National Policy for Handling Medicines Calls

NHS Direct

National Policy for Handling Medicine Calls

NHS Direct

National Policy for Handling Medicines Calls

Summary

This policy defines the type of medicine enquiry that should be handled by NHS Direct call centres, the supporting framework to handle the calls and where referral to other services is appropriate. Within the policy reference to enquiries handled by the On-line Enquiry Service is made where there are differences in approach due to the nature of the service.

The policy is a revision to the previously named Pharmacy and Medicines Policy and has been revised in response to recent developments. [1],[2]

Work is in progress:

• To develop National Pharmacy and Medicine Protocols to support Health Information Advisers.
• To designate a medicine information specialist handling calls supported by access to the UK Medicines Information pharmacist network.
• To develop separate guidance for handling poisons related calls.

Contents

1. Introduction
2. Definition of medicine calls
3. Principles for handling medicine calls
4. Poisons calls
5. Guidance for specific types of calls
6. Approved reference sources
7. Record keeping and documentation
8. Quality assurance
9. Training and development
10. Approval
11. Acknowledgements

Annex 1 Flow of Medicine call

Annex 2 Search Strategies for Medicine Calls

Annex 3 Implementation

1Introduction

1.1 This policy is intended to support front line staff to assess and manage calls about medicines and the therapeutic use of medicines. A separate policy is under development to support staff when calls about medicines and other substances are linked to potential poisoning incidents.

1.2The scope of this policy is the 0845 and OOHs calls and the Online Enquiry Service (OES). The policy defines:

• The range of calls staff are expected to handle
• The resources used to answer the enquiry
• The level of training and experience required
• When to refer calls to expert services

Each site is expected to develop procedures to implement the policy

1.3 More detailed supporting document is under development in consultation with Clinical and Health Information Leads to ensure a consistent approach as the service moves to a virtual networking of calls. This will address:

• The learning outcomes for the training and development of staff
• The process of referral to Medicine Information Services (UKMI),
• How to access the approved resources
• The rationale for the recommended search strategies.

2Definition of Medicine Calls

2.1 NHS Direct staff need a consistent definition of a medicine, a medicine enquiry and when an enquiry should be treated as a potential poisoning incident in order to prioritise the call or enquiry and identify the necessary level of competency to handle the call or enquiry.

2.2 For the purpose of this policy the term “medicine” (medicinal product) will mean any substance or article (not being an instrument, apparatus or appliance) which is manufactured, sold , supplied, imported or exported for use wholly or mainly in one of the following ways:

• Treating or preventing disease
• Diagnosing disease or status of a physiological condition
• Contraception
• Inducing anaesthesia
• Temporarily or permanently affecting a physiological function in any way

(Adapted from Medicines Act 1968)

2.3 Using the definition this includes all prescription-only medicines (POMs), pharmacy-only (P) medicines and general sales list (GSL) medicines along with herbal remedies, homeopathic preparations and food supplements. Recreational drugs and drugs of abuse, cocaine, cannabis, steroids in sport such as nandralone, are also included in this policy.

2.4 All staff involved in medicines calls must have achieved a competency to handle these calls as part of their induction training or as part of a development programme when taking on new roles. A more detailed training and development document is under preparation that details the learning outcomes required for handling medicine calls for all front-line staff.

3Principles for Handling Medicine Calls

3.1This policy is based on a set of shared beliefs between NHS Direct and the users of the service:

3.2Everyone is entitled to be involved in decisions about whether a medicine is right for them, and choose a different option if they prefer

3.3 Everyone will be able to get the medicines information they want and need, from whatever source they choose

3.4 Doctors, nurses, pharmacists and other healthcare professionals will be supported, through training, to communicate effectively and help their patients and their carers be involved in decisions about medicines and use medicines effectively.

4Poisons Calls

4.1 Handling calls involving potential Poisoning incidents will be described in a separate guidance. Referral to the National Poisons Information Service (NPIS) will be limited to calls where a poisoning incident is suspected that could lead to actual physical harm. Toxbase is the recommended reference source for all nurse advisors to use to support these calls. A project is under consideration to investigate a reference source within Toxbase to support information calls to NHS Direct.

4.2 Front line staff will treat calls about medicines as poisoning incidents where an inappropriate exposure to drugs or chemicals is reported, with the potential to cause physical harm. Within this definition judgement will be required to assess the degree of risk and/or the presence of clinical features. All calls that are suspected poisoning incidents require symptomatic assessment. Toxbase is the first point of reference and will advise when to contact the Poisons service for further support.

4.3 The Low Toxicity Poster produced by the National Poisons Information Service (London) can be used by call handlers to prioritise calls by local agreement with the clinical lead. A national training resource is being developed to support call handlers with this role.

4.4 The Online Enquiry Service handles enquiries prioritised according to local procedures. The OES is unable to offer advice regarding poisoning incidents. The enquiry will be returned to the user and advised to call NHSD or seek advice from an appropriate health care professional.

