Community Pharmacist Program - Impetigo and hormonal contraception webinar

Michelle Delaire (Health) 2:26
Good afternoon and welcome to today's Community Pharmacist Program webinar. My name is Dr Michelle Delaire and I'll be presenting today on behalf of the department. If we move to the next slide, please.

I will just start by acknowledging the traditional owners of the lands on which we are all meeting today, wherever we are, and I'd like to pay my respects to elders past, present and emerging. And welcome and acknowledge any Aboriginal elders who may be here today. And I'm on the lands of the Wurundjeri people today.

Thank you very much for joining.

Just a couple of quick things before we get into the content today. We are recording this session so we can post it online and make it available to people who are unable to join us this afternoon.

And also in terms of the format, unfortunately you can't in this format pop on your camera or speak. However, we do welcome questions which you can post into the Q&A. There is a vetting process, so they may or may not come through now, but they'll certainly will be looked at by the team. We'll do our best to answer all the questions we can, but we may not be able to get to the clinical ones today. So just to let you know about that, but we'll do our best to answer any questions that we can.

Let's move on. I'll give you a quick overview of what we're covering. I'll do a quick summary for you. And sorry, I should have said my role is I'm the Project Director of the Community Pharmacist Program for the Department.

I'll give you a summary of the new services we're talking about today. I want to do a bit of a refresher on some of our program requirements, particularly focused on new pharmacies that may have joined us over the last few months, and quickly to touch on our current marketing campaign of Chemist Care Now. And then I'll pass you across to our colleagues from Safer Care Victoria who support the clinical aspects of the program, and they will talk to you in detail about the updated and the new protocols which are now in effect. So next. Thank you.

So December 19, we added the first of the new services to the approved services pharmacists can offer in community pharmacies. That was an expansion to the oral contraceptive service. So now adding two forms of hormonal contraception and bringing in impetigo.

So the vaginal ring and the depot injection are now part of the suite of contraceptives which can be offered to patients. And impetigo treatment, otherwise known as school sores, is also now an option for pharmacies to add to their suite of services for specific situations, non-bullous, two years and over, and limited as to body regions as well.

You will hear much more about that shortly. And just a reminder that the government's announcements around this program is that it will continue to expand over the next two years, bringing the total services to 22 that pharmacists will be able to offer in their pharmacies. So moving to the next slide.
I just wanted to highlight training requirements because they are a little bit particular right at the moment. So to offer the impetigo service, you must have at least one pharmacist who has completed the training. There are two options, both of them will go for about an hour, one hosted by the Pharmaceutical Society of Australia and the other hosted by the Australasian College of Pharmacy.

As always, sorry, the pharmacy has an impetigo, sorry, the college has an impetigo course, but they also have a has a more comprehensive course which covers other skin conditions as well, which in this case are herpes zoster and psoriasis. All of those links, as always, are available on the Resources for Pharmacist page on the project's website.

My team will pop that into the chat, but you should be aware of how to find that on the department's website. That link is also available throughout this slide pack. For expanding the oral contraceptive service to offering hormonal contraception, there's two possibilities. People that have prior or previously completed the Contraception Essentials Explained course, hosted by the Pharmaceutical Society. They've already covered the hormonal contraception and when they're ready they can commence the new services at any point.

If people have done, on the other hand, the college course, that only covers the oral contraceptives, so they are not yet enabled to be able to supply those additional contraceptives. They can, of course, complete the other available course, but we are looking into options to cover that new content and enable people who've done the college course to provide the full range of contraceptives and you will hear more about that through our newsletters in future.

I'll move to the next slide, which is about the smartforms that you can access through your pharmacy, which, which have to be used to deliver the services when you're sitting down with patients in the consultation room. So, there was an automatic update to the oral contraception form to bring in the new options. And there's also some changes to eligibility, which you will hear about shortly. You need to familiarise yourself with that because it is different to how it was prior to December 19, and obviously the Impetigo smartform is now available.

There are a number of pharmacies, I think about 120 have already requested access to that. We have an online form. And so that's been actioned. If pharmacies, as they're ready, as people are trained and they want to bring that service in, they need to go to that online form. We'll get that link into the chat for you again, and it's simply a matter of filling that in. It can take a couple of weeks for that to go through and to have that form available in your pharmacies, but you'll get an update when that happens. So that's just a little bit about the process around those changes.

