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Our medical assessment unit!
Mark Oakley (modern matron) & David Young (pharmacist)
Southampton University Hospitals NHS Trust
• Introduce ourselves & our professions• Our plan for the session• Ideas of what you would like us to talk
about
Feel free to shout out with questions or for clarification at any time!
In fact, please do!!
Our MAU at SUHT
• The acute medical unit (“AMU”)• 48 beds in 3 sections, each with a central nurses station• 10 side-rooms for isolation patients• Its own drop-off area, waiting area and 2 interview rooms• Accept admissions 24 hours a day• Average 1,100 admissions a month
– 60% from A&E, 40% from GPs• Consultant post-take ward rounds twice daily• MDT 0800-1700 on Mondays to Fridays• Ambulatory care clinic (largely nurse-led via PGDs)
– Outpatient DVT, cellulitis, blood transfusion, follow-up– 5 beds set aside for “STATing” of GP referrals
• The future is EAUs (emergency admission units)– Combined medical and surgical admission units
David Young,AMU pharmacist
• 4 year degree in pharmacy (MPharm)– Medicinal and physical chemistry, biology, statistics– Formulation, physiology, pharmacology– Law, ethics & practice of pharmacy– Clinical pharmacy– Research project
• Pre-registration year at Bournemouth Hospital• Registration exams
– 70% community, 20% hospital, 7% primary care (industry, academia & other)
• Rotational jobs at Portsmouth & Southampton• Haslar & Lymington
David Young,AMU pharmacist
• Postgraduate diploma in clinical pharmacy• Future for pharmacy
– Ongoing CPD will be compulsory soon– Expansion of non-medical prescribing
• Supplementary prescribing – formulating a “clinical management plan” agreed between the NMP, responsible medic and the patient
• Independent prescribing– Outpatient clinics– Splitting of the RPSGB
• GPC responsible for registration and professional standards• A leadership body that will be responsible for representing
and supporting the profession– Revalidation expected to start by 2012
Mark Oakley,Modern Matron for AMU
• Registered General Nurse 1990 • Teaching and Assessing in Clinical Practice• UKRC ALS Provider• UKRC PALS Provider• UKRC ALS Instructor• Advanced Physical Assessment and
History Taking• Cardiac Care Course• Management Courses
Mark Oakley,Modern Matron for AMU
• Thromboprophylaxis in Practice• Change Management• Studying MSC in Management of Health
and Social Care• Member of the Society of Acute Medicine• Member of the Royal College of Nursing• Member of the UK Resuscitation Council
Our plan
• The pharmacy department
• Typical day for me as a MAU pharmacist
• What we add on the ward
• Other roles• Thromboprophylaxis
guideline at SUHT
• The patient journey through the hospital
• Structure of our AMU• Typical presenting
problems• Introduction of
Clexane to SUHT• Thromboprophylaxis
opinions
Dispensary
• Supply medicines to individual patients– Inpatients– Outpatient– Patients being
discharged
Technical services (“aseptics”)
• Prepare infusions and other individual items:– For paediatrics where
the doses used are small (risk reduction and cost saving)
– For some adult wards to reduce the risk of contamination when prepared on the ward
– Total parenteral nutrition (TPN)
– Items not commercially viable (e.g. due to short expiry date)
Medicines information
• Answer medicines-related enquiries:– Is warfarin safe in pregnancy?– Does lamotrigine cause
dysphagia?– What antiepileptics are
available in South Africa?– Tablet identification
• Audit & support other local NHS medicines information centres
• Review new medicines for cost-effectiveness & applications for adding new items to the local prescribing formulary
Clinical pharmacy
D a vid Yo u ngA d m iss io n s p h a rm a c ist
Ja m es A llenL e a d p h arm ac is t fo r e m e rge n cy m e d ic ine
