journey of patient
DESCRIPTION
Pharmacy RevisionTRANSCRIPT
Pharmacy Practice 1Induction
Journey of the Patient
Dr Angela MacAdam
Pharmacy Practice 2Induction
Stages of the journey
• Diagnosing• Prescribing• Dispensing• Monitoring• Consulting
Pharmacy Practice 3Induction
Diagnosing
• “The minute you walked in the door . . ”
Pharmacy Practice 4Induction
A twelve year old boy and his mum ...
Pharmacy Practice 5Induction
Pharmacy Practice 6Induction
“How can I help?”
• Complaining of . . . .• Listen to the patient's story• 90% of the process of diagnosis comes from • the history
Pharmacy Practice 7Induction
Pharmacist’s ApproachMnemonics
• WWHAM• ASMETHOD• ENCORE• SIT DOWN SIR
• Read Introduction to Community Pharmacy by Paul Rutter
Pharmacy Practice 8Induction
Past Medical History
Pharmacy Practice 9Induction
Family History
Sometimes familyhistory gives us a clue . . .
Pharmacy Practice 10Induction
Social History
Pharmacy Practice 11Induction
Drug History
Pharmacy Practice 12Induction
“Let’s have a look at you . .”
Pharmacy Practice 13Induction
Pharmacy Practice 14Induction
Pitting in psoriasis
Pharmacy Practice 15Induction
Oral Candidiasis
Pharmacy Practice 16Induction
Pharmacy Practice 17Induction
Vital signs
• Pulse• Temperature• Blood Pressure• Blood sugar
Pharmacy Practice 18Induction
Investigations . . .
• Blood/urine tests– haematology– biochemistry– Immunology
• Infection screen• Cytology/Histology• X Rays• Scans, ultra sound, MRI etc
Pharmacy Practice 19Induction
Differential diagnosis
• History• Observation• Examination• Investigations
The process of weighing the probability of one disease versus that of other diseases possibly accounting for a patient's illness.
Pharmacy Practice 20Induction
• Most common medical intervention in patient care
• Drugs costs account for a significant amount of NHS expenditure–Approx £8.2 billion / year (doubled over last 10 years)
DH 2008
Prescribing
Pharmacy Practice 21Induction
• Maximise effectiveness– Achieve therapeutic aim in suitable timescale
• Minimise risks– Managing side effects vs. benefits
• Minimise costs• Respect and include patient choice – Lifestyle
• Evidence Based Medicine
Good prescribing practice
Pharmacy Practice 22Induction
• Medical practitioners / Doctors • Dentists• Non-medical prescribers:– Supplementary– Independent
Who can prescribe medicines?
Pharmacy Practice 23Induction
Pharmacists, nurses and other HCP e.g. podiatrists, physiotherapists
Do not diagnose Repeat Rx and monitor under supervision of
independent prescriber Work under a detailed Clinical Management
Plan for a named patient who shares in the decision making
Supplementary prescribers
Pharmacy Practice 24Induction
Pharmacist, Optometrist and Nurse Take full responsibility for the patient Not acting under direction of another
prescriber Can prescribe any medicine, almost, for any
condition within their competence
Independent prescribers
Pharmacy Practice 25Induction
Must be qualified prescriber!1. Collect information – see diagnosing2. Analyse information and make a
prescribing decision3. Make appropriate records4. Monitor
Prescribing process
Pharmacy Practice 26Induction
• Interpret and analyse patients signs, symptoms and any results (part of diagnosis)
• Consider treatment options (may not include medication)
• Concurrent disease and medications• Involve the patient – Side effects vs. Benefits– Lifestyle– Ask questions
2. Prescribing decision
Pharmacy Practice 27Induction
• Once class of drug decided upon• Choose specific drug and formulation • Dose• Duration– Short course (antibiotics)– Longer (when next monitoring required)– Do they pay for their Rx?– Likely to overdose / ADR?– BNF– Local / national guidelines
2.cont. Choosing the drug
Pharmacy Practice 28Induction
• Document in medical notes– Drug, duration and dose– Review and monitoring plan
• Follow up GP / IP /Hospital?• Document drug allergies, inc type of reaction and date• Report all ADR’s
• Electronic prescribing will automatically save record of Rx
3 & 4. Recording and monitoring
Pharmacy Practice 29Induction
• Cheapest?• What is new on the market?• Design and colour of tablets?
