The
Pharmaceutical Journal Vol 266 No 7129 p30-31
Pharmaceutical care needs of patients and the problems associated with CFC-free inhalers were among the issues discussed at the autumn symposium of the UKCPA, which was held in Blackpool on November 24-26, 2000
Are patients in the United Kingdom
ready to use pharmaceutical care plans?
Taste and mouth sensation problems associated with CFC-free inhalers
Sharing single-use parenteral products is the most likely cause
of cross-infection
Pharmaceutical care needs of angina patients
Reasons for missed drug doses in stroke patients not clear
UKCPA Glaxo Wellcome awards
Many patients with hypertension had either not been diagnosed with the disease
or had been treated ineffectively, said Mr John McAnaw (University of Strathclyde,
Glasgow) giving the Astra Zeneca travelling fellowship award lecture together
with Ms AnnAMarie McGregor (Abbey Chemist, Glasgow). The British Hypertension
Society’s revised guidelines recommended a lower target blood pressure range
of <140/85mmHg, in line with the United States and the World Health Organisation
guidelines.
Although pharmacists working in primary care were in an ideal position to contribute
to and improve blood pressure control, there had been few formal studies of
the value of long-term blood pressure monitoring by pharmacists in the United
Kingdom. In the US, studies had shown that community pharmacists involved in
providing education and blood pressure monitoring to patients with hypertension
improved control and medication appliance. A visit was made to the US to report
the provision of pharmaceutical services involving blood pressure monitoring
and assess how such a service might be adapted within the development of pharmaceutical
care in the UK, said Mr McAnaw.
The researchers visted different sites in the states of Minnesota, Colorado
and Iowa, US, to assess the different models of pharmaceutical care offered
to patients receiving treatment for hypertension. Among these was a community
pharmacy clinic (Main at Locust Pharmacy, Davenport, Iowa) which provided a
basic blood pressure monitoring service where patients and members of the public
chose to have their blood pressure monitored. They also visited an ambulatory
care clinic (at the college of pharmacy, University of Colorado health sciences
centre, Denver, Colorado) where a pharmacist had scheduled patient consultations,
after which recommendations in line with previously agreed treatment protocols
were made to a physician.
Electronic blood pressure monitoring was carried out at one of the sites visited.
Most of the pharmacists interviewed thought that electronic blood pressure measurement
was inaccurate and unreliable, mainly because it measured pulse waves rather
than the operator relying on sounds.
Mr McAnaw said that reimbursement and payment varied between sites and, as in
the UK, there was a need to show the “value of pharmaceutical care”. It was
questionable as to whether doctors, who had already been paid for this service,
should pay pharmacists for providing pharmaceutical care. Where patients paid
the pharmacist, the fee was a contribution to the costs of providing the service.
Mr McAnaw said that documenting patient information to support pharmaceutical
care was time-consuming work. However, doctors were pleased to receive information
from pharmacists to support recommendations they were making. The researchers
also looked at the types of electronic documentation software being used.
Discussing whether the pharmacy services for hypertensive patients seen during
the study should be termed pharmaceutical care or disease management, Mr McAnaw
commented that pharmaceutical care implied planned follow-up and evaluation
and this was not performed at every site. He also commented that in terms of
expectations, health care systems and health insurance plans, “the typical US
patient was very different to a UK patient”. He questioned whether patients
and general practitioners in the UK were ready to use care plans.
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Differences in taste or mouth sensation were among the main problems when
patients were changed from CFC (chlorofluorocarbon) to CFC-free salbutamol inhalers,
according to Mrs Fiona Arris (school of pharmacy, Robert Gordon university,
Aberdeen).
A subgroup within Grampian Primary Care NHS trust was set up to advise on the
transition from CFC to CFC-free inhalers and guidance was issued to all general
practices and community pharmacies in the area in June, 1999.
A study, led by Mrs Arris, was carried out to determine patients’ opinions regarding
the changeover from CFC to CFC-free salbutamol inhalers. Eight of the 28 patients
interviewed had been changed to a CFC-free inhaler, six of whom had received
counselling from their general practitioner or pharmacist regarding the changeover.
All six of these patients reported differences in taste and feel between the
inhalers. Three patients preferred CFC-free inhalers to their previous therapy.
Of the patients who were still using CFC salbutamol inhalers, most were aware
that production had been restricted, but were unaware of the imminent changeover.
