The Pharmaceutical Journal
Vol 278 No 7453 p617-620
26 May 2007

This article
Reprint   Photocopy

PDF 100K, Acrobat Reader

CPD: what pharmacists are doing

By now, pharmacists will be familiar with the Societys CPD recording format and, to date, over 20,000 members have made a record on www.uptodate.org.uk. The Journal asked seven of these pharmacists to give an example of the CPD they have recorded

Continuing professional development articles

CPD Diary

Supplementary prescriber: learning through an adverse event

Community pharmacist: auditing drug misusers for compliance

Community pharmacist: skills to provide advanced services

Hospital pharmacist: learning to write patient group directions

Community pharmacists: improvements through peer review

Superdrug pharmacist: working to help detect skin cancers

Society & CPD

Supplementary prescriber: learning through an adverse event

Graeme Lavender (pictured, right, with his primary prescriber) is a supplementary prescriber who works three days a week in a GP practice in Southampton, performing medication reviews. His hobbies include fishing and horse riding. In this CPD diary, he presents the outcome of a routine asthma review and describes how he used it for his CPD

Mr JC was a 58-year-old man with asthma and angina, who had had a myocardial infarction four years before. He had not had a proper asthma review since his MI because, he told me, he felt that his heart condition was his primary concern. His notes mentioned increased dyspnoea since his MI and, on questionning, he said that because of his shortness of breath he was now only able to walk slowly and was defeated by
inclines.

I conducted spirometry, including a reversibility test. A 30 per cent reversibility to salbutamol, indicated poorly managed asthma. Mr JC had a spacer device but did not use it, so I checked his technique and encouraged him always to use the spacer (at least for his beclometasone) and made an appointment for a follow up two months later.

Three weeks later one of my practice GPs told me that Mr JC had needed an emergency appointment because he had had three angina attacks in one day. The GP had done an electrocardiogram to eliminate acute coronary syndrome and, after looking at my recent asthma review, identified that the increased angina had been caused by increased exercise capacity. After the review, Mr JC had started using his spacer and felt increasingly less breathless and tired, which had allowed him to do more exercise. On the day of the emergency appointment he had felt so well that he had gone for a long walk with his dog and this had resulted in the three angina attacks.

Applying root cause analysis, I considered all the events that led to the emergency. With stable angina, Mr JC had a known exercise ceiling and an increased oxygen demand by the heart would have resulted in the attacks. A step further back was increased effectiveness of the steroid inhaler through the use of the spacer device, which was a direct result of my counselling. And before that, the 30 per cent reversibility to salbutamol had been the basis of my decision to focus on inhaler technique. The challenge at this point was to identify the root cause.

The area that caused me most concern was whether or not I should have predicted the consequences of the improved asthma control. I contacted a nurse at our local respiratory centre. She said that hindsight always makes an issue clearer but the 30 per cent reversibility could have been seen as a warning signal that Mr JC’s dyspnoea might significantly improve with better asthma control and, naturally, he would be able to do more.

The root cause of the emergency was my inexperience in failing to recognise the significance of the degree of reversibility and link this to the patient’s exercise capacity, which was limited by angina. Of particular interest with this medication review was that no changes to the patient’s prescription were made — the simple correct use of asthma inhalers had led to the significant adverse consequences.

I recorded this event online, using the Society’s CPD records. I have no problems using the system and it takes me 15 minutes at most to make one record. I see my records as being for my benefit and not anyone else’s so I can enter what I want. I think CPD is absolutely essential, especially so that we do not fall behind the nurses. For example, about 30 nurse prescribers are being trained for every four or five pharmacist prescribers.

Community pharmacist: auditing drug misusers for compliance

Uzma Chaudhry is a relief pharmacist manager at Lloydspharmacy in Oxford. She has been a pharmacist for three years. In her spare time she likes shopping and watching films

My pharmacy has a number of addicts. I felt I needed to know more than just the basics so I took a course in the management of drug misuse, run by the Royal College of General Practitioners (RCGP). The course was recommended by the pharmacist on the Oxfordshire Drug and Alcohol Action Team. It highlighted the problems drug misusers face, which can cause them to start taking illegal drugs or later suffer a relapse.