How do prescribers choose what drug to prescribe?
Pharmacy Practice 30Induction
‘Closing the gap between research and everyday practice to ensure clinical decisions are based on the
best available scientific evidence’
• Compare evidence for different treatment options
• Clinical trialsNew drug and outcomesDrug A vs. drug B
• Guidelines–NICE
Evidence based medicine
Pharmacy Practice 31Induction
Chapter 10: “Understanding and interpreting prescriptions” in Foundations of Pharmacy Practice by Whalley, Fletcher, Weston, Howard and Rawlinson
Dispensing
Pharmacy Practice 32Induction
What is a prescription?
• Legal message from prescriber to dispenser to provide a patient with a medicinal product.
• Legal requirements– Unique patient identification, prescriber
identification, details of drug, signed and dated• Legal classifications– P and GSL don’t legally need a prescription BUT
you wouldn’t get paid on NHS without one.– POM – legally required
06:51:16 AM
Pharmacy Practice 33Induction
What types of prescription are there?
• NHS– Doctor– Dentist– Other prescribers
• Private– Doctor– Dentist– Vet
• Hospital06:51:16 AM
Pharmacy Practice 34Induction
How to find your way around a prescriptionName and address of patientAge (legal
requirement if under 12)
Endorsement box(to tell the pricing authority what you have supplied to get the right payment)
Name of drug, dosage form, strength, how to use and quantity
Prescriber’s signatureRelevant date. Either the date the prescription was written or the date after which the prescriber wants the drug supplied
Prescribers name and address and NHS number
Number of days supply
06:51:16 AM
Pharmacy Practice 36Induction
Latin Abbreviations
• ‘O’ = ‘one’ e.g. od = one daily• ‘b’ = ‘two’ e.g. bd = twice a day• ‘t’ = ‘three’ e.g. tds or tid = three times a day• ‘q’ = ‘four’ e.g. qds or qid = four times a day
• Nb ‘qqh’ = every four hours
• Mane = morning, e.g. 1 mane = one in the morning
• Nocte = night, e.g 1 nocte = one at night.
06:51:16 AM
Pharmacy Practice 37Induction
Abbrev. Contd.
• ac = (ante-cibum) = before food• pc = (post cibum) = after food• stat = immediately• im = intra muscular• iv = intravenous
06:51:16 AM
Pharmacy Practice 38Induction
• NHS– Patient seen by a prescriber under the NHS (doesn’t
pay)– Prescriber writes a script on an NHS script form– Pharmacy dispenses it (if patient is not exempt they
pay one charge for each item)– Scripts sent to NHS Business Services Agency
(NHSBSA) at end of each month– NHSBSA calculate payment for drug plus dispensing
charge minus fees taken at the till
What is the ‘journey’ of a prescription
06:51:16 AM
Pharmacy Practice 39Induction
What is the ‘journey’ of a prescription
• Private– Prescriber seen as a private arrangement (pays)– Writes a prescription – Dispensed at pharmacy– Patient charged cost of drug, plus 50%(usually)– Prescription filed at pharmacy for two years– Record of prescription in prescription record book
06:51:16 AM
Pharmacy Practice 40Induction
MAIN POINTS OF DISPENSING
Necessary ChecksLegal• patient details• legal requirementsClinical• product details and dosage and directions for
use• for drug interactions06:51:16 AM
Pharmacy Practice 41Induction
MAIN POINTS OF DISPENSING
Necessary Actions• Produce appropriate label• Dispense correct product• Ensure correct patient given medication • Patient counselling• Disposal of Prescription
06:51:16 AM
Pharmacy Practice 42Induction
Labelling and pickingRight drug/right patient – dispensing part 2
Chapter 12 : “Labelling medicines” in Foundations of Pharmacy Practice by Whalley, Fletcher, Weston, Howard and Rawlinson
Pharmacy Practice 43Induction
Why label medicinal products?
