine as soon as it's available to them,’ she said.
PSA General Manager Policy and Program Delivery Chris Campbell said there had been a surge in demand for immunisation training.
‘Pharmacist immunisers will be needed now more than ever, and we are seeing record numbers put up their hands to complete immunisation training before the COVID-19 vaccine arrives,’ he said.
While it is important to remain up-to-date with the release of mandatory government-funded training modules, Mr Campbell said it would also be prudent for pharmacists keep an eye out for additional modules that relate to the vaccines they will be administering, in addition to the current required training for pharmacist immunisers and the newly released modules. The AstraZeneca module is expected to be released in the coming weeks.
'It is expected community pharmacists and general practice will be largely administering vaccines yet to be approved in Australia, such as the AstraZeneca vaccine,’ he said.
‘It is suggested that pharmacists complete the core modules as soon as practical, keeping in mind they will need to complete additional modules for the vaccine they will be administering.
'Pharmacist immunisers working in hospitals and across vaccine hubs as part of the Phase 1 roll out have already started completing the modules, in preparation for vaccination to start hopefully the end of February.'
Pharmacists critical to rollout
Community pharmacies will be ‘critical in the rollout to the wider population’ given their footprint across the country, according to the Member for the federal seat of Dobell and pharmacist Emma McBride MPS.
But it is important to ensure pharmacists receive adequate remuneration for non-Pharmaceutical Benefits Scheme (PBS) services, she said in parliament last week.
‘I and many others were pleased to see the government commit $200 million to supporting the administration of COVID-19 vaccines by community pharmacists,’ she said.
‘I've undergone the training myself to be an immuniser, as have thousands of other pharmacists who are trained, prepared and ready to be part of this big nationwide effort.’
While the funding was welcome, Ms McBride said there was a clear need ‘to ensure adequate funding for services that pharmacists provide outside PBS expenditure’.
‘Pharmacists, like general practitioners and other medical professionals, are required to adhere to the strict protocols to administer the vaccine to the community,’ she said.
‘GPs are concerned around the level of remuneration, and, intuitively, pharmacists are concerned as well, particularly given that they must adhere to the same criteria and, as it stands currently, for less remuneration.’
Ms McBride also paid tribute to pharmacists across the country for their ongoing efforts during the pandemic.
‘I would like to acknowledge my fellow pharmacists, who have made a considerable contribution on the front line, staying open and offering critical services when many other primary care providers were closed – hospital pharmacists managing supply and aged-care pharmacists providing telehealth services,’ she said.
‘For many of our most vulnerable Australians who have been forced into isolation, pharmacists have often been the only health professional they've had contact with.’
More information on the COVID-19 vaccination training can be found here.
[post_title] => Pfizer COVID-19 vaccine training open, AstraZeneca shortly
[post_excerpt] => The first government-funded training modules for the COVID-19 vaccination have been released, as federal Minister for Health Greg Hunt confirms the rollout will begin later this month.
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[title_attribute] => Pfizer COVID-19 vaccine training open, AstraZeneca shortly
[title] => Pfizer COVID-19 vaccine training open, AstraZeneca shortly
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[post_content] => People with diabetes need to constantly monitor their diet and weight, which can lead to a difficult relationship with food. And when body image is thrown into the mix, the situation can be more problematic.
A recent article from the ABC highlighted the prevalence of eating disorders in people living with diabetes, who may resort to dangerous tactics to control their weight.
Credentialed diabetes educator and pharmacist Angelica Rostov MPS said that because insulin can cause weight gain, impressionable young patients with type 1 diabetes may skip or reduce their insulin without supervision – a practice dubbed “diabulimia” – or engage in self-induced vomiting to keep slim.
The prevalence of underlying anxiety and depression in people with diabetes can further contribute to disordered eating, Ms Rostov said.
A lack of knowledge
It is common for patients living with diabetes to have a skewed understanding of what healthy eating to manage their condition looks like.
‘Patients will often have their own ideas when it comes to their diet,’ Ms Rostov told Australian Pharmacist.
‘Some might think it’s best to go gluten free, which will not control their diabetes, or others will become a vegetarian, which may lead them to seek sustenance by increasing their carbohydrate intake.’
Ms Rostov said some of her patients seek dietary advice via unauthorised online sources, social media or family and friends that is not catered to their type of diabetes and can therefore impact their condition.
The focus on when, what and how to eat can also influence how patients feel about food, according to the National Diabetes Services Scheme, which can lead to unhealthy fixations and skipped meals.
Pharmacist intervention
Ms Rostov said if a pharmacist suspects a presenting patient may have a comorbid eating disorder with their diabetes, they should initiate a conversation about their care.
‘Pharmacists can inquire whether the patient is seeing a diabetes educator, dietician, endocrinologist or GP, but it’s important not to stigmatise if they appear to be very slim,’ she said.
If they are not managing their diabetes under specialist care, pharmacists could offer to refer them to their GP, or to make an appointment with a diabetes educator or dietician on their behalf.
Ms Rostov said pharmacists can also emphasise the need to take insulin as advised when dispensing the medicine.
‘We try to explain to our patients that if they have continued high blood sugar levels, they risk seriously damaging their health and organs,’ she said.
Directing patients to accredited online diabetes resources, such as the Baker Heart and Diabetes Institute, Diabetes Australia, or their state-run diabetes service can also provide them with some guidance for managing their diet.
‘I always say to patients, “If you want to do your own research please visit government-accredited websites”,’ Ms Rostov said.
‘Baker, for example, has fact sheets, carbohydrate-counting tools and advice from dieticians, and Diabetes Victoria has information about the different types of diabetes, along with prevention tactics, recipes, guidance around eating take away foods and exercise.’
Above all else, however, Ms Rostov said it’s important to tread lightly.
‘If you push these patients, they are unlikely to return or seek the specialist advice they need,’ she added.
[post_title] => Disordered eating common in people with diabetes
[post_excerpt] => People with diabetes need to constantly monitor their diet and weight, which can lead to a difficult relationship with food.
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[title_attribute] => Disordered eating common in people with diabetes
[title] => Disordered eating common in people with diabetes
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[post_content] => In a world of information overload, how can pharmacists prevent patients from falling into a medicine-induced downward spiral?
Every day Australians swallow millions of pills without much awareness of adverse effects or drug interactions.
Problems with medicines are ‘alarmingly common’, according to PSA. The biggest failing in patient safety comes ‘from ineffective communication, rather than a lack of clinical knowledge or skill’, with 250,000 hospital admissions each year for medicine-related problems.1
Yet many people assume that medicines are safe, unless told otherwise. Similarly, many pharmacists and health professionals assume consumers are confident to use medicines safely, unless they disclose pertinent information or ask questions. This clash of assumptions can lead to crucial information gaps that place patients’ health at risk.
Flying blind
Communication gaps and delays are found right across the healthcare system. Often the pharmacist must turn detective to ascertain what consumers know about their medicines – the potential harms and benefits – or if they are taking them correctly, sharing with family and friends, or stockpiling.
Professor Richard Osborne, Director of the Centre for Global Health and Equity at Swinburne University of Technology, says the teach-back communication method is widely used in Australia and internationally by healthcare providers.
Teach-back involves asking the patient to repeat in their own words what a healthcare provider has told them. This ‘checks and balances’ approach puts the onus on the provider to ensure consumers understand their medicines and how to take them safely, Prof Osborne says.
‘If a person can’t recount back accurately, then the healthcare provider can explain it in a different way, maybe using smaller chunks of information.’
And as Deborah Hawthorne MPS, a consultant and general practice pharmacist based in Wangaratta, Victoria, has learned when asking about drug-specific adverse effects during any sort of medicine review, it is useful to build a rapport with a patient by explaining why questions are asked and how some drugs cause certain symptoms to exhibit in the body.
‘If needed, I’ll also ask specific disease-state monitoring questions. For example: “How often do you measure your blood sugar levels at home? Would you mind showing me your book?”
‘If specific issues are identified, I like to raise these with the patient at the interview, as I believe it helps to empower patients to have greater interest in and control over their own health. It also helps to enforce that we are making a plan together, with pharmacist-doctor-patient involvement.’
Professor in Medicines Use Optimisation at the University of Sydney Parisa Aslani MPS, says consumers often accept that prescription drugs may have adverse effects but think that non-prescription and complementary medicines are safe ‘simply because they can buy them off a shelf’.
‘All medications have a risk of harm, even paracetamol,’ she says. ‘Health professionals are fully aware of the harms but consumers aren’t always.’
Every day 9 million Australians take a prescribed medicine, 2 million take non-prescription medicine, and 7 million take a complementary medicine, according to a YouGov Galaxy poll conducted for NPS MedicineWise.2
Health and wellbeing data collected in 2017 by market researcher Roy Morgan found that almost 90% of Australians had taken a medicine in the previous 12 months, with general medicines such as aspirin, paracetamol and ibuprofen the most common, followed by allergy drugs and antihistamines, cold and flu medications, vitamins, supplements and digestive system medicines.3
Prof Aslani advises School of Pharmacy students to obtain a complete picture from consumers of all their medicines. This fact-finding includes consumer awareness of adverse effects, drug interactions, drug and food interactions, allergies, and the complexities of polypharmacy, and requires the pharmacist to have the people skills of emotional intelligence, communication, teamwork and negotiation.
Words matter
Time is also one of the rewards of being a consultant pharmacist, according to Deborah Hawthorne.
‘For an hour or more, we can sit with a patient and get a good feel for their health literacy and general understanding of their medicines – something not always evident in quicker interactions. Another advantage is the ability, generally when meeting a patient for the first time, to ask the most basic of questions. For example: “How many paracetamol tablets do you take on a normal day?”
‘To fully investigate patients’ medicines and disease-state understanding, my consultancy-work interviews, both in the GP clinic and in a patient’s home, follow a rough plan. I also like the conversation to be patient-led where possible, as I find a natural flow will unearth more issues than a one-sided question/answer-type interview.
‘It also allows the patient to say what they want from their medicines. For example: “I wish I didn’t have to take so many (deprescribing hint)”.‘
A patient’s perspectiveDuring a Home Medicines Review, Deborah Hawthorne discovered a patient had seen a television advertisement for [paracetamol] Panadol Rapid and had bought it hoping for relief from chronic back pain. She went through his dose administration aid and his other medicines. ‘It took quite a while to go through everything, e.g. magnesium, [paracetamol] Panadol Rapid, fexofenadine, vitamin D, [docusate] Coloxyl, [dulaglutide] Trulicity (weekly) injections, [glyceryl trinitrate] Nitrolingual Pumpspray, etc,’ the patient told AP. ‘Debbie explained the chemical compound between the [paracetamol SR] Panadol Osteo, which I take 6 a day in my Webster pack (morning, 2 pm and before bedtime), and that by taking the [paracetamol IR] Panadol Rapid it could create a problem in my liver in the near future.’ The patient immediately stopped the [paracetamol IR] Panadol Rapid, and at a later consultation with both his GP and Ms Hawthorne, his nightly temazepam was ceased and [oxycodone/naloxone CR] Targin was reduced. ‘I was advised I could become tolerant to both medications with very little benefit if taken over a long period of time,’ the patient said. ‘Deborah’s expertise and help have been tremendous.’ |
ILWOO PARK MPSManager, Oatlands Pharmacy, Oatlands, Tasmania Tasmania’s Early Career Pharmacist of 2020 finds the teach-back method easier, as a non-native English speaker, to check whether both her pronunciation and her explanation have been understood by her patients. When switching antidepressants, Ms Park says she explains the washout periods, how to be safe, and how many pill-free days are necessary. Then she asks: ‘Did I explain that OK?’ After a usually affirmative answer, she continues: ‘So you took the [fluoxetine] Lovan this morning. Could you tell me when you need to take this new tablet? I would like to check that I didn’t confuse you and keep you safe.’ The answer is often a smile and the response: ‘I won’t take anything for 7 days and will start this new tablet next Wednesday morning. You did well!’ On preventive inhalers for those with asthma who already use a reliever, Ms Park explains the differences between the new preventer and the current blue puffer, emphasises regular use, and demonstrates how to use it. ‘Then I ask: “Did I show you clearly? You can’t just say yes, because it’s your turn next when you show me!” Then I show them one more time.’ Ms Park then talks the patient through the correct technique. ‘So, first? Yap... yap... yes... and hold breath... and yes, what about the lid? The last step? Where’s the water?’ Some people, Ms Park says, recite each step out loud. Then she explains that the new preventer is to be used each day ‘whether you feel good or bad’, and the blue one is for breathing difficulties. She stresses the devices do not replace each other, but with more use, the preventer will mean less use of the blue puffer. ‘You will feel the difference, but not straight away. If not, please come back.’ |
Instead of saying . . . |
Perhaps try . . . |
| Do you have any questions? | What questions do you have? (An example to prompt might be: Have you ever been worried about side effects or drug interactions?) |
| Take four times each day on an empty stomach | Taking a capsule four times a day on an empty stomach can be hard to organise. Can you explain for me how you will fit this into your daily meal routine for the next 5 days? |
| Do you take any other medicines? | This tablet can cause problems with some medicines, particularly antidepressants and diabetes medicines. What other medicines do you use? |
| Have you used this medicine before? | How effective has this medicine been for you in the past? OR If you had to give this medicine a score out of 10, what would it be? |
| Take this tablet every morning | When would you usually take your medicine? |
Assumption . . . |
Safer practice: Assume little to no knowledge with questions like . . . |
| Assuming patients know their medicines well | Why do you use that medicine? How do you take it? What time of day? Is it every day or just when you need it? How do you remember to take it regularly? |
| Assuming adverse effects are known to the patient | Have you ever experienced muscle soreness? What was the pain like (for muscle issues with statins)? |
| Directing what should happen when specific issues are identified | You’ve taken that PPI for X amount of time, but haven’t had any reflux symptoms for Y amount of time. As long-term use of PPIs can lead potentially to vitamin B12 deficiency and an increased risk of fractures from falls, would you be open to reducing the PPI dose, making it ‘when required’ or ceasing it altogether with an antacid or H2 antagonist on hand if needed? |
| What other medicines and natural supplements do you take (of which the GP may be unaware)? | Have I forgotten to ask about other medicines you might use? What others – vitamin supplements, puffers, creams, etc – do you use? What do you use for pain, say, for a headache or sore muscles? How often do you use these products? Have you bought anything else from the pharmacy lately? |
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[post_content] => Case scenario
Mary, 73, a regular customer at your pharmacy, presents with an injury to her ankle that has resulted in some torn skin and bleeding. She knocked her ankle in the supermarket across the road. What assessment should you make, and what management advice should you give? Is referral to a doctor appropriate?
