Hospital Pharmacist Vol 7 No 3
p73-78
March 2000 Articles
Medicines management in elective surgery patients
By Rekha Shah, BPharm, MRPharmS
In this article, the author discusses a new model for medicines management in elective orthopaedic, urology and general surgery patients, developed at the Mount Vernon hospital, Northwood, Middlesex. Mrs Shah was given a 3M customer care award for the North Thames Region in recognition of this work
Three years ago, pharmacy services to the surgical wards at the Mount Vernon hospital (MVH) underwent a radical change in a move to improve services. The new pro-active service is now one of our most successfully established pharmacy services and continues to grow from strength to strength. The service has proved to be very user-friendly to doctors, nurses and pharmacy staff. Most importantly, it is a very patient-focused service. This article will describe:
- The background to the change of service to the surgical ward
- How the change was implemented
- Present services to the surgical wards
- Benefits of the new service
- Any future plans to take the service forward
Background
Many patients admitted to hospital for surgical procedures take long-term medication (cardiovascular drugs, anti-psychotics, anti-epileptics and hypoglycaemics) unrelated to their surgical complaint. These medications can potentially interfere with the anaesthesia or the surgical procedure itself, causing complications ranging from mild discomfort to possible fatality. All medications therefore need to be clearly documented and reviewed prior to surgery, and a decision made on whether they are to be continued, adjusted or stopped pre-operatively.1,2 If a medicine is to be continued, then it is important to ensure that it is available to the patient on the ward. Early re-introduction of a patient's regular medication could help to minimise post-operative complications. Being without normal medication in the post-operative period may have adverse effects on a patient's recovery.3
The surgical ward pharmacists undertook a review of medications (unpublished) taken by surgical patients at MVH. This showed that patients did not always receive the right medication at the right time. A number of areas were identified that needed attention in order to improve patients' pharmaceutical care. These are outlined below.
Inadequate information The information provided on admission about the patient's current medications were found to be inadequate:
- Referral letters from general practitioners (GPs) were sometimes incomplete regarding patient medication
- Patients did not always bring their regular medication with them on admission, as there was no instruction in the admissions letter to do so. Patients, especially the elderly, did not always remember the details of their medication when asked on admission. This led to many patients, particularly those arriving on Sunday afternoon for surgery on Monday, not receiving their regular medication
- Patients often "forgot" to tell the doctor about their medication, as they did not consider certain products to be medicines, for example, the contraceptive pill, over the counter (OTC) products, herbal and homoeopathic remedies, or even asthma inhalers
Poorly-written prescriptions Hospital prescriptions, written on admission by junior doctors, were unclear, for example, nifedipine 10mg bd (really meant to be nifedipine m/r 10mg bd with a specified brand), isosorbide mononitrate m/r 60mg bd (dosing should be od). This led to missed doses and inappropriate or wrong medication being given to the patient. The ward pharmacist often did not see the drug chart until the second day and sometimes not until the third day, if the patient was in theatre on the second day. Consequently, there was considerable time lag between a prescription being written and a clinical pharmacy intervention being made.
Inconsistent advice Patients did not receive consistent advice regarding any adjustment to their long-term medication, for example, the combined oral contraceptive pill and low dose anti-platelet aspirin.
Nursing errors Nurses often omitted giving long-term medication because a patient was nil by mouth (NBM) pre-operatively and sometimes post-operatively.
Long waiting times for TTAs Day case and short stay patients were having to wait a long time for their "to take away" (TTA) medication as these were written post-operatively on the wards.
Regular medication as TTA Patients were receiving their regular medication on the TTA form, often leading to confusion in patients. An example is a patient who did not realise that the Lanoxin she received in community was the same as the digoxin prescribed in hospital.
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Rekha Shah with a patient at the pre-admission clinic |
This avoids last-minute cancellations and makes better use of bed space and theatre time.
