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1. Hospital Pharmacy Tutorial # 2 Title slide without an image

2. Learning Objectives • To recognise the hospital pharmacist as a key member of multidisciplinary healthcare team • To understand the various roles of a hospital pharmacist, including the role in the continuum of patient care

3. Learning Outcomes • At the end of this tutorial you should be able to: • Understand the pharmacist’s role in contributing to prescribing decisions of the multidisciplinary healthcare team • Understand when and how to perform medication counselling in hospitals • Understand how continuum of care is achieved after discharge from hospital

4. Roles of the Clinical Pharmacist • During inpatient stay: • Review charts daily • Medication & other charts • e.g. IV fluids, observation & fluid-balance charts • Identify & prioritise medication-related issues • Contribute to prescribing decisions regarding: • Medication, dose, administration route, monitoring needs • Monitor patient response to therapy • Modify patient therapy based on response & ADRs • Inform & educate patient/carers about medication changes • To prepare them for managing medicines at home after discharge

5. Contribute to Prescribing Decisions • What factors influence the pharmacist’s contributions to prescribing decisions in hospitals?

6. Pharmacist’s capacity to contribute depends on… • Pharmacist factors • Knowledge of therapeutics & disease states, physical assessments, lab & diagnostic tests • Ability to communicate well • Medical staff factors • willingness to accept therapy suggestions • rapport with pharmacist • Patient factors • amount of patient information available from medication history interview, medical records and other (e.g. lab data) • evidence of non-adherence • prior Adverse Drug Reactions (ADRs) • Hospital factors • Formulary available • Treatment guidelines / protocols • Cost of drugs • S100, SAS, clinical trials

7. Therapeutic Planning

8. Therapeutic Planning • SOAP • Subjective/Objective Information • Assessment • Plan • Identify the problem(s) • Prioritise the problem(s) • Select pharmacotherapy and non-pharmacotherapy • Develop a monitoring plan • Propose recommendations to the multidisciplinary healthcare team

9. Therapeutic Planning • Subjective and Objective information gathering • Review all patient information: • Medication history interview • Medical records • Other information • patient’s own medications brought to hospital • carers/family members • community pharmacy dispensing records • GP letter • other healthcare professionals

10. Scenario 2: • Male, 76 years got admitted to the ward with palpitations and shortness of breath, atrial fibrillation with rapid ventricular rate • Dr Jane (Registrar) asks the pharmacist (Edwin Tan) to teach the patient about warfarin

12. Therapeutic Planning • SOAP • Subjective/Objective Information • Assessment • Plan • Identify the problem(s) • Prioritise the problem(s) • Select drug and non-drug therapy • Following review of relevant guidelines/references • Evidence-based, Cost-effective, Meeting local requirements • Develop a monitoring plan • Propose recommendations to the multidisciplinary healthcare team

13. Case Study • Ms Blake, 55 yrs female, admitted to respiratory ward with fever, chills and productive cough • Past medical history: hypercholesterolaemia, obesity • Social history: smokes 10-15 cigarettes/day • Current medicines: Atorvastatin 40 mg nocte • Lab & diagnostic tests: • Leukocytosis with bands • Chest X-ray with right middle lobe consolidation • Lower respiratory infection: Provisional diagnosis of Community-acquired pneumonia, likely Strep pneumoniae

14. Activity: 20 mins Develop a therapeutic plan for Ms Blake • Form 5 groups • Identify the problem(s) • Prioritise the problem(s) • Select pharmacotherapy & non-pharmacotherapy (following review of appropriate medicines information resources) • Each member of the group to focus on a different health problem/condition • Develop a monitoring plan • Each member to develop a plan for the condition allocated to them • As a group then discuss, prioritise and decide how to manage the patient • Propose your recommendations to the multidisciplinary healthcare team

15. Therapeutic Planning • Identify the problem • Prioritise the problem • Higher priority • Likely streptococcal pneumonia • Lower priority • Venous thromboembolism (VTE) prophylaxis • Smoking • Hypercholesterolaemia • Obesity

16. Therapeutic Planning • Select pharmacotherapy & non-pharmacotherapy • Following review of relevant guidelines/references • Evidence-based, cost-effective, meeting local requirements • Pharmacotherapy: • Antibiotic options • Hospital formulary, protocols / guidelines (e.g. Therapeutic Guidelines – Antibiotics), costs • Other (e.g. expectorant, salbutamol, vaccinations) • Non-pharmacotherapy • Chest Physiotherapy? • Hospital admission: Teachable moment? • Social habits (alcohol, smoking) • Diet • Exercise • Screening (cholesterol monitoring)