5Guidance for specific types of calls

5.1 Complex calls: A complex medicine call is where the call involves any one or more of the following criteria:

• Caller/patient is taking 3 or more prescription medicines
• Dose(s) are outside the normal range
• Enquiry involves unlicensed uses of a medicine or an unlicensed medicine
• High risk medicines are involved, i.e. aminophylline, carbamazepine, ciclosporin, digoxin, lithium, methotrexate, phenytoin, theophylline, warfarin.
• Enquiry involves medicines in pregnancy or breast feeding

Action: Staff must be appropriately trained to handle these calls whether the call is primarily for information or for advice about symptoms. Referral to the UK Medicines Information pharmacist network should be considered using the criteria listed in Annex 1- Flow of Medicine Calls

5.2Advice to support a therapeutic choice: Advice to support self-care may include advice about the therapeutic use of medicines that have not yet been prescribed. It is inappropriate to recommend a medicinal product by name. This is particularly important where a caller may be referred to another healthcare professional who may recommend a specific treatment. Exceptions to this will have to be individually assessed; e.g. a caller asks which analgesic is safe in pregnancy from the choice in her medicine cupboard.

Action: Specific medicines should not be recommended, but a therapeutic class of medicines may be suggested. Referral to a community pharmacy to speak to a pharmacist should be considered.

5.3 Advice and information about emergency contraception and unprotected sexual intercourse: Access to emergency contraception where the caller is specifically asking for details of availability may be handled by the first person answering the call. This will usually be the call handler. There are some exceptions to this where advice is sought or the call handler has not had Child Protection training

Action: All calls about unprotected sex where the caller wishes to discuss their options (e.g. consequences of taking no action, risk of sexually transmitted infections (STIs), alternative forms of emergency contraception to “morning after pill”) should be transferred to a nurse. If the caller is under 18 years and the call handler has not received Child Protection training, any call, including a simple request for access to emergency contraception, e.g. Emergency Hormonal Contraception, should be transferred to a nurse advisor.

5.4 Dental medicine calls: Dental nurse advisors may be asked for information or advice about a dental problem where medicines are involved, e.g. caller is taking medicines they have purchased from a pharmacy for toothache or medicines they have been prescribed by a dentist, e.g. antibiotics.

Action: Dental advisors must transfer any call to a nurse advisor, where the caller requires advice about medicines outside the Dental Practitioners Formulary or the caller wants more complex advice, e.g. caller is taking other medicines that may interact with their dental treatment, or they are pregnant or breast feeding. (See 5.1 and 5.2)

5.5 Third Party and Intermediary calls: Information about the uses of medicines can be provided to third party or intermediary callers (see National Policy on the Handling of Third Party and Intermediary Calls).

Action: The caller should be provided with information related to the licensed uses of the medicines stating the reference source, i.e. Electronic Medicines Compendium or BNF. Advise the caller that sometimes clinicians prescribe medicines for other conditions outside the product licence and so sometimes medicines are used for other purposes. Callers requesting information about unlicensed uses of medicines for a third party should be advised to discuss this with the individual’s prescriber.

Identification -Action: Calls that involve requests to identify suspected illicit drugs, contraception and any other medicine(s) that are not the caller’s property should be referred to a community pharmacy to speak to a pharmacist, once it is established there is no immediate or urgent clinical risk to anyone. Callers should be advised about the limitations of identification without seeing the “preparation”.

5.6 Request for repeat medication: Callers requesting a repeat supply of medication may be asking for a variety of reasons. It is important to ensure the person for whom the medicine is intended is not at risk.

Action: As part of the prioritisation process the caller will receive a series of questions to determine:

• If the medication is taken regularly, or as required
• If the medication has been taken more than usual recently, then it will prompt a referral a Nurse Advisor as Priority 2
• If the medication has not been taken more then usual recently, then the call becomes a quick call or standard health information call

Staff should check the urgency of the repeat supply particularly in the OOHs period. Additional guidance is being developed to prompt questions about nearest access points for emergency supplies if the patient’s GP is unavailable.

6Reference Sources

6.1 Information about medicines is constantly changing and the information available about a medicinal product may differ between brands for the same medicine. To support the handling of medicine calls the reference sources used by staff must fulfil the following criteria:

• Listed as an approved reference source for call centres and the OES.
• If used as a sole reference the member of staff handling the call must have absolute confidence that it is the best available reference to answer the enquiry.
• The recommended search strategy for the category of call has been used to identify the most appropriate sources to use (See annex 2).
• The most up to date edition/version has been used.
• Medicine FAQs are available on the intranet can be used as sole reference source, where appropriate, by health information and nurse advisors.

6.2 Staff should use the eBNF as their first reference source, unless otherwise stated in the recommended search strategies. If the electronic resource is temporarily unavailable staff may use hard copy BNF, but this must be the most up to date edition, and it is the individual’s responsibility to ensure this.