So I'll just do a couple of little updates and reminders. Moving to the next slide, please.

As I said, mainly for new pharmacies, but also as a bit of a refresher. So the ability for a pharmacist to administer, supply or sell a Schedule 4 poison without a script is enabled through a secretary approval by the Secretary of Health. Those are all in the Government Gazette. We always make those links available on the website.

And that has its conditions that every pharmacist providing those Schedule 4 poisons must have done the training specified, must follow the protocol. That's always published online and linked through the Med Advisor forms, and in particular in the case of travel vaccines that they reported to air as per usual. There has been an update to the Gazettal at the end of December bringing in these new services and the modification to oral contraceptives and the link on the webpage is linked to that updated Gazette notice. So it's worth being across that and understanding exactly the conditions under which those drugs can legally be provided.

The other thing I wanted to mention is private consulting rooms. We do unfortunately continue to get complaints from patients who have told they had the consultation at the counter. We really do not want to see that happen. When an owner applies to be part of the program, there's a declaration that they do have an appropriate consulting room. So this is just a reminder, make sure obviously that it's there, make sure that all of the consultations are done in that space as you work through the process on the online form with the patient. There's some of the detail there and there's more information around it with some links which are on the slides we'll get you but also we can post those. So really important that privacy aspect of this service is one of the foundations of enabling it to run in pharmacies.

A little bit of an update on costs. These did change about six months ago. So medications are no longer subsidised under the program. They are not subsidised under the PBS. So patients do, of course, have to pay the full cost of the medication. Please speak to patients before the consultation so they were aware if they are likely to need PBS medication that they understand the difference and the options. I'm sure that you would all do that as a matter of course. There's a fact sheet to support you in that if you need it, which is on the website. For consultations, eligible consultations, will continue to receive the $20 payment from government per service managed in the back end through the consultations recorded in the system. Eligible services are listed at the link on the website and they cannot be charged. You cannot charge a fund per patient for any of those consultations.

The difference is travel health. We know that's a different thing. Pharmacies will still get $20 for every eligible consultation that includes administration of at least one travel vaccine. But for that particular service, you can charge the patient for the consultation and obviously the cost of any vaccines provided.

And Jackson, if we could just move to the next slide. Just a little reminder that from November, government has branded this whole program to the public as Chemist Care Now.

Obviously, with pharmacists and within the department, we still call it our Community Pharmacist Program because that's what it is. But a lot of work was done to look at awareness and what resonated with the public and what stuck in their minds. And that's why it's now branded as Chemist Care now. And the idea is to have consistent branding right across the pharmacy. So people start to recognise if they're away on holiday or somewhere else and they see the signage, they think, oh, I could pop in there and this could be a UTI or pop in there and get the additional oral contraceptive they need or whatever the service is. So please have a look at the assets on the website. We're always open to requests if there's something you think that's missing that you'd like.

But the idea is just about consistency and it being recognisable to patients throughout Victoria in our 800 plus pharmacies that are currently registered to offer services.

Okay, so that brings me to the end of the things that I wanted to cover. I will check in if there's, I'll have a quick look at the questions that are in the system. So the first question is about whether you still get the payment if you've done the consultation, they're not eligible. There's a little bit of grey around this. So if someone comes into a pharmacy and says, look, I think I've got a UTI, can I access the service? And they're clearly not female, then they would not be eligible and it wouldn't make sense to sit down and go through that whole process and then say, sorry, I can't treat you. You have to be referred to a GP. But if you talk to someone and it seems reasonable and obviously you're not always going to know someone's biological sex when they come into a pharmacy, and you have that whole process and you do the discussion, give them the handout and you talk about self-care and you say, look, here's what you can do, but you will need to see a GP. That is a consultation, that's a service. It's perfectly valid to put that through the system and it's perfectly valid to have that $20 payment. So it's really just this discretion.
Whether it really looks like someone is completely and obviously outside the scope of what would be eligible. But, you know, we understand that may not be evident upfront and it's perfectly fine to give them that other assistance, have the conversation and that would get the payment.
The next question, I'm not promising we'll answer them all, but I will do the ones I can quickly. If people previously did the PSA course for old contraceptive 2 years ago even, they technically are ready to provide the new hormonal contraceptives.

