The majority of patients will look to treat symptoms of cold and flu within three days of onset, and many will expect an all-in-one product to relieve all symptoms. Every interaction with a patient is an opportunity to provide the most appropriate advice and treatment recommendations. However, engaging in a consultation with patients about their cold or flu symptoms can sometimes be difficult. Many just simply ask for a specific product and are not looking for additional advice from the pharmacy team. This is where our pharmacy teams can focus on ensuring that all patients are getting the best possible care, and most appropriate treatment.

Consultation pathway

There are several stages in the consultation pathway, and the whole pharmacy team should use the same system to promote consistent care. The first stage during any consultation begins when the patient presents to the counter and ends with the patient satisfied with their recommended treatment:

• Initiating the consultation: Greet the patient, identify what brings them to the pharmacy and build a rapport;
• Gathering information: Use your usual questioning technique such as WWHAM to gather information related to the patient’s problem. Example questions, Stage 2:
  1. Can you describe your symptoms and how long they have been present?
  2. Is there anything about these symptoms that is worrying you?
  3. Have you tried anything to relieve your symptoms?
  4. Do you have any medical conditions or allergies?
• Shared decision-making: Put the patient at the centre of decisions about their own care. This is an important stage where the pharmacy team has the opportunity to provide detailed information on symptom management, appropriateness of antibiotics, the product options available and other patient-specific factors to allow them to make a fully informed decision about their own care. As self-care is essential for the future management of cold and flu, any decisions should be made in collaboration with the patient;
• Patient education: This important stage ensures the patient knows how to use the medication effectively and safely, and to store it appropriately. During the consultation, patients should be educated on the correct dosage and administration, what to expect in terms of symptom relief and improvement, and any red flags to watch out for. Patients should be told what to do if there is no improvement or if an adverse reaction is experienced, and also when to look for advice or need to return to the pharmacy. Pharmacy teams can also provide patients with details regarding the next steps for their management, including non-pharmacological treatments and self-care measures; and
• Close the consultation: Check that the patient is happy with the agreed management and treatment plan. It is also important to check the patients understanding of all the information provided and give them the opportunity to ask questions.

Patients wishing to purchase specific products can be less willing to engage in a consultation. This is where our pharmacy teams need to focus to ensure that the product is suitable  

Patients who present wishing to purchase specific products can be less willing to engage in a consultation. This is where our pharmacy teams need to focus to ensure that the product is suitable. Rather than going straight to select the product for the patient we can direct the conversation back through the consultation pathway. Start by asking if the product is for them or someone else. By engaging in a conversation with the patient it will initiate the consultation journey and work through the stages outlined. If a patient has pre-selected a cold and flu product to purchase, discuss their symptoms alongside the appropriateness of the product selected. Alternative management options should be presented with reasons why these options may be suitable.

Cold and flu treatments

Many patients can find it difficult to find the appropriate treatment, with so many options available. Patients often choose incorrect treatments to relieve their symptoms. Patients are at risk of using too many products to treat their symptoms and can often be over-medicating and overusing some ingredients. This is where our pharmacy teams can ensure the most effective treatment for cold and flu symptoms. Pharmacological management consists primarily of symptomatic relief for the presenting symptoms. Following the consultation pathway, the choice of product should be based on patient preference, presenting symptoms, and clinical considerations. Pharmacists and their team need to ensure that patients are aware of the active ingredients in combination products and that the correct product is selected to manage symptoms.

Special consideration should be given to certain groups where their management may require additional care, intervention and attention. For instance, older people, those who are pregnant or immunocompromised.

Identifying need for referral

A community pharmacist can easily diagnose a common cold. If a more serious infection is suspected, or involvement of the lower airways, then patients should be referred to a medical practitioner for further assessment. When assessing patients’ presenting symptoms, pharmacists can identify red-flag symptoms which warrant direct referral to a GP:

• Fever ≥39°C in adults;
• Fever for five days or more, or fever returning after a fever-free period in adults;
• Fever ≥38°C in infants; or
• Rising fever or fever lasting more than two days in children of any age.

Some red-flag signs and symptoms accompanying cough /sore throat can include but is not limited to:

• Cough that lasts for more than three weeks;
• Unexplained cough that recurs regularly;
• Discoloured or purulent sputum present with cough;
• Coughing up blood or blood present in sputum;
• Chest pain;
• Shortness of breath;
• Wheezing (may be suggestive of other conditions, such as asthma);
• Persistent nocturnal cough in children;
• Stridor;
• Sore throat that lasts for more two weeks;
• Difficulty in swallowing;
• Sore throat with mouth ulceration or blistering; or
• Suspected adverse drug reaction or medicine-induced agranulocytosis:
  • Examples of medicines known to contribute to agranulocytosis include captopril, carbimazole, cytotoxic medicines, clozapine, sulfasalazine and sulphur-containing antibiotics.

Further information can be found in the International Pharmaceutical Federation (FIP)’s handbook for pharmacists, Cold, Flu and sinusitis: Managing symptoms and supporting self-care (available at fip.org/file/5089).

Role of the pharmacist

Pharmacists have a unique opportunity to make a differential diagnosis, educate patients on the management of these common conditions, and provide appropriate therapy and advice. Ensuring pharmacy teams engage in effective consultations when patients present with cold and flu symptoms will ensure the highest standard of care for all patients. There is also an important role in antimicrobial stewardship and supporting self-care.

Antimicrobial stewardship

Pharmacists have a huge role in antimicrobial stewardship (AMS). A lot of patients can expect an antibiotic for treatment of their cold and flu symptoms. AMS not only looks at challenging inappropriate prescribing of antimicrobials but also plays a role in the prevention of infection and promoting self-care for cold and flu, right from the initial contact with the patient. Pharmacists are ideally placed to educate patients about the indications for use of antibiotics and the importance of avoiding their misuse and overuse. Patients should be educated on the difference between bacterial and viral infections as well as the reasons why antibiotics are not effective against viruses, which are the primary cause of the common cold and flu. Pharmacy teams can help reshape the patients perceptive of managing cold and flu symptoms. Pharmacists must encourage their teams to reinforce public health messaging around prevention of infection and self-care for cold and flu, and they must strongly discourage patients from automatically seeking antibiotics. This message needs to begin at the start of the patient journey — at first presentation, when initiating the consultation. This can be achieved through an effective consultation, with appropriate treatment recommendations resulting in successful symptom relief.

Supporting self-care

According to the World Health Organisation, self-care is defined as; “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider”. Self-care is a broad area that looks at many factors such as a patient lifestyle, their nutrition, general and personal hygiene and self-medication. Pharmacists can empower patients to help them make healthy lifestyle choices, recommend appropriate non-prescription medicines, and educate them on when they should visit a GP.

Flu vaccination

Flu vaccination is one of the most effective methods of preventing flu illness. Vaccination has been associated with a reduced risk of flu infection and transmission, hospitalisation, and risk of flu-related death in at-risk patients. As pharmacists, we can help to ensure our patients are offered a flu vaccine each year, especially those in at-risk groups. By providing a flu vaccination service in our pharmacies we are reinforcing our roles as first-line, easily accessible primary healthcare professionals.

References available on request.