Learning objectivesAfter reading this article, pharmacists should be able to:
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People with aged and fragile skin are at increased risk of skin tears, a significant problem for patients and the healthcare professionals who treat them. Skin tear wounds can be painful, causing distress and affecting quality of life. They can result in hospitalisation and prolong a hospital stay, and are often preventable.1–3
The International Skin Tear Advisory Panel defines a skin tear as ‘a traumatic wound caused by mechanical forces, including removal of adhesives.’1,3
Mechanical forces causing a skin tear injury are commonly shear, friction or blunt trauma, resulting in the separation of the skin layers, which can lead to the creation of a flap of skin.2 The classification of a skin tear is based on the extent of skin flap loss.1,2
A skin tear injury can occur on any part of the body, but it most commonly occurs on the extremities – hands, arms and lower legs.3 Up to 80% of skin tears occur on hands and arms.3 If not treated correctly, infections can occur and the injury can become a chronic complex wound, particularly on lower extremities and/or in patients with comorbidities.1,3
Individuals at risk of skin tears because of fragile skin include the elderly, the critically or chronically ill, neonates and paediatric populations.1 Skin tears are the most common wound in elderly patients, accounting for almost 55% of all wounds, according to Australian research. Incidence is increasing as the population ages.4
In aged care facilities, the incidence ranges from 2% to 92% annually, with a lower incidence in the community – 2% in men and 5% in women.3,4 The injury is more common in women, as decreased oestrogen levels after the menopause affect wound healing. Women’s greater life expectancy also increases the risk.4
Skin tear injuries are often under-recognised and under-reported in clinical practice.3 The World Health Organization states that it is important to correctly identify a skin tear so it can be treated appropriately. Standardised terminology is essential.3
Pharmacists should be able to identify and assess a skin tear injury, provide recommendations on its management, and refer for medical attention when appropriate.4,5 Treating a simple skin tear with wound cleaning and use of bandages is simple and effective.4 In addition, pharmacists can advise patients and carers on strategies to reduce the risk of developing skin tears, including safe patient handling techniques, limb protection and avoidance of potential irritants (e.g. alkaline soap).6 Use of moisturisers may help protect the skin.4
BOX 1 – Dressing selection|
ISTAP skin tear type |
Dressing |
Indication |
Considerations |
|
Types 1, 2 or 3 |
Silicone foam dressing |
Moderate exudate Longer wear time (2–7 days depending on exudate levels) |
A silicone wound contact layer May need a secondary cover dressing appropriate to amount of exudate Mesh maintains moisture balance and is useful in minimising damage on removal |
|
Types 1, 2 or 3 |
Silicone mesh |
Dry or exudative wound |
|
|
Types 1 or 2 |
Skin glue |
To approximate wound edges |
For experienced practitioners |
|
Types 2, 3 |
Hydrogel |
To create a moist environment |
For necrotic, sloughy or painful wounds Non-adherent; needs secondary dressing e.g. foam |
|
Type 3 |
Foam, mesh or hydrogel |
Choose based on wound characteristics |
No need to protect flap |
References: Wounds International,3 eTG: Skin tears,11 eTG,12 AMH Aged Care Companion13
Identification
Experts have stressed the importance of differentiating a skin tear from the general term ‘laceration’, which is defined by soft tissue tearing.3
Mechanical force causing a skin tear injury can result in partial or full separation of the skin’s outer layers and, commonly, creation of a flap of skin. Separation of the epidermis (top layer of skin) from the dermis (lower layer) is a partial thickness wound, while separation of both the epidermis and the dermis from the underlying structures is a full thickness wound.3 The injury’s severity varies by depth, but it does not extend through the subcutaneous layer. See skin layers in Image 1.
Classification
The International Skin Tear Advisory Panel (ISTAP) classifies a skin tear according to the severity of skin loss1:
Australian practitioners may also use the validated Skin Tear Audit Research (STAR) classification system, which takes into account colour distinction.2,3,7 Pale, dusky or darkened skin or flap colour may indicate ischaemia or haematoma, which can affect skin or flap viability.7
Skin tears can be considered uncomplicated (heal within 4 weeks) or complicated (chronic/complex).3
Causes vary and may not be apparent on presentation. Mechanical force (shear, friction or blunt trauma) resulting in a skin tear can occur during daily activities such as dressing and bathing, bumping into furniture or other objects, falls, patient transfers, and use of wheelchairs and mobility aids. Healthcare workers can inadvertently cause skin tears when handling patients or removing adhesive bandages and tapes.3,4
Many factors increase the risk of skin tears. The most common characteristics of persons with skin tears are a history of skin tears, impaired mobility and impaired cognition.4
Older people are susceptible to skin tear development because ageing skin is weaker, drier, thinner and less elastic.3,4 Skin cannot regenerate as easily and the immune system is less efficient, resulting in greater risk of skin breakdown from any trauma or small amount of force. Care of an older person’s skin should be a priority for healthcare professionals.3
Skin changes with ageing3,8:
Individuals dependent on help with daily activities (e.g. mobility, washing, dressing) are more likely to suffer skin tears. Agitated behaviour (e.g. by those with mental health conditions) can also increase risk.4
To determine a patient’s risk of skin tears, assessment should include the patient (general health, mobility), the wound (fragility of skin, previous tear) and the environment (hazards).3
If untreated, there is a risk of complications such as delayed wound healing, local infection, cellulitis or general sepsis.1
IMAGE 2 – ISTAP type 2 skin tear
The first step in managing a skin tear is assessment of the wound and surrounding tissue.10 Document the characteristics of the wound, classification, size, exudate, skin flap loss, and presence or absence of infection.11 Accurate assessment is essential for effective management of the wound.3
It is useful to categorise the skin tear with a validated classification system – the ISTAP or the more involved STAR.3
Initial management depends on the degree of tissue trauma.11 The aim of treatment is to preserve the skin flap, maintain the surrounding tissue, re-approximate the edges of the wound (i.e. close the wound), and reduce the risk of infection and further injury.3,13
Management of a simple skin tear
The management of a simple skin tear (ISTAP type 1) is within a pharmacist’s scope of practice.6
Control any bleeding by6,11:
Wash and decontaminate the area, including2,6,12:
Attach elastic wound closure strips (without tension) to hold any viable skin flaps6:
Apply a small amount of amorphous hydrogel (as moisturiser).6 If there is a loss of epidermis, apply silicone tulle to the open area and cover with a two- or three-layer foam dressing. Use a light cohesive bandage to keep the dressing in place:
Management of a skin tear flap
When the skin tear involves skin loss, the patient needs to be referred for the flap to be managed (see Table 1).11
Continue to monitor the wound for signs of infection and loss of skin flap viability.11 Significant improvement is expected within 7–14 days. The patient should be referred for specialist advice if healing is not progressing as expected.3,11
If untreated, a skin tear can lead to complications such as delayed wound healing, local infection, cellulitis or general sepsis.1
Other interventions for skin tears
Other management strategies include3,10,11,14:
Refer to eTG: Skin tears11 for more information.
A skin tear dressing should provide a moist wound environment, manage exudate, minimise pain and not cause further trauma to the wound on application or removal.11 The dressing is chosen according to the wound characteristics.5,11,13 A silicone-based dressing is commonly used with the addition of a hydrogel dressing if the area is at risk of drying out.11,13 See Table 1, p52 for information on dressing types.
Skin tears are usually not deep,3 and aged skin is fragile, so sutures, staples, skin closure strips (e.g. Steri-Strips) or adhesives should not be used.3,11 Alginate dressings should be avoided as primary dressings on bleeding wounds because they can adhere to the wound.11 International experts recommend against iodine-based dressings as they dry the wound, increasing the risk of skin tear development.3
After applying the dressing, mark it using a felt-tip pen with the date of application and an arrow to show the direction in which it should be removed, to help prevent further damage on removal.11 See Image 3. The frequency of dressing change is guided by the wound’s condition, including exudate management.3 The dressing should be reviewed after 24 hours, and if a skin flap is present, aim to leave the dressing for at least 5 days so the flap can reconnect. Silicone mesh dressings can be left in place for 2 weeks.11
IMAGE 3 – Marking a dressing
If a patient presents to a pharmacy with a skin tear, the pharmacist should make a clinical assessment on whether a simple wound can be managed in the pharmacy or by the carer at home, or whether a more significant tear should be referred for medical attention.
Skin tear wounds need to be monitored for changes requiring referral. Dressings should be changed more frequently if there are signs of infection or changes such as increased exudate, pain, erythema or loss of skin flap viability. If the wound hasn’t significantly improved within the expected 7–14 days, the patient should be referred back to their doctor.3,5,11 Referral is also appropriate to manage complications (e.g. persistent bleeding) or comorbidities that may exacerbate the condition.11
Identifying at-risk patients by completing a skin assessment on admission to an aged-care facility is crucial in the prevention of skin tears.3
Most preventive measures are common sense, such as eliminating trip hazards and removing dressings gently. Other strategies include padding furniture or equipment (e.g. wheelchair, bed rails) and ensuring a well-lit environment without obstacles. A patient could be encouraged to avoid tight clothing and wear protective clothing—socks or shin guards, long sleeves and pants.4,12
Carers should be gentle when handling a patient’s skin. Carers should avoid wearing jewellery and keep their nails short to reduce the risk of skin tears.3,12
Avoid skin irritants such as alkaline or fragranced soap, and aqueous cream BP because it contains sodium lauryl sulfate, which can increase skin thinning and dryness.6
As dry, ageing skin is susceptible to skin tears, skin protection is important. Preventive measures include reducing the patient’s sun exposure, using products that are pH-balanced and contain emollients, minimising frequency of bathing and ensuring bath water is not too hot, gently patting skin dry with a soft towel instead of rubbing, and regular moisturising.3
A West Australian study demonstrated the effectiveness of twice daily moisturising on extremities in aged care residents, with a 50% reduction in skin tear incidence.4
For other strategies, refer to Caring for ageing skin in AMH Aged Care.13
The pharmacist is an integral member of the healthcare team, able to provide advice on the prevention and management of skin tears, including the risk associated with some medicines, avoidance of irritants, appropriate dressing choice and use of moisturisers.
If the pharmacist has provided first aid for a simple skin tear, they should consider if tetanus vaccination is needed. The patient should be offered analgesia and referred for medical attention if appropriate.
The pharmacist can provide education to patients/carers on risk factors for skin tear development, preventive strategies, skin hygiene and moisturising, and appropriate use of dressings, including adhesives and non-adhesive products for securing dressings.5
Resources
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As the most common wound in older adults, a skin tear needs to be managed effectively with correct identification, evidence-based decisions and appropriate dressing selection to facilitate healing and reduce risk of complications. Pharmacists have a role to play in providing advice on management strategies and use of preventive measures in those at risk.
