Journey of Patient

Pharmacy Practice 1Induction

Journey of the Patient

Dr Angela MacAdam

Stages of the journey

• Diagnosing• Prescribing• Dispensing• Monitoring• Consulting

Diagnosing

• “The minute you walked in the door . . ”

A twelve year old boy and his mum ...

“How can I help?”

• Complaining of . . . .• Listen to the patient's story• 90% of the process of diagnosis comes from • the history

Pharmacist’s ApproachMnemonics

• WWHAM• ASMETHOD• ENCORE• SIT DOWN SIR

• Read Introduction to Community Pharmacy by Paul Rutter

Past Medical History

Family History

Sometimes familyhistory gives us a clue . . .

Social History

Drug History

“Let’s have a look at you . .”

Pitting in psoriasis

Oral Candidiasis

Vital signs

• Pulse• Temperature• Blood Pressure• Blood sugar

Investigations . . .

• Blood/urine tests– haematology– biochemistry– Immunology

• Infection screen• Cytology/Histology• X Rays• Scans, ultra sound, MRI etc

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.

• 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

• 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

• Medical practitioners / Doctors • Dentists• Non-medical prescribers:– Supplementary– Independent

Who can prescribe medicines?

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

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

Must be qualified prescriber!1. Collect information – see diagnosing2. Analyse information and make a

prescribing decision3. Make appropriate records4. Monitor

Prescribing process

• 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

• 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

• 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

• Cheapest?• What is new on the market?• Design and colour of tablets?

How do prescribers choose what drug to prescribe?

‘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

Chapter 10: “Understanding and interpreting prescriptions” in Foundations of Pharmacy Practice by Whalley, Fletcher, Weston, Howard and Rawlinson

Dispensing

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

What types of prescription are there?

• NHS– Doctor– Dentist– Other prescribers

• Private– Doctor– Dentist– Vet

• Hospital06:51:16 AM

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

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

Abbrev. Contd.

• ac = (ante-cibum) = before food• pc = (post cibum) = after food• stat = immediately• im = intra muscular• iv = intravenous

06:51:16 AM

• 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

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

MAIN POINTS OF DISPENSING

Necessary ChecksLegal• patient details• legal requirementsClinical• product details and dosage and directions for

use• for drug interactions06:51:16 AM

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

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

Why label medicinal products?

•Identify•Inform•Warn

What types of product

• Direct from manufacturer sold straight to public

• Those you dispense

Direct from manufacturer

Tell you what it is Tell you how to use it

Batch numbers and Expiry

Warnings

‘Highly flammable’

Labelling Requirements for dispensed Products

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

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

Monitoring

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

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.

• 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

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

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

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

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”

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

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

Therapeutic window

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

Consulting for Pharmacists

What types of communication are there in a pharmacy?

• Responding to Symptoms• Counselling after dispensing a prescription• Taking a drug history in the hospital

Traditionally, counselling is

Just telling the patient something about their medicine

• Examples: • Take it after food• Finish the course • May make you drowsy

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

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

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

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

Gathering the information

• Information from prescription?– Drug – indication?– Dose – does patient take it?

• Information from PMR? – Drug history – reliability?

Information from the Patient?

• A large amount of information comes directly from the patient

• What Information Do We Need From the Patient?

Social/Family history

Patient-Centred Approach

Compliance assessment

Symptom patterns

Reasons for poor compliance

Full drug history

Complementary

Allergy

Any test resultsPrescribed

Physical examination

• See under diagnosis

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

Closing the session

• Summarise the discussion• Check patient’s understanding• Ask patient if there are any other questions• Thank patient for their time

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?

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