•Identify•Inform•Warn
Pharmacy Practice 44Induction
What types of product
• Direct from manufacturer sold straight to public
• Those you dispense
Pharmacy Practice 45Induction
Direct from manufacturer
Pharmacy Practice 46Induction
Tell you what it is Tell you how to use it
Pharmacy Practice 47Induction
Batch numbers and Expiry
Pharmacy Practice 48Induction
Warnings
‘Highly flammable’
Pharmacy Practice 49Induction
Labelling Requirements for dispensed Products
Pharmacy Practice 50Induction
Pharmacy Practice 51Induction
Dispensing Correct Product– Beware similar • Names• Packs• Strengths
• Beware– Very busy times– Very quiet times
Other factors leading to greater chance of error
Low Lighting
Little space
Insufficient staff
Distractions
Pharmacy Practice 52Induction
What can go wrong?
• Elizabeth Lee• http://www.dailymail.co.uk/news/article-1081069/Grandmother-cancer-died-Tesco-pharmacist-gave-letha
l-dose-wrong-drugs.html
Pharmacy Practice 53Induction
Monitoring
Pharmacy Practice 54Induction
Today • Safe use of medicines lecture - human error causing harm
• Drugs causing harm– Yellow card scheme–Reporting– Adverse drug reactions–Role of the pharmacist– Therapeutic drug monitoring
Pharmacy Practice 55Induction
Medicines and Healthcare products Regulatory Agency • Executive agency of the Department of Health• No product is risk-free• Responsible for assessing safety, quality and
efficacy (i.e. protect public/patients)• Issue licences for sale/supply of human
medicines/products in UK.
Pharmacy Practice 56Induction
• Drugs are discovered, undergo clinical trials and are then licensed
• Only most common ADR’s are detected at time of marketing
• Post marketing surveillance – Reporting– Investigation– Monitoring
The Yellow card scheme
Pharmacy Practice 57Induction
The Yellow card scheme • Who can report to MHRA–NHS / Private healthcare professionals
• Doctor, dentist, pharmacist, nurse, coroner
–Patients and carers• By post / online • HCP - Voluntary reporting (problem!)
• Drug companies have legal obligation to report ADR’s to MHRA
Pharmacy Practice 58Induction
Newly licensed medicines• Shown in BNF• Monitored intensely by MHRA– New active substances– New route or delivery system– New indications– New combination of active substances
• All suspected reactions involving a drug must be reported (even if not serious)
• Reported even if unsure that medicine caused the reaction or the reaction is well recognised
• Black triangle data is reviewed after 2 years
Pharmacy Practice 59Induction
Established drugs and vaccines
• Health care professionals must report all serious suspected reactions– Fatal,– Life threatening,– Disabling or– Result in prolonged hospital stay, even if reaction well
recognised• E.g.- Anaphylaxis– Blood disorders– Jaundice and any drug interactions
Pharmacy Practice 60Induction
Adverse drug reactions
An adverse reaction to a drug is defined as any noxious or unintended reaction to a drug that
is administered in standard doses by the proper route for the purpose of prophylaxis,
diagnosis, or treatment (BMJ 1998;316:1511-1514)
http://www.bmj.com/cgi/content/full/316/7143/1511?eaf
“an unwanted side effect”
Pharmacy Practice 61Induction
Type A & B reactions
Type A• Augmented
pharmacologic effects
• Dose dependent and predictable
e.g. Insulin and hypoglycaemia
- Warfarin and bleeding
Type B • Bizarre effects (or
idiosyncratic) • Dose independent and
unpredictablee.g. tinnitus with use of
AspirinAmoxicillin and rash
Pharmacy Practice 62Induction
Therapeutic drug monitoring (TDM)
Dosage of (some) drugs can be monitored by measuring their plasma concentration
Drug Therapeutic plasma concentration range
Digoxin 1-2 mcg /L
Phenytoin 10-20 mg /L
Theophylline 10-20 mg/L
Gentamicin (Pre)Trough <2mg /L(Post) Peak 5-10mg /L
Pharmacy Practice 63Induction
Therapeutic window
Pharmacy Practice 64Induction
Monitoring
• Drugs with a narrow therapeutic window (TDM)– Digoxin etc
• Dangerous drugs– WBC during chemotherapy
• Interactions– Warfarin and amiodarone (↑ INR)
• Efficacy– Blood pressure medication / BP
Pharmacy Practice 65Induction
Consulting for Pharmacists
Pharmacy Practice 66Induction
What types of communication are there in a pharmacy?