S p e c ia lis t p ha rm a cis ts (C F , d iab e te s,h e p a to log y/ ga s tro e nte ro lo g y)
M e d ic in e fo r O ld e r p e o p le p ha rm a c is ts
C a ro n U n d e rh illD ire c to ra te p h a rm ac is t (M E C )
D ire c to ra te p ha rm a cis ts (su rg e ry, ca n cer ca re ,w o m en & ch ild re n , n e u rosc ien ce s, ca rd io th ora c ic
& c rit ica l ca re)
P rin c ip a l p h a rm a c is t - c lin ica l se rv icesM ic ro b io lo g y co n su lta n t p h a rm a c ist
R isk p h arm a c istP a in se rv ices p h a rm a c ist
S h a rron M illenH e a d o f c lin ica l p h arm a cy
S u rind e r B a ssanH e a d o f P h a rm a cy
Pharmacy people on our MAU
• Assistant– Checks what is needed in the stock cupboards & orders– Transfers medicines for patients moved to other wards– Returns medicines to pharmacy or destroys medicines
for patients discharged– Requests medication history information from the GP
surgeries
• Medicines management technicians– Piece together information from talking to the patient or
a relative and the medication history, medicines patient has brought into hospital to provide an accurate drug history
• Pharmacists (2 and a bit of extra help)
AMU nursing structure
E m erg en cy d e pa rtm e nt
H e a lth ca re a ss is ta n ts
S ta ff n u rse s (b a nd 5 )
S is te rs tea m (b a nd 6 )
C la ire S m ith (b an d 7 )S e n io r sis te r & ed u ca tio n le ad
A M U / A M AM a rk O a k ley (b a nd 8 a)
M o d ern M a tron
M e d ic ine M e d icin e fo r O ld e r P e o p le
V a n e ssa A rn e ll-C u llenC a re g rou p m a na g er
(e m e rg e n cy m e d ic in e)
N ico la L u ceyH e a d o f Nu rs ing
(d iv is io n 2 - u n sch e d u le d care d ivis io n )
My role as a pharmacist on MAU
• Reconciling a patient’s drug & allergy history on admission– Using an up-to-date drug history (e.g. as too ill or confused, no up-to-
date information available overnight or recent verbal alternations)– Identifying medicines that could be responsible for causing admission
(≈ 5-10% of admissions)– Organising supplies of medicines that aren’t available or changing to a
stocked equivalent as appropriate
My role as a pharmacist on MAU
• Advice to doctors– Appropriate drug and dose of new medicines– Ensuring that medicines that could exacerbate a condition are stopped
or withheld (e.g. NSAIDs in a patient with haematemesis)– Avoiding duplicated (e.g. tiotropium in a patient on ipratropium
nebules), contra-indicated (e.g. co-amoxiclav in a patient with a penicillin allergy) or interacting (e.g. trimethoprim in patients on methotrexate) medicines
– Ensuring that the plans are followed– Advising on writing legal prescriptions– Considering historic blood or culture results when selecting an
appropriate treatment (previous MRSA colonisation, usual treatment)– “What antibiotic can I give this pneumonia patient who is allergic to
penicillins & vomiting with doxycycline?”
My role as a pharmacist on MAU
• Advice to nursing staff– Supply of medicines– Safe administration of medicines
• “Should I give ramipril to this patient with a blood pressure of 95/50?”• “Is it okay to give this vancomycin stat (as prescribed)?”
– Prompting nurses about new medicines– When to arrange transport on discharge– Problems
• Patients with swallowing difficulties• Storing medicines• Maintaining confidentiality for a methadone addict
• Other allied healthcare professionals:– Physiotherapists – what drugs affect muscle strength & movement (PD,
analgesics)– Occupational therapists – patients getting confused with medicines
My role as a pharmacist on MAU
• Access to resources:– Toxbase (for the treatment of overdoses)– GP records (indication for medicines, previous diagnoses, other
medicines tried in the past)– Dose adjustments in disease states (reduced renal function, obesity)– Referring patients to the appropriate specialist nurses and teams (e.g.