The whole question of keeping up to date and across obviously would apply, but technically if you've done that course you are fine, you don't have to repeat it.

Then there's a couple of links and thank you for posting the information. I might leave it there and I'll check what else is in the chat later in the session this afternoon. So what I'd like to do now is hand you over to some of our pharmacists who are assisting the project from our Safer Care Victoria team.

So firstly, I'll hand you to Elizabeth Su, who will take you through in more detail the Hormonal Contraception protocol, and then she will pass on to Robert Luong about Impetigo, and then I will come back online at the end. So thank you, and over to you, Liz.

Elizabeth Su (SCV) 15:32
Thank you so much, Michelle. So hello to everyone. I'm Liz. I'm a pharmacist who is a secondee with Safer Care Victoria, working with their program to develop protocols. So today I'll be sharing a high-level overview of the resupply of hormonal contraception protocol. Further protocol detail is in the full protocol documents available via the program website.

And to reiterate on Michelle's point earlier, please be aware that pharmacists are required to undergo specified education before providing this service. Next slide, please.

So the protocol for resupply of hormonal contraception is a revision of the previous protocol for resupply of the oral contraceptive pill or OCP for short. So with this updated protocol, in addition to oral contraceptive pills, the protocol will allow for the resupply of additional hormonal contraceptives.
Females aged between 16 to 50 years of age can access this service if they meet eligibility criteria.
Next slide please. So I'll be sharing a high level overview of the updated treatment options for the protocol, eligibility, clinical review and referral criteria that are a bit different compared to the previous protocol.

So in the revised protocol, in addition to oral contraceptive pills that were previously listed, pharmacists will be able to resupply additional options. So these are estetrol drosperinone oral contraceptive pill, which you might know better by the brand name Nextstellis®, the combined hormonal contraceptive vaginal ring, which you might know better as NuvaRing®, and also the depot-medroxyprogesterone acetate injection. And just to be aware, under this protocol, pharmacists may administer depo-medroxyprogesterone if they have suitable premises, training and competency to deliver deep intramuscular injections.

Thank you. So next I'd like to share the eligibility criteria for resupply of hormonal contraceptives in this revised protocol.

So firstly, a medical practitioner, nurse practitioner or endorsed midwife must have prescribed the hormonal contraceptive initially and also those authorised prescribers must have reviewed the appropriateness of continuing the hormonal contraceptive within the preceding 2 years of the appointment that the pharmacist is having with the patient.

Secondly, the patient must be stable on their current hormonal contraceptive. So this means having used the same hormonal contraceptive for at least 12 months if the patient is aged between 16 to 17 years and at least six months if they're aged 18 years and above.

Thirdly, the revised protocol does allow for resupply when there has been a break in continuous use of the hormonal contraceptive under certain circumstances. So if a break in continuous use has occurred, the pharmacist should consider the patient's need for emergency contraception and or pregnancy testing before resupply. If the pharmacist is satisfied that the patient is not pregnant or possibly pregnant, and there has been a break in continuous use of fewer than two years in the preceding 30 days, the pharmacist may supply one original pack of the hormonal contraceptive. If the patient is not pregnant or possibly pregnant and there's been a break in continuous use of two to four weeks in the preceding 30 days, the pharmacist may supply one month, resupply, sorry, one month supply of the vaginal ring or oral contraceptive pill, only, but this excludes depo-medroxyprogesterone. And in this case, the patient must also be concurrently referred to their usual prescriber to review whether this hormonal contraceptive is actually the most appropriate option for their needs.

There's also been a change in criteria for measuring a patient's weight to calculate their body mass index or their blood pressure. So to allow for situations where a patient may be returning to the same pharmacy for an appointment with a pharmacist who has access to weight or blood pressure measurements that have been taken and recorded in the preceding 12 months, and there's been no changes at all in the patient's health status, then in these cases there is no requirement for the pharmacist to retake those measurements unnecessarily. They can use existing records if these are up to date.
And then finally, there have been some updates in referral criteria. So for criteria to refer the patient to their GP or other healthcare provider without resupplying the medication, the revised protocol wording brings them more attention to looking for unexplained or uninvestigated signs and symptoms of endometriosis or polycystic ovary syndrome. So patients who have unexplained signs or symptoms must be referred to their GP or other healthcare provider for further investigation without resupply by the pharmacist. So the wording just makes that a bit clearer. The revised protocol also has criteria where the pharmacist may resupply the hormonal contraceptive to support continuity of care, but they also must concurrently refer the patient to their GP or other healthcare provider for further care. So, these referral and treat points include the need for STI screening or cervical screening test, and also where there is possibility of reproductive coercion, sexual abuse or sexual violence.

