Minutes of the meeting held on Thursday 12th November 2015
Pharmacy Seminar Room, 1st floor PCH
There were no declarations of interest with regard to items discussed.
In Attendance:
Dr C Gardner / Deputy Medical Director – ChairMrs C McIntyre / Chief Pharmacist
Mrs A Ritchie / Pharmacist Team Manager Procurement and Formulary - Joint Secretary
Mrs S Mavani / Pharmacist Team Manager Medicines Governance – Joint Secretary
Dr D Mlangeni / Consultant Microbiologist (arrived at 13.30)
Ms C Johnson / Interface Lead Pharmacist, Greater East Midlands Commissioning Support Unit.
Dr R Mittra / Consultant General Medicine
Mr G Sabbagh / Quality Governance and Compliance Manager
Angeline Boaden / Colorectal Nurse Consultant
Ms I Augustine / Pre-reg pharmacist (observing)
Minute Taker: ML Denton, PA to Chief Pharmacist
15/56 Apologies for Absence:
Ms K Broad / Specialist Pharmacist – C&PJPG/HCD, Cambridgeshire Peterborough CCGDr D Woolf / Consultant Paediatrician
Mr A Massraf / Consultant Orthopaedic Surgeon
Dr C Jephcott / Consultant Oncologist
Mr P Taylor / Consultant General Surgery
Mr K Claire / Lead Pharmacist, Peterborough and Borderline LCG
Due to concerns regarding attendance at this meeting it was agreed that members should nominate someone to come for each area if they are unable to attend. C Gardner requested a detailed list from A Ritchie regarding who should attend, who does attend and how often. The Terms of Reference, in particular membership and quorum issue, to be reviewed at the next meeting.
15/57 / Minutes of the Formulary and Medicines Management Meeting heldon Thursday 17th September2015.These were accepted as a true record of the last meeting.
15/58 / Matters arising from the minutes:
15.16.13 Guidance for Post-operative Analgesia after Day-case Arthroscopic Shoulder procedure: It is not known whether this document has been amended as the registrar has now left the Trust.C Murray (Specialist Pharmacist) to speak to Mr White (Consultant).
ACTION: On hold
15/27.4:Protocol for the Prescribing and Administration of Tecfidera (Dimethyl Fumarate): This is still not ready and to be deferred again.
ACTION: To be deferred to a future agenda.
15/27.8 Peripheral Venous Cannulation in Babies, Children and Young People Guideline: The author is no longer in this area, reply fromKaty Eley. This is not a clinical policy or guideline; it is a procedure and shouldn’t be on Sharepoint. This must beconsistent practise. Local approval on QA form. SM to contact Tim Jones and ask him if this should go ahead etc. ActionSM
15/43 Special solution for lifting polyps:C.McIntyre raised concerns that this is not a stable product and will look into this. The Medicines Information Pharmacist has looked into this from a NMC point of view. This practice contravenes code of conduct and must not be done. Action: CMc to inform N Kumar
15/46.3 Guidelines for Glycaemic Control during Contrast Angiography: these are old guidelines which now require reviewing. A number of changes were requested such as referring to combination preparations with metformin also. Approval committee should be changed to FMMC. Outcome: approved with changes.
Update:This also needs to go to QGOC.
Concern was expressed that it is not possible to know that all changes have been made and that the final version presented has had the changes made and is the one the Committee endorsed. There is an issue with changes being requestedbut no list of changes being kept. Even if the author is present this presents a problem. It is not normal practice to record minor changes in the minutes of the committee meeting. In order to do so, each change would have to be individually commented at a measured pace to allow the minute taker time to get them noted down.
It is expected that from early in 2016 that policies will be checked by the designated pharmacist for that area(Pharmacy Clinical Leadership Team). As a result the policies should not contain errors when brought to this committee; at most some minor tweaks could be expected. The pharmacist would also be required to attend the meeting and be responsible for recording any changes which are required.