One of the course assignments was to carry out an audit. I chose to audit how many doses are missed by patients who are prescribed methadone or Subutex. Missing doses could mean that the patient is taking illegal drugs or lacks motivation. Even a low number of missed doses needs to be identified and dealt with — ideally, no doses should be missed. Performing audits is also a part of the new pharmacy contract and I felt it would be good practice for me.

I used the Royal Pharmaceutical Society’s guide (PJ, 13 August 2005, pp203–4 (PDF 60K)) to design my audit, which was conducted over three months. At the end of each month I counted the number of methadone and Subutex prescriptions dispensed, the total number of doses on the prescriptions and the number of missed doses. I was surprised by the results because I had expected the number of missed doses to be higher.

My audit results showed that the rate of missed doses is low, indicating that our system is working well. A low number of missed doses suggests that patients are motivated to treat their addiction and that their prescribed doses are sufficient for their needs — one reason for missed doses could be that the patient has used illicit drugs because the dose of methadone or Subutex is not high enough.

In addition, I noticed that during the audit there was a decrease in the number of missed doses. I discussed this with my tutor at the RCGP course, who suggested that this could be a reflection of the skills I have put into practice from the course (eg, being better able to empathise with the patients and encourage regular attendance).

I found that a common reason for some patients to miss doses is that they need to fit in collecting their dose with going to work and this can be difficult. Perhaps arranging for the patient to have a take-home dose on some days would improve compliance. I also think pharmacists need regularly to send report forms to the prescriber and drug worker if a patient misses a dose.

I recorded the hours I spent on the course on the Society’s CPD website. Using the website can be time-consuming and difficult at times. However, recording CPD online is more convenient than using paper. This CPD directly impacted on my work. It showed me the important role I can play in helping drug misusers and the influence I can have on compliance.

Community pharmacist: skills to provide advanced services

Nitin Gudka is a pharmacy manager at Abbott Pharmacy owned by Napclan Ltd, a small multiple in North London. In his role he offers services, such as supervised methadone or buprenorphine consumption, smoking cessation and emergency hormonal contraception under a patient group direction. He has recently joined a study group for pharmacists in Barnet and attends their meetings regularly. Working an average of 55 hours a week, Mr Gudka does not have much spare time, but he enjoys DIY and the occasional game of golf with his family

I became accredited to conduct medicines use reviews in January 2006 but I believed my clinical knowledge was not sufficient for me to answer some questions that patients might ask during a review. The opportunity to improve my clinical knowledge arose when I was invited to participate in a five-day course on “Training to support advanced services in the new pharmacy contract”, organised by Barnet Primary Care Trust.

The series of workshops covered various topics, including an introduction to MUR services, communication strategies, osteoarthritis, chronic obstructive pulmonary disorders and asthma, cardiovascular disease and diabetes. I made a record for each workshop I attended. Below is a description of my CPD cycle for the cardiovascular disease workshop.

Reflection A large percentage of my patients suffer from cardiovascular disease and many are being treated for hypertension and hyperlipidaemia. In addition, recent headlines in the press about beta-blockers and statins have prompted many questions from the public. There has also been the updated guidance from the National Institute for Health and Clinical Excellence for the management of hypertension in primary care.

In order to address patients’ questions and to conduct MURs effectively, I needed a thorough understanding of this topic. A CPD alternative was a meeting on lipid management organised by a drug company, which I eventually attended in addition to the Barnet workshop.

Planning I discussed the workshop invitation with my boss and he agreed to find locum cover for me (funding for the cover was provided by the PCT). I then tackled the pre-workshop task, which consisted of obtaining and reading four documents, including an article on the significance of lipid measurements from The Journal and material from MeRec publications and Bandolier. I allocated six hours to the work, but it took closer to seven and a half hours. I completed the tasks over a couple of weekends. The pre-workshop tasks improved my knowledge on hypertension and hyperlipidaemia, allowing me to participate fully in discussions during the workshop.