So thank you very much for your attention. For further information, please read the full protocol document, including supplementary information which is available on the program website. I'll now hand over to my colleague Rob, who's going to share an overview of the management of Impetigo protocol.

Robert Luong (SCV) 21:17
Thanks so much, Liz. Lovely to be here today. So I'm Rob, and like Liz, I'm also a pharmacist secondee here today on behalf of Safer Care Victoria. I've been given the opportunity to share a high-level overview of the newly established management of Impetigo protocol that I've been involved in the development of. Before I get started, though, I did want to take the opportunity to echo on from both Liz and Michelle's
earlier comments that this session is only for providing a high level overview and that all pharmacists are still urged to refer to the Program website to access the clinical protocol directly for a detailed review.

A reminder that all pharmacist must undergo the specified education and training offered by both PSA or ACP before providing the service. Next, thanks, Jackson.

Okay, so opening up, what is impetigo? So most commonly known as school sores, impetigo is a contagious bacterial skin infection. The bacteria in question is typically caused by staphylococcus aureus or streptococcus bacteria. Typical presentations will often cause red sores or lesions, which then mature and often burst or ooze and form a yellowish brown or honey coloured crust.

Why empirical management? So impetigo occurs in all ages, but it's most common in children aged 10 and under and highly contagious via direct contact with the sores, particularly the ooze. The majority of presentations of impetigo, just about 70% of them, are the uncomplicated non-bullous form.
Early treatment of impetigo with empirical antibiotics may thus support shortening of the illness and reduce spread. Next, thanks, Jackson.

So protocol scope. So this protocol is a new service as part of the Chemist Care Now Program. As part of this service, pharmacist can now supply select topical, and oral antibiotics for the treatment of non-bullous impetigo. Pharmacist can also treat patients aged 2 years and older if they meet the eligibility criteria, which we'll go through shortly. Next, thanks.

So an overview. So the next sections, I will be running through the treatment options available as per the protocol, patient eligibility criteria, patient referral criteria, and some key non-pharmacological care highlights from the Impetigo protocol. Thanks, Jackson.

Now, the treatment options available in the protocol align conservatively with the therapeutic guidelines, empirical treatment recommendations for impetigo. So for limited presentations of impetigo, that's defined by the Therapeutic Guidelines as where there are no more than two sores or lesions, pharmacist may consider treatment with topical anti-infectives.

So your first line being your mupirocin, 2% ointment or cream, better known as Batroban®, or second line being the hydrogen peroxide 1% cream, which is available over the counter and pharmacist may know it as Crystaderm®.

For extensive presentations of impetigo, that is where there are more than two sores or lesions, and for the purposes of the protocol affecting no more than two different body regions, such as the hand and the mouth, patients may be eligible for empirical treatment with oral antibiotics. So as you can see on the slide, your first line being your dicloxacillin. Pharmacists may know this as Distaph®. Flucloxacillin, your Flopen® brand. For second line, cefalexin or Keflex®. And third line, trimethoprim combination with sulfamethoxazole or your Bactrim®. Now, as per the Therapeutic Guidelines advice, cefalexin maybe preferred in children due to less frequent twice daily dosing and better tolerated oral liquid formulation. But please, all pharmacists refer to the clinical protocol for more advice on treatment option guidance and special consideration around the anti-infectives. Thanks, Jackson.

Now, eligibility criteria, so within the protocol, eligibility starts off at children aged 2 years and over only clearly defined presentations of non-bullous impetigo are eligible for management. That is where patients presenting with either bullous or eczema forms of impetigo or unclear presentations aren't eligible because it suggests deeper and more complicated infection or risks.

Only patients presenting with non-recurrent impetigo are eligible for therapy. Recurring impetigo often suggests underlying antimicrobial resistance or other underlying risks. Patients with clearly defined non-recurrent, non-bullous impetigo affecting no more than two body regions are eligible for therapy. So as an example, as mentioned before, if a patient presents with impetigo on both hands, they would be eligible. If they present with one hand and one on the lip, they would be eligible for therapy. Patients with impetigo affecting 2 body regions, though, as I've discussed, may be eligible for treatment, but also require concurrent referral to their regular authorised medical practitioner.

