Hospital Pharmacist
Vol 10 No 6 p269-270
June 2003

At the heart of a coronary care unit ward round

By Emily Larsson, MPharm, and Bastienne Cavey, MPharm

The consultant cardiologist at the Conquest Hospital, Hastings, Dr Richard Wray, approached the pharmacy department in August 2002 to ask whether we, the two preregistration trainees, would be interested in attending his ward round on the coronary care unit. We agreed enthusiastically and soon became integral members of the weekly coronary care unit (CCU) ward round.

A situation that could have been intimidating quickly developed a relaxed atmosphere where all members of the team could actively participate in discussions and contribute their opinions. As a result we believe that we have a clinical input into patient care as well as being in a rich learning environment. We are able to gain knowledge from the ward round and play a role in educating other team members on pharmaceutical issues.

We take part in several activities during the cardiology ward round, including:

• Prescription screening and pharmaceutical input for each patient

• Answering queries raised each week by the cardiology team

• Teaching the team

Prescription screeening

For each prescription, the medication is clinically assessed under the supervision of the cardiology pharmacist. The indication, dose, frequency and route of administration of drugs are checked and pharmaceutical problems such as drug interactions or contraindications are identified. Subsequently, any potential problems are brought to the attention of the cardiology team and either an alternative medicine or referral of the patient to an appropriate clinical team is suggested.

This open format enables all members of the team to contribute ideas and, therefore, agree on the best treatment for each patient. The exchange of ideas allows multi-disciplinary input to patient care and also educates team members and builds good working relationships.

One example of our input into patient care involved an elderly man on CCU who was diagnosed with acute myocardial infarction. He was sweaty and thirsty and his blood results showed a high blood glucose level. His medical notes lent further evidence to the suspicion that he had diabetes. It became apparent from talking to the patient that he thought might have diabetes, but a confirmed diagnosis had never been made, and so his diabetes was neither controlled by drugs nor diet. We therefore recommended to the cardiology team that his blood glucose was controlled and monitored. We suggested that while he was on CCU he should be started on a sliding scale intravenous infusion of insulin until his cardiac-related condition stabilised and should then be referred to the diabetes team. Due to our intervention, the patient received the most appropriate care for his individual needs.

This example highlights one particular advantage of pharmacy participation in specialist clinical team ward rounds. Other health care professionals on the team tend to focus on cardiac-related problems and certain pharmaceutical issues outside the specialty can often be identified and resolved more effectively through pharmacy involvement.

Answering queries

After each ward round, we discuss a subject that we will research for the following week. This can be a topic that Dr Wray wishes to receive further information about, or a subject that he would like the members of his team to be taught more about. These subjects tend to fall into one of the following categories:

• The pharmacological action of drugs

• Drug interactions

• Local practice and policies and NHS issues

For example, one week he asked "Why does nicorandil not cause nitrate tolerance even though its chemical structure contains a nitrate moiety?" To compose an evidence-based answer, we obtained information from several sources. We conducted a literature search on the internet and contacted the manufacturers of nicorandil in order to obtain key research papers about the drug. Through the evaluation of this information it was possible to answer the query. The process of retrieving information and researching the topic provided us with experience of using a variety of resources as well as allowing us to learn about the subject we were researching.

An example of a subject that we researched in the drug interaction category is interactions with grapefruit juice. The task was to establish the mechanism of action of individual drug interactions with grapefruit juice and rank them according to their significance. From doing this, we were able to advise other health care professionals in a constructive and helpful manner.

The choice of heparins for different indications at the Conquest Hospital is an example of one of the questions posed regarding local practice. We were asked to investigate which types of heparin were used at this hospital and how this might compare with the practice at Eastbourne Hospital. We started by reviewing the evidence for each heparin, its cost effectiveness and indications for use. The query evolved into thinking about the role of clinical pharmacists in hospital formulary development and procedures for changing a formulary. Obstacles to this change, such as funding, training and behavioural aspects, also had to be considered.

Teaching the team

From the weekly tasks the findings are fed back to the cardiology team through written and verbal methods. The written report tends to be one side of A4 or a diagram in order to emphasise the most relevant points in a summarised format — this also makes them easier to remember. The verbal feedback includes a presentation of findings and sometimes product demonstration.

Dr Wray encourages us to bring examples of various drugs and appliances as he believes that doctors prescribe drugs, but seldom see what the products look like, or know about their administration. A range of products such as glyceryl trinitrate spray, helicobacter treatment packs, inhaler devices, insulin pens and penfills have been demonstrated.

The future

As health care evolves, different needs arise for specialty teams. One such need that has been identified by Dr Wray is the requirement for input by diabetes specialists in the weekly ward rounds. He has recognised the fact that there will be a huge increase in the number of type 2 diabetes patients in the future due to changes in dietary habits and the ageing population. Therefore he wants to establish closer teamwork with the diabetes specialists at the Conquest Hospital and a diabetes nurse practitioner will also attend CCU ward rounds to assess and improve patient care.

In relation to pharmacy, there is potential for further developments in clinical training and preregistration trainees' input. Due to the rewarding experience gained from our interaction with the cardiology team, future preregistration trainees could benefit further by extending this multidisciplinary ward round. They could, for example, rotate through different specialties during the year in a similar way to junior doctors. It may be possible to be involved in three different clinical areas over the year, thus broadening the experience and learning from a wider range of sources.

The once weekly involvement limits the time input required from the medical team, while still allowing a valuable insight into the way in which they work. The ward round enables people from different disciplines to develop better working relationships, which has helped immensely when talking to other health care professionals on wards and when deciding whom to approach with particular questions.

Our involvement does not interfere with the normal running of the ward round. Questions are asked during the round as usual, and any presentation of answers to queries or product demonstrations take place over about five minutes at the end of the round.

The research and writing-up does, however, take time, but having to do these has helped us to improve our time management skills and to prioritise work more effectively. It is a flexible arrangement whereby we can set our own deadlines and therefore not compromise our learning needs relating to other aspects of our preregistration training.

Conclusion

Being involved with the cardiac team so early on in our careers has emphasised to us the importance of developing good clinical skills and has encouraged us to be more closely involved with other health care professionals.

We hope that in the future other consultants will be interested in taking advantage of the skills available from pharmacy staff and that the benefits that can be gained on all sides will be realised.

ACKNOWLEDGEMENT
Thanks to Dr Richard Wray and other medical and nursing staff on CCU, Kerry Allegria-Ramirez and other pharmacists at the Conquest Hospital