Case scenario continuedYou examine the wound, assess Mary’s condition and decide to give first aid. You know she has mild hypertension, and keeps very well despite appearing a little unsteady on her feet. She has a mobility aid, but doesn’t use it. Her medication regimen consists of irbesartan daily, low-dose aspirin daily and paracetamol when required. With your sterilised, gloved finger you apply gentle pressure to the wound until the bleeding stops. You wash the area with saline and diagnose a simple skin tear. After attaching an elastic wound closure strip (without tension) to hold the skin flap in place, you cover it with a light cohesive bandage. You suggest she take 2 paracetamol 500 mg tablets to help with the pain, and you check when Mary last received a tetanus vaccination. You ask her to come back within 7 days so you can check the healing progress, and you advise her to see her doctor if any signs of infection develop. |
ANN WINKLE BPharm, BArts, AACP, MPSis a contracting and accredited pharmacist with extensive experience in developing and delivering education programs to GPs and pharmacists. Ann has previously worked for PSA on the National Resource Development team, NPS MedicineWise as a facilitator and as a clinical hospital pharmacist.
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[post_content] => Case scenario
Melissa has come into your pharmacy with a prescription for metronidazole for her daughter, Isabella (17 years old), for a gastrointestinal infection. Melissa explains that Isabella is a competitive swimmer and has a major competition next week. She is concerned that the antibiotic may be a banned substance.
Learning objectivesAfter reading this article, pharmacists should be able to:
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The use of drugs (prescription, non-prescription and recreational) by athletes for medical, recreational and performance-enhancing purposes in both competitive and non-competitive sports is common.1,2 Despite little evidence, there is a common belief that certain medicines will lead to enhanced sports performance.1 Athletes may also use medicines for legitimate medical purposes. Medicines commonly used by athletes include non-steroidal anti-inflammatory drugs, antibiotics, and medicines for the management of chronic medical conditions (e.g. hypertension, depression and asthma).3 Pharmacists have an important role to play in providing advice to athletes, coaches, management teams and other health professionals on the appropriate use of medicines and supplements in sport.2,4
The misuse of drugs in sport has been a long-term problem, going back to ancient times before the introduction of organised sport.5 ‘Doping’ is defined as the ‘use of drugs or other substances for performance enhancement’.5 Performance-enhancing drugs include prescription medicines, recreational drugs and dietary supplements.5
BOX 1 – Reasons for drug misuse by athletes|
Performance enhancement |
|
|
|
|
|
References: Reardon5; AMA6
The incidence of substance misuse by athletes varies based on the substance used, sport and type of athlete. A 2014 publication identified that 2% of elite athletes competing in different sports had used a substance that was banned by the World Anti-Doping Agency (WADA). Anabolic steroids had been used by 9% of professional football players at some time in their career, while 3% of college athletes had used stimulants in the previous 12 months.5While performance-enhancing drugs may give athletes an unfair advantage when competing, many banned substances also carry risks to athletes’ health.6 For example, there is a risk of cardiovascular complications occurring from the use of erythropoietin or stimulants, and a risk of cancer with the use of growth hormones.7 The level of risk can be drug and dose-dependent.5
While gaining a competitive advantage is one reason why athletes may use substances, they may also be used for other reasons (see Box 1). Athletes may be at a higher risk of having undiagnosed or untreated mental health conditions, which can also be precipitated and/or caused by substance abuse.5 A survey of athletes at the Australian Institute of Sport found that athletes were significantly more likely to experience ‘high to very high’ levels of psychological distress compared to the general community.8
WADA, an independent international agency, is responsible for maintaining the World Anti-Doping Code, a document that incorporates anti-doping policies from all countries and sports.9 The WADA Prohibited List is a list of substances and methods banned for use by athletes, and is updated every year.2 Sport Integrity Australia adopts the principles of the WADA Code, and complies with the WADA Prohibited List.10
The decision on whether a substance should be prohibited is based on fulfilling two out of three criteria4,7:
Substances on the list may be prohibited at all times (both in an out of competition) or during competition only. Certain substances are only prohibited in particular sports.4,7 Substances included in the WADA Prohibited List are outlined in Table 1.
TABLE 1 – WADA Prohibited List 2020–21
|
Substances prohibited at all times |
Substances prohibited during competition |
Substances prohibited in particular sports |
|
|
|
|
||
|
||
|
||
|
||
|
References: WADA11; WADA12 A complete list of substances within these categories and further information about WADA can be found at: www.wada-ama.org/en
The WADA Prohibited List includes substances from a range of therapeutic classes. While there is evidence that a number of drugs misused by athletes can enhance performance, other drugs have little evidence to support their benefits for this purpose.1 Ongoing research is therefore needed to assess the impact of drugs in sport.6
The following are examples of substances prohibited for use in sport.
This group includes exogenous testosterone, synthetic androgens, androgen precursors and selective androgen receptor modulators. Higher levels of testosterone increase muscle mass and strength.5 Anti-oestrogens, such as tamoxifen, and aromatase inhibitors, may be used to increase serum testosterone. However, there is no strong evidence to show they increase muscle strength.5
Oral beta agonists may reduce body fat, reduce protein breakdown and increase muscle. Beta-blockers can reduce heart rate, hand tremors and anxiety, which may be performance-enhancing in sports such as archery and shooting.5
While diuretics do not enhance sports performance, they may be used by athletes to prevent the detection of performance-enhancing drugs.7 They can also be used to promote rapid weight loss for sports such as wrestling and boxing.5
Recombinant human growth hormone has been shown to increase muscle mass and reduce adipose tissue. Growth factors, including insulin-like growth factor and insulin, are assumed to have similar effects.5
Stimulants have been shown to improve endurance, anaerobic ability, reaction time and alertness, and to reduce fatigue and assist with weight loss.5
Blood transfusions, erythropoiesis-stimulating agents, hypoxia mimetics (e.g. desferrioxamine and cobalt) and artificial oxygen carriers have been used to increase oxygen transport. Erythropoiesis-stimulating substances have been shown to increase exercise tolerance and aerobic ability.5
Alcohol, cannabinoids and narcotics may be used to reduce anxiety, and narcotics may be used for pain relief while training or competing.5
Dietary supplements may be taken by athletes to enhance performance. International research has identified the most common supplements taken by athletes include protein, vitamins, weight gain powders, amino acids, creatine and caffeine.13,14
As regulations by the Therapeutic Goods Administration (TGA) for these supplements are less stringent than those for regulated substances (e.g. prescription medicines), there is a risk that these supplements may contain ingredients not listed on the label. This poses not only a health risk, but also the risk that athletes may inadvertently consume a prohibited substance.6
An Australian survey in 2016 found that one in five supplements tested contained at least one prohibited substance.15
The Australasian College of Sport and Exercise Physicians recommends a ‘food first’ approach to fulfil nutrient needs. If the use of an evidence-based supplement is needed, athletes should only use these on the advice of a sports dietitian, sport and exercise physician or other practitioner experienced in sports nutrition.16
Sport Integrity Australia advises that no supplement is safe.15 In the event that supplements are taken by athletes (e.g. on the advice of a sports dietitian), it is recommended that only supplements that have been screened for prohibited substances by an independent company be used. This reduces the risk that an athlete will use a prohibited substance, but does not eliminate it completely.15
The TGA announced that from November 2020, particular sports supplements will be regulated as therapeutic goods (medicines). Supplements will be included in this category if they claim to improve sports performance and contain: an ingredient listed in a Schedule in the Poisons Standard, a substance included in the WADA Prohibited List, or substances identified as being a risk to consumers.17
Sports supplements which intend to be marketed as ‘foods’ will need to change their product claims, ingredients and dosage forms where needed. Those that will remain as ‘medicines’ will need to be included on the Australian Register of Therapeutic Goods (ARTG) as listed or registered medicines.17 A consumer fact sheet about this change is available on the TGA website (www.tga.gov.au/community-qa/sports-supplements-declared-be-medicines).
A Therapeutic Use Exemption (TUE) can be requested when a medicine on the WADA Prohibited List is required to be used by an athlete for medical reasons for which there is no appropriate alternative.1 The exemption is assessed and decided on by the Australian Sports Drug Medical Advisory Committee (ASDMAC), an independent panel of medical practitioners.6 The ASDMAC approves the use of a prohibited substance by an athlete if his or her sport allows an athlete to obtain approval to use a prohibited medicine for a legitimate medical reason and the TUE contains medical evidence covering each of the WADA criteria needed for permitting an exemption.18 The exemption will only be granted if it will not provide an unfair advantage over other athletes.19
An application for a TUE may be made in advance (prior to using the substance) or retrospectively.19 Further information about the sports and criteria for athletes requiring a TUE prior to use of a substance can be found on the Sport Integrity Australia website (www.sportintegrity.gov.au/resources/therapeutic-use-exemption/advance-therapeutic-use-exemption).
A retroactive TUE may be approved if a substance is required for emergency treatment or to treat an acute medical condition. In exceptional circumstances, the rules allow the athlete to apply for a retroactive TUE, if WADA and ASDMAC agree that this is fair.19
BOX 2 – FIP recommendations for pharmacists to ensure appropriate use of drugs in sport
|
|
|
|
|
|
Reference: FIP 7
If a TUE is granted for a medicine, there is usually a maximum therapeutic dose that can be prescribed. A dose much higher than the accepted maximum dose may indicate that the medicine is being used for a performance-enhancing effect.7
Pharmacists are recognised internationally as playing a key role in promoting the appropriate use of medicines and supplements by athletes, including at major events such as the Olympic Games.13 Pharmacists have demonstrated their ability to collect specimens from athletes for drug-testing, and to educate colleagues about drug use in sport.13
The International Pharmaceutical Federation (FIP) guidelines, The Role of the Pharmacist in the Fight against Doping in Sport, outlines ways pharmacists can be involved in anti-doping in sport (see Box 2).7
Pharmacists need to recognise situations when athletes and others may be inappropriately using substances. This is relevant not only to elite athletes, but also to school students, body builders, and aspiring athletes.6,7 The use of prohibited substances may occur during competition or while preparing for an event.7 The inadvertent use of prohibited substances by athletes, with serious consequences, also occurs.20 Many athletes and coaches have limited knowledge about medicines and supplements, and depend on the advice of health professionals, such as pharmacists, to ensure appropriate use.2 Athletes see pharmacists as a valuable source of information about medicines and supplements, and trust their advice.13
Pharmacists can also provide advice and guidance to athletes, coaches and management teams on the use of medicines and supplements.4 This includes advising athletes against the use of medicines for non-medical purposes. Athletes who participate in competitive sport should be educated to check the medicines they take against the WADA Prohibited List. Pharmacists must also perform checks using the Global Drug Reference Online (Global DRO), an online checking tool based on the WADA Prohibited List, when dispensing or recommending medicines to athletes (www.globaldro.com/AU/search).6,21
In the event that an athlete has been prescribed a medicine on the WADA Prohibited List, the pharmacist should contact the prescriber and determine whether an alternative medicine could be used. If this is not possible, the athlete and prescriber must request a TUE.4
Pharmacists can also advise athletes requesting dietary supplements and other complementary medicines. This includes advice on products that may contain ingredients not listed on their labels, including banned substances, which can lead to positive drug tests.6
Sport Integrity Australia outlines the three As for athletes considering using supplements15:
Athletes may develop substance use disorders, similar to those of the general population.5 Pharmacists have a role in identifying individuals who may be misusing substances, and providing support and referring to a medical practitioner to receive the correct treatment.6
A survey of Australian pharmacists found that although the majority believed that pharmacists have an important role to play in educating athletes to avoid unintentional drug misuse, only 29% believed they had appropriate knowledge to be able to advise athletes,2 which is similar to findings internationally.13 The authors suggested that further upskilling in this area could support pharmacists in providing advice to athletes.2 Other research has also noted a lack of educational opportunities for pharmacists in this area.13,14 See Resources for education opportunities available for pharmacists in this area.