Thanks, Jackson.

Now, referral criteria. So when should patients be referred to their GP or authorised medical practitioner and are not eligible for treatment? So the first category would be patients who are at high risk of complications from impetigo.

So group A streptococcus skin infections carry a greater risk of complications in particular populations. Please refer to the protocol for a full comprehensive list of risk factors. However, one of the big ones to look out for is your acute rheumatic fever, which is the precursor to rheumatic heart disease.
So again, there are details in the protocol to support pharmacists. Second category being patients who are immunocompromised or have chronic diseases require referral for care. Atypical or complicated patients often require referral as these patients may experience a more rapid spread or could be at higher risk of complications.

If patients present with not clearly defined non-bullous impetigo, echoing the previous slides, unclear skin presentations do require referral for care and review.

Now, presentations with signs or symptoms of severe infection, vasculitis, or toxin-mediated illnesses require immediate referral to the emergency department.

For a full list of ED referral criteria, please refer to the protocol, but examples of signs and symptoms that pharmacists may look out for could be widespread painful rash, non-blanching purple rash, or blistering of the skin.

And lastly, with regards to widespread or severe lesions affecting more than two different body regions, they often imply higher bacterial burden or systemic involvement, and thus those patients require referral for assessment and or testing. Thanks, Jackson.

And lastly, for my last slide, I'll just be calling out some key non-pharmacological advice included in the protocol. Pharmacists are advised to refer to the pharmacist and patient resource sections of the protocol and any patient or pharmacist handouts for more details and support.

So first point being, patients should be advised to clean and gently de-crust their sores or lesions to reduce their bacterial load, especially before applying topical medications if they're on topical antibacterials. Covering the sores, especially before oozing or bursting, reduces the spread of the impetigo. Pharmacists may consider bleach blots as an adjunct to reduce the bacterial load. Please refer to the Royal Children's Hospital Bleach Parts fact sheet for detailed advice on how to do this safely.

And lastly, good hygiene reminders such as daily linen changes and not sharing towels or face washes may reduce household spread of impetigo.
Thank you all for attending and for your continued support of the community. I'll hand back over to Michelle now that my section's over. Thanks.

Michelle Delaire (Health) 29:19
Thank you so much, Rob and Liz, for going through that. So we have tried to respond to as many questions as we can through the chat as we've gone through. Please have a look at that. If it's not immediately obvious, I think you can click the show one comment.

I will just comment on the Chemist Care, because there were a couple of questions around that. That was a marketing decision based on evidence from the research that was done. So I do think that that is going to be the branding of this program for some time to come. And all I can say is while we understand it's not the preference of some pharmacists or potentially many pharmacists, it is what is resonating with the public. So I hope that you're able to adopt that and use that branding in your pharmacies for the consistency.

Just a couple of things from me at the end. So all of the patient handouts, which are on the Resources for Pharmacist webpage, have been updated onto that new branding. And additionally, obviously, there's a new one there for impetigo, an updated one for contraception. So please download the new ones, throw out the old ones that you've probably got there, and make sure you've got those new ones to provide to patients. They also have the updated links for support and other sources and other advice. So really great to have the current ones on hand. And there was a questions about the UTI and the update of the antibiotic treatments, because we are aware that right now it's not in line with the therapeutic guidelines, with trimethoprim still the first line. We are expecting that that will be updated next week to come into line with Therapeutic Guidelines. However, until that lands, until it's legal, until we have an updated Gazette and an updated secretary approval, you can't work to that.

But as soon as that is available, the protocol will be updated. The new handout will be there and there'll be the link to the updated Gazette and we will send a newsletter out giving you all the links and the information. And I think we'll be sending out the updated UTI protocol so people can easily have a look at what's changed in that. And we're also considering whether we do a forum on that as well for you in.

coming weeks. So I think that brings me to the end. I'll just quickly check if there's anything else we need to respond to, if my team need to post anything else. There's a lot of links for you there. As I've said, we will put this up on the website. We're also looking at making these slides available for you.
But thank you very much for joining. We do appreciate your participation in the program and your attendance at events like this. Thank you all very much and have a great afternoon. Goodbye.