Mrs Arris commented that the small sample size might have meant that the results
were “unrepresentative of the CFC-free implementation process in the Grampion
health board area as a whole”. However, as the transfer process had not yet
been completed, and many of the standard inhalers were still available as CFC
products, it was important that there was good communication between health
care professionals and patients, she said.
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Sharing contaminated parenteral drugs was the most likely cause of cross-infection
in hospitals, said Mr John Dade (St James’s university hospital, Leeds). To
minimise the risk of cross infection, multidose vials should be restricted to
one patient only.
In a study to determine the extent to which single use parenteral drugs were
being reused in one or more patients within the Leeds Teaching Hospitals NHS
trust, pharmacists interviewed senior ward or department staff in all clinical
areas in six hospitals within the trust.
Of the 167 wards involved in the study, 45 wards carried out multiple use of
single-use products in individual patients and 56 used a single-use product
for more than one patient. Multiple use of drugs in bags or 100ml glass vials,
such as intravenous flushes and diluting nebulisers, was carried out on 36 wards.
One-hundred-and-five wards were found to have retained used products such as
insulin, saline and water for injection. Mr Dade commented that with glass bottles
with metal fold-back tops it was not easy to know whether they had already been
used and most glass vials should be replaced with plastic ampoules to prevent
this problem.
At the Leeds trust, glass vials of water and sodium chloride 0.9 per cent had
now been withdrawn from most clinical areas and replaced with plastic ampoules.
Mr Dade said that the study demonstrated the need to alter current practice
and that the results would probably mirror practice in many centres in the United
Kingdom. He said that the Leeds trust’s medicines code needed to be revised
to prohibit, for example, multiple dose use of single-use products.
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There should be regular prophylaxis for all angina patients, except those
with minor symptoms, according to Mrs Elizabeth McGovern (Stobhill hospital,
Glasgow). Patients should know when to seek medical advice if appropriate use
of sublingual glyceryl trinitrate (GTN) did not relieve symptoms.
In a study undertaken in a local health care co-operative in east Glasgow, sublingual
glyceryl trinitrate administration technique problems were identified in 108
out of 347 patients.
Only 69 per cent of patients had a satisfactory knowledge of how to use sublingual
GTN and only 36 per cent of patients knew when to seek medical help appropriately
after sublingual GTN use. Most patients used sublingual GTN at least once daily.
Mrs McGovern commented that regular low dose aspirin was recommended for all
patients with ischaemic heart disease. However, in this audit, only 73 per cent
of patients were taking aspirin, either prescribed or purchased over the counter.
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A substantial number of medication doses were missed in stroke patients with
no clear, documented reason, said Miss Alison Robertson (Stirling Royal Infirmary).
A study was undertaken to investigate the extent of, and reasons for, missed
doses in patients admitted to hospital with acute stroke.
A total of 91 patients were involved in the study, 73 of whom suffered ischaemic
stroke and 18 had a haemorrhagic stroke. In the ischaemic stroke group, antiplatelet
therapy was started in 26 patients within 48 hours of admission, 27 patients
within the following five days and in 13 patients more than seven days after
admission. Almost all patients were on regular drug therapy (83 out of 91).
Overall 1,298 missed doses (out of a total of 7,595 prescribed doses) were identified,
with 5 per cent of the total number of prescribed doses being missed during
the first three days after admission. Among the most commonly missed drugs were
cardiovascular agents, anti-infectives and respiratory drugs. No reasons for
missed doses were documented on patients’ drug charts for 36 per cent of doses
missed. “Nil by mouth”, “unable to swallow” and “drug not available” were among
the documented reasons, said Miss Robertson.
Information on formulations, alternative drugs and other administration routes
was being prepared for pharmacists, nurses and speech therapists caring for
patients with dysphagia, she said.
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During the UKCPA symposium, Glaxo Wellcome awards were won by Mr Nigel Gooding
(Leicester Royal infirmary) for the best first-time presenter - oral presentation;
Mrs Fiona Reid (University of Strathclyde, Glasgow) for the best overall presenter
- oral presentation; Ms Jenny Stirton (Stobhill hospital, North Glasgow University
Hospitals NHS trust) and Mr Steve McGlynn (University of Strathclyde, Glasgow)
for the best poster; and Miss Helen Jamison (Lothian University Hospitals NHS
trust), Miss Moira Kinnear (University of Strathclyde) and Mrs Pauline Westwood
(Lothian Primary Care NHS trust, Edinburgh) for the best poster for study based
in primary care.
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