Pharmacist Prescribing in the Acute Medical Unit. Jan Basey Consultant Pharmacist Acute Admissions Royal Liverpool University Hospital

Transcription

1 Pharmacist Prescribing in the Acute Medical Unit Jan Basey Consultant Pharmacist Acute Admissions Royal Liverpool University Hospital

2 Acute Medicine at RLUH Royal Liverpool major city centre teaching hospital One of the most acute hospitals in UK 850 beds 12 floors All major medical & surgical specialties Takes tertiary referrals for the majority One of the country's busiest EDs 106,500 attendances each year (2013/14)

3 Emergency Services RLUH Emergency Services Floor:- Emergency Department:- Triage Hub Minors Majors Resuscitation suite (Trauma centre) Observation wards x 2 (Mobs & Fobs 10 beds) Acute Medical Unit (AMU) 37 beds Emergency Surgical Assessment Unit (ESAU) 14 beds

4 Pharmacy Services to AMU Provided 7 days a week Pharmacists: - Medicines reconciliation Clinical issues Education Technicians: Patients Own Medication Dispensing for Discharge Health Care Assistant: - Weekly stock top up

5 Medication Histories Why AMU? 260 admissions per week Average length of stay 18 hours Medical decisions made on AMU Aim to get it right at the start of the admission Improve patient care timely medication Avoid transcription errors reduce risk Speed up the discharge process

6 Sources for Medication Histories Patient Patients own medication GP repeat / FP10 GP summary (computer printout) MAR chart from Nursing Home Recent TTO - electronic EMIS Web (Most Liverpool GPs since Feb 09) Ring GP Surgery / DDU (problem out of hours)

7 Problem! Medication information not acted upon despite: - Documenting in case notes in green ink Writing at top of medication chart Using luminous post it notes Making entries in Doctors job list All of the above!!

8 Solution! Do it Yourself!

9 Why Me? Already established good working relationships with AMU staff Desire to improve the service to patients in current area of clinical practice Professional frustration Career opportunities extended role Like being a trailblazer Like a challenge

10 2 Types of Prescriber Supplementary (dependent) prescribers responsible for the continued management of patients who have been assessed by an independent prescriber Independent prescriber responsible for diagnosis and decisions about clinical management required

11 So What s Supplementary Prescribing? A voluntary partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patients agreement

12 Pharmacist Prescribing the story so far 1987 Cumberledge Report first proposed nurse prescribing 1992 District nurses and health visitors can prescribe limited range of products 1999 Review of Prescribing, Supply and Administration of Medicines (Crown Report) extend prescribing rights to other nurses and other professionals 2001 Extended Formulary Nurse Prescribers

13 Continued 2003 Nurse & Pharmacist Supplementary Prescribers 2005 Physiotherapist, Optometrist, Podiatrist, Radiographer Supplementary Prescribers 2006 Independent Prescribing for Pharmacists and Nurses 2008 Optometrist Independent prescribing 2013 Physiotherapists and podiatrists Independent prescribing

14 So How Long Does It Take? 38 days 26 taught / self directed and12 in practice Duration usually 6 months Competency based Courses accredited by GPhC (Be prepared to be chained to a computer for the vast majority of the time)

15 So What Does the Course Involve? Learning about competencies, reflection & portfolios Competencies 9 areas (NPC Framework) Clinical management plans 6 week physical examination skills course Consultation skills Therapeutics modules if required And I nearly forgot the law

16 Competencies The consultation Clinical knowledge Communicating with patients Prescribing effectively Safety Legislation Prescribing in context Information relevant & current Teamwork

17 What About the 12 Days of Practice? Need to be supervised by DMP Need to provide evidence that you have completed the required time (12 days) Need to demonstrate reflective practice Need to write it all down! (Evidence) Need to meet regularly with DMP to discuss

18 Exams? Portfolio assessed Written exam (law) Reflective essay OSCEs

19 My Journey November 2000 The vision initial paper to D&T Committee Chairman January 2004 Accepted by LJMU February 2004 Started SP course May 2004 Finished course!! July 2004 Passed!! September 2004 Registered sp Support from all 6 AMU Consultants

20 Progress continued December 2004 Prescribing role approved by RLUH D&T Committee Started prescribing in January 2005 Improved job satisfaction Better use of professional skills Improved integration into AMU team Better service to patients