17. Therapeutic Planning • Develop a monitoring plan • Pneumonia monitoring to ensure response to therapy • Temperature, respiratory rate, oxygen saturation, blood pressure, appetite • WCC, neutrophils/bands, sputum culture and sensitivities • When can IV therapy switch to oral antibiotic therapy? • Preparing for discharge • Continue antibiotic therapy until all finished • Reinforce adherence (post-discharge) • Smoking reduction/cessation • Brief intervention • VTE prophylaxis in medical patient with reduced mobility • Continue prophylaxis until back to baseline mobility • Dietary modification • Dietician referral during hospital • Exercise regimen • Physiotherapy referral during hospitalisation • Chest physiotherapy for pneumonia, also • Monitor cholesterol, liver function tests • Determine when GP last reviewed this or may ask GP to follow-up post-discharge • Not directly relevant to the acute hospital admission, therefore lower priority

18. Smoking reduction/cessation • Brief intervention • VTE prophylaxis in medical patient with reduced mobility • Continue prophylaxis until back to baseline mobility • Dietary modification • Dietician referral during hospital • Exercise regimen • Physiotherapy referral during hospitalisation • Chest physiotherapy for pneumonia, also • Monitor cholesterol, liver function tests • Determine when GP last reviewed this or may ask GP to follow-up post-discharge • Not directly relevant to the acute hospital admission, therefore lower priority

20. Therapeutic Planning • Identify the problem • Prioritise the problem • Select drug and non-drug therapy • Develop a monitoring plan • Continue antibiotic therapy until all finished • Quit attempts • Vaccination? • Check adherence • Dietary modification • Exercise regimen • Monitor cholesterol • Propose recommendations to the multidisciplinary healthcare team • Discuss with the clinical team • Document recommendations in patients medical records

21. Patient Counselling

22. Patient Counselling • Why? • Pharmacists have in-depth drug knowledge & are most appropriate to counsel patients to improve patient safety and Quality Use of Medicines • When? • During inpatient stay • At discharge • How? • Verbal (face-to-face) • Written (Medilists, CMIs, other)

23. Factors to consider prior to counselling: • Communication skills • Use verbal & non-verbal communication • Ask patient to repeat key messages to assess comprehension • Things to avoid: • Using medical terminology • Switching between brand & generic drug names • Ignoring patient emotion • The patient should be the focus!

24. Patient Counselling • What information do we need to convey during patient counselling?

25. Patient Counselling • What if patient is unavailable for counselling?

26. If patient is unavailable for counselling… • Reschedule during inpatient stay • Speak to carer/family members • Counsel at discharge • Prepare Medilist • Provide CMI / Patient information leaflets • Webster pack / Dosette box

27. Presentation title

28. 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

29. 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

30. Roles of Clinical Pharmacist • Dispense discharge medicines • Counsel patient on medicines • Reinforce information provided during inpatient stay • Provide verbal & written information

31. Continuum of Care

32. Continuum of Care • How is continuum of care achieved? • communication between hospital & community health professionals • Discharge summary to local GP/specialist • Discharge script • MediList (see Blackboard) • Contact nursing home • Contact community pharmacy

33. Ensuring Continuum of Care • Know where patient is being transferred to: • own home • continued therapy under ‘hospital in the home’ • hospice, rehabilitation, nursing home • Know who will continue to treat patient: • hospital Dr via outpatient clinics • community GP • Specialist/s

34. Continuum of Care • How do we ensure continuum of care for the patient? • Discuss how the Hospital Pharmacist facilitated Continuum of Care in the scenario

35. From the Austin hospital…

36. Discharge Process • Hospitals generally dispense PBS quantities • Inform community pharmacist if blister pack/dose administration aid required • Inform community nurse if administration required • E.g. IV, SC, IM • Information/forms that accompany discharge • Medication cards (e.g. Medilist) provide patient their own record • Other forms such as warfarin discharge plan

37. Discharge Summary • Timely transfer of written discharge information to GP/other health professional • e.g. by fax, email, conventional mail, via the patient • Should be accurate as medication history on admission • More than a current drug list, includes: • Changes made to treatment, and reasons for changes • Medications found ineffective or caused ADRs • Specialist knowledge about medicines use • e.g. the need to monitor for ADRs, adherence • Any issues needing follow up

38. Presentation title

39. Activity: 10 mins • Discharge meds: - Amoxycillin 1 g po tds (20 caps) - Paracetamol 500 mg tabs prn • Prepare a Medilist (use the electronic form on Moodle) and counsel Ms Blake on discharge • Consider: • Drug name (brand name) • Dose, frequency, route of administration • Drug–drug or drug – food interactions • Adverse drug reactions • Adherence (what to do if doses are missed) • Duration of therapy • Monitoring requirements: e.g. screening, signs and symptoms to contact Doctor

41. References • SHPA Standards of Practice for Clinical Pharmacy • Clinical Skills for Pharmacists, A Patient-Focused Approach (Tietze, J, ed3) • Pharmacy Practice Experiences – A Student’s Handbook (Setlak, P) • Hospital Pharmacy (Stephens, M ed2) • Medication Review: A Process Guide for Pharmacists (Chen, T et al, ed2) • Australian Medicines Information Training Workbook (ed1)