Pharmacy and Pharmaceutical Sciences
Hospital Pharmacy
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Tutorial # 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
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
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
Contribute to Prescribing Decisions
 What factors influence the pharmacist’s contributions to prescribing
decisions in hospitals?
Pharmacist’s capacity to contribute depends on…
 Pharmacist factors
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Knowledge of therapeutics & disease states, physical assessments, lab & diagnostic tests
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Ability to communicate well
 Medical staff factors
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willingness to accept therapy suggestions
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rapport with pharmacist
 Patient factors
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amount of patient information available from medication history interview, medical records
and other (e.g. lab data)
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evidence of non-adherence
–
prior Adverse Drug Reactions (ADRs)
 Hospital factors
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Formulary available
–
Treatment guidelines / protocols
–
Cost of drugs
–
S100, SAS, clinical trials
Therapeutic
Planning
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
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
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
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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
Case Study
 Ms Blake, 55 yrs female, admitted to respiratory
ward with fever, chills and productive cough
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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
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
Therapeutic Planning
 Identify the problem
 Prioritise the problem
– Higher priority
• Likely streptococcal pneumonia
– Lower priority
• Venous thromboembolism (VTE) prophylaxis
• Smoking
• Hypercholesterolaemia
• Obesity
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)
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 postdischarge
• Not directly relevant to the acute hospital admission, therefore lower
priority
– 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
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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
Patient Counselling
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)
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!
Patient Counselling
 What information do we need to convey during patient counselling?
Patient Counselling
 What if patient is unavailable for counselling?
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
Presentation title
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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
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
 Counsel patient on medicines
– Reinforce information provided during inpatient stay
– Provide verbal & written information
Continuum of Care
Continuum of Care
 How is continuum of care achieved?
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communication between hospital & community health professionals
Discharge summary to local GP/specialist
Discharge script
MediList (see Blackboard)
Contact nursing home
Contact community pharmacy
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
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
From the Austin
hospital…
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
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
Presentation title
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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:
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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
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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)