Emergency supply

[pharm112]

Today a lady came in asking to buy salamol! I had previously done ES for her in Aug as she presented herself breathlessness. On checking today, she also came in Sept and was given ES and the reason the duty pharmacist had written done for giving ES was that pt had presented with breathlessness. Today she was not breathless but had run out. Now, the lady lives in a town just 15 mins away. She also told me she seems to run out when she's in our town? I suggested that she neede to see her GP and also that if she were to feel she needs the salamol she should head done to A&E to which she replied that it takes long at A&E. I faxed an intervention letter to her GP explaining the situation and also suggesting that GP has a consultation with patient to ascertain done/ frequency of inhaler. What would you have done??

[bobbin]

Today a lady came in asking to buy salamol! I had previously done ES for her in Aug as she presented herself breathlessness. On checking today, she also came in Sept and was given ES and the reason the duty pharmacist had written done for giving ES was that pt had presented with breathlessness. Today she was not breathless but had run out. Now, the lady lives in a town just 15 mins away. She also told me she seems to run out when she's in our town? I suggested that she neede to see her GP and also that if she were to feel she needs the salamol she should head done to A&E to which she replied that it takes long at A&E. I faxed an intervention letter to her GP explaining the situation and also suggesting that GP has a consultation with patient to ascertain done/ frequency of inhaler. What would you have done??

She needs a review by her GP. I would not have done an ES either. Some 'helpful' pharmacists would happily do an ES under these circumstances.... the outcome of which would probably be that a patient who needs a review doesn't bother to see her doctor because she has been able to obtain medication without seeing a doctor. What the patient wants is probably not in her best interests. Poorly controlled asthma can be very harmful and we should not be complicit in allowing customers to avoid seeing their doctors because they don't want to or because it's not convenient. A salbutamol inhaler contains 200 sprays. If we could supply an inhaler containing 20 sprays it might be different.

A few points....

For patients who pay for their prescriptions, ensure that emergency supplies for salbutamol are not cheaper than a prescription charge. This can lead to misuse of the service.

Some patients use emergency supplies as a convenient 'alternative' to getting a prescription, rather than in a genuine emergency.

Repeat requests for emergency supplies, often involving patients who are familiar with the term 'emergency supply' (I've just popped in for an emergency supply of...' suggest that the service is being abused. After all, it is not called a convenience supply.

[pharm112]

Thanks for your reply Bobbin, its good to know someone else would have acted in the same way. Sorry for all the errors/typos in my original post. I hadn't had my dinner yet after a 9 hr shift

[Pharmanaut]

It does look like this particular person has caught on to the "Emergency Supply" system.
I'd be most surprised if this person didn't just go along to the next pharmacy.

It does come as shock that a supply can be refused for some people.

[bobbin]

I'd be most surprised if this person didn't just go along to the next pharmacy.

Probably, and then she won't bother to go to her doctor, she won't get her prophylactic medication sorted out etc. etc.

[bobbin]

Thanks for your reply Bobbin, its good to know someone else would have acted in the same way.

Yeah, she wasn't breathless and didn't need salbutamol right now. Providing lots of ESs to such patients could be harmful to their health in the long run. It allows people to avoid seeking proper medical treatment. Just imagine how many ESs she had got from elsewhere as well as from your pharmacy. Since she wasn't far from home, she could easily have arranged to see the doctor. If you make the ES too convenient she won't bother. Don't be a door mat!

[hibernia]

we should not be complicit in allowing customers to avoid seeing their doctors because they don't want to or because it's not convenient. A salbutamol inhaler contains 200 sprays. If we could supply an inhaler containing 20 sprays it might be different.

You have hit the nail on the head regarding why salbutamol inhalers are by far the most abused emergency supply. If patients run out of tablets we give them a few days supply and it is easier to to to their doctor for a prescription than seek repeated emergency supplies a couple of times a week. Once the patient has the 200 dose inhaler it is very easy to forget all about it until it runs out again (I know because I've let it happen with my own daughter even though I'm looking at inhalers and talking to the surgery every day!).

None of us likes to refuse an emergency supply in case the patient really does need it but a 'two strikes and you're out' policy is fair. The second time you give an ES supply you tell them it is on their record and you cannot supply them again until you get a prescription and that their only option will be A+E.

[SolomonQ]

so choice is between, refusing the patient an ES because they've had it too many times OR giving it just incase they have an asthma attack.

The way I would think is to say if the patient is a genuine asthma patient but is not supplied an inhaler but then goes on to have an attack, who would be responsible? Do I want to be responsible for this.