microbiology ward-rounds)– Actioning drug alerts & recalls at the ward level
• Explaining changes to patients & counselling on new and ongoing medicines– Risk-benefit of medicines (e.g.warfarin vs. aspirin for AF)– Best way to take medicines (e.g. use of inhalers (how & which one),
sulphonylureas taken at bedtime)– Side effects to be aware of (e.g. carbimazole)
A typical day for me
• Shift working to increase hours covered – 50% of prescriptions are written outside normal working hours– Able to do discharges from evening PTWR
• Getting drug histories for about 2-3 patients– Difficult or no available doctor
• Medicines reconciliation for about 20-30 new inpatients• Reviewing drug charts of about 10 patients who have been
previously seen by a pharmacist– Are they getting better?– Monitoring requirements & interpreting results– Any drugs withheld or stopped that are indicated
A typical day for me
• Preparing 5-10 discharge summaries and medicines for discharge– Documenting all of the current medicines a patient is taking– Drugs stopped and started and the reason for doing so; review
dates as appropriate– Communication with appropriate people in primary care
(NOMADs, depot injections, nursing homes)– Checking what supplies the patient has at home reduces
drug costs, expediting supply
• 5 trips to the emergency department– Advise on medicines or to supply medicines
My other roles outside of MAU
• Guideline review and writing– Enoxaparin for DVT & PE treatment– Hyperkalaemia– Parenteral drug administration
• Teaching to doctors, medical students, nurses etc.– FY1 teaching session on anticoagulation
• Ordering medicines for outpatient clinics• Intervention & activity monitoring• Training of newly qualified pharmacists• Audit
– NICE guidance on medicines adherence• Finance
– Justify over-spend, patients from other directorates, high cost drugs
My other roles outside of MAU
• Guideline review and writing– Enoxaparin for DVT & PE treatment– Hyperkalaemia– Parenteral drug administration
• Teaching to doctors, medical students, nurses etc.– FY1 teaching session on anticoagulation
• Ordering medicines for outpatient clinics• Intervention & activity monitoring• Training of newly qualified pharmacists• Audit
– NICE guidance on medicines adherence• Finance
– Justify over-spend, patients from other directorates, high cost drugs
My other roles outside of MAU
• Guideline review and writing– Enoxaparin for DVT & PE treatment– Hyperkalaemia– Parenteral drug administration
• Teaching to doctors, medical students, nurses etc.– FY1 teaching session on anticoagulation
• Ordering medicines for outpatient clinics• Intervention & activity monitoring• Training of newly qualified pharmacists• Audit
– NICE guidance on medicines adherence• Finance
– Justify over-spend, patients from other directorates, high cost drugs
The SUHT VTE prophylaxis guideline
• At the time medication errors and VTE prophylaxis was the top priority on the patient safety arm of the Trust’s patient improvement framework
• Team set-up to lead– Pharmacist, clinical director, anticoagulation nurse specialist,
medical consultant
• Thrombosis committee, including a clinician from each care group, formed
• Agreed points and raised issues for discussion in the individual care group– e.g. timing of doses post-operatively discussed at individual
forums leads by specialists from anaesthetics and surgery
The SUHT VTE prophylaxis guideline
• A band 6 nurse employed (funded by industry)– Educate nurses in the importance of thromboprophylaxis– Increase awareness of IPC and it’s role
• Support from sanofi-aventis representative:– Facilitating networking
• Arranging study days and recruiting participants• Knowing who had solved a problem already
– Providing the evidence base for decision making– Arranging stock (risk assessment stickers, bags)– Arranging training for clinical staff
