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psychoanalytix

Prescribing from the A and E

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In an attempt to improve the on-call services provided to the A & E by psy sho,some of my colleagues and I were having a discussion about what medication may be safely prescribed from the a and e, and whether there was any justification in doing the same.

Our a and e also doesn't stock 'psychiatric medication' (funding)

Could anyone give us some feedback as to the on call practices in their area,namely what kind of medication may be prescribed and if there were any relative merits of stocking certain medication in the a and e?

Thank You

P-A

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Do you mean prescribing by ourselves at A&E or by our A&E colleagues? I cannot imagine our colleagues would be comfortable starting someone they see at A&E on an antipsychotic / antidepressant and followed up by us at our clinics. If that was the case, this paves the way for PDs who present with voices and wanting medication getting them.

I seriously doubt it is workable, esp if the budget is kept by the hospital trust i.e. the A&E dept. The atypicals are very expensive and I cannot imagine A&E stocking Risperidone, Olanzapine, Quetiapine, Aripiprazole and Clozapine in decent amounts. They might already have stocks of Haloperidol and CPZ which are useful in an acute setting and reasonably cheap.

There is also the practical side storing the medication and stock checking along with security procedures if the medication is paid for by the primary care trust and kept at the A&E dept. Most trust policy requires 2 people when the meds trolley is opened to reduce the opportunity of theft and misuse. Who will do the checking and the controls?

A way to help our punters who turn up at A&E is getting your pharmacy to keep a small stock of medication 'ready to go' in a drug cupboard on the nearest psych ward to the A&E dept. In my trust, we have prepared boxes of medication (2 - 3 days worth of Olanzapine, Risperidone, Haloperidol, Zopiclone, Chlorpromazine and a few more) kept on a psych ward. This is helpful to tide the patient through the night / weekend / until pharmacy is open,etc. We sign out everytime something is removed, countersigned by the ward nurse and the stocks are checked by our own pharmacist during working hours. This is useful if the psych ward is relatively nearby but unfortunately not if it is miles away.

Hope this was useful

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can be frustrating...esp. when you're trying hard to prevent an unecessary admission!

i've done something similar in one of my previous posts, requested the nearby psych ward and got the charge nurse to sign out a couple of zopiclone, olanzapine,etc.

fortunately, we've now got the luxury of a crisis team with their black bags full of psychotropics!

sometimes the medical assessment ward/observation ward in the general hosp attached to the A&E has a small stock...

all the best!

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if you r prescribing from the A&E it means that u are sending the patient home and it is safe so. In that case , U might be better off giving them a precription (F-10's ) so that they can buy it. We have a list of pharmacies that are open out of hours.

If u start dispensing them, u will soon send the wrong message and u will have more people who just want some meds like Benzo's.

It should be very rare that u need to prescrieb fro the A&E

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If there are people who turn up and they require meds to cover their weekend..I will flag it up to their team so that they are aware and this can be prevented ... dispensing for such people is not the solution and it will make matters worse. The answer is that the teams should be proactive rather than having an attitude that if there is a prob of meds, anyway u can get it in the A&E!

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The problems with FP-10s are that they are like gold... I know the the trust I work in, it is easier and a lot less hassle to get someone who registered a red on clozaril monitoring back on clozapine compared to getting a FP-10 pad from the pharmacists. Also, many of our punters are on benefits but do not have / keep the certificate to get free medication and thus they have to pay £6.10 or what ever the going rate is at the moment just for a few days worth of medication.

I am not advocating giving them weeks supply of medication. We are an emergency service and thus, if we do give them anything, it would only to cover the period; be it overnight, the weekend, etc. The sector teams should know of all overnight contacts the next day anyway so follow-up can be arranged quickly if required.

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Generally I think it s a very bad idea.

If you are prescribing in A&E I think you have to ask who you are treating, The patient's or your anxiety?I think the number of A&E presentations that require medication is tiny.

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Dear SH .. i do take your point that not all patients can afford the FP-10's. But for those who are on benefits..they can claim the money back or not pay at pharmacy(see the backside of FP-10 for details). If it costs them, I think it will be a useful reminder for these people that they must get their act together during working hours itself!!

Most A&E's should have FP-10 pads so that u can just use one odd form .. i dont thnk u need to keep a pad with u always.

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Thank you for your feedback.

I have actually gone ahead and tried to make an audit out of this. And the SHO replies I have recieved so far say the same things.

My a and e is under a different trust. And I have heard all the stories about funding. I agree that to some extent it does help cure our anxiety levels, but considering the fact that the on call doctor doesn't have a team with him at the a and e, is under some pressure due to lack of beds, prescribing seems to be one of the options we have been falling back on.

I strongly feel that the points you have raised should be a pert of the topics covered under supervision. From the first day of our job we have the power to prescribe from a and e, often we start using them even before we realize the impact it may have on our practise.

I hope to present the audit soon, and any more feedback is always helpful.

I would also like to know about the use of im meds and rapid tranquillization , since we do not have 'trained psychitaric nurses' at the a and e, a and e staff would prefer we get a team over from my hospital. that of course is not possible as the nurses under our trust are not 'covered' if they work in the a and e!

We do hope to get a liaison team in place soon...

Sigh!

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I have prescribed several times in a&e, sometimes on an fp10 and sometimes from their small supply of chlorpromazine, diazepam etc.

It's not something I do lightly.

Perhaps our MH trusts should be discussing this with the A&E people - after all, these are their patients, we are offering an opinion. In many ways it ought to be up to them to do the prescribing on our advice. I know it doesn't work like that.

In terms of rapid tranq - never known it happen in A&E. Not sure I would want it to. If someone is that disturbed, they need to be assessed prior to medication, and I imagine admitted ASAP, under MHA with a view to medication on arrival. If they need restraining, ask security, or failing that the police.

I think if the staff felt they could use it, they would end up sedating patients if they have to wait for us, on the basis that the patient is causing trouble. Then we won't be able to assess them properly. Then we'll get into an argument that if we had come when they called us, there wouldn't have been a problem. (A&E sometimes forget we also have a unit to cover, I think).

Not that I'm cynical or anything...

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