Implementing change
In 1996, to ensure better use of hospital resources, orthopaedic, urology and general surgeries went fully elective at MVH. The urgent surgeries were now to be carried out at the other hospital in the trust. It was decided at this stage to provide pharmacy services at the PACs. An improved pharmaceutical care of ear, nose and throat (ENT) has been demonstrated in patients when care was planned from a PAC.6,7 The pharmacist's role at the PAC was thus defined as follows:
- To take accurate drug histories
- To advise patients on any changes to be made to their long-term medication, according to agreed guidelines
- To transcribe relevant details onto the prescription chart, including any agreed prophylactic anti-thrombotics and antibiotics
- To ensure, on admission, that patients have medication available on the ward
- To prescribe analgesia for day case and short-stay patients according to agreed protocols, and advise patients on effective use of analgesia on discharge
- To co-ordinate and facilitate prompt discharge
The service today
The aim of the change was to provide total pharmaceutical care of the surgical patient from admission to discharge.
Drug history taking at the PAC All patients are now asked in the admissions letter to bring in their prescribed and purchased medicines to the PAC. A procedure for taking drug histories has been written to provide uniform service to our patients.8,9,10 Before interviewing the patient, the pharmacist currently in post usually familiarises herself with the medical records (via case notes).
The interview Each patient is interviewed using a drug history questionnaire. The pharmacist takes the drug history, preferably before the clerking doctor sees the patient. If, however, a patient has already been clerked by the doctor, the pharmacist still sees the patient, and the drug history taken would then remain as a record in the case notes for future reference. During the interview, the pharmacist enters the details of the prescribed and purchased medication on the drug history form as well as any allergies or intolerances to any medication or other substances. If any patients are having problems with their medication, these, too, are documented. The patients are also asked if they have had any medication changes or courses of steroids in the past 12 months. Patients occasionally forget to bring in their medications to the PAC, despite the request in the admission letter. In this instance, the pharmacist rings the patient's GP to confirm the medication or sort out any queries related to patients' medications.
At the end of the interview, the pharmacist advises the patients if it is necessary to adjust any regular medication pre-operatively and also if it is necessary to bring in any of their medication. The present policy is to use hospital supply. Exceptions are non-formulary items for short-stay patients, brands of modified-release preparations which differ from hospital stock, calendar packs, trial drugs, inhalers, eye drops, creams and ointments. Patients are also advised at this stage that they will not be receiving any of their regular medication on discharge and that arrangements should be made to have adequate supplies at home when discharged. Patients from nursing/residential homes often bring medication in a Dossette box. Nurses on the ward prefer not to use such medication, as it is not from a labelled container. The pharmacist in this case transcribes medication as normal and advises the carer of the arrangements. Dossette boxes, therefore, do not need to be brought in on admission.
After the interview, the pharmacist transcribes the relevant information onto the drug chart and indicates in the "pharmacy box" on the drug chart whether this regular medication is available as stock on the ward, to be supplied by the pharmacy or to be brought in by the patient. Patients requiring additional pharmaceutical care are identified with a note in front of the drug chart. They include diabetic patients, patients on warfarin or lithium, patients undergoing gastrointestinal (GIT) tract surgery who might need parenteral nutrition post-operatively, or patients with special requests about their regular medication. The top copy of the drug history form is attached to the drug chart, and the duplicate is kept in the pharmacy department. The PAC nurse ensures that the clerking doctor has checked and signed all the regular medications so that the nurses on the ward can administer them. At the end of each PAC session, the pharmacist lists all the drugs that need to be sent to the ward. On the Friday of the week before admission, after checking on the admission lists that patients are definitely coming in, the medications are sent up to the ward, each marked with a "to come in" (TCI) date. On the ward, a drug storage space has been allocated for these TCI drugs. Medication is sent up for the expected length of stay and not the usual seven days.
The peri-operative period During drug history taking at the PAC, patients regularly ask if they need to continue their medication right up to surgery. Although most medicines are continued up to surgery and immediately post-operatively, there are certain groups of drugs that need adjusting or stopping pre-operatively.1,2
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Long-term medication taken by surgery patients can interfere with anaesthesia and surgical procedures |
- A patient on warfarin for atrial fibrillation was booked to come in seven days before the operation for heparinisation. The clerking doctor did not intervene. The pharmacist liaised with the haematologist and changed the admission to one day pre-operatively. The clerking doctor agreed and the pharmacist advised the patient when to stop the warfarin at home.
- A patient on warfarin for a prosthetic heart valve was booked to come in just the day before the operation. This was changed by intervention to three days pre-operatively for heparinisation, and the patient was advised accordingly.
