1. To explore problems encountered when children are discharged from hospital on an unlicensed medicine
Dr Sharon Conroy, Lecturer in Paediatric Clinical Pharmacy
and Mandeep Bhoday, Research Associate,
University of Nottingham, Derbyshire Children’s Hospital

2. to the NPPG for funding the project
HUGE THANK YOUs
to the NPPG for funding the project
and to everyone who has helped so far

3. Introduction
Unlicensed medicines are used when no suitable licensed product is available
Made extemporaneously, bought in as a Special or imported

4. Background & Incidence
Neonatal intensive care:
10% prescriptions unlicensed
Conroy S, McIntyre J, Choonara I. Arch Dis Child Fetal Neonatal Ed 1999;80:F142-5
General paediatric wards across Europe
7% prescriptions unlicensed
Conroy S, Choonara I, Impicciatore P et al. BMJ 2000;320:79-82

5. Aims of the study
To explore the experiences of families and healthcare professionals in obtaining or providing further supplies of unlicensed medicines in the community.
To identify potential means to improve current systems.

6. Methods
Hospital pharmacies & ward pharmacists in Derby, Nottingham, Leicester & Sheffield identify prospective participants for the study
Telephone interviews with parents, GPs, community pharmacists and outreach nurses to discuss experiences & suggestions for improvement or examples of good practice.

7. Parent Results (n=35) GP related issues
GP won’t prescribe as medicine is not on their computer
Hospital paperwork not reached GP in time
Community Pharmacist (CP) related issues
CP doesn’t know where to order medicines from so parents have to travel back to hospital each month
CP uses a different supplier each time so consistency of medicine is different every time
CP will not order medicine until they see prescription

8. GP Results (n=4)
Lack of communication/delays in receiving information from hospitals (n=3)
Reluctance to prescribe UL medicines - due to high costs in community and limited clinical evidence (n=1)
Not all GPs are able to add new products to computer list making it difficult to prescribe UL medicines (n=1)
Happy to prescribe – if sufficient written information from hospital regarding drug and dose (n=1)

9. GP suggestions Improved communication (n=4)
phone call from hospital doctor, nurse or pharmacist would be appreciated to pre-warn surgery and provide opportunity to ask relevant questions and advice
written information including clinical indication from hospital consultant with clear instructions including information on monitoring
Preference for hospital to continue supply (n=2)
as already familiar with prescribing, obtaining and monitoring UL medicines

10. CP Results (n=11) Lack of awareness Lack of communication
parental expectation very high - expect medicines to be available as quickly as in hospital (n=8)
Lack of communication
from GPs, hospitals, and parents (n=7)
Lack of adequate supply upon discharge
hospital supply runs out while waiting for prescription from GP or further supply from CP (n=4)

11. CP suggestions for improvement
Improved communication from hospitals
encourage parents to take discharge notes to CP
fax details to GP and CP at discharge
ask parents which CP they use & telephone at patient discharge
provide parents with contact details for paediatric pharmacists
Hospitals to educate parents prior to discharge
many parents unaware that UL medicines are not available “off the shelf”
Hospitals to provide adequate supplies

12. Outreach Nurses Results (n=2)
Problems experienced by families are due to
Parents leaving it to last minute before ordering further supply - leads to children missing doses
GPs unwilling to prescribe liquids due to cost – nurses have to provide prescriptions from hospital
Outreach nurse team is helped by
Having a pro-active hospital pharmacist who educates parents before discharge & contacts GPs and CPs if/when problems have occurred.

13. Top 10 problem medicines Name of medicine No. of times reported
Spironolactone 9
Omeprazole 7
Phenobarbital 6
Furosemide
Chlorothiazide 4
Clobazam
Glycopyrronium 3
Tizanidine
Captopril
Sodium Chloride 2

14. What can we do? Communication is key!
highlighted by parents, GPs, CPs and outreach nurses
need to be contacting GPs and CPs with details of formulations, strengths, suppliers, dose & warn when supply will run out in order to ensure seamless care
need to take a pro-active role in educating parents about UL medicines before they go home

15. Opportunities? Specials Tariff New medicines service
Medicines Use Reviews

16. Any Questions?