Resources
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Athletes may use medicines and supplements for both medical and performance-enhancing purposes, and there have been numerous cases where athletes have inadvertently used banned substances. The WADA Prohibited List outlines substances that are prohibited to be used by athletes both in and out of competition. Pharmacists have a key role to play in providing advice and education to athletes, their support team, and to other health professionals about the appropriateness of using medicines and supplements, and a variety of resources are available to pharmacists to fulfil this role.6
Case scenario continuedYou check metronidazole using Global Drug Reference Online, and reassure Melissa that metronidazole is not a prohibited substance in swimming, either in or out of competition.21 You also offer to make a note in Isabella’s dispensing record that she is a competitive swimmer, so that you and the other pharmacist in the pharmacy can check any other medicines she may be prescribed in the future. Melissa is grateful for your advice and assistance. As her daughter has been unwell, she is also wondering whether she should be taking a multivitamin to increase her energy. You explain the risk of supplements potentially containing banned substances that are not listed in their ingredients, and advise that obtaining nutrition from foods is preferable. You recommend that Isabella talk with her doctor or a sports dietitian if she has any concerns about her nutrition. Melissa appreciates your advice and agrees to discuss this with her daughter’s doctor next week. |
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Mr Chin, a 65-year-old male, returns to your pharmacy with a repeat for cefaclor 375 mg MR tablets; the original prescription was dispensed 3 months ago. Mr Chin looks unwell. He has a cough, is having trouble breathing and he tells you he has a fever and chills. He is a smoker (10–15 cigarettes/day) and his past medical history includes chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidaemia and gastro-oesophageal reflux disease. His current medicines are perindopril, atorvastatin, Trelegy Ellipta and pantoprazole. He has no known allergies. He tried to see his GP today but wasn’t able to make an appointment.
You feel it is inappropriate to dispense the cefaclor prescription from 3 months ago and call Mr Chin’s doctor to advise him of your concerns. The doctor tells you he can see Mr Chin today.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Pneumonia is the second leading cause of morbidity and mortality worldwide.1 In 2018, pneumonia was the 12th leading cause of death in Australia.2 The introduction of Haemophilus influenzae B and multivalent pneumococcal vaccines has significantly reduced the overall burden of bacterial pneumonia.2
Pneumonia is defined as inflammation of lung tissue caused by a bacterial or viral infection.3 Specifically, it is the parenchyma, the functional tissue of the lungs, that is affected, as opposed to connective or supportive tissue.3 The infection causes inflammation. Fluid and pus fill the alveoli, making breathing painful and limiting oxygen exchange.3
Pneumonia can affect people of any age. A significant proportion of worldwide deaths from pneumonia are in children under the age of 5 years.1,4 People at higher risk of infection include infants, the elderly, those with chronic health conditions, the immunocompromised, smokers and Indigenous Australians.5,6
Pharmacists can identify individuals at risk of pneumonia and advise them of preventive measures. These measures include vaccination, ensuring continuity of care, and collaborating with other healthcare professionals to ensure that antimicrobial stewardship principles are implemented and abided by for optimal patient outcomes.
Pneumonia is usually classified according to the environment in which it is acquired.7 It may also be classified by the type or location of the infection within the lung and the severity.7
Community-acquired pneumonia (CAP) is defined as pneumonia that develops in patients living in the community (including residents of aged care facilities) or those who have been in hospital for <48 hours.7,8
Patients who have been in hospital for longer than 48 hours and develop pneumonia are classified as having hospital-acquired pneumonia (HAP).7,8 This classification excludes patients who were incubating the bacteria on admission.7 Prolonged bedrest, poor respiratory function or weakened immunity due to illness or trauma increases the risk of developing pneumonia in hospitalised patients.8
Treatment with empirical therapy is dictated by the classification as the most likely pathogens can vary. HAP is more likely to involve bacteria that are resistant to first-line antibiotics, further complicating treatment.7 Additionally, as later onset HAP can be caused by either community-or hospital-related pathogens, it may also be resistant to empirical treatment.9
Patients requiring mechanical ventilation and intubation for a period greater than 48 hours are at risk of ventilator-associated pneumonia (VAP). This is due to intubation interrupting the bodily mechanisms that work to minimise bacterial contamination of the airways.8 A person with CAP who requires mechanical ventilation should continue to be managed for CAP.8 Those who develop pneumonia after being ventilated in hospital will likely have similar pathogens to those implicated in HAP, and are treated as per HAP protocols.5
There are more than 100 potential microorganisms that may cause pneumonia. Even after extensive microbiological testing, the causative organism is not identified in up to 50% of cases.10
The most common cause of pneumonia is bacterial, Streptococcus pneumoniae. It is the predominant organism and is responsible for most deaths.8 Aspiration of bacteria from the oropharynx is a cause of pneumonia in many cases.8
Pneumonia may also be viral. Distinguishing viral pneumonia from bacterial pneumonia in the community setting is difficult. It is estimated that viral pneumonia is responsible for approximately 25–44% of total pneumonia cases.11 Furthermore, bacterial pneumonia may occur secondary to viral pneumonia, and they may also coexist.
Pneumonia caused by mycoplasma, also referred to as atypical pneumonia or ‘walking pneumonia’, presents with different signs and is usually milder and more gradual in onset.12,13
Table 1 and Table 2 list some of the pathogens responsible for community-and hospital-acquired pneumonia.
Both lifestyle factors and underlying medical conditions may predispose individuals to developing pneumonia. Patients with respiratory disease, such as asthma or COPD, and those with chronic heart disease and diabetes, are particularly vulnerable.5
Smoking, including passive smoking, also significantly increases the risk of developing pneumonia. Smoking reduces respiratory defence mechanisms and increases adhesion of microorganisms to epithelium tissue in the lungs.6
Patients with chronic renal and liver disease are also at high risk of developing pneumonia.5 High alcohol consumption is associated with increased risk by impairing immune response and increasing risk of aspiration.10 The risk of aspiration is further increased with neurological conditions such as dementia, stroke, Parkinson’s disease and conditions such as gastro-oesophageal reflux disease.5,10
Medicines associated with an increased risk of developing pneumonia include14–19:Pneumonia symptoms usually differ from those of other common respiratory infections, such as acute viral bronchitis.8 Although people with both pneumonia and bronchitis typically present with cough and may have purulent or coloured mucus, the presence of rigors, pleuritic chest pain and tachypnoea are more suggestive of pneumonia.8
Other common symptoms include:
One study identified the presence of one of the following symptoms in combination with lower respiratory tract symptoms as highly predictive of pneumonia: temperature >37.8 º C, crackles on auscultation, oxygen saturation <95% or pulse >100 beats/min.20
For patients residing in aged care facilities, the Loeb Criteria is a useful tool to assist in identifying lower respiratory tract infections that may benefit from antibiotic therapy. The Loeb Criteria takes into account various factors such as age, temperature, pulse, cough, respiration rate and comorbidities.
The McGeer Criteria is a surveillance tool to confirm a previous infection and involves three criteria21:
Both bacterial and viral pneumonia present with some common symptoms, including chest pain and shortness of breath. In order to distinguish between a bacterial or viral cause, an accurate history of symptoms and physical examination are required.
The following lists contain findings that may help differentiation22:
Viral pneumonia
Diagnosis of pneumonia involves the presentation of appropriate symptoms in combination with positive test results. There is considerable overlap between the presentation of pneumonia with other cardiopulmonary or respiratory disorders, such as congestive heart failure, interstitial lung disease, bronchitis and pulmonary embolism.5
The following tests can be used8:
Pneumonia severity and comorbidities will determine the appropriate level of management. A disease severity assessment involves identifying those patients with mild CAP who can be managed in the community and those with more severe CAP who require inpatient management. If a patient is unable to be classified as mild or severe, they are classified as moderate-severity and will need inpatient management.8
Disease severity is assessed using scores, such as the CRB-65, in conjunction with clinical judgement.8 The scores help to guide practitioners to determine if hospital admission is required. Therapeutic Guidelines set the following parameters, based on expert opinion, to help guide clinicians to determine what level of care is required.8
Any one of the following symptoms are suggestive of more serious disease that may require hospital admission8:
Empirical treatment is used for the initial management of pneumonia and is based on symptoms and testing when the exact causative organism is not yet known. Treatment varies according to the following factors:
Pneumonia may be treated with monotherapy or combination antibiotic therapy; combination therapy may be more appropriate if follow-up within 48 hours is not possible.8 For a patient residing in the community, with low severity CAP, management with oral antibiotic therapy may be appropriate.8
Amoxicillin is the medicine of choice due to increased resistance of Streptococcus pneumoniae to tetracyclines and macrolides.8 Cefuroxime is the preferred cephalosporin due to its superior anti-pneumococcal activity.8 Therapeutic Guidelines Antibiotic details other treatment options according to the scenarios.
Oral therapy for patients in residential care may be suitable if the person is able to consume food and liquids and the following parameters are met8:
If there is no response after 48 hours of amoxicillin therapy, beta-lactamase–producing strain of Haemophilus influenzae or Moraxella catarrhalis may be present; clavulanate may need to be added.8
Preventive strategies for pneumonia should be discussed with all people who are at risk. These include immunisation strategies, smoking cessation, medication review to identify medicines that may increase risk of developing pneumonia, and involvement of a speech pathologist for those with dysphagia and at high risk of aspiration.
Pneumonia is a complex condition, which requires comprehensive clinical assessment to determine the best approach to management. The severity of symptoms and comorbidities will determine the most appropriate setting for treatment.
The pharmacist’s role in the management of patients with pneumonia is even more important during the current COVID-19 pandemic; a severe complication of COVID-19 is pneumonia.11 Pharmacists can educate patients about the importance of vaccination, how to manage risk factors, and help identify patients with symptoms that need further medical review. Pharmacists should provide guidance on antimicrobial stewardship principles and ensure appropriate medicines are used for treatment.
Case scenario continuedMr Chin comes back 5 days later and is feeling much better. He lets you know he was diagnosed with community-acquired pneumonia (CAP) and was started on amoxicillin. You take this opportunity to discuss his current medicines during a MedsCheck and suggest Mr Chin has a Home Medicines Review (HMR). To facilitate the HMR, you download the HMR request for referral form from the PSA website. An HMR may aid in rationalising his medicines, and to determine if any medicines are increasing his risk of developing pneumonia in the future. You check Mr Chin’s vaccination status to ensure he is protected against further episodes of pneumococcal pneumonia. You encourage him to get a yearly influenza vaccine and the COVID-19 vaccine. You also discuss his cigarette use and help him to devise a plan for cessation. |
NEIL PETRIE BPharm, MPS, AACPA is a consultant pharmacist based in Melbourne, specialising in Quality Use of Medicines (QUM) in the residential aged care setting.
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Kathleen, 80, has a history of hypertension well controlled with indapamide. She was recently prescribed citalopram 10 mg at night for her low mood. The doctor and pharmacist told her she might notice some fatigue and an upset stomach for the first 2 weeks, but it would then improve.
After 2 weeks on citalopram, Kathleen felt very tired and confused. She had a dizzy spell and a fall when out shopping and was taken to hospital. On arrival, her sodium
was measured at 124 mmol/L.
Learning objectivesAfter reading this article, pharmacists should be able to:
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Although healthcare in Australia is regarded as among the safest in the world, preventable adverse events do occur.1
Australian research of incident reporting in hospitals shows that medicine-related incidents are the second most common type of incident after falls.2 Consequences include suffering and hardship for patients as well as financial costs to the healthcare system.2 Medication errors can occur at many points during a patient’s hospital stay – from admission through to discharge.3 These incidents are caused by system failures and a breakdown in processes due to the complexity of the process and the many steps and individuals involved.3 To combat these problems, good clinical governance is required to enable delivery of safe and effective healthcare.
Clinical governance is defined by the Australian Commission on Safety and Quality in Health Care (the Commission) as ‘the set of relationships and responsibilities established by a health service organisation between its state or territory department of health, governing body, executive, clinicians, patients, consumers and other stakeholders to ensure good clinical outcomes’.1 The purpose of clinical governance is to ensure systems are in place that will promote continuous improvement of services and high standards of care.1 It requires clinical leadership, teamwork, a patient focus and good data.1
The Commission was established by the Council of Australian Governments to lead and coordinate programs and provide information and resources to improve safety and quality in healthcare.2 It has developed a National Model Clinical Governance Framework3 for public and private healthcare organisations providing acute care based on the National Safety and Quality Health Service (NSQHS) Standards.3,4 The Standards were developed by the Commission in consultation with the Australian Government, states and territories, the private sector, clinical experts and patients and carers.4 They describe the quality of care that should be provided by a health service and the systems needed to achieve that care.4 All Australian hospitals are assessed against the Standards to determine whether they can be accredited.1
State-based Therapeutic Advisory Groups guide and coordinate safety projects based on the NSQHS Standards carried out at the hospital level by Safety and Quality Committees and Drug and Therapeutics Committees. While each department has a dedicated Safety Officer, all health professionals have a role in maintaining safe, high-quality care.