- Pharmacists have also had to intervene when patients come in for a procedure under local anaesthetic, as doctors frequently assume that there is no need to stop the warfarin.
The haematology department welcomes this approach as it occasionally saves them from having to supply fresh frozen plasma for a fully anti-coagulated patient taken to theatre. Junior doctors appreciate the help and guidance and do not waste time on the ward sorting out patients' warfarin management. The management of warfarin by the pharmacist is so popular that a formal set of guidelines is being written.
A copy of the general guidelines on long-term medication and surgery is kept at the PAC, on each of the surgical wards and in the pharmacy department. During drug history taking at the PAC, the pharmacist advises the patients of any necessary adjustments to be made to their medication and indicates this on the drug chart for doctors' and nurses' awareness. For day case patients who are nil by mouth (NBM) from midnight, the pharmacist advises the patients which medication they must take before coming in and how it should be taken.
TTAs for day case and short-stay patients Currently at MVH, 50 to 65 per cent of all routine operations are done on a day case basis. Effective post-operative pain management is important for the patient's well-being. It promotes early mobilisation and can reduce post-operative complications. If patients are to be discharged early, it is necessary to give them adequate analgesia and appropriate advice; otherwise they will soon contact their GP for better pain control.11
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Figure 1:The traditional pharmacy practice model for service to the surgical wards was retrospective and reactive14 |
Figure 2: The new model of pharmacy service to the surgical wards is proactive14,15 |
Benefits of change
The new service has brought about a number of positive changes in terms of patient care and staff utilisation.
Taking drug histories Taking an accurate drug history has become a very important role for the pharmacist and there are many ways in which it has improved patient care, as the following shows.
Patient counselling Taking drug histories at the PAC has provided a unique opportunity for the patients to have a one-to-one consultation with the pharmacist to discuss all their prescribed and purchased medications. Most of these patients have never been able to discuss their total medication with an expert on medicines. It is frequently revealed that patients have medication-related problems that include adverse drug reactions, inappropriate prescribing, drug interactions, lack of knowledge, and poor compliance with the prescribed regimens.12 Examples of these problems include:
Some recurring medication-related problems presented at the PAC are shown in Panel 1 on page 78. The junior doctors who clerk the patients and look after them on the wards do not always notice these problems, and, even if alerted, they are often unwilling to change patients' long-term medication. This could result in a surgical patient's medication-related problem being unresolved and the patient continuing with the problem until an emergency arises.
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Panel 1: Common medication problems at the PAC
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Documenting and quantifying allergies This avoids unnecessary use of potentially more toxic, less effective or more expensive drugs. Particularly with penicillin, patients often say it has no effect or it gives them diarrhoea. Hence it is important to differentiate drug allergies from drug intolerances.
If a patient is asthmatic, on warfarin or has a history of gastric or duodenal ulcer, then a "caution with anti–inflammatory drugs" would be documented in the allergy and intolerance box. This is very important drug history documentation, considering anti-inflammatory drugs are frequently prescribed post-operatively and a high percentage of the population experience adverse effects with these drugs.
Full drug history Important information for the anaesthetist and the doctor is derived by asking if the patient has had any medication in the past year. This would be important if, for example, the patient was asthmatic or had Crohn's disease, and had been on steroids. The patient might need additional cover during surgery to avoid a sudden drop in blood pressure. Any medication used in the past 12 months is recorded, providing ready information for the doctor if any of the regular medication is to be reviewed.
Drug economy Patients are advised that they will not be receiving any of their regular medication on discharge. This avoids duplication or confusion and drug wastage.
Purchased medicines There is a growing use of over-the-counter products, many of which are herbal medicines and homeopathic remedies. All of these can have the potential to interfere with the prescribed medication, and it is important, therefore, to document all the medicines that were purchased as well.
Special drugs The pharmacist now highlights on the front of the drug chart if a patient is on a drug or therapy that needs extra monitoring (eg, warfarin, lithium, diabetes).