• Responding to Symptoms• Counselling after dispensing a prescription• Taking a drug history in the hospital
Pharmacy Practice 67Induction
Traditionally, counselling is
Just telling the patient something about their medicine
• Examples: • Take it after food• Finish the course • May make you drowsy
Pharmacy Practice 68Induction
Counselling or Consulting?
• Unstructured
• Telling what to do• ‘Any problems?’• Provide as much
information as possible
• One formula for all
• Structured– Gather data first
• Assess patient’s pharmaceutical needs
• Close the knowledge gap
• Target individual
Pharmacy Practice 69Induction
THE TITANIC OF CONSULTING (Davies, 1997)
HOW & WHEN
PROVIDEINFORMATION
OR REFER
ESTABLISH THE PATIENT’S NEEDS
DATA COLLECTIONDrug history, Compliance assessment,
Patients knowledge, Understanding of illness, Views about medicines, Perception of benefits
and risks,Lifestyle, Past experiences
Pharmacy Practice 70Induction
Calgary-Cambridge Model
• Medical model from 1996 for consultation• Five Stages• Initiating the session• Gathering the information• Physical examination• Explanation and planning• Closing the session
Pharmacy Practice 71Induction
Initiating the session
• Greet the patient by name• Introduce yourself (full name & role)• Explain the purpose of the interview• Ask consent• Start to develop rapport
Pharmacy Practice 72Induction
Gathering the information
• Information from prescription?– Drug – indication?– Dose – does patient take it?
• Information from PMR? – Drug history – reliability?
Pharmacy Practice 73Induction
Information from the Patient?
• A large amount of information comes directly from the patient
• What Information Do We Need From the Patient?
Pharmacy Practice 74Induction
Social/Family history
Patient-Centred Approach
Compliance assessment
Symptom patterns
Reasons for poor compliance
Full drug history
OTC
Complementary
Allergy
Any test resultsPrescribed
Pharmacy Practice 75Induction
Physical examination
• See under diagnosis
Pharmacy Practice 76Induction
Explanation and planning
• Identify potential and real pharmaceutical problems
• Produce practical solutions• Prioritise• Discuss with patient so concordant• Provide information• Refer where necessary• Monitor outcomes• Document care plan
Pharmacy Practice 77Induction
Closing the session
• Summarise the discussion• Check patient’s understanding• Ask patient if there are any other questions• Thank patient for their time
Pharmacy Practice 78Induction
Consultation Checklist1. Do I know more now about the patient?2. Was I curious?3. Did I really listen?4. Did I find out what really mattered to them?5. Did I explore their beliefs and expectations?6. Did I identify the patients’ main problems?7. Did I use their thoughts when I started explaining?8. Did I share the treatment options with them?9. Did I help my patient to reach a decision?10. Did I check that they understood what I said?11. Did we agree?12. Was I friendly?