Action I completed the pre-workshop task and attended the workshop. During the session, I learnt how to use the Joint British Societies cardiovascular risk prediction charts that are in the back of the British National Formulary correctly. I also had the opportunity to work through various case studies, to do MUR role-plays, with feedback from an observer, and to complete an MUR form.

The workshop also looked at how best to engage patients for an MUR through addressing patient-oriented outcomes.The group discussed the general medical services contract and how pharmacists could promote the MUR service to GPs and help them achieve points in the quality and outcomes framework.

Evaluation Having read articles related to cardiovascular disease in the pharmaceutical press and discussed the issues with colleagues, attending the workshop provided me with an opportunity to consolidate my understanding of the topic. After attending the workshop, I am more able to answer questions from patients with hypertension and hyperlipidaemia about their medication and their side effects and I feel more confident in recommending lifestyle changes.

I am also now actively looking at patients who might benefit from a discussion. For example, I asked one patient when he had last had a clinical review after I noticed he had been taking aspirin and clopidogrel for over a year.

Recording I used the Royal Pharmaceutical Society’s paper version of “Plan and record” to record my CPD, although the online version is easier to use in completing sections such as competencies. I find that the template for “learning that starts as an action” is easier to complete than the template for “learning that starts as a reflection on practice”, but I try to have a fair mix for both types of learning.

Hospital pharmacist: learning to write patient group directions

Sejal Parekh is a rotational pharmacist at the St Charles Hospital in West London, but will shortly be taking up a senior pharmacist position at the Royal National Orthopaedic Hospital in Stanmore, Middlesex. She has a keen interest in photography and likes to travel

A few months ago I was asked to join a primary care trust PGD steering group (a panel of PCT pharmacists, lead nurses and other practitioners) to update patient group directions (PGDs) for the childhood immunisation programme. Although I had come across PGDs before, writing them was a completely new experience. This identified a gap in my knowledge, which I set about correcting, recording my progress by using a CPD cycle along the way.

I started by reviewing what I already knew about PGDs and created a plan to fill the gaps before the panel’s first meeting in a week’s time. The Royal Pharmaceutical Society has an excellent article on its website entitled “Patient group directions: a resource pack for pharmacists”. I downloaded and read this, highlighting relevant sections and acquainting myself with the legislation. I also obtained and read example PGDs, one that the panel had previously written and a second from another trust, until I was familiar with how they were written. Finally, I created a summary of everything I had learnt from the resource pack and the example PGDs.

As a result of my efforts, I felt I had much better knowledge of PGDs, not only the legalities but also the clinical benefits, the necessity and the scope that they cover. I attended the steering group meeting with a real understanding of the requirements and the process, and was better able to contribute to the updating of the PGD. On completion I reinforced my knowledge by presenting the PGDs to nurses being accredited for them. I have since been asked to update further PGDs and feel much more confident.

I recorded this particular CPD cycle on paper, although I often use the Society’s online version of “Plan and record”. I found it quite daunting at first but as I have become accustomed to the format, I have found that it is actually much simpler than it at first seems.

Community pharmacists: improvements through peer review

Joyce Byrne and Steve Baldwin work for the Waremoss Group, a Sussex-based family-owned chain of 28 pharmacies. Mrs Byrne manages a pharmacy in Langney, Eastbourne. She has been a pharmacist for 25 years and spends much of her spare time looking after her daughter’s horse. Mr Baldwin is the pharmacist manager of a pharmacy located in a health centre, near Pevensey. Having completed his preregistration training in hospital, he joined the Register in 2006. He enjoys watching Brighton and Hove Albion football club. The two met at the Waremoss Pharmacy Managers Conference, where activities included reviewing a selection of each other’s CPD entries

Mrs Byrne’s CPD I use the Royal Pharmaceutical Society’s online system (www.uptodate.org.uk) for all of my CPD entries. The more have I used it, the easier it has become. One of my entries was about learning some of the features on the new dispensary computer system. I started at the “action” step of the CPD cycle by reading the relevant sections of the manual and telephoning colleagues for advice on how to use some of the functions on the system. I included “managing the dispensing process” as an area of competence that this learning objective related to.