Asthma attacks lead to hospitalisations. which lead to death. In this case I would make a straight forward ES, i.e. not a loan or ordering a repeat Rx. Charge the patient the full amount. That would be my duties done. In the long term this might be harmful to her health but that is her responsibility, it could be more harmful in the short term if she has an attack and that would fall under my responsibility because she has come to me now for her inhaler.

It is the way the pharmacist thinks about the health of the public in general not just this one patient. Who's responsible for one's health. The patient? the doctor plus other HCPs? or the state?

In my opinion in this scenario the lady is responsible for her own health. The State has provided avenues for her to get more than adequate healthcare, free doctor visits probably free meds, free further care treatments at hopitals etc.. also but if she refuses to use these for her own benefit, are the rest of society meant to try and force her?

In my opinion the only reason for refusal could be abuse of meds, in other EUROPEAN countries you can buy things like salbutamol MDIs and various other meds that for some reason this country is uptight about, another example would be mucodyne, probably the only proven "chesty cough" syrup, available to buy in ireland (i think).

I always get european immigrant including Spanish and Italians aswell as Eastern Europeans coming in asking to buy what i would class as very safe POM meds, which I assume is because they can buy these in their own countries. Point of which is more POMs should be switched to Ps for a reasonable price, so the pharmacist can offer proper meds not watered down strenghts of POM meds e.g. diclofenac 12.5 mg (what a joke-anyone seen a doctor prescribing this strength for a normal patient....ever-O.K. this is a double joke max strenght tabs are 25mg WOW!!!!!!!---triple joke is the price...OMG!!!!!)

nuff said

[bobbin]

>>>The way I would think is to say if the patient is a genuine asthma patient but is not supplied an inhaler but then goes on to have an attack, who would be responsible? Do I want to be responsible for this.

In order for an ES to be legal it must be impractical for the patient to obtain a prescription. Had this patient even attempted to obtain a prescription? I suspect not. Perhaps you could ask her to contact the surgery whilst in the pharmacy, to find out whether she could make an appointment or order a repeat prescription? If there would be a delay in seeing a doctor or getting a prescription, it would then be legal to provide an ES. It is not a case of being 'difficult', repeated requests for ESs ring alarm bells.

>>>Asthma attacks lead to hospitalisations. which lead to death.

Overuse of beta agonists in the absence of anti-inflammatory steroids has been linked to hospitalisation and asthma deaths. This could mean that patients who are given multiple emergency supplies of salbutamol may be at significant risk. By providing yet another ES, you are helping a patient to avoid seeing her doctor, and therefore putting her at risk.

>>>In my opinion the only reason for refusal could be abuse of meds, in other EUROPEAN countries you can buy things like salbutamol MDIs and various other meds that for some reason this country is uptight about

OK, but salbutamol remains a prescription-only drug in the UK. It is not correct that abuse of meds is the only reason for refusal. It may be useful to revisit the guidelines on emergency supplies.

Salbutamol has an excellent safety record when used correctly, but some patients with poorly controlled asthma overuse it to a phenomenal extent. Asthma is an inflammatory disease. Salbutamol does nothing to address the inflammation. Repeatedly selling salbutamol as if it were a P-med is not good medical care. It could be that this woman was needing salbutamol much more frequently than normal - she may require initiation/increase of prophylactic medication, or even a short course of oral prednisolone.

>i would class as very safe POM meds

Salbutamol could a useful P-med in a much smaller pack size. 200 sprays is far too much to sell OTC. Considering that asthma is a potentially serious condition and that salbutamol is frequently overused by patients, selling a 200 dose spray could be detrimental overall. It makes it far to easy to avoid seeing a doctor.

[SolomonQ]

" By providing yet another ES, you are helping a patient to avoid seeing her doctor, and therefore putting her at risk."
we can go round in circles and at the end it becomes more like what came first, chicken or the egg. The patient's health will surely suffer but because of themselves, whatever you do, how likely is the patient to go to the doctors if the inhaler is not supplied? if she tries to book an appointment, it might not be until a week later if she is lucky and if she happens NOT to be one of those scroungers who are leeches to the state then she might have to take time off work which she might not be able to afford especially in these dire times.

What people, aswell as HCPs need to understand is that although HCPs have a certain amount of responsibility towards a patient's health, the overall responsibility is the patient's own. How many people do we need to run after to make sure they are doing things best for their health.

How long before we should stand by the donuts in supermarket bakeries in our own time and tut at every fatty that picks one up (highly unlikely), or are we better placed by the cake stand. How many people are hospitalised because of obesity related conditions?

i'm not saying a patient walks into the pharmacy says I want an emergency supply of x and i just give it to them, obviously the right questions need to be asked, but how can you refuse if not supplying bears such great IMMEDIATE risk to a person's health?