• Compliance with thromboprophylaxis: 20% 80%
Acute Medical Unit
• 2001 DOH NHS Plan• AMU, MAU, CDU• 4 hr targets for A&E• Right place, right time, right person• Ambulatory Care Units• STAT clinic started 2009• Documentation
– Medical and nursing clerking– VTE risk assessment
Acute Medical Unit
• Assessment, Diagnosis, Treatment, Discharge, Transfer
• Length of stay• Acute Physicians• MDT• 11 trained nurses, 3 CSW long days• 10 trained nurses, 2 CSW nights• Physiotherapist, Occupational Therapist,
Social Services, Speech and language Therapy, Dietetics, Nurse Specialists
My Day as a Matron
• Check night shift • Handover (twice weekly take case load)• Walk round• Bed meeting• Environmental checks• Various meetings• Peer reviews• Patient stories
Matron’s Role
• Clinical Leader• Visible presence• Patient advocate• Police• Auditor• Role model• Link between “ward and board”• Change agent• What the public want
How AMU Works
• 24 hr admission service• Rapid assessment of patients• Rapid access to diagnostics• MDT• Rapid treat and transfer/ discharge• Partnership
Typical presenting complaints
Chest pain
Psychiatric
Short of breath
Limb painSepsis
GI bleeding
Diabetes
Headache ± confusion
Neurological problems
Diarrhoea
Weakness or falls
Chest pain
Final diagnosis Tests/ procedures Drug treatment
Myocardial infarction
Cardiac monitor, ACS protocol, 5 day rest working up to normal, ECG,?angiography, CABG
Aspirin, clopidogrel, ACEI, statin, enoxaparin
Arrhythmias ECG, cardiac monitor, ?electrical cardioversion
Dependant on diagnosis, often ß-blockers, calcium-channel blockers, digoxin
Angina ECG, exercise tolerance test, ?angiography
AntianginalsGTN spray for symptom relief
Musculoskeletal CXR,ECGAnalgesicsNSIADs
Short of breath
Final diagnosis Tests/ procedures Drug treatment
Pneumonia CXR, bloods, physiotherapy
Antibiotics, nebulised bronchodilators, steroids
Exacerbation of asthma or COPD
CXR, nebs, peak flows, Respiratory centre, physiotherapy, lung function tests
Heart failureCXR, daily weight, fluid balance chart, daily U&E, heart failure nurse
Diuretics, ß-blockers, ACEIs, spironolactone
Pulmonary embolism
D-dimer, ABG, CXR, VQ scan, CTPA
Heparin (usually LMWH), warfarin
Sepsis
Final diagnosis Tests/ procedures Drug treatment
Urinary sepsis Urine dipstix, MSU, IV fluids, daily FBC, U&E
Antibiotics according to likely source or broad spectrum then rationalised according to investigations & culture results
Chest sepsis CXR, FBC, CRP, physiotherapy
Abdominal sepsis AXR, FBC, CRP
Neurological problems
Final diagnosis Tests/ procedures Drug treatment
Epilepsyneurological observations, ?CT scan, ?LP, epilepsy nurse, neurological review
Antiepileptics (add, adjust doses or change),
Headache ± confusion
Final diagnosis Tests/ procedures Drug treatment
Subarachnoid haemorrhage
CT scan, ?LP, neuro surgical review, ?surgery
Avoid anticoagulants (? duration)?Nimodipine
Meningitis/ encephalitis
CT, LP, neurological observations
Antibiotics ± antiviral
Migraine FBC, U&E, ?neurological review
Analgesics?Triptans?Prophylaxis
GI bleeding
Final diagnosis Tests/ procedures Drug treatment
Upper or lower GI bleeding
NBM, OGD, IVI, FBC, ?blood transfusion
PPI?Antibiotics (variceal)
Inflammatory bowel disease
Isolate, stool culture, IVI, gastro review, dietician review
5-ASA compoundsSteroids (iv/ po/ pr)
Diabetes
Final diagnosis Tests/ procedures Drug treatment
New onset diabetes
BM stix, FBC, U&Es, glucose, urine dip, HbA1c
Oral antidiabetic agents, insulin (BD/QDS), pens, meter, hypo advice
Hypo- or hyperglycaemia
Adjustment of diabetic treatment
Diabetic emergency (DKA, HONK)
IVI, diabetic nurse review, endocrine review, regular urine dipstix, BM stix
Sliding scale insulinAdjustment of diabetic treatment
Diarrhoea
Final diagnosis Tests/ procedures Drug treatment