The Medication Safety Standard is one of eight NSQHS Standards and focuses on areas of medication management that are known to be prone to error.5 The Standard is based on the medicines management pathway.5 This pathway describes the steps and activities involved in medicines use (i.e. procurement, prescribing, dispensing, administration and monitoring).6 The pathway provides a method to identify where there is a potential for errors and develops strategies to reduce the chance that they will occur.5
A culture of safety and quality improvement is important to ensure that patients receive safe, high-quality care.1 A positive safety culture derives from strong leadership. It communicates a vision for high-quality care, an engaged workforce, and a working environment which is open, welcomes good ideas and values education and research.3,6 Good clinical governance creates a learning environment which deals with adverse events by creating structures to prevent similar events from occurring in the future.6
The Australian Charter of Healthcare Rights states that patients should be treated with dignity and respect. The Framework acknowledges this by identifying that systems should be in place that encourage patients to be partners in their own care, and that enable healthcare staff to share information with them and work with them to make decisions, set goals and plan their own care.1 Patients should be encouraged to provide feedback, complaints and compliments about their experience through survey participation.1
Medication policies, procedures and guidelines support healthcare staff to use medicines according to best evidence-based practice.5 They may be developed by multidisciplinary teams within clinical units before approval by the Drug and Therapeutics Committee of the organisation.5 They can include the use of a national inpatient medication chart, and the use of electronic medication management, and they should also5:
Implementing a process to record a best possible medication history
Transitions of care, such as admission and discharge from hospital, are recognised as times of high risk for medication errors due to inaccurate and incomplete recording of a patient’s medication history. Studies show that prescribing errors can occur at a rate of two errors for every three patients admitted to hospital.2 Pharmacists have an essential role to play in this area, with a meta-analysis showing a reduction of 66% of patients with medication discrepancies in pharmacy-led medication reconciliations compared with usual care.7
An accurate medication history can be used at every transfer of care to ensure continuity of care and reduce errors and readmissions.8 Timely follow-up with a medication review after discharge for patients at risk of medication-related harm has been shown to reduce hospital readmission.9 Home Medicines Reviews (HMRs), Residential Medication Management Reviews (RMMRs), MedsChecks and the placement of pharmacists in general practice are valuable services to assist with this.9 Outreach hospital pharmacy services, such as the use of hospital pharmacy-prepared interim residential care medication administration charts, have been shown to reduce the risk of missed or delayed medication doses for individuals after discharge from hospital and transfer to residential aged care.10
Managing high-risk medicines
High-risk medicines have a high risk of causing harm if not used correctly.11 Alerts and supporting tools (e.g. protocols, policies, guidelines) on the safe use of high-risk medicines can help to reduce patient harm.11 Medicines commonly recognised as high risk include anti-infectives, potassium, insulin, narcotics/sedatives, chemotherapy medicines, and heparin and other anticoagulants. These medicines can be remembered by the acronym ‘A PINCH’.11 Registers of high-risk medicines used in an organisation should be kept, and ongoing education and protocols for their use should be in place.11
An example of a high-risk medicine guideline is the NSW Clinical Excellence Commission’s Intravenous Potassium Standard Checklist.12 This checklist contains requirements such as having approved protocols, removing concentrated potassium ampoules from ward stock, using premixed potassium solutions and using infusion pumps to minimise the risk of incidents involving potassium. Other examples include:
Incident reporting
Hospital incident reporting systems enable staff to identify and report clinical incidents, near misses and complaints. This allows contributing factors to be investigated and action taken to prevent future events.1 Incident reporting systems should encourage the workforce to recognise and report incidents without the fear of blame and with the expectation of being treated fairly.6 Incident reporting systems should emphasise learning from incidents and making changes to improve safety.
Reporting adverse drug reactions
Adverse drug reactions (ADRs) cause approximately 5% of hospital admissions and occur during hospital stays at a rate of 6–15%.11,14 The rate is higher in the elderly, with one study finding 18% of patients aged over 65 years were admitted to hospital with an ADR.15 They are a major cause of morbidity and mortality and can increase a patient’s length of hospital stay and costs to the healthcare system.9,14,16
The aim of ADR reporting is to prevent re-exposure of patients who have already experienced an ADR and to increase knowledge and awareness of the adverse reactions of drugs among doctors, pharmacists and nurses.5 ADR reporting also contributes to post-marketing surveillance of new medicines.
Reports of suspected ADRs should be comprehensive and include a description of the reaction, an assessment of time of onset and duration of reaction, the date the suspected drug was started and ceased, and any relevant pathology.17 People reporting past ADRs and antibiotic allergy to a pharmacist during the taking of a medication history at admission should be asked about18:
The importance of a detailed report is highlighted in this edition of Australian Pharmacist in the article by Lucas and Lucas on penicillin allergy (p34). They point out that if a person is incorrectly labelled penicillin or cephalosporin allergic and an alert assigned in the hospital alert system, it can result in an unnecessarily restricted choice of antibiotic for a potentially serious infection.19 Alerts should also contain enough detail to allow a treating clinician to assess the severity of a previous reaction and decide whether an antibiotic should be withheld in all circumstances. It is now known that over 90% of reported penicillin allergies can be excluded by skin testing and oral provocation. Also penicillin allergy can wane over time, and 50% of people will no longer be allergic in 5 years.18
In managing an ADR, pharmacists should17:
Pharmacists have a primary role in organising ADR reporting, and evaluating, documenting and increasing awareness of ADRs within their hospital.
Medication review and therapeutic drug monitoring
Clinical medication reviews and therapeutic drug monitoring (TDM) by pharmacists ensure that medicines are administered correctly and at an appropriate dose. This supports the quality use of medicines (QUM).17 Clinical reviews involve reviewing patient-specific clinical information, co-morbidities, biochemistry, and detecting actual and potential medicine-related problems. The pharmacist should then prioritise these issues based on the risk and urgency and discuss these with the prescriber.17 TDM involves measuring, monitoring and interpreting concentrations of certain drugs (e.g. aminoglycosides) to ensure optimum dose and avoid toxicity.17
Quality improvement
Increasing awareness among staff that certain medicines are high risk is seldom sufficient alone to prevent errors occurring.20 Risk-reduction strategies such as self-assessment, forcing functions (conditions that must be met before an action can proceed) and audits that impact on as many steps of the medicines management pathway as possible must also be in place.20
The Medication Safety Self Assessment for Australian hospitals (MSSA) is based on a tool developed by the Institute for Safe Medication Practices in the United States and adapted for Australian hospitals by the NSW Clinical Excellence Commission.21 This self-assessment supports hospitals in assessing the safety of medication structures and systems in their facility, identifying areas requiring improvement, and in recommending actions required to reduce risks.21 Self-assessment is done with the aid of the MSSA workbook, which contains a detailed set of self-assessment items covering patient information, medicines information, communication of medication orders, labelling, packaging, storage, distribution, devices, workflow, staffing, competency and education.21 An online database is available to assist users in recording and analysing their hospital’s self-assessment results.
The National Quality Use of Medicine Indicators for Australian Hospitals has been developed by the NSW Therapeutic Advisory Group for the Commission.22 These sets of process indicators complement the structure indicators from the MSSA by collecting data as part of local quality improvement projects.22 The indicator sets cover antithrombotic therapy, antibiotic therapy, medication ordering, pain management, continuity of care, hospital-wide medication management policies and acute mental health care.17 Data collection tools are available for each indicator. The use of these indicators using clinical audit, analysis and interpretation of data provides information to guide ongoing quality improvement work and to meet the NSQHS Standards.22 The Commission and other state and territory authorities provide help with monitoring tools and information on how to analyse data.22 An example of a QUM audit is the percentage of patients that receive prophylaxis for venous thromboembolism appropriate for their level of risk.22
Medicines use evaluation, formerly known as drug use evaluation, is an activity that measures the appropriateness of medicine use for particular indications/situations. They can be used to compare use with guidelines and to determine whether education or another type of intervention is required to improve use.23
Pharmacists are the natural leaders of medication safety programs as medication safety is integral to the pharmacist’s role. The Society of Hospital Pharmacists of Australia’s SHPA Standards of Practice for Medication Safety (currently under review) state that pharmacists should be at the forefront of medication safety programs and lead the governance of medication safety committees.24 Activities in which pharmacists should be involved include24:
leading programs that can be assessed against accreditation standards (e.g. medication reconciliation, management of high-risk medicines, use of the national inpatient medication chart)
The National Strategy for QUM aims for ‘best possible use of medicines to improve health outcomes for all Australians’.19,25 This can be challenging because, as people age, their medicine use can increase due to an increasing number of chronic conditions. With an increasing burden of disease and number of medicines taken, there is a greater chance for errors and adverse events to occur.27 Added to this is the complexity of hospital care and the large numbers of staff involved from the time a patient is admitted to hospital until after they are discharged. Therefore, effective governance, standards, systems and strategies are essential to prevent errors from occurring. Pharmacists contribute to clinical governance by helping to ensure that harm is minimised through utilisation of their skills, and through providing education and leadership in best practice medicines management.
Case scenario continuedThe emergency department (ED) pharmacist noted the hyponatraemia in conjunction with indapamide and citalopram. The hyponatraemia could be caused by the combination of indapamide and citalopram, or even by citalopram alone. The mechanism is most likely due to the syndrome of inappropriate antidiuretic hormone secretion. After speaking to the ED doctor, citalopram was ceased and Kathleen recovered over the next week. The TGA has received similar reports of hyponatraemia occurring in elderly people who were taking a combination of a diuretic (hydrochlorothiazide or indapamide) and a selective serotonin reuptake inhibitor (SSRI) or serotonin and noradrenaline reuptake inhibitor (SNRI).27 The pharmacist completed an ADR report for the patient. This report was noted at the next meeting of the hospital’s ADR Committee, which actioned an alert to be placed in the patient’s file. Copies of the report were sent to Kathleen’s GP, community pharmacist and the TGA. It was also recommended that this report be noted in the next pharmacy newsletter for staff education. This example highlights the value of a pharmacist completing a medication history. A pharmacist’s knowledge and advice combined with reporting adverse reactions can prevent this event happening in the future. |
MORNA FALKLAND BPharm, MSHP has worked as a Clinical Pharmacist and Medicines Information Pharmacist at the Canberra Hospital. She chaired the TCH Adverse Drug Reactions Reporting Committee.
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[post_content] => In 1945 Australian pharmacologist Howard Florey, together with physician Alexander Fleming and biochemist Ernst Chain, received the Nobel Prize for Physiology and Medicine for the development of the first broadly effective antibiotic, penicillin. The use of penicillin and related penicillin antibiotics is nowadays ubiquitous and has transformed clinical practice, but with its abundant use, patient-reported unwanted reactions to penicillins are also common.
Learning objectivesAfter reading this article, pharmacists should be able to:
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These adverse drug reactions (ADRs) can broadly be classified as Type A (predictable side effects based on known drug pharmacological properties, e.g. gastrointestinal side effects with certain antibiotics), or Type B (unpredictable “idiosyncratic” adverse reactions).1 Type B reactions that are immune mediated are termed drug allergies. ADRs that cannot entirely be explained by either mechanism are referred to as ‘intolerances’.2
In the last 75 years we have made significant progress in our understanding of the pathogenesis of drug allergies; however, this has not translated efficiently into the development of faster and more reliable diagnostics for the distinction of true penicillin allergy from presumed allergy. This is especially true for immunoglobulin E (IgE) mediated reactions which carry the risk of rapid onset, life-threatening anaphylaxis. There are several reasons for this; most prominent are the gaps in our understanding of the biology of IgE. IgE is produced in minute amounts only (hence it is measured in units/litre, not gram/litre), making it difficult to study. Even the most basic of processes behind IgE production, such as the genesis and lifespan of the IgE-producing B cells and plasma cells, are not well characterised.
A second reason concerns the unavailability of stable haptenized penicillins to use in diagnostic assays. The lack of confirmatory assays has resulted in an accumulation of patient-reported, but unassessed, penicillin allergy in our healthcare system.3 This presents a major clinical problem and is being addressed through the use of risk stratification tools in combination with conventional drug provocation and skin testing. Despite our lack of understanding of IgE mediated penicillin allergy, our grasp of T cell mediated reactions to penicillins has made significant steps forward. This review summarises the basics of penicillin allergy and puts into context the latest developments in the field.
Penicillins are small molecules which bind to bacterial transpeptidase enzymes preventing the cross-linking of bacterial cell wall proteins, specifically peptidoglycan molecules. A failure to cross-link peptidoglycans leaves the cell wall porous and unable to resist osmotic pressure, which bursts the bacterium.4 Gram positive bacteria are vulnerable to penicillins during cell division when the bacterial cell needs to expand to encompass 2 daughter cells. Gram negative bacteria possess a lipopolysaccharide outer coating of their cell walls which protects them from penicillins.
Penicillin interferes with transpeptidase activity by mimicking characteristics of the alanine amino acid, which then leads to covalent bonds forming in the active site of the enzyme with the C7 atom of the beta-lactam ring.5 This reactivity also results in penicillin binding to free amino-groups such as lysine present on plasma proteins, disrupting the beta-lactam ring and forming a penicilloyl group (see Figure 1).