15/46.4 Nutritional Guidelines for adults in Critical Care: Update:this document is again for reviewing. There are no major changes or changes in drugs but this must be recorded as being for over 18s only. The amended document must come back to the Committee. S.Muneer wrote guidelines when she was the pharmacist on the Nutritional Steering Group. These should be reviewed by the group. Taner Zor (Specialist Pharmacist) will now be involved with this group. The amended guidelines need to come back to this committee.
15/46.5 Guideline for the Use and Administration of Intravenous Iloprost for Raynaud’s, Severe Peripheral Arterial Occlusive Disease and Buerger’s Disease: this document is approved with changes. Outcome: approved with changes
Update:The Chair had requested to see the document to confirm the changes. The guideline has not been seen and needs to be chased
15/46.6 Guideline for the management of Sedation, Analgesia and Delirium in the intubated adult patient within the CCU: a number of amendments are needed.
Outcome: approved subject to changes
Update:This document has not been seen to confirm the changes and needs to be chased.
15/46.11 Citrate Haemofiltration Prescription & Monitoring Chart: The chart is to be sent back for amendment.Outcome: not approved.
Update:This chart has not yet come back to the Group.
15/46.12 Guidelines for the Management of Anticoagulant reversal in Adults: Not to be used until pink chart is revised and updated. Callum Gardner to email Sateesh Nagumantry regarding this action. Action: CG Outcome: To be put on hold
Update:C Gardner has not yet met with S Nagumantry. S.Mavani has chased the amendments. There are too many changes to try and get this finished for insertion to the new Trust Drug chart. It needs to go back to Sateesh with a message to the effect that he must have a meeting to discuss and sort this.
15/46.13 Policy for the Management of Deep Vein Thrombosis (DVT) Nurse Led Clinic: a number of minor changes were requested. Outcome: approved with changes.
Update:It has been discovered that the document submitted was an old one and since then changed. This is still ongoing and will come to the January meeting.
Post Meeting Note:SM has met Jacqui Aistrup and Sarah Shah regarding the changes to this document. The original was a very old document with a lot of major changes.
15/48 NICE-Medicines Management Guidance: Update: C.McIntyre clarified that although a pharmacist may be part of the CMTs, compliance should be by the doctors and not just pharmacists. S.Milne has checked on medicines adherence but it is difficult to record that this is done as although it is routine behaviour how can it be evidenced. The document is asking about drug adherence and all doctors/consultants should be asking their patient if they are taking their medication.
Each directorate needs to feedback to Guy Sabbaghto say they are compliant and that patients are being spoken to regarding medicine compliance. This needs to be discussed in individual Governance meetings. It would not be possible for Pharmacy to ask patients as they do not see every patient.Medicationsshould be checked on admission and/or if medication is changed. Medicines reconciliation will also pick this up. This could be audited but this would only be a snapshot (audit within 48 hrs of admission and post out-patients.
G.Sabbagh would be able to use medicines optimisation audit as evidence.
15/51.3 IVIG demand management panel: A.Ritchie to check if there is a requirement for this group to report to the Committee.
Update: an IVIG demand management panel is still required by the commissioners NHSE. The Trust is paid on outcomes. L.Wilmer (Specialist Pharmacist) completes the database and the outcomes of treatment but has to chase to get this information. CMcIntyre to talk to L Wilmer. Action CMc
15/52 Future format of the Formulary and Medicines Management Committee Meetings:Comments regarding the formula of future meetings as outlined by CMcIntyre at last meeting.Update: CMcIntyre has received no feedback. The new agenda will start from January.
15/59 / Formulary Items given Chair’s Approval, New Drug Requests and Updates
15/59.1 AmphotericinEye Drops: This drop was approved for one patient. These are the only antifungal eye drop available to us. The full formulary submission paperwork is still awaited. A Ritchie asked if when this is received it could be forwarded for Chair’s action to prevent delays for other patients.
There was a problem when this request came through of the 3 key personnel not being available due to unforeseen circumstances. It was agreed that another pharmacist who is unlikely to be absent when A Ritchie is away be added to the group. The Chair decided that C.Gardner’s secretary is to be added to the email list.
15/59.2 Sodium valproate sachets. The drugs for control of the epilepsies section of the formulary still needs to be updated to ensure NICE guidance is met.