Gastroenteritis (viral, bacterial)
Isolate, isolation proforma for audit trailStool charts & culture
RehydrationAntibiotics as appropriate
Clostridium difficile infection
Psychiatric
Final diagnosis Tests/ procedures Drug treatment
Overdose
Levels, INR, U&EsPsychiatric review - ?need for admission or community support
AntidoteWithhold & restart when appropriate (e.g. lithium)Limiting supplies
Schizophrenia
Rapid tranquillisation for their safety & that of othersAntipsychotics
Confusion
Final diagnosis Tests/ procedures Drug treatment
Dementia
High observable bedReturn the wandering patient, reassuranceSeptic screenPsychogeriatric review
Symptomatic treatment
Limb pain
Final diagnosis Tests/ procedures Drug treatment
CellulitisFBC, CRP, x-raysProforma?vascular review
AntibioticsAnalgesics
Deep vein thrombosis
ProformaAnticoagulationAnalgesics
Arthritis or goutCPRRheumatology review
AnalgesicsNSAIDsSteroids
?suit
able
for
AM
A
Weakness and falls
Final diagnosis Tests/ procedures Drug treatment
Stroke/ TIACT scan, carotid dopplerFBC
Aspirin ± dipyridamole, BP control, statin?VTE prophylaxis
Postural hypotension
Lying & standing BPOften over-medicatedBone protection
Parkinson’s disease
NG tube is a priority if NBMMedication timings is important
Electrolyte disturbance
U&Es As indicated
Introduction of Clexane to SUHT
• Positive example of how change management works
• Good communication to the right people at the right time
• Sanofi-aventis input:– Information packs & wall displays were useful– Good education and support pre-change – Ensured staff awareness and appropriate training– Ongoing support and teaching
• Didn’t feel as though the change was ‘imposed’ on us
Thromboprophylaxis opinions
• We asked a variety of AMU staff:– What they guess the estimated number of deaths
annually from VTE contracted in hospital is– Do they believe the actual number– What proportion of these occur in medical patients– What the incidence of VTE is in the typical MEDENOX
patient– How effective they think thromboprophylaxis is– Whether they know the hospital guideline on
thromboprophylaxis in medical patients– Who’s responsibility is it to risk assess patients– What is their role in VTE prevention
Thromboprophylaxis opinions
• Average number of estimated deaths from hospital VTE ≈ 4,500
• Typically thought that about one-third of these occurred in medical patients
• Guessed that incidence of DVT in a MEDENOX patient would be about one-third
• Thought that RRR with enoxaparin ≈ 85%• No-one knew what the hospital guideline was for VTE
prophylaxis in medical patients– but correctly identified many of the VTE risk factors
• Most people thought that all of the doctors, nurses & pharmacists caring for the patient were responsible for identifying patients for VTE prophylaxis– “How often have you challenged a doctor whether a patient
should be prescribed thromboprophylaxis” mostly never
Visiting a ward
• For medicines not currently used– Discuss with consultants (via secretaries) &
pharmacy– Consider non-medical prescribers as these
become available
• Arranged teaching sessions are preferable– Discuss with the ward manager or educator– Background to the disease– Ideally 30 minute sessions between 2-3pm
VTE prophylaxis related challenges as we see them
• What do other hospitals recommend for VTE prophylaxis in medical patients?
• Who is the most appropriate person to do the VTE risk assessment?
• Where should this be documented?• How can we encourage this to be considered at the PTWR?• How can we ensure that VTE prophylaxis is considered after
admission (especially when contra-indicated on admission)?• Sharing of guidelines and risk assessment tools?• What is the best way to counsel patients on their VTE risk
on admission?• How can VTE prophylaxis be integrated into electronic
prescribing systems most effectively?