21 Pharmacist Independent Prescribing 1 May 2006 Legislative changes June 2007 Accepted for Independent Prescribing Conversion Course - Chester May 2008 Registered as IP 2010 Prescribing role seen as normal practice by Consultant Medical Staff April 2012 Can prescribe CDs

22 My Practice Write medication on admission (or not!) Ability to rewrite and sign prescriptions (rather than amend with a green pen!) Stop inappropriate medication Implement policies antibiotics, VTE Prescribe on ward rounds Transcribe onto electronic prescribing system Prescribe independently All within my competence

23 What is the impact? First 12 weeks (2005) I prescribed: 280 items For 148 patients After that I stopped counting!

24 What s the impact? Access to Independent Rx course requires portfolio of current practice!! May 2007 = More counting & documentation: 4 weeks 49 patients 107 items Same as 2005!

25 Number of Items Prescribing Analysis Gastro-intestinal Cardiovascular Respiratory Central Nervous Infections Endocrine Obs, Gynae & Urology Malignant disease Nutrition & Blood Musculoskelatal Eye ENT Skin Vaccines Anaethesia

26 Number of Items Prescribing Analysis Gastro-intestinal Cardiovascular Respiratory Central Nervous Infections Endocrine Obs, Gynae, Urology Malignant Disease Nutrition & Blood Musculoskeletal Eye ENT Skin Vaccines Anaesthesia

27 Number of items Prescribing Analysis Gastro-intestinal Cardiovascular Respiratory Central Nervous Infections Endocrine Obs, Gynae, Urology Malignant Disease Nutrition & Blood Musculoskeletal Eye ENT Skin Vaccines Anaesthesia Other

28 Number of items Prescribing Comparison Gastro-intestinal Cardiovascular Respiratory Central Nervous Infections Endocrine Obs, Gynae & Urology Malignant disease Nutrition & Blood Musculoskelatal Eye ENT Skin Vaccines Anaethesia Other

29 Examples Parkinson's medication Insulin pump changed to Novorapid TDS + Glargine at night Inhalers (especially steroids) Eye drops (Doctors don t see these as medicines!) GI bleed stop NSAID and Rx PPI Darunavir, raltegravir, maraviroc

30 Friday 28 th July Female aged 85 AMU Admitted via ED. Found on the floor - dehydrated & confused No information re medicines Pre-reg obtained fax from GP Humulin M3 insulin 10ml vial Checked blood sugar 10.8 on admission

31 July 28 th 2012 continued Contacted GP for DN telephone number Contacted DN: Humulin M3 18 units Mane 14 units Teatime Checked blood sugar chart Prescribed insulin (and other medicines x 12) Lunch (1 hour late)

32 Impact 2009 / 2010 June 2009 (4 weeks) Medication histories for 270 patients Prescribed for 111 patients 292 items May 2010 (4 weeks) Medication histories for 266 patients Prescribed for 102 patients 257 items

33 Prescribing Comparison

34 Why the increase? More time More experience / confidence Teamwork with junior pharmacists Requests from nursing staff Gastrografin Paracetamol Metoclopramide / cyclizine Insulin Change route levofloxacin / paracetamol Chlordiazepoxide (had to refuse that one!) Methadone

35 2008 / 2009 January 2008 Decision to apply for Consultant status for post All posts must be SHA approved Huge amount of paperwork April 2008 More details needed July 2008 approved January 2009 started new role

36 Consultant Role Approx 60 Consultant Pharmacists Only 1 for acute admissions! More time on AMU (50%) See patients before AMU rounds Prescribing Follow up of prescribing problems (traditionally junior doctor role) Research PhD (20%)

37 PhD results Medicines reconciliation paper published BMJ Quality & Safety medicines per patient 46.2% patients have error on prescription Average 1.2 errors per patient 86.6% omissions 1% major impact insulin, antiepileptics 59% rectified in 24 hours; 69% in 48 hours

38 What Next? Write another paper Continue research Develop Pharmacy Admissions Team Expand service to ED recruitment underway Develop role of Consultant Pharmacist both locally and nationally

39 Recognition.. Trust Employee of the year June 2007 For Exceptional Services to Patients

40 That s All Folks - Any Questions?