6.3 Training to support staff using the appropriate search strategies and familiarity with the reference sources is a necessary part of induction, and for developing new roles, before handling medicine calls.

6.4 The resources used to support an enquiry to the OES may have to differ given the nature of the service and any reference material provided by email has to be available in the public domain for free public access. Local guidelines are in place to support staff.

7Record Keeping and Documentation

7.1 Expert service advice e.g. UKMI service and/or information used to complete a call should be noted in the call record. This includes information provided by email or fax.

7.2The recommended reference sources used to support the answer should be noted in the call record.

7.3The Medicines Algorithm results in the end disposition of “home care with pharmacy”. However, if the caller describes clinical symptoms that require further assessment with another algorithm and the outcome of the assessment leads to a higher disposition such as see a “GP within 48 hours” then the final disposition for the call must be recorded using the higher disposition with the appropriate advice.

7.4If the call is referred to UKMI for them to complete the call, the outcome is recorded as referral to pharmacy. UKMI will call back to the enquirer and document the call according to their national standards and documentation

7.5If referral to a community pharmacy is recommended then callers should be advised to:

• Speak to the pharmacist, rather than the medicines counter assistant
• Tell the pharmacist they have spoken with NHS Direct
• Use their usual pharmacy that holds their medication record, so that the pharmacist can check any possible medication issues against their record. Check local information about community pharmacy services. If interpretation services are required at the pharmacy, staff should check the local information about community pharmacy services to see what is available.

7.6Community pharmacists are available to discuss medicine queries for all aspects of health and should have a quiet area they use for confidential issues.

8 Quality Assurance

8.1 Mystery Shopper will test the handling of medicines calls as part of the on-going quality assurance programme.

8.2 Centres will ensure that medicine calls are part of the CQI (Continuous Quality Improvement) process, including call review and patient satisfaction surveys.

8.3 External audit will be used to inform the development of the service and as part of the continuing professional development of staff. UKMI will undertake a programme of external audit and peer review for all centres including the OES

9Training and Development

9.1Training will apply at role preparation for call handlers, health information advisors, dental nurse advisors, nurse advisors, health information officers throughout the service. Additional training and continuing professional development is required as staff continue in the role. Health Information staff who handle complex calls (see section 5.1) will be expected to undertake specific medicine information skills training. A national programme is under development as part of the Common Preparation Programme. A set of learning outcomes has been identified for induction and on-going professional development for all front-line staff.

10Approval

Dr. Mike Sadler

Medical Director

11Acknowledgements

11.1This policy has been prepared with the help of the NHS Direct Medicines, and Pharmacy Group (previously the Handling of Medicine Calls Project Group) and the Pharmacy Support Network for NHS Direct ( with representation from national professional pharmacy groups and national organisations including the Royal Pharmaceutical Society of Great Britain, National Pharmaceutical Association, Pharmaceutical Services Negotiating Committee, the UK Medicines Information Pharmacist network and the National Poisons Information Service).

Annex 1 Flow of Medicine Calls

0845 4647 and Oaths Medicine Call Flow

P4Quick Call PPP

Access to pharmacy services and

Medicines, e.g. Emergency Hormonal

Contraception, Repeat medication

Priority 4Priority 1, 2, 3

Local protocols CAS algorithm for symptoms

OR

National pilot Medicine and Pharmacy protocolsMedicine Algorithm

-Access as for P4QC-Wrong dose

-Identification-Side effects

-Travel-Interactions

-Administration & dosage-Therapeutic dose, e.g.

-Therapeutic dose, e.g. pregnancy, breast feeding pregnancy, breast feeding

-Interactions-Administration and dosage

-Side effects-Travel

(Expected order of frequency of call type)-Identification

ReferralLocal procedure

Medicines Information Service (UKMI)

Note: A national SLA with UKMI is in place for 2005/6 to support all sites. For some calls this will include MI pharmacist speaking directly to the caller and completing the calls once local referral procedure in place.

Annex 2: Search Strategies for NHSD Medicines Calls

To support the handling of medicine calls the reference sources used by staff must fulfil the following criteria:

Listed as an approved reference source for call centres and the OES

If used as a sole reference the member of staff handling the call must have absolute confidence that it is the best available reference to answer the enquiry

The recommended search strategy for the category of call is used to identify the most appropriate sources. The order of priority is as listed top to bottom within each category.

The most up to date edition/version has been used

Refer to UKMI service according to criteria in Annex 1- Flow of Medicine Calls to support search.

The eBNF is available via the NHS Direct Intranet at nww.intranet.nhsdirect.nhs/bnf/

Medicines Complete library can be used, if available, to access Martindale, Stockley, Herbal Medicines.

The NHSD FAQs and the NHSD Online website are a recommended reference source for all calls and should be used alongside other resources appropriate to need of the call. Other medicine information sources are under evaluation.

Search Strategies for Medicine calls