Before starting work at the PAC, the pharmacist was not involved in all aspects of pharmaceutical care to the surgical patients. The interventions made on regular medication at the ward level before the service change were mainly of unclear dose or frequency, unstated brand of modified release preparations and unavailable non-formulary items. Additional patient information, obtained from case notes and interviews with patients, helps to provide total pharmaceutical care for the patient.13
This service change has allowed the pharmacist to be introduced to patients at the first key stage of care in hospital, and total pharmaceutical care can commence at this stage. Warfarin is a classic example. The pharmacist knows from the start that the patient is on regular warfarin, and can make the decision to have it stopped peri-operatively and restarted post-operatively.
Information transcription Transcribing information onto the prescription chart is an important step forward for pharmacists managing surgical patients' medication. The pharmacist only transcribes relevant, accurate information on to the prescription chart.
For example, if patients take Tylex (paracetamol with codeine), the pharmacist can ask them at the PAC if they would be willing to try a similar preparation stocked by the dispensary, since Tylex is not kept at this hospital. If the patients are not agreeable to this, they can be requested to bring in their own supply of Tylex. Prior to the pharmacist involvement, a doctor would have transcribed Tylex on to the drug chart and if the patient did not bring in the drug, then the pharmacist would have had to intervene on the ward. With this new service, the problem is sorted out prior to admission and there is concordance with the patient. Nurses on the ward find the information about the supply of regular medication useful and their time is saved as medication is already on the ward. Moreover, time is saved by the doctor who does not have to chart patients' regular medication.
Supply of medication in advance of admission This has been one of the most significant benefits of the change in the service. Previously, patients who were admitted on a Sunday afternoon, for surgery on Monday, sometimes did not receive their Sunday night dose and/or Monday morning dose. Even during the week, if the patient was admitted in the afternoon and the doctor had not clerked the patient until late in the day, the patients could often miss their evening dose of medication.
Nurses, through regular teaching sessions from the pharmacist, are now more aware of the importance of the availability of regular medication to the patient. Sometimes, if a patient is directly admitted to the ward, the pharmacist is bleeped to review and transcribe the patient's regular medication.
Thus, since most patients are not bringing in their medication on admission, there is less clutter in the drug trolley. In addition, the patient's medication is not being left on the wards, a common complaint from the GP.
Guidelines and protocols Guidelines and protocols have made it possible for the professionals involved to offer researched, consistent and agreed advice to the patients. With junior doctors changing every three to six months, this is not only useful to them but helps to provide a consistent standard of care to patients.
Future goals
We have plans to improve the service by undertaking the following projects:
- A self-medication scheme - the pharmacist will review patients' suitability for self-medication at the PAC
- Making the pharmacist responsible for writing discharge medication on the surgical wards
- Ensuring that the pharmacist communicates with the GP and the community pharmacist if any changes or additions have been made to the patients' regular medication
- Preparing further guidelines, including those for prophylactic antibiotics in surgery and for thromboprophylaxis in surgery. (Although these are written at the PAC and individual consultant's preferences are adhered to, researched protocols would give more consistent care to the patients. Other guidelines being proposed relate to nausea and vomiting post-operatively, artificial nutrition post-operatively and diabetes and surgery)
- Involving the pharmacist in the operating theatres and working with the anaesthetists
- Computerising the service, thereby reducing the pharmacist's workload
Conclusion
PACs are the first, key stage of elective surgical patients' care in the hospital and are now a fairly routine procedure. The involvement of pharmacists at the PAC is, however, relatively new. Providing a pro-active service from the PAC has transformed the pharmaceutical care of patients admitted to the hospital.
Accurate drug history taking, written policies and protocols have enabled the pharmacist to take a leading role in the management of patient's medication from admission to discharge. There is continual positive feedback from the doctors and nursing staff.
Patients are beginning to recognise the specialist role of the pharmacist. There is now more familiarity between the patient and the pharmacist on the ward, and the patients are more forthcoming in providing answers to any medication-related queries. Patient attitude is going to be important in this changing role of the pharmacist, as more awareness will be created by such patient-pharmacist interviews.
The pharmacy service is now fully integrated into the PAC system. This model of service has allowed us to provide patient-focused care and total medicines management and can be the future template for providing total pharmaceutical care for all elective surgery patients.
ACKNOWLEDGMENTS: The author would like to thank Joan Ashby, pharmacy and dietetics services manager, Mount Vernon and Watford hospitals NHS trust, for her continued support throughout the setting up and running of this new service and Danielle Adams for her invaluable help in setting up this service.