1 / 41

Title slide without an image

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

tbradbury
Télécharger la présentation

Title slide without an image

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

  11. 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

  12. 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

  13. 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

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

  15. 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)

  16. 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

  17. 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. 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

  19. Patient Counselling

  20. 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)

  21. 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!

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

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

  24. 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

  25. Presentation title

  26. 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

  27. 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

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

  29. Continuum of Care

  30. 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

  31. 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

  32. 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

  33. From the Austin hospital…

  34. 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

  35. 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

  36. Presentation title

  37. 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

  38. 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)

More Related