One of the skills I developed was an ability to use the patient medication record system to determine the number of prescription items dispensed in any week. In my evaluation, I included the positive feedback from the rest of my dispensary team when I showed them how to do this as well.

Mr Baldwin’s feedback This entry is a good example of how an everyday piece of learning can be used as the basis for a brief CPD record. I suggested to Joyce that her entry could have started at reflection (eg, “I need to fully understand how to use all the features of the new dispensary computer system”) and it could have included a planning section on ways to achieve this, such as reading the manual, observing as well as speaking to colleagues and contacting the IT helpdesk. I also mentioned that the evaluation could have led to other IT-related learning needs being identified.

Mr Baldwin’s CPD As a preregistration trainee, I used the paper-based system for recording my evidence of competencies but since I qualified I have used the Society’s online system, which I find straightforward. One of my CPD entries was about becoming accredited to supply Levonelle via a local patient group direction. Under “reflection”, I included wanting to understand how emergency hormonal contraception works as well as the legal and professional issues around using a PGD. I also included broader areas, such as increasing my awareness of sexual health and teenage pregnancy and improving my communication skills when counselling teenagers about their sexual health.

Under “planning”, I noted that this learning need was of high importance to my patients as well as to me. For “action”, I noted that I had completed the Centre for Pharmacy Postgraduate Education distance learning pack on EHC and attended my primary care trust training course. In “evaluation”, I included the positive feedback from my local GP practice when I informed it of my PGD role.

Mrs Byrne’s feedback This was a comprehensive CPD entry and looked excellent. Steve had not included the time he spent on the CPPE course, so I suggested that he add this. Also, I said that he could consider adding feedback from one of his PGD clients to his evaluation entry.

Mark Donaghy, professional development manager for the Waremoss Group remarked: “The Waremoss Group supports its pharmacists with undertaking CPD. Rather than formally asking to inspect CPD records we encourage our pharmacists to peer review each other’s. This allows for an open and honest discussion about the range and quality of each person’s CPD entries.”

Mrs Byrne and Mr Baldwin have met again since the conference to further discuss their CPD records.

Superdrug pharmacist: working to help detect skin cancers

Martin Crisp is head of pharmacy for Superdrug stores plc. He has worked for multiples for all of his 20-year career. He has four daughters and, as a keen music fan, he loves attending concerts and festivals in his spare time. Mr Crisp supports Brentford football club

One of the most interesting pieces of CPD I have carried out recently is to learn about diagnostic screening for skin cancer. I identified the need when Superdrug was considering a pilot service to provide mole checks in stores. It was important for me to fully understand both the background to the condition and the credibility of a mole check service.

In terms of planning, I arranged to visit a mole clinic and carried out a literature search to find out more about skin cancers and what services had been provided in other countries.

Action I went to the mole clinic and spent time with a nurse who had been trained to assess visible moles and understand how digital imaging equipment works to look below the surface of a mole. I also collated a portfolio of extracts from journals and relevant websites as reference. I then worked with my team, alongside the Mole Clinic company, to build a workable service deliverable from Superdrug stores.

Evaluation I had not realised that skin cancer is the most common cancer in the UK and melanoma is the most common cancer in the 20 to 39 years age group. This group forms a large proportion of Superdrug’s customers. In addition, the mortality rate for melanoma in the UK is more than one in five, whereas in Australia, where screening services at primary care level are well established, the rate is less than one in 10. Reviewing the pilot was essential to learn how the service could be improved and rolled out from the three London trial stores to a further 20 stores nationwide. We took the decision to recruit our own nurses so that Superdrug can offer additional services in the future to complement the current ones undertaken by our pharmacists.

Recording I tend to keep a folder of all relevant information and rough notes aligned to the CPD cycle with key dates. Once I have three or four pieces of CPD, I try to set aside time to log them into the Society’s electronic format. I found the logging process a bit challenging at first but find it easier now I have found my way round the various web pages. Ideally, I would log my CPD electronically as I do it and this is my intention going forward.