CENTRE FOR PHARMACY POSTGRADUATE EDUCATION Clinical medication review A CPPE workshop Workshop book W/MEDREVIEW/HO March 2017 Clinical Medication Review_Workshop Bk A4 24pp.indd 1 15/03/2017 09:13
Clinical medication review Workshop book CPPE programme developer(s) Michelle Styles, regional manager Project team Nina Barnett, consultant pharmacist, Northwick Park NHS Trust Liz Butterfield, consultant pharmacist, Brighton and Hove CCG Jenny Butterfield, medication review pharmacist, West London CCG Anne Child, head of pharmaceutical care and clinical standards, Avante Care Sally Greensmith, Surrey LPN chair and CPPE tutor Barbara Jesson, community pharmacy advisor, Croydon CCG Ayisha Karim, learning development pharmacist, CPPE Maria Medina, prison healthcare pharmacist, Care UK Sarah Ridgway-Green, regional manager, CPPE Matthew Shaw, deputy director, CPPE Sharon Steel, deputy lead, General practice pharmacist training pathway, CPPE James Townsend, pharmacy technician, Bromley Healthcare Reviewer(s) Nuala Hampson, general practice pharmacist, West Bridgford medical centre Helen Kilminster, general practice pharmacist, Whiteacres medical centre CPPE reviewer(s) Jane Brown, deputy lead, General practice pharmacist training pathway Paula Higginson, lead pharmacist, learning development Piloted by Laraine Clark and Funke Lawal, CPPE tutors Editor Sarah Bromley, editorial assistant, CPPE Video production University of Manchester Media services produced the videos that form part of this learning programme. Disclaimer We have developed this learning programme to support your practice in this topic area. We recommend that you use it in combination with other established reference sources. If you are using it significantly after the date of initial publication, then you should refer to current published evidence. CPPE does not accept responsibility for any errors or omissions. External websites CPPE is not responsible for the content of any non-cppe websites mentioned in this programme or for the accuracy of any information to be found there. All web links in this resource were accessed on 21 February 2017. Published in March 2017 by the Centre for Pharmacy Postgraduate Education, Division of Pharmacy and Optometry, The University of Manchester, Oxford Road, Manchester, M13 9PT. www.cppe.ac.uk Brand names and trademarks CPPE acknowledges the following brand names and registered trademarks mentioned throughout this programme: QRISK 2. Production Design and artwork by Gemini West Ltd Printed by NB Colour Print Ltd Copyright Controller HMSO 2017 2
Contents Workshop activities 4 Activity 1 Prioritising patients for clinical medication review 4 Activity 2 Causes of falls 4 Activity 3 Medicines that can contribute to falls 5 Case study 1 Deborah Wilson 6 Case study 2 Jim Turkington 8 Workstation 1 Documenting clinical medication reviews 10 Workstation 2 Consultation with simulated patient (Mr/Mrs Mederiova) 12 Workstation 3 Developing a structured process for clinical medication review 14 Clinical medication review Workshop book Workstation 4 Consultation with simulated patient (Mr/Mrs Baria) 15 Workstation 5 Adverse effects and monitoring requirements of commonly prescribed medicines 17 Workstation 6 Communication with prescriber (role play) 19 Next steps 20 Action points 20 2 3
Clinical medication review Workshop book Workshop activities Activity 1 Prioritising patients for clinical medication review In your groups, make a list of patients you think are the highest priority for clinical medication review. Choose your top three. Use this space to note down your key learning points from this activity. Activity 2 Causes of falls With your group, make a list of reasons why older people are more likely to suffer a fall. While medicines may contribute to falls, they are not the only reason so try to think of other factors as well. Use this space to note down your key learning points from this activity. 4
Activity 3 Medicines that can contribute to falls The tutor will give you an envelope containing a number of cards which list some commonly prescribed medicines. In your group, rate each medicine red, amber or yellow according to the likelihood that it can cause falls. Use the space below to make notes or record your ideas. Red (High risk) Amber (Moderate risk) Yellow (Possible risk in combination) Clinical medication review Workshop book 2 5