The penicilloyl group has novel structural characteristics which can be recognised by both antibodies and T cells. The first encounter of immune cells with proteins or protein fragments containing this group is likely to occur in the context of the bacterial infections that the drug is treating. Under such conditions, the penicilloyl protein complex is not ignored but acts as a hapten. Haptens are small molecules that when conjugated to a larger carrier molecule (e.g. a protein) become immunogenic and drive immune responses.
The Gell-Combs classification has been used since the 1960s to divide allergies into 4 types (Type I–IV) based on their pathological presentation.
FIGURE 1 – Conversion of penicillin to penicilloyl
Type I reactions
A Gell-Combs type I immediate hypersensitivity is initiated by the penicilloyl protein complex being taken up by antigen-presenting cells, which present peptide fragments on major histocompatibility II molecules (MHCII) to naive CD4+ T cells. A naive CD4+ T cell that specifically recognises a penicilloyl peptide will proliferate as penicillin specific type 2 helper T cells (Th2) in the presence of the cytokine interleukin (IL)-4. When these Th2 cells encounter a penicillin specific B cell they respond by secreting more IL-4 and IL-13, which in turn drives the B cell to differentiate into a plasma cell. This results in the production of high levels of penicillin specific IgE antibodies which bind to the surface of mast cells. If the subject is now re-exposed to penicillin, cross-linking of penicillin specific IgE on the mast cell occurs, which triggers mast cell degranulation.
Clinically, IgE mediated type 1 reactions manifest as immediate-onset drug allergy. They occur typically within 1–6 hours after exposure to the culprit drug and present with mild or moderate symptoms such as flushing, urticaria, generalised pruritus and angioedema to severe reactions with airway involvement (throat, tongue swelling, shortness of breath), cardiovascular compromise (hypotension, floppiness in small children) and anaphylactic shock.1
IgE mediated reactions are most commonly assessed by skin prick testing. Intradermal injection of the antibiotic does increase the sensitivity of testing and is used in conjunction with skin prick testing. Skin testing is routinely performed using benzylpenicillin, the minor and major determinants of penicillin, amoxicillin and the culprit antibiotic.6
There are several in vitro diagnostic assays for IgE mediated allergies but they all lack sensitivity. The most common is the test for serum specific IgE by enzyme immunoassay (EIA), ImmunoCAP, formerly known as RAST testing. As the half-life of IgE in serum is 2–3 days, this testing is only useful within 6–12 months after the reaction. The overall sensitivity of this test ranges from 38%7 to 54%.8 False positive results for penicillin V have also been reported.⁹
Increasingly, basophil activation testing (BAT) is being used for the assessment of drug allergy.10 The BAT is a flow-cytometry based assay which measures the activation of the patient’s basophils upon stimulation with the drug allergen. For penicillin antibiotics, its sensitivity is comparable to serum IgE testing. Activation of basophils manifest as an up-regulation of two activation markers, namely CD63 and/or CD203c, and is triggered when the drug allergen can bind to IgE bound on the cell surface of the basophils.
Basophils are the blood circulating counterparts of mast cells and used in this blood assay as a surrogate for mast cells. This assay is time sensitive, work intensive and requires whole blood to test a patient’s basophils; thus, new assays have been developed which use generic mast cell lines instead of a patient’s basophils to probe a patient’s serum for penicillin specific IgE, which will become crosslinked and trigger degranulation following stimulation with penicillin antigen.11
Type II reactions
Gell-Combs type II cytotoxic reactions are the result of a sustained activation of the immune system by penicillin hapten leading to the development of additional classes of penicillin specific antibodies, such as IgG. Circulating hapten-complexes can bind non-specifically to other blood components, such as red blood cells and platelets. These complexes become targets for high affinity penicillin specific IgG antibodies or complement protein fragments. This results in either direct lysis or phagocytosis by macrophages. Both responses can lead to development of haemolytic anaemia, petechia and thrombocytopenia.6
Type II reactions are very uncommon clinically. Sudden onset severe thrombocytopenia due to drug-dependent platelet reactive antibodies has been described with piperacillin, piperacillin-tazobactam12 and amoxicillin.13 Piperacillin and penicillin can also cause an antibody mediated haemolytic anaemia.14 Testing for drug-dependent antibodies can be performed in specialist centres.
Type III reactions
Gell-Combs type III immune complex reactions occur in response to penicillin specific antibodies binding penicillin hapten. Due to their size, these complexes are not able to be phagocytosed.6 They bind the complement C1q molecule to the Fc regions of the antibodies. Due to the quantity of immune complexes formed, they are not able to be cleared from circulation but become deposited, typically, in the walls of blood vessels. Neutrophils which express the FcγRIIIb receptor can directly bind these complexes triggering degranulation, including NETosis (regulated form of neutrophil cell death), causing cell damage and initiating inflammation.
Clinically, these reactions present as serum sickness-like reaction with a delayed onset, typically 1 week after exposure to the antibiotic. High grade fever combines with a range of symptoms, including malaise, arthralgia, myalgia, skin rash, jaw claudication, a high CRP and low complement levels. The diagnosis is often made after other clinical causes, such as an infection, auto-immune disease or lymphoproliferative disease, are excluded. Serum sickness-like reactions have been described with a range of penicillins, including amoxicillin/clavulanate,15 piperacillin-tazobactam and penicillin.16
Type IV reactions
Penicillin hapten can also directly bind to both the widely expressed MHCI molecules and to MHCII molecules expressed predominantly by dendritic cells (DC). The presentation of penicillin hapten by DC can stimulate T cells whose receptor binds the MHC hapten complex with sufficient avidity. Such activated T cells proliferate, circulate in the blood stream and become activated to release cytokines or cytotoxic molecules, such as granzyme B, when they bind the penicillin hapten in blood or inflamed tissues.6 Such T cell mediated reactions take from days to weeks, and thus are also known as delayed type reactions. The clinical presentation of the various T cell mediated reactions is extremely heterogenous and ranges from benign rashes to severe reactions with organ involvement (e.g. interstitial nephritis, drug-induced liver injury) and the severe cutaneous adverse reactions (SCAR; see Table 1).
Delayed Type IV reactions are assessed by skin patch testing, skin prick and intradermal testing with delayed readings (after 48 hours, 96 hours, up to 7 days). In patch testing and skin prick testing the drugs which are applied to the skin, penetrate the epidermis.6 In the case of intradermal testing, the antigen is injected into the dermis. Here, the drug elicits an immune response which leads to swelling of the site, due to the migration of drug specific CD4+ and CD8+ T cells and associated inflammation. Patch testing has a sensitivity of 40% for Stevens-Johnson syndrome–toxic epidermal necrolysis (SJS-TEN). Intradermal testing with delayed reading has improved sensitivity for delayed T cell mediated reactions but is strictly contraindicated for SJS-TEN. In vitro assays, which are performed at specialist centres, include the lymphocyte proliferation assay which measures T cell proliferation after drug/drug-hapten stimulation. Less commonly, interferon gamma secretion by drug stimulated T cells is measured using enzyme-linked immunosorbent spot (ELISPOT) assays or intracellular cytokine staining by flow-cytometry.2
TABLE 1 – Types of T cell-mediated reactions against drugs, including beta-lactams [caption id="attachment_12792" align="alignnone" width="1492"]
IFN = interferon, IL = interleukin, FasL = Fas ligand, GMCSF = granulocyte-macrophage colony-stimulating factor, MPR = maculopapular rash, DRESS = drug reaction eosinophilia and systemic symptoms syndrome, FDE = fixed drug eruption, SJS = Stevens-Johnson syndrome, TEN = toxic epidermal necrolysis, AGEP = acute generalised exanthematous pustulosis References: Demonly et al,1 Blumenthal et al,2 Castells et al6[/caption]
Genetic predisposition
As discussed above, the binding of penicillin hapten to the antigen presenting molecules MHCI and MHCII can lead to activation and proliferation of penicillin specific T cells, leading to T cell mediated tissue damage. There is clear evidence of preferential binding and presentation of beta-lactam containing antibiotics to a restricted set of MHC molecules. In humans the MHC molecules are known as human leucocyte antigen (HLA) molecules, and HLA associations have been revealed using genome-wide association studies (GWAS) which have the sensitivity to identify very low incidence associations with a clinical phenotype. Such studies have revealed that the antigen presenting molecules of patients suffering drug-induced liver injury (DILI) due to amoxicillin-clavulanic acid treatment is probably HLA-DRB1*15:01+,17 and DILI following flucloxacillin treatment is highly associated with the expression of HLA-B*57:01.18 Although it is technically possible to ascertain the HLA type of patients before drug treatments, the low incidence of DILI reactions in the broad treatment population and the low positive predictive value for the presence of these HLA associations (<1% for both drug types) means that such testing is not cost effective and would deny this effective therapy to the many patients expressing these molecules, but not likely to get DILI. However, for patients that subsequently develop clinical symptoms of liver injury, the ability to test for these HLA associations is helpful for a positive diagnosis of DILI.
While all beta-lactam antibiotics contain a lactam ring, they can differ by the presence or absence of an R2 side chain. Penicillins lack an R2 side chain, while cephalosporins have one. Despite the similarities between penicillins and cephalosporins, true cross-reactivity to a cephalosporin in penicillin hypersensitive patients is estimated at less than 2%,19 except for patients with a demonstrated aminopenicillin allergy. These aminopenicillin allergic patients show up to 35% cross-reactivity when challenged with aminocephalosporins,20 suggesting that the allergic determinant is related to the R1 chain structure, rather than the beta-lactam ring. The cross-reactivity described above relates to Type I IgE mediated reactions. The cross-reactivity for Type II to Type IV reactions is less defined. Cross-reactivity to aminocephalosporins secondary to the shared R1 side chain has been described for 2.8–31.2% of non-SCAR Type IV reactions to aminopenicillins.21 In a more recent study of Type IV reactions, including delayed rashes and SCARs, 55.6% of patients with a skin test proven amoxicillin reaction showed cross-reactivity to another beta-lactam antibiotic.22 Thus, the safest recommendation for patients with a previous SCAR due to a penicillin is to avoid all beta-lactam antibiotics.
Currently 13% of Australians in the general population,23 18% of adults, and 5–7% of children in Australian hospitals describe a reaction to an antibiotic. At this point the patient is said to be antibiotic allergy ‘labelled’ (AAL) because alerts are attached to ensuing clinical documentation, and patients are assigned allergy-identifying wristbands. Although this procedure is designed to protect the patient from harm by alerting providers to avoid prescribing a drug that may result in anaphylaxis, studies have shown that about 90% of subjects reporting a penicillin allergy can tolerate the drug after the incident reaction without reaction.24 In Australia the most common culprit antibiotics reported for children and adults are penicillins, which often cannot be otherwise specified, followed by amoxicillin and amoxicillin/clavulanic acid. Incorrect attribution of antibiotic allergy affects patient care directly by limiting choice of antibiotics for any given infection, potentially leading to selection of clinically inferior alternatives, and indirectly by increasing costs associated with alternatives, restricted antibiotic choices, antibiotic resistant infections, increased hospital admissions and length of stay.25–30 Of global importance, antibiotic resistance is associated with the avoidance of narrow-spectrum antibiotics such as penicillin.28,30
The consequences span a lifetime; an AAL acquired in childhood commonly carries through to adulthood. In Australia, the prevalence of AAL is greatest among older patients and patients with complex and chronic illness, including cancer as a disease of ageing, likely reflecting the greater usage of antibiotics in geriatric populations.31–33
Although the clinical and economic benefits of challenging unverified labels appear self-evident, the long-term societal and health sector impacts have not been fully explored,30,34 neither has data linkage been employed in Australia to reveal the granular data required for such an analysis. There is also a pressing need to investigate why, following exclusion of an antibiotic allergy, a number of clinicians and patients are, respectively, reluctant to change prescribing habits, or take antibiotics they have been shown to tolerate.24,35 In order to reduce the burden of AAL, it is not enough to actively challenge clinically unverified labels, it is necessary to understand the drivers of self-reported allergy and the context in which health professionals make the decision to assign an allergy label. Understanding these drivers and factors that enable the maintenance of evidence-based allergy status will lead to targeted education for patients and health professionals at each stage of the patient journey through the health system.
Ideally, everybody with a self-reported penicillin allergy should be investigated; however, this may not be feasible. Therefore, referral for drug allergy testing should be prioritised for patients with likely future need for antibiotic treatment, including those who are immunosuppressed, patients with cancer and chronic diseases or those with multiple antibiotic allergies. A family history of a penicillin allergy alone is not predictive of true penicillin allergy for IgE mediated reactions; it is, however, for SCARs.