15/59.3Woundcare Formulary: ARitchie gave a verbal update. Meeting with pharmacist and tissue viability nurse who have been looking at this. CCG woundcare requirements mean there may be changes with some items coming off. Link in withCathy at South Lincolnshire. This formulary only covers woundcare, not stoma care products.
15/59.4Lecicarbon A suppository. This is requested for use prior to bowel surgery and diagnostic procedures. Concern was expressed that it may be used for other conditions if approved. It can be allowed for specific procedure only and if amount used increases this will be investigated. This will be reviewed at 6months. To be kept inpre-assessment clinic only. A PGD would be needed and labelled product (80 per year). There was concern over the lack of evidence for this product. Not approved in Lincolnshire where there are concerns about effectiveness of the product.
The product was added to the formulary for use under PGD in preadmission clinic.
15/60 / Horizon Scanning:
New Drugs On-line Newsletter September 2015 (see attached paper) – for information.
NICE Technology Appraisals in Development (see attached paper) – for information.
15/61 / Trust policies and guidelines for approval
15/61.1 Policies given Chair’s Approval:
15/61.1.1 Final Local Guideline for the Management of Patients with Stroke.
15/61.1.2 TIA Pathway
15/61.1.3 Thrombolysis Pathway for Acute Ischemic Stroke
These documents had been taken to QGOC (and rejected) but not to this committee. In addition it was given approval by Jo Bennis and John Randell and is currently on Sharepoint. It was agreed that there needs to be a single policy. Unfortunately the lead clinician is not available for comment. A number of errors and problems have been found. Committee members to read the documents and forward any comments. S.Mavani will look at this with Charlotte Murray, Specialist Pharmacist and track any changes. It will then be sent on to C.Gardner for final comments. There is nothing unsafe in it, it is incomplete rather than dangerous.
Outcome: not approved
15/61.1.4 Carotid Artery: This had been looked at in the March extra meeting when it needed clinical input. This has since received Chair’s Action and has been approved. Outcome: approved
15/61.2 Guidelines for Approval
15/61.2.1 Policy and assessment for clinicians in the administering of intravenous (IV) drugs: This waspresented by Fiona Holdich. Currently there is no clear guidance around using hepsal and there is anew heparin flushing solution. Use of a PGD was discussed by due to the limited usage this will be prescribed. It was requested that the brand name Hepsal be removed from the policy as it no longer exists. The strength of the heparin flushes to be amended to 200 units in 2ml and 50 units in 5ml. Formulary and Medicines Management Committee to be added in as approval group. Outcome: approved
15/61.2.2 Clinical Guideline for the Treatment of Acute Hypophosphataemia in Adults: This document is not fit for purpose and needs more support from Pharmacy. To be sent to Steven Martin and Samson Oyibo. Outcome: not approved
15/62 / Cambridgeshire and Peterborough Business Case template 2016 – 17 (see attached paper). For information. Clinicians need to be involved with horizon scanning for high cost drugs however it is difficult to know in advance how many patients will be seen with conditions which need high cost drugs..
15/63 / NICE Technology Appraisals published September and October 2015(see attached paper). NICE TAs must be on the formulary if the indication is treated here. It was asked if some guidance could be put in as to the ones least to be used.
TA355 Edoxaban for preventing stroke and systemic embolism in people with non‑valvular atrial fibrillation. An implementationplan is wanted by CCG.
TA356 Ruxolitinib for treating polycythaemia vera (terminated appraisal).
TA357 Pembrolizumab for treating advanced melanoma after disease progression with ipilimumab – this condition is not treated here
TA358 Tolvaptan for treating autosomal dominant polycystic kidney disease.
TA359 Idelalisib for treating chronic lymphocytic leukaemia.
TA360 Paclitaxel as albumin-bound nanoparticles in combination with gemcitabine for previously untreated metastatic pancreatic cancer.
TA361 Simeprevir in combination with sofosbuvir for treating genotype 1 or 4 chronic hepatitis C (terminated appraisal)
TA362 Paclitaxel as albumin-bound nanoparticles with carboplatin for untreated non-small-cell lung cancer (terminated appraisal)
G.Sabbagh stated thatawareness on the assessment side doing well. A.Ritchie will send him an implementation plan so that he is aware of the information required.
