Transcript Document

Lessons from the Field:
Supplementary Prescribing in a
Hospital-Based Heart Failure Service
Helen Williams
Pharmacy Team Leader –
Cardiac Services,
King’s College Hospital
My Credentials!
Qualified as a pharmacist in 1994
 Worked in cardiology since 1995
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– OP clinics since 1997
– Working in HF clinics since July 03
Trained as a SP from Sept 03 – Jan 04
 Qualified in June 04
 Prescribing in HF since October 04
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Overview of the HF Service (1)
Traditional Management of HF
 Patients seen at intervals by cardiology
team
 Interim management (dose titration etc)
by:
– ?GP / hospital
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Failure to achieve therapeutic targets
 Lack of structured support for patients
 Recurrent readmissions / poor symptom
control / high mortality / poor compliance
Overview of Service (2)
Multi-Disciplinary Team Approach at King’s
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HF Nurse Consultant (new post) / Specialist
Pharmacist-led with input from cardiologists as
required
Diagnosis confirmed on first visit by cardiologist
Further management delegated to nurse and
pharmacist
Intensive clinic supervision until symptoms
controlled, drug therapy optimised, then 3 to 6
monthly review as necessary
Additional medical input available if required
Clinic Roles
Nurse Consultant:
Pharmacist:
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Initial assessment / class
Tests and investigations
Physical examination
Educating patients on HF
pathology
Lifestyle advice
Social Issues /
Psychology
Dealing with carers
Coordinating clinic visits
Tele-clinics
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Drug histories
Medication review
Optimising dosing
Tailoring drug therapy
Monitoring response
Dealing with adverse
effects
Encouraging compliance
Provision of patient
information and GP letters
Using Supplementary Prescribing
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Patients diagnosed by independent prescriber
Responsibility for follow-up delegated to both
SPs (nurse and pharmacist)
Clinical management plan signed and agreed
for all patients referred
– On-going assessment and examination, further
investigations, changes to drug therapy, psychosocial
adjustment, liaison with primary care
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Referral back to IP if any change in diagnosis,
complications or annual review due
– On-going MDT review as required
Clinical Management Plan (CMP)
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Needs to be broad enough to allow SPs to practice
efficiently
For heart failure it might include:
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Symptom control
Optimising outcomes
Hypertension management
IHD: secondary prevention
IHD: anti-anginal therapy
AF management
(Obesity, sexual dysfunction etc., etc., etc.)
Regularly reviewed in line with clinical data and
local agreement
Problems…….
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Management of Co-morbidities
– Rheumatoid arthritis – NSAIDs can effect
HF management: should pain control be
in CMP?
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Restrictions of the CMP
– What if patients develop gout?
• Is this a new diagnosis? Or an adverse effect?
Other Problems…….
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Pharmacists ordering and analysing
– 24 hour tapes, 24hour ABPM, ECGs
– Angiography, 2D and 3D Echos, CXrays,
– U&Es, FBCs, inflammatory markers, etc
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Non-pharmacological issues
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Underlying pathology, role of revascularisation
Lifestyle advice
Travel
Devices
HF Clinic – Preliminary Audit
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275 patients registered with the clinic (2003–2005)
143 patients offered and agreed to Supp Rx’s
– No patient has refused management by Supp Rx’s
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284 items prescribed over the first 8 months
– 168 by nurse consultant
– 116 by clinical pharmacist
– 60% of items were classic “heart failure” drugs
• Ramipril, carvedilol, bisoprolol, spironolactone, candesartan
– Off-CMP prescribing has resulted in additions to CMP
• Laxatives
• Vitamins and minerals
• LMWH for thromboprophylaxis
Benefits of Supplementary Rx
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MDT working – better skill mix
Holistic approach to care
Consistency in approach
Tailored dosing regimens
Addressing compliance issues
Dealing with adverse effects
Achieving drug dose targets more quickly
Patient satisfaction (not formally assessed)
Working with an Independent Prescriber
Must have confidence in each other
as clinicians – prior rapport helpful
 IP must be an expert in clinical field
 IP must be available to support SPs
 Works best where arrangement is
flexible
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– Managed by both SPs and IP depending
on clinical needs of individual patients
The Challenges
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Developing CMPs, managing paperwork
 The consultation process (for pharmacists)
– Undertaking physical examination
– Dealing with sensitive issues
• Prognosis, Palliative care, Sexual dysfunction
• Cultural differences / attitudes
– Seeing the bigger clinical picture
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The prescribing process (for nurses)
 Other issues
– getting support within Trusts, budgets, resources
clinic space, competition between professions
The Future….
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Independent prescribing…….
= more freedom to act
= able to prescribe off-CMP if
appropriate (i.e. continuation therapy)
= less delay for patients awaiting Drs
assessment / ratification of plan
= reduced paperwork (CMPs
individualised from a standard template)
= greater responsibility on individual Rxer