The majority of patients will be able to tolerate penicillin antibiotics after appropriate assessment. Dismissing a penicillin allergy after adequate testing is known as “de-labelling”. There is increasing evidence that children and adults with a distant history (more than one year36 or more than 5 years37) of a “benign” rash do not need to be assessed by skin testing. A “benign” rash is defined as a macular or maculopapular rash without systemic symptoms or mucosal involvement.36 These patients can be offered a direct drug provocation test in the outpatient setting, if appropriate management of anaphylaxis can be provided, as the risk of an objective reaction occurring during a low-risk penicillin challenge is low at 2%.
It is important to distinguish a true penicillin allergy from a presumed allergy. Systematic drug allergy assessment is likely to mitigate many of the associated clinical and economic impacts of unverified penicillin allergy. However, unless patients and their health providers grasp the fact that they can now safely take penicillins after their assessment, there is a real danger that they will continue to avoid these highly efficacious medicines. This highlights a critical role for pharmacists in the management of reported penicillin allergy. Pharmacists are the first port of call to report an allergy in a patient, they ensure appropriate documentation is prepared, and can initiate the clinical evaluation of the patient’s allergy.
PROFESSOR MICHAELA LUCAS MD Dr Med FRACP FRCPA is a clinician, scientist, immunologist and immunopathologist at the University of Western Australia and the QEII Medical Centre in Perth. She is the President of the Australasian Society of Immunology and Allergy, and Project Lead in Drug Allergy for the National Allergy Strategy.
DR ANDREW LUCAS BSc, PhD is a biomedical scientist and research fellow in the Medical School at the University of Western Australia. He has expertise in antigen presentation, chemokine biology and allergy.
[post_title] => Penicillin allergy: Where are we up to in 2021? [post_excerpt] => It is important to distinguish a true penicillin allergy from a presumed allergy. Systematic drug allergy assessment is likely to mitigate many of the associated clinical and economic impacts of unverified penicillin allergy. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => penicillin-allergy-cpd [to_ping] => [pinged] => [post_modified] => 2021-03-16 22:36:00 [post_modified_gmt] => 2021-03-16 11:36:00 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=12790 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Penicillin allergy: Where are we up to in 2021? [title] => Penicillin allergy: Where are we up to in 2021? [href] => https://www.australianpharmacist.com.au/penicillin-allergy-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 12793 )td_module_mega_menu Object
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[post_content] => For 93-year-old Patrick Timbs MPS, pharmacy provided a lifelong vocation and the chance to be a passionate community advocate in his hometown of Glen Innes, in rural New South Wales.
Mr Timbs passed away shortly after this article was published in the April 2021 edition of Australian Pharmacist. The PSA would like to extend its sympathies to his family.
How did you get your start in pharmacy?
When I first started out, you had to do a 4-year apprenticeship in order to qualify. I began my apprenticeship at a pharmacy in Newcastle, New South Wales, in 1946, before moving to Sydney in 1947 to attend the University of Sydney and finish up my apprenticeship at a pharmacy in Guildford. After graduating, I moved back to Newcastle until my uncle, who was based in Kyogle, northern NSW, told me that the local pharmacist wanted me to come and work up there.
After 3 years in Kyogle, where I met my wife, who was a nurse at the hospital, we were making our way back down to Newcastle when we passed through Glen Innes to visit my grandfather. He lived next door to a pharmacist, who asked me if I wanted a job.
I worked with him until 1955, when I asked for a raise, which he said he’d think about. When I asked him again a few months later, he said he was still thinking about it, so I went to work for another pharmacy up the road.
The pharmacist in change, Mr Grover, was a remarkable man and mentor who paid me above the award and let me buy the pharmacy at half the goodwill price in 1962. I owned Timbs Pharmacy until I retired about 12 years ago at the age of 80.
You also worked in the hospital?
When I first moved to Glen Innes, the local hospital needed a pharmacist. For 50 years, I would do the morning shift 3 days a week from 7:30– 9:00 am before heading back to the community pharmacy for the day.
I particularly enjoyed the last few years I worked as a hospital pharmacist. I collaborated with the doctors to reduce the number of medicines that patients were taking. I would do a drug profile on a patient and then discuss with the doctors which medicines should be discontinued.
Some of the older patients were on up to 25 medicines before we intervened. As a pharmacist, I think pharmacovigilance is really important, and we don’t always see enough of it.
'The biggest change I’ve seen in my lifetime is the number of new medicines that have been developed to treat specific diseases.'
What are your retirement activities?
Aside from playing golf three times a week, I continued to visit Glen Innes Prison up until recently to provide guidance to some of the young men there. I was a volunteer at the prison for almost 33 years.
What has changed in pharmacy practice since you started your career?
The biggest change I’ve seen in my lifetime is the number of new medicines that have been developed to treat specific diseases.
In the first 20–25 years of my career, we used to have to compound our own medicines – suppositories, pills, ointments and creams were all made up for each patient.
What’s the best thing about working in rural and remote pharmacy?
The service. As accessible healthcare practitioners, the pharmacists in rural and remote areas are required to give patients a lot of medical advice. The practices are all locally owned and operated, and the pharmacists know their patients individually and are concerned about the medicines they take.
What advice would you give to young pharmacists just starting out?
I recommend doing drug profiles on all your patients and establishing a great working relationship with the local GPs. That way, you can easily communicate with them should a patient need to change or add a medicine to their treatment plan.
[post_title] => A long life of service to a community
[post_excerpt] => For the late Patrick Timbs MPS, pharmacy provided a lifelong vocation and the chance to be a passionate community advocate.
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[post_content] => Brendan West MPS was destined to become a pharmacist. After decades as a specialist compounder in Bundaberg, he moved inland to buy a pharmacy in the outback Queensland town of Wallumbilla.
What led you to pharmacy?
Pharmacy is in the family. My parents are pharmacists, and I have aunts, uncles, grandparents and great grandparents who are pharmacists on both sides. When I was younger, I wanted to be a motorcycle mechanic.
It wasn’t until I started my senior year in high school that I thought pharmacy would be a good career path. All that history and watching how my father practised changed my mind. In those days, pharmacists were often stuck in the dispensary, whereas my dad took the time to chat with and counsel patients. He was ahead of the curve, practising forward-pharmacy before it became a thing.
I eventually bought into dad’s pharmacy, which we sold in the mid-’90s, and then I purchased a pharmacy in Bundaberg which seemed a perfect fit – having been there for 120 years.
My family also has a strong background in compounding, which led me to speciality compounding in the early 2000s.
Why did you leave Bundaberg?
I sold up when a big box pharmacy came to town. I was told they would close down three pharmacies in the next 2 years, and mine would be one of them. I worked as a locum for a while and moved back to Brisbane and the Gold Coast to work in some pharmacy chains until 2017.
For a wonderful 2 years I also worked in the Whitsundays for the fabulous Livelife group, until Wallumbilla Pharmacy came up for sale. I always enjoyed rural life. The figures were good, the work conditions excellent and the price very reasonable. I could be my own boss again, not constantly under the watchful eye of a head office.
What are the healthcare differences between the city and the outback?
A large regional centre like Bundaberg provides much easier access to healthcare than a town like Wallumbilla.
My customers regularly travel up to 4 hours to Toowoomba for health services that we took for granted in Bundaberg and Brisbane. I’ve also had to become accustomed to different healthcare conditions, such as Q fever. In this big cattle-producing region, a few patients have presented with it, so I had to learn more about symptomatology and effects.
I’ve had to refresh my knowledge on skin cancer, too. People in Wallumbilla work out in the bright sun for their entire careers, so their skin is often riddled with cancer.
I have to continually stress the importance of getting any lesion checked and help manage their treatment with Efudix cream.The ‘she’ll be right’ attitude of rural men can pose some issues, however. They don’t often seek help for mental or physical health issues and just think things will resolve by themselves.
How do you challenge this indifference?
It’s a case of opening up the conversation and checking their compliance to their medicines, which I’ve got plenty of time to do. I tell them there’s not much point in taking their medicines if they don’t take them properly, or I ask if they want to see their grandkids grow up. My patients tend to respond better to blunt delivery rather than skirting around the issue.
Recent changes in remote healthcare?
The use of telehealth, which was accelerated by COVID-19, has been a huge plus. It has changed things dramatically for my patients, with much better access to healthcare. People on the land can’t always keep appointments. Sometimes it will suddenly start raining and they’re bogged in [on their property], or they need to throw a crop in as that’s their livelihood. With telehealth, they can either take the call from home or come to our local health clinic and have their consultation on the big screen.
Why consider a career ‘out there’?
Rural life is fantastic! The people are wonderful and welcoming, and there’s plenty to do. I met the love of my life living three doors down, a teacher at the local school who was about to transfer back to the coast! She’s staying put now, so the school keeps a wonderful teacher.
You also build real relationships with patients, and all the health professionals, and you are a respected and valued member of the team.
The remuneration is also better. You can still buy a pharmacy of your own for a decent price.
DAY IN THE LIFE of Brendan West MPS, owner, Wallumbilla Pharmacy, Queensland.8.30 am – Starting the dayOpen the pharmacy, do banking and reconcile bank statement against our accounting program. 9.00 am – Admin and antibiotic stewardship Check emails, serve and chat to customers, and check any rainfall! Talk a customer out of buying Chlorsig Eye Ointment for gritty eyes from cattle yards. He insists it previously worked for him, but I convince him Poly Visc is essentially the same without the unnecessary antibiotic component. 10.30 am – Once-a-week deliveries On Tuesdays I drive 40 kilometres to Roma for banking, picking up stock, and delivery of medicines to consumers. A Roma GP has some patients on low-dose naltrexone for fibromyalgia, who are responding well to treatment. I deliver compounds from the lab I set up in Redcliffe, where my son works. Midday – Storytelling to grey nomads As a 4th generation pharmacist, and son of one of PSA’s historians, who lectured at the University of Queensland on pharmacy history, I have up to 300 pharmacy artefacts on display in glass cases, including a pill rolling machine. Grey nomads passing through town love to hear stories of the old days – and always comment on the leech jar. 2.00 pm – Preventing discrepancies Check dose administration aids, request scripts for packing consumers. Liaise between Wallumbilla Hospital registered nurse (RN) and GPs in Roma. A GP visits Wallumbilla once a week, and patients sometimes attend without telling their regular GP in Roma, so there can be discrepancies. 3.00 pm – After-school 'rush' Train after-school assistants and deal with the after-school ‘rush’ hour, where we typically see patients with worms, head lice, colds and mild pain. Recommend a dressing for a wound from pig tusk gash on the calf, via a digital image. Field a call from the hospital about what we have to treat a rash. Many locals still go to the RN for primary care, as this pharmacy has only been here for a few years, so we confer often and have a great symbiotic relationship. 5.00 pm – Heading home Lock up and walk 500 metres home. No traffic woes here! No after-hours work to worry about either. We have enough quiet spells during the day to keep everything up to date – including CPD. |
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[post_content] => Bridget Totterman MPS is a master behind the scenes, helping pharmacists deliver a seamless service to patients and improving access to medicines in challenging times.
As the Chief Operating Officer of the White Retail – White Medical Group, Ms Totterman rapidly translated and adopted new protocols when COVID-19 first hit to help the pharmacists in her network best serve their communities.
She was recognised for this outstanding leadership and change management at the 2021 PSA Queensland Pharmacist Awards on 20 March.
Ms Totterman’s reach also spans policy, education and general practice as a Clinical Fellow of the Queensland University of Technology; a member of PSA’s Queensland Branch Committee; leader and manager of seven pharmacies and eight medical practices; and business owner of an additional four pharmacies.
‘Bridget has demonstrated exceptional leadership, business acumen and change management within her career,’ PSA Queensland Branch President Shane MacDonald said.
‘PSA commends Bridget for building frontline healthcare teams in primary care, across both pharmacy and general practice, and for her contribution to the profession across immunisation, palliative care initiatives, the urinary tract infection pilot and now supporting COVID-19 vaccination.’
Despite her numerous achievements, Ms Totterman told Australian Pharmacist she was humbled to receive the award.
‘There are so many worthy pharmacists in our industry across all different fields, so I feel very honoured,’ she said.
‘But it's a real thrill and the highlight of my career, to be honest.’
Supporting pharmacists during COVID-19
At the start of the COVID-19 pandemic, Ms Totterman acted quickly by rallying teams to follow systems and updating pharmacists on the constant legislative and practice changes.
‘There was so much information coming from [everywhere],’ she said.
‘I saw myself as a conduit for all that information. I put it together and sent emails to our team – weekly, daily and even hourly – with regards to legislative or dispensing changes.’