C.Gardner asked about implementation plans whether this is a spreadsheet oversight plan with escalation. ARitchie stated that she does not do implementation plans it is for the specialist pharmacists, this would be looked at by the PharmacyClinical Leadership Group.
15/64 / QIPP / CIP initiatives: These will looked at by the Pharmacy Clinical Leadership Group.
Insulin – potential to reduce number of syringes supplied at discharge.
15/65 / Unlicensed Medicines Update:outstanding issues.
Midodrine: now licensed.Unlicensed packs being run down. The new packs contain 100 and must be kept in the original container.
Oral magnesium: There is now a licensed product. Need to review what needs to be used.
Vitamin D:similarly a review of licensed products is needed.
(Dr D Mlangeni arrived at 14.30).
15/66 / NPSAs alerts: verbal report from S.Mavani. An alert stage 2 due to a death from inappropriate Naloxone usage.
Adhering and being over cautious.
15/67 / Reports from Groups and Subcommittees:
15/66.1Antibiotic Prescribing Group: there is a new version of the antibiotic policy with an ACU section in case clinicians need to use it. Also a diverticulitis section. Referral process to opiate needs to be tied up, ACU will have an overview. Microbiologist must be involved. Tighten up process electronically. Nikki Phillimore (Specialist Pharmacist) working on guidelines. C.McIntyre will meet with Nikki. Aide Memoire different to policy. Guideline and policy should reference there is an ACU section and this be cross referenced in both.
15/66.2 Medication Safety Committee (Safer Prescribing Group):
15/66.3 IVIG demand management panel: see section 15/58.
15/66.4 Thrombosis Committee:
15/66.5 Oxygen Committee: the last meeting was cancelled and the next is due in December.The issue of making this group part of the Formulary and Medicines Management Committee was discussed and C.Gardner to talk to Seema Brij (current Oxygen committee chair). Post meeting note: Seema Brij agreed that the Oxygen Committee could become part of the F&MM Committee and will no longer meet separately.
15/66.6 C&PJPG: next meeting due next week. Diamorphinevs morphinewas discussed and A Ritchie was asked to raise the issue at the meeting. C.Johnson will look at Lincolnshire issues.. The Trust and Thorpe Hall only use morphine.
15/66.7 NMAG: Steven Conway gave a talk about cost savings on Oxygen. C.McIntryewill send the information out.
15/68 / For Information:
Dates of future meetings – invites sent out.
Thursday January 21st 2016
Thursday March 10th 2016
Thursday May 26th 2016
Thursday July 21st 2016
Thursday September 15th 2016
Thursday November 24th 2016
15/69 / Any Other Business
S.Mavani: Ketamine becomes a schedule 2 drug from 30th November 2015.
S.Mavani: Dyspagia; the thickening agent needs to be prescribed onto the drug chart. In the past a sticker was used (speech and language therapy) of what to do and when to stop using. This was taken to QGOC who were not happy with this. Speech and Language therapists are unable to use PGDS. S.Mavani to look at proposal with Lucia Hyams. Speech & Language therapists currently do the SALT assessment and then ask the doctors to prescribe it.
S.Mavani: Ian Scott has drawn up aninfliximabprescription. Some areas use the drug chart, other areas use prescriptions. (S.Mavani left at 14.45). The biologics pharmacist will work with the areas using and administering infliximab to produce/ finalise procedures. If completed before January they will be sent to the Chair for Chair’s approval.
C.Johnson:In Lincolnshire antibiotics that previously were hospital only are now amber drugs and GPs can now prescribe.
C.McIntyre: pharmacists have highlighted a problem with some TTOs written by locum 11; there is no evidence or audit trail of who they are. To be discussed with Helen Tiplady.
Guy Sabbagh: mentioned a stamp containing Doctors information but this would not help when it is done electronically.
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Date of Next Meeting: Thursday 21st January 2016, 12.45pm in the Executive Meeting Room, 4thFloor, PCH
Minutes of Formulary and Medicines Management CommitteePage 1 of 7
November 2015