Jaidev Mehta
HAVING completed the secondment on ePMA (electronic medicines and administration), I was ready to resume my clinical duties on gastroenterology & rheumatology wards.
Let me take you with me as I complete my daily duties as a hospital pharmacist.
The morning coffee kick-started the neurons in my brain and led to a quick mnemonic check of pre-ward visit preparation. I’m convinced that coffee goes straight to my brain via sublingual absorption!
1. Check the rota – covering gastroenterology and rheumatology wards
2. Get the ward folder + keys + ward sheets + green pen
3. Get correct bleeps for each ward
4. Check whether I have pharmacy technician support on wards today
5. Check on intranet whether any electronic TTOs (to take out discharge prescriptions) have been written by the doctors
6. Have NHS smart card for accessing SCR (summary care records). I would have been very annoyed with myself if my NHS smart card was left behind. It’s a very long walk back from wards!
7. Check on junior band 6 pharmacist on how s/he is coping with ePMA on wards. The pharmacist was more than competent on ePMA so no worries for me then!
The hospital was under pressure for beds which meant that a heavy workload was expected.
Fast forward to the rheumatology ward and work was prioritised in the following manner:
1. Get a copy on nurse’s handover on gastroenterology ward. Gastroenterology ward is prioritised first because doctor’s ward rounds start earlier on gastroenterology and therefore potential TTOs are written earlier then rheumatology ward.
2. Quick hand over with nurse in-charge to discuss potential discharges and supplies of urgent/non-urgent medicines. Give a quick heads-up to doctors to bleep me once they finish writing TTOs.
3. Ring rheumatology ward quickly and check with nurse in charge there of any potential discharges and urgent requests for medicines. Ask the sister in charge to bleep me if I’m required, otherwise I will be covering rheumatology ward once work finishes on gastroenterology.
4. Prioritise work on ward by checking pharmacy book for drug requests, ask nurses in all bays whether they want any medicines supplied, annotate handover sheet with ‘N’ for new patients (they will require drug histories completed), and write down any pending actions from yesterday such as ‘check INR’ or ‘monitor renal function’ or ‘query antibiotic duration/check gentamicin levels’ (can be a long list of to dos)
And now to the highlights of my day:
Case 1 – Crush and disperse
A patient has swallowing difficulties and the nurse requests all medicines to be converted to liquid formulation. A quick chat with the patient (Mrs A) reveals that she is not too keen on having soluble Adcal-D3 or other medicines as it does nothing. Mrs A is also prescribed multivitamins, thiamine and other medicines. A quick chat with the dietician leads to a joint decision of stopping unnecessary multivitamin and thiamine. The dietician agreed to ensure that Mrs A is supplemented instead via her feeds.
Mrs A was told about stopping unnecessary medicines and counselled about the need for Adcal-D3. As on so many occasions reassurance was all that was required.
The other medicines were converted to liquid formulations where possible and some were endorsed as ‘crush and disperse in water for administration’ on the drug chart.
Sources of information: NEWT guidelines, BNF, dietician, and Mrs A (you always get valuable information from patients, so imperative to involve them in decisions)
Case 2 – TTO counselling
Mr B was a young gentlemen with high output stoma discharged with a complicated regimen of medicines and St. Marks solution. The following took place:
I introduced myself to the patient and explained my purpose i.e. counselling on new medicines, screening the discharge prescription, printing counselling leaflets, appropriate signposting and supplying necessary medicines prior to discharge from hospital.
Mr B was very anxious and didn’t understand the rationale of taking lots of loperamide and codeine. Also why did he need to take allopurinol, as he doesn’t have gout?
He was reassured that loperamide and codeine reduce the gut motility and reduces stoma output (counselling leaflet provided for future reference and digitally signposted to patient.co.uk. The allopurinol (off-label use) reduces the requirement of azathioprine (immunosuppressant used for treatment of Crohn’s disease) and therefore it’s not for gout.
The information on preparation of St. Mark’s solution was provided and advised on how to take and store.
Once counselled the next focus was screening TTO (to take out discharge prescriptions) and supplying necessary medicines. The discharge process was also explained so Mr B knew what to expect when leaving hospital and how long it might take to receive his medicines from pharmacy (after all no one wants to sit on ward wondering what happens next!).
I was thanked by Mr A and in return I wished him all the best post discharge. Sources of information: BNF, UKMi St. Marks Solution Q&A, patient.co.uk, and my rotational experience on gastroenterology ward
Case 3 – Urgent drug history
Mr Doctor says: “Mr Pharmacist, what medicines does Mrs C take? We are unsure”.
Mr Pharmacist says: “No problem, give me 5 minutes”.
I have a quick chat with Mrs C who is unsure what medicines she takes and hasn’t bought them to hospital with her. She remembers taking a tiny red tablet and paracetamol and other round white tablets.
Mr Pharmacist: “So Mrs C, can I assess your GP record or contact them to confirm your medicines?” (Consent is very important! Let’s not forget that).
Mrs B: “Sure dear”.
Time to put my NHS smart card to good use to access Mrs C’s ‘summary care record’ (SCR) document; drug history on drug chart; check notes/previous TTOs as second sources of information; print SCR and file paperwork in patient notes; and finally take the drug chart back to doctors with confirmed drug history.
Phew!
The process took longer than 5 minutes but accurate documentation and patient safety is paramount.
Sources of information: Summary care record, Mrs C, medical notes, recent TTOs for Mrs C.
There was a lot more to my day, which also involved:
1. Walking up and down between gastroenterology and rheumatology wards to screen urgent discharge prescriptions (TTOs) .
2. Advising a nurse on reconstitution of aciclovir .
3. Dealing with a request to supply high cost adalimumab with the arrangement to ensure continued supply on home care prescriptions’.
4. Advising a registrar on managing pain control for a patient who prescribed ‘fentanyl 100 micrograms patch regularly’ and ‘Sevredol 40mg up to four times a day when required for breakthrough pain’ .
5. Advising a team of junior doctors on the starting dose of prednisolone for autoimmune hepatitis .
6. Converting levodopa (combination medicines such as co-careldopa) to rotigotine patches for a ‘nil by mouth’ Parkinson’s disease patient.
7. And obviously seeing all new patients and addressing any pending pharmaceutical queries/issues on both wards.
After all of the above, it was nearly 1pm and time to have lunch. The afternoon was dedicated to screening TTOs and safely discharging patients from hospital as a part of ‘discharge liaison service’.
Overall it was a rigorous and satisfying day for me.
How are your days usually?
Disclaimer: This blog is meant to serve a mere snapshot of what a hospital pharmacist does routinely, maybe shed a light on how a pharmacist brain works in prioritising workload, and goes about interacting with patients, doctors, nurses and patients. Any similarities with other hospital pharmacists are not co-incidental but purely a result of an awesome NHS training.
Jaidev Mehta is IM&T Applications Manager (ePMA Specialist Pharmacist) at Royal National Orthopaedic Hospital NHS Trust
Follow Jaidev @JaidevMehta