There is a dedicated pharmacist in ED/SSOU from Mon – Fri 8am-4:30pm who can be contacted on ext 49012. The main pharmacy is open on weekends and public holidays from 9am-1pm.

Things they can help with:

• Assist with medication history, particularly for patients with recent medication changes or those who do not know their medications.
• Coordinate discharge medication changes in Webster-Packs or for patients from Nursing Homes
• Education for patients being discharged with new high-risk medications - anticoagulation, Epipens, anticonvulsants
• Facilitate opioid replacement therapy (Methadone, Suboxone)
• Medicines information (i.e. compatibility, dosing)
• Practicalities of giving medications to children

Most medications are kept in the secure Pyxis automated dispensing machines throughout the ED and the hospital. Interns and HMOs do not have access to these. New registrars and Consultants will need to undergo training and be registered to use them.

Medications in Pyxis are not to be used by staff for personal use. See below regarding the Staff Medication Kit.

Unlike on the wards, you are personally responsible for your discharge scripts. See here for a reminder on how to complete discharge scripts legally and accurately.

Please ensure you place a patient sticker on all three pages of the prescription and write the patient's name. Give the first two copies to the patient and tear off the back sheet to place in the medical records.

Look up the drug, dose and duration if you are unsure: therapeutic guidelines (eTG) is an excellent resource. It also links to the PBS schedule for correct drug quantities and Authority codes.

It is good practice to document in EPR exactly what you prescribed as it takes time for the paper script to get scanned in to DMR and may get misplaced.

The patient is able to take the prescription (both copies) to any external pharmacy. The UFS pharmacy on the corner of Barnard and View Streets is open daily from 0700-2300.

If there are any errors or concerns from the community pharmacists, they will call the ED Consultant in charge. If a prescription error has been made, at best, it will cause inconvenience to the patient, pharmacist and your consultant; at worst, it can cause patient harm.

During business hours on Monday to Friday, the ED pharmacist can provide assistance on request in SSOU and in the main ED.

Paediatrics

Take care with paediatric dosing. This is usually weight based and most drugs are prescribed as a liquid/suspension. There may be different strength formulations available. Ensure that the patient’s weight is recorded on the prescription.

Double check your calculations to ensure correct dose, strength and volume. Ensure you provide enough medication for the entire course, for example, they may need more than one bottle of antibiotic to complete the course.

Take-home packs

There is a small selection of take-home packs of medication from ED. These are kept Pyxis in the main drug room. Patients still need to have a prescription written. This should be placed in the tray in top of the fridge in the drug room. To remove from Pyxis, select the relevant patient, then "Override" and then search for the medication. Alternatively you can search "Discharge" to see which medications are available. The label on the discharge medication needs to be handwritten with the appropriate dose and patient details.

Often in the ED, we initiate treatment and non-urgent regular medications are charted later on, either by an admitted team or in SSOU.

It is vital, however, that you chart time-critical regular medications, especially in SSOU:

• M ovement disorders—Parkinson’s / myasthenia medication
• I mmunomodulators including HIV meds
• S ugar—diabetes medication
• S teroids—Addison’s & adrenal insufficiency
• E pilepsy—anticonvulsants
• D OACs & warfarin

A MISSED dose can harm your patients!

See this clinical alert.

It should not be common that you are prescribing opioids to patients on discharge. Ensure that other steps are taken to reduce pain - ensure fractures are appropriately splinted, start with regular simple analgesia, try non-pharmacological options e.g. ice or heat.

We should only really be prescribing opioids from ED for new, acutely painful conditions being seen for the first time in ED, and only immediate-release preparations.

When opioids are required, check SafeScript (see below).

Prescribe the smallest dose and shortest duration (maximum 3 days, adjust for patient's ability to access their GP). Please familiarise yourself with the reduced pack size limitations, introduced by the PBS in June 2020 here.

It is also important to counsel the patient on the adverse effects. They should be advised to follow-up with their GP in the coming days to review their analgesic requirements. It is good practice to ask them to start laxatives if they are using regular opioids.

A useful resource for further reading can be found here: Opioid Analgesic Stewardship in Acute Pain- Clinical Care Standard 2022

Sustained-Release (SR) opioids are NOT to be prescribed in the setting of acute pain. They are only to be prescribed to in-patients if they have been on them long-term.

If you or the treating team feel that SR opioids may be appropriate, they should NOT be prescribed, rather a referral should be made to the Acute Pain Service (APS).

Refer to this policy on Opioid Analgesia in Acute Pain.

SafeScript is a clinical tool that provides access to a patient’s prescription history for high risk medicines to enable safer clinical decisions.

It is mandatory for all prescribers to check SafeScript prior to prescribing all monitored medicines on discharge from the ED. This does not prevent clinicians from prescribing a medication they believe is clinically necessary.

The monitored medications are:

• Opioids
• Benzodiazepines
• ‘Z-drugs’ (Zolpidem, Zopiclone)
• Quetiapine
• Codeine-containing products
• Pregabalin
• Gabapentin
• Tramadol

It is important to document in EPR that SafeScript has been checked and also what has been prescribed (e.g. Rx Endone 5mg x 4 tabs, SafeScript checked).

As a general rule, we should not be providing repeat prescriptions for patients on any of these medications and they should be directed back to their regular prescriber.

There is a Staff Medication kit in the Main medication room in Resus. It is only for assisting in symptomatic relief whilst on duty and all medication needs to be signed out in the register provided.

Each dose of medication removed from the kit must be signed out by the staff member using the medication, filling in the appropriate information in the sign-out register provided. A nurse or pharmacist must supervise any medication removed and countersign the register.

See here for a list of available medications.