Delivering timely information to pharmacists on the frontline freed them up to focus on patient care with confidence.
Pharmacists’ mental health and wellbeing was also prioritised through regular check-ins and ensuring team members’ hours were rotated.
Ms Totterman coordinated the safety upgrades for the pharmacies in her group, including social distancing stickers on the floors, sneeze screens and hand sanitiser stations.
To prepare for the rollout of the COVID-19 vaccine, Ms Totterman organised the Expression of Interest (EOI) submissions for the GP clinics she oversees.
‘I’ve been working with the practice managers in each GP clinic to ensure a smooth and frictionless process for patients when they come in [for the COVID-19 vaccine],’ Ms Totterman said.
‘But they're the real heroes who do all the hard work. I'm just trying to take whatever pressure I can off them, so they can keep doing what they do.’
All the pharmacies Ms Totterman oversees put forward an EOI to administer the COVID-19 vaccine, and she has met with pharmacy managers to plan for the delivery of a safe service should they be approved.
Making medicines more accessible
What Ms Totterman loves about pharmacy practice is providing advice and ready access to safe medicines to treat problems before they become worse.
And her involvement in Queensland’s Urinary Tract Infection Pharmacy Pilot, a provision for pharmacists to provide antibiotics to patients with uncomplicated UTIs, aims to do just that.
‘There’s such a need for patients to have access to these medicines,’ Ms Totterman said.
‘Pharmacies are open long hours and offer a walk-in service. We can help patients get timely access to the right medicine and prevent patients experiencing a worsening infection and further ramifications, such as missing work, through the delays that may be encountered if they cannot get a timely appointment at their GP clinic.’
Improving access to medicines for palliative care patients is another area Ms Totterman is passionate about.
‘I went to a palliPHARM focus group early on, where I learned that many pharmacies don’t stock medicines that are needed for end-of-life treatment,’ she said.
‘If you have a loved one at the end of life who needs a script filled to make them more comfortable and the pharmacy needs to order the medicine in – that’s just not good enough.’
Touched by what she learned from the focus group, Ms Totterman made it her mission to ensure all the pharmacies in her network keep palliative care medicines in stock based on palliPHARM’s most used medicines list.
‘Even if the medicine expires, we'll order in another one to keep the pledge of continuing to stock these medicines on our shelves, should anyone in our community need them,’ Ms Totterman said.
More pharmacists honoured
Ms Totterman wasn’t the only Queensland pharmacist honoured for outstanding work recently.
Hospital pharmacist Hannah Knowles MPS received the Early Career Pharmacist (ECP) of the Year award for her contribution towards transitions of care and action for change.
Ms Knowles’ work and advocacy saw PSA secure an election promise from the Palaszczuk government to look at best practice transitions of care across all 16 Hospital and Health Services in the state.
Since coming on board as a PSA branch committee member, she has provided insights from her hospital residency, community pharmacy and through her contribution to International Pharmaceutical Federation committees.
‘Her willingness to contribute and lead and support fellow early career pharmacists is exceptional,’ Mr MacDonald said.
Joshua Clements was recognised for his academic excellence and contribution to the pharmacy community through his receipt of the James Dare PSA Graduate of the Year award.
Mr Clements was awarded a Bachelor of Pharmacy with Distinction from Griffith University in December 2020 and earned the Griffith University Awards for Academic Excellence for every year of his enrolment, from 2017–2020.
As an active member of PSA for more than 45 years, former State Councillor Gilbert Yeates was awarded the Lifetime Achievement Award.
He was recognised for his significant and ongoing contribution to the profession over many years and across all walks of practice – from community pharmacy to hospital, academia, professional development, policy, advocacy and professional indemnity.
‘Gilbert is well respected by his patients and peers for his confidential and expert advice on professional responsibilities,’ Mr MacDonald said.
‘He engages with those at all levels of the profession, and generously provides counsel to many pharmacists in official and informal capacities.
‘There has not been an issue relating to the practice of pharmacy in recent history that Gilbert has not been involved with and significantly contributed to, from pharmacist immunisation though to medicine management, prescribing and practitioner development.’
The PSA also recognised the contribution of pharmacists who have been elevated to the honour of PSA Fellowship. This year both Joyce McSwan FPS and Prof Beverly Glass FPS were conferred as PSA Fellows.
[post_title] => Queensland pharmacist of the year shows leadership in crisis
[post_excerpt] => Bridget Totterman MPS is a master behind the scenes, helping pharmacists deliver a seamless service to patients and improving access to medicines in challenging times.
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[post_content] => For former athletics star Emily Shears MPS, combining sport and pharmacy set her on track to help other female athletes reach peak performance.
What led you to pharmacy?
I fell into it. I commenced my tertiary education with medical science, and after completing the first year, I knew I needed a change. I chose a Bachelor of Pharmacy at the University of Sydney and was offered a sports scholarship. It’s one of the best decisions I’ve made.
Could you describe your career path?
In a word: atypical. I graduated knowing I wanted to bring my passion for sport together with pharmacy. Rather than embarking on my intern year immediately, I completed a Graduate Diploma in Exercise Science. I eventually completed my intern year and gained registration, before embarking on a Master of Education.
In 2010, I became a managing partner at two pharmacies in Melbourne. I transitioned one of the businesses into a compounding pharmacy and, despite the successes that came from this, I still felt unrest with the path I was forging. I sold my share of the partnership in 2015.
Why did you start the Female Athlete Network (FAN)?
It came together during lockdown last year, when I had the time to reflect on my strengths and skill set. I am a former athlete with extensive clinical and sports science knowledge who has seen firsthand the knowledge gap among women when it comes to their physiology.
This is only amplified in athletes, and I saw an opportunity to service a niche market. The FAN is a source of education for female athletes to better understand their physiology and use this to achieve peak performance. The majority of education is centred around understanding the menstrual cycle – what’s healthy, what’s not. When I was an athlete, this information and support was not available, and rather than being a monthly insight into your health, your period was viewed as a barrier that needed to be dealt with quietly. How little we knew!
How does your pharmacy background help in this work?
Pharmacy knowledge is integral to what I do. On a daily basis, I conduct medicine reviews of sorts – I just work with a younger demographic who have different goals. I collaborate with other healthcare professionals and provide health advice to my clients. I feel that many who have worked in community pharmacy for an extended period of time underestimate the depth and breadth of their clinical knowledge, and their ability to educate.
What role has sport played in your life?
Sport has allowed me to travel, taught me time management and commitment, and the importance of hard work and perseverance. It has also taught me so much about physiology and biology, stress and pressure to perform.
I still recall asking Professor Andrew McLachlan in the halls of the School of Pharmacy to be a referee for me to gain entry into the Master’s. He said that while it might not be the usual path for a pharmacist, there are so many obvious crossovers, particularly at high levels. He probably does not know how motivating that 60-second conversation was for me as a graduate wanting to go against the grain.
Tell us about your new role as Wellbeing Coordinator of the Geelong Falcons.
I’m responsible for the wellbeing and mental fitness of the boys and girls under-19s AFL/AFLW players. This role is a huge responsibility and challenge. The ability to communicate at a clinical level with colleagues, and to relay health information to players in a language they understand, has come from years of talking to patients and health professionals in a community pharmacy setting.
What advice would you give to early career pharmacists?
Have faith in your passion and ability. Just because something hasn’t been done before doesn’t mean it can’t happen.
What do you still hope to achieve?
Big picture, I hope that in the future every professional sporting organisation has a women’s health lead who is there to collaborate with medical staff and educate coaching and support personnel, along with players, and that the conversation around female physiology is no longer taboo.
In the short term, I’m going to knuckle down and gain board certification as a pharmacist with the Australian Society of Lifestyle Medicine in 2021.
DAY IN THE LIFE of Emily Shears MPS, founder of the Female Athlete Network (FAN) in Torquay, Victoria.6.00 am – An early start Start the day with exercise. If not at the gym, then the beach for a walk or swim with our dog, Piper. No better way to start the day. 7.30 am – Kicking off Breakfast with the kids and time to get the first FAN Instagram post up. Given the target demographic, I’ve had to get my social media skills up to speed (it’s a work in progress). 9.00 am–11.00 am – Client consultations One-on-one consults with athletes, talking through information from new patient questionnaire – there's always more to see and hear than what’s on paper. One athlete with history of amenorrhoea, dysmenorrhoea and RED-S was taking naproxen for period pain, ibuprofen for back, knee and migraine pain, and celecoxib for neck pain, and unaware this anti-inflammatory cocktail was likely causing her gastritis and GORD. Discussed immediate reduction, trialling a triptan, ceasing ibuprofen and initiating paracetamol 665 mg. Discussed magnesium supplement and compounded topical cream, and blood tests to further understand issues (calcium, iron, and vitamin D deficiencies, parathyroid, estrogen, progesterone, thyroid function). 2.00 pm – Report writing Report writing from consults, usually involving some level of medicine review, and phone calls to practitioners if referring a patient/making recommendations requiring collaboration. Contact an endocrinologist with additional qualifications in exercise sport science and a psychologist specialising in women’s health re athlete above. 5.00 pm – 6.00 pm – Attend training Attend Geelong Falcons training. Catch up with players who have requested to talk through mental fitness needs or want general health advice. Many have concerns about the year ahead and managing study and football. Conversation around tools to assist with maintaining good mental fitness. As stressors for these athletes evolve, so too will the presenting challenges and need to problem-solve. 6.30 pm – Winding down Dinner with family. Try for some time for my own mental health – usually a stretch on the foam roller or quick Pilates session. 8.00 pm – Bedtime reading Before bed is when I tuck into my CPD reading, write education sessions or prep Instagram posts. |
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[post_content] => Mandy Wang MPS is a strong proponent of pharmacist vaccinations, winning the 2020 ACT Early Career Pharmacist of the Year award for delivering extensive vaccination services during the height of COVID-19.
Why did you choose to study pharmacy?
I’m actually the first pharmacist in my family. I come from a long line of doctors, and my mother wanted me to follow suit, but my father was against the idea. He wanted some variety in the family, and I thought pharmacy seemed like the more interesting path. After 10 years I’ve never looked back.
How do you support other pharmacists?
Over the last few years I’ve been responsible for the growth and development of more than 20 newly registered pharmacists.
I’m the state intern training coordinator and chief immunisation pharmacist in my organisation, and both of these roles allow me to train and inspire the next generation of pharmacists. I mentor them in areas such as clinical and managerial decision-making, and I’m there to offer mental health support.
Recently, I was accredited as our workplace Mental Health First Aid Officer, so I can tie those skills into my role in a support capacity.
How did you work in the community during COVID-19?
We continued to provide influenza vaccination services to all members of the public during the peak of COVID-19, and expanded our flu vaccination program to include international students, temporary visa holders and international embassy staff. Many people from these groups live in Canberra’s community but don’t have access to the Pharmaceutical Benefits Scheme or other healthcare support.
I personally visited embassies so I could vaccinate the staff and some of the ambassadors. This way, I was able to catch those who couldn’t make it into the pharmacy and ensure our local people were vaccinated.
‘[Becoming an accredited vaccinator] is such a good way to connect with the community, build a rapport and give back to your patients.’
What was your role in the 2020 influenza National Immunisation Program (NIP) delivery?
We participated in the 2019 pilot program and had such a positive response from the community that we decided to partake in the 2020 program. We collaborated with other members of the healthcare profession to deliver the service, starting with ACT Health to organise the delivery of medicine to the pharmacy.
We offered additional training to our pharmacist immunisers. Where possible, we also included our interns so they could get exposure and, hopefully, some inspiration from the whole process.
I also worked with GPs in the area, so they were able to refer patients as they saw fit to ease the burden on their practices.
Would you recommend other early career pharmacists become accredited vaccinators?
Yes, it’s such a good way to connect with the community, build a rapport and give back to your patients. I often hear people say that it’s difficult to book in to see their GP just to get the flu vaccination, along with the added expense of consultation fees.
How are you preparing to deliver the COVID-19 vaccination?
We reviewed our COVID-19 Safety Policy to make sure that we are able to offer the best service possible and quickly implement the delivery of the vaccine when the legislation allows for it.
This includes allocating a bigger space, potentially a close-by off-site location, to offer the service, and ensuring that everyone who is waiting to get vaccinated in the pharmacy is social distancing – which is what we did when delivering the flu vaccination.
Providing vaccination services is something I’m very passionate about, so the announcement that pharmacists will be involved in this process is extremely exciting.
[post_title] => The pharmacist vaccinator
[post_excerpt] => Mandy Wang MPS is a strong proponent of pharmacist vaccinations, winning the 2020 ACT Early Career Pharmacist of the Year award for delivering extensive vaccination services during the height of COVID-19.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