Clinical medication review Workshop book Case study 1 Deborah Wilson Deborah Wilson is 78-years-old and lives alone. She has two sons who live locally and visit regularly. Deborah is a sprightly lady who generally feels well. She is able to go shopping and attends regular church events and a lunch club once a week. She is a keen knitter and produces gifts for the local hospice shop to sell. Past medical history n Hypertension 2006 n U&Es normal (last tested over 12 months ago) n egfr 60 ml/min/1.73 m 2 n Doesn t smoke or drink n BMI 26 kg/m 2 n BP three weeks ago 155/92 mmhg n BP last week 145/90 mmhg n BP today 152/90 mmhg Repeat medicines n Amlodipine 5 mg one in the morning (started Jan 2012 following diagnosis of hypertension) n Ramipril 5 mg one in the morning (started June 2014 following several high BP readings) n Simvastatin 40 mg one at night (started Jan 2012 for primary prevention of CVD following QRisk2 score of 22) n Omeprazole 20 mg one in the morning (started March 2013, no indication recorded) What factors might place Deborah at higher risk of suffering an adverse drug reaction? What questions would you like to ask Deborah at the consultation? 6
Use the NO-TEARS screening tool to review Deborah s medicines. Make a maximum of three suggestions for change based on any immediate clinical concerns or identification of medicines that may be potentially inappropriate. 1. 2. 3. Clinical medication review Workshop book What were the advantages and disadvantages of the NO-TEARS screening tool that you used for this case study? Advantages Disadvantages Having watched the video which shows Deborah s perspective on her health and medicines, choose your top three recommendations for the prescriber. 1. 2. 3. 2 7
Clinical medication review Workshop book Case study 2 Jim Turkington Jim Turkington, 82-years-old. Jim lives alone since his wife passed away 12 months ago. He has one daughter who doesn t live locally and has no carers. Past medical history n NSTEMI, May 2015 n Heart failure NYHA III with reduced ejection fraction, November 2015 n Urinary frequency, March 2016 n Depression, October 2016 n Last U&E, full blood count and liver function tests done over 12 months ago, all normal n Stopped smoking May 2015 (previously 20/day) n Approx 12 units of alcohol per week n BMI 27 kg/m 2 Repeat medicines n Bisoprolol 10 mg once daily (May 2015) n Clopidogrel 75 mg once daily (May 2015) n Ramipril 10 mg once daily (May 2015) n Furosemide 40 mg one in the morning (November 2015) n Aspirin 75 mg once daily (May 2015) n Simvastatin 40 mg at night (May 2015) n Oxybutynin 5 mg twice daily (March 2016) n Lactulose 10 ml when required (May 2016) n Citalopram 10 mg at night (October 2016) What high-risk medicines is Jim taking? What factors might place Jim at higher risk of suffering an adverse drug reaction? What questions would you like to ask Jim at the consultation? 8
Use the STOPP/START screening tool to review Jim s medicines and make a maximum of three suggestions for change based on any immediate clinical concerns or identification of medicines that may be potentially inappropriate. 1. 2. 3. Clinical medication review Workshop book What were the advantages and disadvantages of the STOPP/START screening tool that you used for this case study? Advantages Disadvantages Having watched the video which shows Jim s perspective on his health and medicines, choose your top three recommendations for the prescriber. 1. 2. 3. 2 9
Clinical medication review Workshop book Workstation 1 Documenting clinical medication reviews You have approximately 20 minutes for this workstation. 1. Review case study 2, Jim Turkington. Document your agreed actions and recommendations on the medication review action plan template overleaf. 2. The General Pharmaceutical Council standards require you to keep full and accurate records of the professional services you provide in a clear and legible form. How will you keep records of the clinical medication reviews that you undertake? What will you record? 3. If you are not working in a GP practice, how will you share the action plan with the patient s GP? 4. How would you monitor the changes to ensure that they are working for Jim and how would you document this? 10
Medication review action plan template Patient: Jim Turkington Problem Priority Rationale/ Suggested action Timescale Monitoring evidence base Clinical medication review Workshop book 2 11
Clinical medication review Workshop book Workstation 2 Consultation with simulated patient (Mr/Mrs Mederiova) You have approximately 20 minutes for this workstation. At this workstation, you will meet Mr/Mrs Mederiova, a patient who has been booked to see you for a clinical medication review. One of you will play the role of the pharmacy professional and the other will observe and keep time. The person playing the role of the pharmacy professional will have up to five minutes to review the patient s notes and prioritise suggestions for action. If you are new to clinical medication review you may wish to start by considering the list of possible medicines-related issues that we have identified from reviewing the patient s list of repeat medicines and blood test results. If you have previous experience of clinical medication