Hospital & community differences. Goals of hospital pharmacists. Roles of Hospital Pharmacists. Clinical Pharmacy in Hospital Setting

Transcription

1 Hospital & community differences Patients eg critically ill, isolated, surgical Medical conditions eg oncology, transplants, infectious diseases Drugs and therapies eg injectable drugs, chemotherapy, parenteral nutrition Documentation eg medication charts, patient medical records Dynamics patients, pharmacists, other HCPs are in one location; can monitor patients daily Goals of hospital pharmacists Participate directly in patient care Clinical pharmacy Key member of multidisciplinary healthcare team Medical: consultants, registrars, residents, interns Allied health: nurses, dieticians, speech pathologists,, physiotherapists, occupational therapists, social workers Patient as the centre of care Roles of Hospital Pharmacists Clinical Pharmacy in Hospital Setting Hospital Pharmacy Department Dispensary Outpatient and inpatient dispensing Manufacturing Non sterile and sterile manufacturing Drug Information Centre Provide medical information to HCPs and patients Other Clinical trials Drug Utilisation Evaluation Practice research In Patient Wards Satellite pharmacy Clinical pharmacy Direct care for patients hospital at home (HITH) Direct interaction with multidisciplinary healthcare team Definition: Patient oriented pharmacy practice Pharmacist works as part of multidisciplinary healthcare team Aim: optimise patient outcomes to achieve quality use of medicines (QUM)

2 Roles of Clinical Pharmacists Clinical Pharmacy in Hospital Setting Perform medication reconciliation Obtain medication history Review medication charts Document patient medical records Participate in medical ward rounds Respond to medical information enquires Contribute to prescribing decisions Monitor drug therapy Counsel patients on QUM Ensure continuum of care Medication history interviews Medication chart review Medical records Discussion with community pharmacist GP letter Patients Clinical Pharmacists Based on in patient wards Face face, phone calls Ward rounds HCPs Patient s Journey in Hospital Medication Reconciliation Emergency department Pre admission clinic In patient wards (Eg. cardiology, respiratory, surgical) Definition: On admission: process of comparing the patients pre admission medications to the medications prescribed on medication chart

3 Medication Reconciliation Definition: On discharge: process of comparing the patients medication chart with the discharge script Medication Reconciliation Definition: On admission: process of comparing the patients pre admission medications to the medications prescribed on medication chart On discharge: process of comparing the patients medication chart with the discharge script Aim: To prevent medication related safety issues and ensure QUM as patients transition from the community to hospital setting Medication Reconciliation Process 3 step process: 1 st : obtaining medication histories 2 nd : reviewing medication charts 3 rd : documenting within medical records Medication History Taking Why? Pharmacists have in depth drug knowledge, and usually take more accurate and comprehensive medication histories When? Preferably within one day following admission How? Preferably face face interview Other sources as appropriate

4 Medication History Interview Factors to consider prior to interview: Logistics within hospital setting Patients lying in bed Patient comfort Communicate at eye level Privacy (usually shared rooms) Different types of hospital patients Sedated (eg. Post surgery) Critically ill (eg. Intensive Care Unit (ICU)) Confused, amnesia (eg. Major trauma) Speech impaired, unable to speak (eg. Stroke, intubated) Unwilling to participate (eg. Terminally ill) Medication History Interview Factors to consider prior to interview: Communication skills Verbal and non verbal communication Open questions first Followed by targeted, focused questions Things to avoid Asking leading questions Using medical terminology Switching between brand and generic names of drugs Ignoring patient emotion Medication History Interview Medication Chart What data do we need to collect during interview? Ascertain on case by case basis Higher priority Current and previous medications prescription, OTC, CAM, and vaccinations Adverse drug reactions Allergies Patient adherence Definition: Record of all medicines prescribed and administered for the in patient while in hospital Lower priority Demographic information Dietary information Social habits (eg. Smoking, alcohol) Illicit drug use Pregnancy status

5 Information available: Patient demographics List of all medications prescribed (by medical staff) Record of all medications administered (by nursing staff) Important tool used by multidisciplinary health care team, including pharmacists Medication Chart Medication Chart Pharmacists role: Review to ensure correct medicines are prescribed (reconcile medication history information with medication chart) Check appropriateness of prescribed drugs Check doses, routes of administration, and timing of administration Drug drug interactions Drug disease interactions Review medication chart daily Medical Records Medical Records Definition: Legal document which contains complete medical information relating to patients hospital admission (current and previous) What it contains: Input from all members of multidisciplinary health care team, including pharmacists Updated daily to document patient progress Picture of medical record

6 Role of Clinical Pharmacist Medical Records: Refer for comprehensive patient information Document activities performed: Medication reconciliation No discrepancies identified all meds prescribed correctly OR Discrepancies identified and action taken regular meds omitted Xalatan eye drops 1 bd contacted resident and recommended to prescribe Xalatan Role of Clinical Pharmacist Medical Records: Document activities performed: Any other interventions (drug, dose, administration related issues) patient prescribed medication they are allergic to Ceftriaxone inj prescribed but patient is allergic to Keflex Contacted registrar to recommend alternate antibiotic timing of administration is incorrect Transiderm Nitro 25mg patch prescribed daily Contacted nurse and recommended 14 hour application only Medical Record Documentation Guidelines Maintain legal, ethical and professional standards Format Write clearly and legibly in ink SOAP or freestyle Heading clinical pharmacy Date and time Patient specific data Document factual information (avoid judgements) Sign off (signature, name and title) Definition: Medical Information Provision of medical information with clinical interpretation Aim: To provide reliable, accurate, up to date and evidenced based medical information

7 Receiving Medical Info Enquires Received by? Mainly clinical pharmacists and DIC (also any hospital pharmacist) Received from? Mainly HCPs (also patients) How? Mainly face to face (or phone/fax/ to DIC) Types of Medical Info Enquires Patient specific General Types of Medical Info Enquires Role of Clinical Pharmacists Dosing eg. What is the dose of imipenem in renal impairment? Drug administration Eg. Is sodium bicarbonate compatible with amikacin via same iv line? Drug interactions Eg. Is there an interaction between Florinef and Zoloft? Indications and therapeutic use Eg. Can acyclovir be used for HSV encephalitis? Adverse drug reactions Eg. Could amitryptiline cause prolongation of QT interval? Product specific concerns Does oral tramadol contain porcine? Other Eg. Is cefepime safe during pregnancy? Eg. Can a 60 year old female patient receive Pneumovax on the NIP? Providing medical information: Determine primary question also timeframe for response Develop search strategy Access relevant information Critically appraise information Provide response within required timeframe

8 Determine Primary Question Determine what information is needed may not be what is asked Eg. Patient treated with simvastatin presents with peripheral neuropathy What is the HCP really asking? Determine Primary Question Determine what information is needed may not be what is asked Eg. Patient treated with simvastatin presents with peripheral neuropathy What is the HCP really asking? Does simvastatin cause peripheral neuropathy? Determine Primary Question Ask several clarifying questions patient specific information demographics, concomitant medications drug history, medical history nature of ADR laboratory and physical findings Develop Search Strategy Formulate search strategy before performing any search Think about the question and match up the most appropriate resources

9 Access Relevant Information What information sources do we have available? Primary: original research articles, case reports Secondary: abstracting services (eg. Medline) Tertiary: review articles, textbooks (eg. AMH, MIMS, Therapeutic Guidelines) Access Relevant Information Which references do we use when? Standard Texts: dosing, indications, drug interactions, compatibility, common ADRs Literature search: investigational drugs, off label use for marketed drugs, rare ADRs Access Relevant Information Eg. Does enalapril cause cough? 1 st : textbooks (eg. AMH, MIMs, PI) 2 nd : Martindale, Micromedex 3 rd : literature search (eg. Medline) Critically Appraise Information All information must be critically appraised Who are the authors? What is the methodology? Was the statistical analysis of results appropriate? Are the conclusions plausible? Is the information current? Who funded the study? Aim: To provide reliable, accurate, up to date and evidenced based medical information

10 Provide Response When do we provide a verbal versus written response? Depends on nature of enquiry Simple versus complex Format in which the enquiry was received Via phone/in person versus /letter Preference of the enquirer What purpose the reply will be used Provide Response All responses (verbal and written): Appropriate to audience Accurate Timely Clear Concise Referenced Clinical Pharmacy in Hospital Setting Medication reconciliation: obtaining medication histories reviewing medication charts documenting within medical records Providing medical information to HCPs: Determine primary question Develop search strategy Access relevant information Critically appraise information Provide response within required timeframe Roles of Clinical Pharmacist During in patient stay: Review chart daily Medication and other charts (eg. iv fluids, temperature, fluid balance) Contribute to prescribing decisions Choice of drug, dose, route of administration, monitoring requirements Monitor patient response to therapy Modify patient therapy based on response and ADRs

11 Roles of Clinical Pharmacist During in patient stay: Dispense medicines for in patient use Dispensary (eg. medicines on hospital formulary) Non sterile manufacturing (eg. suspensions, creams) Sterile manufacturing (eg. iv infusions, TPN, chemotherapy) Ensure safe storage of patients own medicines Other ADR reporting, inventory control, disposal of expired medicines Contribute to Prescribing Decisions Why? Pharmacists focus on therapeutics (not diagnostics), therefore can have significant input into prescribing decisions. How? Different dynamics in hospital setting (multidisciplinary team present in one location) Facilitates a therapeutic partnership between pharmacist and multidisciplinary team Pharmacists have opportunity to suggest options for: new therapy modifying existing therapy (depending on patients response, ADRs) When? Retrospectively Following medication chart review Prospectively Face to face interaction with multidisciplinary team Participation in medical ward rounds Contribute to Prescribing Decisions Therapeutic Planning What factors may influence Pharmacists prescribing decisions in hospital setting? Pharmacist Expert knowledge of therapeutics and diseases Good understanding of physical assessments, lab and diagnostic tests Medical Willingness to accept therapy suggestions Hospital Formulary Treatment guidelines / protocols Cost of drugs S100, SAS, clinical trials Patient Comprehensive patient information medication history interview, medical records, and other Evidence of non adherence Any prior ADRs Identify the problem Prioritise the problem Select drug and non drug therapy Develop a monitoring plan Propose recommendations to the multidisciplinary healthcare team

12 Therapeutic Planning Identify the problem Review all patient information: Medication history interview Medical records Other (GP letter, community pharmacy dispensing records, carers/family members, other healthcare professionals) Therapeutic Planning Identify the problem Prioritise the problem Select drug and non drug therapy Develop a monitoring plan Continue antibiotic therapy until all finished Check adherence Dietary modification Exercise regimen Monitor cholesterol Therapeutic Planning Identify the problem Prioritise the problem Select drug and non drug therapy Develop a monitoring plan Continue antibiotic therapy until all finished Check adherence Dietary modification Exercise regimen Monitor cholesterol Propose recommendations to the multidisciplinary healthcare team Document recommendations in patients medical records Patient Counseling Why? Pharmacists have in depth drug knowledge and most appropriate to counsel patients to improve patient safety and QUM When? During in patient stay At discharge How? Verbal (face to face) Written (medi lists, CMIs, other)

13 Patient Counselling Factors to consider prior to patient counselling: Logistics within hospital setting Patients lying in bed Patient comfort Communicate at eye level Privacy (usually shared rooms) Different types of hospital patients Sedated (eg. Post surgery) Critically ill (eg. Intensive Care Unit (ICU)) Confused, amnesia (eg. Major trauma) Speech impaired, unable to speak (eg. Stroke, intubated) Unwilling to participate (eg. Terminally ill) Patient Counselling Factors to consider prior to counselling: Communication skills Verbal and non verbal communication Ask patient to repeat key messages to check for comprehension Things to avoid Using medical terminology Switching between brand and generic names of drugs Ignoring patient emotion Patient Counselling What information do we need to convey during patient counselling? Drug name (brand name) Dose, frequency, route of administration Drug drug or drug food interactions Adverse drug reactions Adherence (what to do if doses missed) Duration of therapy Monitoring requirements Screening Signs to contact Dr Roles of Clinical Pharmacist On admission: Medication reconciliation In patient: Contribute to prescribing decisions Therapeutic planning Patient counseling On discharge: Medication reconciliation Patient counseling Continuum of care

14 Roles of Clinical Pharmacist Medication reconciliation: On discharge: process of comparing the patients medication chart with the discharge script Identify any discrepancies and have action plan Roles of Clinical Pharmacist Dispense discharge medicines Dispensary, non sterile/sterile manufacturing Counsel patients on medicines Reinforce information provided during in patient stay Verbal and written information Continuum of Care How do we ensure continuum of care for the patient? Know where patient is being transferred to continued therapy under hospital in the home hospice, rehabilitation, nursing home own home Know who patient will continue to be treated by hospital Dr via outpatient clinics community GPs / specialists Continuum of Care How is continuum of care achieved? Need to have communication between hospital and community HCP Discharge summary to local GP / specialist Discharge script Medi list Contact nursing home Contact community pharmacy

15 Background Role of Clinical Pharmacist during in patient stay: Review chart daily Medication and other charts (e.g. iv fluids, temperature, fluid balance) Contribute to prescribing decisions Choice of drug, dose, route of administration, monitoring requirements Monitor patient response to therapy Modify patient therapy based on response and ADRs Subjectively: Monitoring Patient Response to Therapy Direct patient questioning Observation of the patient Objectively: Measurement of drug concentrations in plasma, urine, CSF, bronchial fluid... Therapeutic Drug Monitoring Definition: Measurement of plasma drug concentrations, and application of clinical pharmacokinetics to optimise drug therapy Therapeutic Drug Monitoring Why do we perform TDM? Provides information to multidisciplinary team to guide treatment decisions

16 Therapeutic Drug Monitoring When do we perform TDM? Non linear pharmacokinetics (eg. phenytoin) Narrow therapeutic index (eg. theophylline, digoxin, aminoglycoside antibiotics) Special patient populations (eg. paediatrics, elderly, renal impairment) avoid adverse drug reactions Role of Clinical Pharmacist Contribute to prescribing decisions Multidisciplinary team present in one location Facilitates a therapeutic partnership between pharmacist and multidisciplinary team Pharmacists have opportunity to suggest drug therapy options Retrospectively following medication chart review Prospectively Face to face interaction with multidisciplinary team Participation in medical ward rounds Role of Clinical Pharmacist Contribute to monitoring decisions Advise multidisciplinary healthcare team when TDM is required When to take samples for TDM How to interpret TDM results and suggest drug therapy options Eg. Reduce dose, reduce frequency etc References SHPA Standards of Practice for Clinical Pharmacy Clinical Skills for Pharmacists, A Patient Focused Approach (Tietze, J, edition 3) Pharmacy Practice Experiences A Students Handbook (Setlak, P) Hospital Pharmacy (Stephens, M edition 2) Medication Review: A Process Guide for Pharmacists (Chen, T et al, edition 2) Australian Medicines Information Training Workbook (edition 1)