review, you may wish to review the patient s repeat medicines and blood test results and identify the potential medicines-related issues yourself. During the preparation time, you may discuss the case with your colleague and use the British National Formulary (BNF) or other reference sources including medication review screening tools. You will then have ten minutes to consult with the patient, find out their priorities and agree actions to stop, start or continue the medicines. We suggest that you focus on a maximum of two to three issues during the consultation. The patient will then provide feedback about the consultation process including your ability to establish their perspective and priorities and share the agenda for the medication review. The observer will also provide feedback. If you are playing the role of a pharmacy professional give your workshop booklet to the observer to complete the observation form (overleaf). 12
Consultation skills observation form Skill/technique What are my strengths? What could I do differently? Welcoming n Greets the patient professionally using name n Establishes a shared agenda with the patient n Builds rapport Questioning n Uses open questions to gather information n Actively listens and reflects back key points Building relationship/rapport n Uses open body language n Shows empathy when appropriate n Is non-judgemental Explanation and planning n Uses appropriate language (no jargon) n Establishes patient knowledge before providing information n Establishes what advice/information the patient would like Patient-centred approach n Involves the patient in decisions and planning n Makes suggestions rather than gives directives Closing the consultation n Summarises key issues n Asks the patient to reflect back actions n Checks the patient is comfortable with the plan n Safety net what to do if things don t go to plan n Uses visual clues to indicate closure Clinical medication review Workshop book 2 13
Clinical medication review Workshop book Workstation 3 Developing a structured process for clinical medication review You have approximately 20 minutes for this workstation. Use your learning from the first part of this workshop to develop your own structured process for undertaking clinical medication review. n How will you prioritise patients for clinical medication review? n What questions will you ask to identify the patient s ideas, concerns, expectations and feelings about their medicines? n What questions will you ask to identify patients at increased risk of ADRs? n What further information will you need and where will you obtain it? n How will you identify potentially inappropriate medicines? Which screening tools will you use? n How will you balance the patient s priorities with your own concerns about patient safety issues? n How will you prioritise the issues for discussion with the prescriber? n How will you follow up the patient? Your process for clinical medication review 14
Workstation 4 Consultation with simulated patient (Mr/Mrs Baria) You have approximately 20 minutes for this workstation. At this workstation, you will meet Mr/Mrs Baria, a patient who has been booked to see you for a clinical medication review. One of you will play the role of the pharmacy professional and the other will observe. The person playing the role of the pharmacy professional will have up to five minutes to review the patient s notes and prioritise suggestions for action. If you are new to clinical medication review you may wish to start by considering the list of possible medicines-related issues that we have identified from reviewing the patient s list of repeat medicines and blood test results. Clinical medication review Workshop book If you have previous experience of clinical medication review, you may wish to review the patient s repeat medicines and blood test results and identify the potential medicines-related issues yourself. During the preparation time, you may discuss the case with your colleague and use the BNF or other reference sources including medication review screening tools. You will then have ten minutes to consult with the patient, find out their priorities and agree actions to stop, start or continue the medicines. We suggest that you focus on a maximum of two to three issues during the consultation. The patient will then provide feedback about the consultation process including your ability to establish their perspective and priorities and share the agenda for the medication review. The observer will also provide feedback. If you are playing the role of a pharmacy professional at one of these workstations, give your workshop book to the observer to complete the observation form (overleaf). 2 15
Consultation skills observation form Skill/technique What are my strengths? What could I do differently? Welcoming n Greets the patient professionally using name n Establishes a shared agenda with the patient n Builds rapport Questioning n Uses open questions to gather information n Actively listens and reflects back key points Building relationship/rapport n Uses open body language n Shows empathy when appropriate n Is non-judgemental Explanation and planning n Uses appropriate language (no jargon) n Establishes patient knowledge before providing information n Establishes what advice/information the patient would like Patient-centred approach n Involves the patient in decisions and planning n Makes suggestions rather than gives directives Closing the consultation n Summarises key issues n Asks the patient to reflect back actions n Checks the patient is comfortable with the plan n Safety net what to do if things don t go to plan n Uses visual clues to indicate closure Clinical medication review Workshop book 16
Workstation 5 Adverse effects and monitoring requirements of commonly prescribed medicines You have approximately 20 minutes for this workstation. Aim to spend ten minutes on Part A and ten minutes on Part B. Part A The table below contains a list of adverse effects associated with commonly prescribed medicines. For each adverse effect, use your BNF to identify at least three medicines that are associated with this effect. Try to choose the medicines that you see most frequently in your practice. Be specific and write the names rather than classes of medicines involved. Clinical medication review Workshop book Adverse effect Commonly prescribed medicines that can cause this effect Dry mouth Hypotension Hyponatraemia Sedation Confusion Increased bleeding risk Constipation Dizziness 2 17
Clinical medication review Workshop book Part B Many commonly prescribed medicines have certain parameters that should be monitored before and during treatment to ensure patient safety. Complete the table below, using your BNF to identify the monitoring requirements for the medicines listed. You may also find it useful to refer to the following online resource during this activity: www.sps.nhs.uk/articles/suggestions-for-drug-monitoring-in-adults-in-primary-care/ Medicine Parameters that require monitoring Frequency Azathioprine Atorvastatin Diclofenac Digoxin Levothyroxine Ramipril Rivaroxaban 18
Workstation 6 Communication with prescriber (role play) You have approximately 20 minutes for this workstation. At this workstation, one of you will play the role of a pharmacy professional who has undertaken a clinical medication review with a patient and the other will play the role of the patient s GP and will keep time. The pharmacy professional will have consulted with the patient and will be aware of the patient s priorities. The pharmacy professional and patient will have agreed to stop, start or continue certain medicines but the pharmacy professional needs to discuss these with the prescriber so that they can agree the changes. You will have five minutes to read the brief and prepare for the discussion. During this time, do not discuss the case with your colleague. You may however use the BNF or other reference sources. Clinical medication review Workshop book You will have ten minutes to discuss and agree actions. The person playing the role of the GP will then provide feedback about the pharmacy professional s ability to present evidence-based, prioritised recommendations for optimising medicine regimens. 2 19
Clinical medication review Workshop book Next steps Now take the time to reflect on all the workstations. Reflect on what you think you did well and what you think you could improve. Review any feedback you have received. Complete the following: The main learning points for me were: 1. 2. 3. What will I put into practice tomorrow? Action points Taking part in this workshop may have led you to identify additional learning needs to develop your clinical knowledge, things that you might need to follow-up, or changes you need to make to your practice. Make a list of these below. 1. 2. 3. 20
Notes Clinical medication review Workshop book 2 21
Clinical medication review Workshop book Notes 22
Notes Clinical medication review Workshop book 2 23
Contacting CPPE For information on your orders or bookings, or any general enquiries, please contact us by email, telephone or post. A member of our customer services team will be happy to help you with your enquiry. Email info@cppe.ac.uk Telephone 0161 778 4000 By post Centre for Pharmacy Postgraduate Education (CPPE) Division of Pharmacy and Optometry 1st Floor, Stopford Building The University of Manchester Oxford Road Manchester M13 9PT Share your learning experience with us: email us at feedback@cppe.ac.uk For information on all our programmes and events: visit our website www.cppe.ac.uk Funded by: Developed by: